Health Education Research Advance Access published online on July 17, 2008
Health Education Research, doi:10.1093/her/cym003
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The pit and the pendulum: the impact on teen smokers of including a designated smoking area in school tobacco control policy
1 Prevention Program, British Columbia Cancer Agency, Kelowna, BC V1Y 5L3, Canada
2 Health Care and Epidemiology, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
3 Tobacco Reduction Initiative, Nanaimo, BC V9T 2L9, Canada
4 Department of Public Health Science, University of Alberta, Edmonton, AB T6G 2E1, Canada
Correspondence to: * Correspondence to: L. E. Baillie. E-mail: lbaillie{at}bccancer.bc.ca
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Abstract |
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Thirty per cent of school districts in British Columbia do not ban smoking outright on school grounds, and in several instances, smoking is permitted in smoking pits, regardless of school district policy. While there is evidence to suggest that enforcing a tobacco-free environment for students does reduce adolescent smoking rates, the concomitant safety and discipline problems it creates for school staff and administration are demanding and complex, and may override concerns regarding student smoking. This study uses a qualitative approach to explore the meanings that students place on tobacco control policy and the impact that these meanings have on their own smoking behaviours. We found that students were surprised and concerned that smoking was permitted on school property and that it negatively impacted their own tobacco prevention/control/cessation attempts.
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Introduction |
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Smoking remains the leading cause of preventable illness, disability and death in Canada [1]. In the province of British Columbia (BC), >7000 people take up smoking every year; 90% of which are children and teens [2]. Those youth who initiate smoking before the age of 15 years double their risk of lung cancer compared with those who initiate after the age of 20 years [3]. Young females appear to be particularly vulnerable, for example, a girl who starts to smoke within 5 years of menarche increases her likelihood of developing breast cancer by up to 70% [4].
This information, taken with the fact that teens spend 
25% of their waking hours in school, make school-based programming an obvious vehicle for tobacco control [5]. However, years of school-based tobacco control programme evaluation have yielded disappointing long-term results [6], and with them the realization that increasing knowledge about smoking and its dangers to health offers little or no protective effect. This fact has not escaped the tobacco industry and is one reason they have long supported and promoted these kinds of strategies [7].
Although virtually all schools across Canada espouse a ban on tobacco use, there appears to be a wide range of variability in the ways in which this ban is implemented, monitored and enforced [8]. For example, in BC, despite the government's adoption of the Health Promoting Schools concept in 2005, which is built on the premise that schools can directly influence children's health, it remains the situation that while a smoke-free environment must be provided for staff, there is currently no legal obligation to provide a smoke-free environment for students. Consequently, the latitude afforded by this discrepancy has permitted inconsistencies both in providing a smoke-free environment for students and in applying tobacco control policy. Thirty per cent of school districts in BC do not ban smoking outright on school grounds, and in several instances, smoking is permitted in smoking pits, regardless of school district policy [2].
Sussman [9] argues that having a designated smoking area on school property serves only to legitimize tobacco use. Countering this argument are the concerns that schools not accommodating student smoking will have to face the consequences of teens, sometimes in large groups, leaving school property during school hours to smoke elsewhere [2]. These students then not only are removed from the learning environment and any tobacco control provision that the school may offer but also are at greater risk of causing problems within the surrounding community. Schools that strictly uphold a tobacco-free environment and resort to punitive enforcement measures, such as suspension and expulsion, may be providing the perfect opportunity for teens to pursue the very behaviour that they are attempting to stamp out [8].
While there is evidence to suggest that enforcing a tobacco-free environment for students does reduce adolescent smoking rates [10], the concomitant problems it creates for school staff and administration are demanding and complex. As a direct result of these problems, Ashley et al. [11] found that one-third of school administrators from 213 Ontario high schools advocated a return to designated smoking areas. In essence, high schools that permit smoking on campus do so at some considerable cost to student health, but the problematic issues of not only successfully implementing and enforcing policy but also effectively dealing with unintended consequences remain.
If school tobacco control policy is to be successful, it must address how youth view both tobacco use and control. Several quantitative studies have considered the statistical relationship between school tobacco control policy and student smoking [12–14]. For example, Leatherdale et al. [15] conducted an analysis of survey data collected from the School Smoking Profile Project. They found a significant relationship between schools with peripheral smoking areas and student susceptibility to smoking. Kumar et al. [8] similarly used data from the Monitoring the Future Project to analyse correlations between school policy and student smoking. When considering high school tobacco control policies, researchers have primarily focused on the experiences and observations of staff and administration and in terms of implementation and effect; the ways in which students, themselves, experience and interpret policy content and implementation have received little attention [16]. The student perception of the contexts of smoking can be very different from those of the adult observer [17] and given the complexity of school tobacco control policy implementation, added insight into student thinking could further inform practice. This paper explores the meanings that students place on tobacco control policy and the impact that these meanings have on their own smoking behaviours.
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Methods |
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In order to access these personal meanings from a student perspective, a qualitative approach was used.
Focus group participants were recruited by placing posters in community centres, sports venues and coffee shops in two towns located in the interior of BC and by the snowball technique. Both towns are served by high schools that have designated smoking areas. Recruitment was limited to resident teens attending these high schools aged between 14 and 18 years and who self-identified as being current smokers, ex-smokers or never smokers. Recent research has suggested that smoking youth employ a very personal set of descriptors to describe their smoking history and behaviours [17, 18]. Those teens who volunteered to take part were provided with hard copies of research information and consent forms requiring parent or guardian signature. These teens were then telephoned 1 week before and again 2 days before focus group meetings. As an incentive to participate in the groups, and also to thank them for their contribution to the study, we served pizza, salads and juice. We also gave each participant a $20 coupon for a CD. Ethics approval was granted for this study by the BC Cancer Agency Behavioural Research Ethics Board.
Using established methods, three focus groups, each of which comprised of between six and 10 teens, were led by two trained facilitators. Each focus group session lasted 90 min. A research assistant was also present to take notes and to provide logistical support. All focus group meetings were audiotaped and transcribed for analysis by the complete research team. Questions were broad and open-ended, allowing participants to talk freely about their own experiences and to remain within their own contexts of meaning (Table I).
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Initial stages of analysis involved each research team member thoroughly reading each transcript and identifying emerging themes and issues, which were then shared with the research team. Next, using these identified themes and issues, a coding frame was collaboratively created, and all interviews were fully coded. Data coded under specific consistent themes, e.g. pupils' perceptions of smoking pit location, were then selected and a team member (L.E.B.) wrote descriptive summaries. These thematic summaries were then referred to throughout each round of analysis and incorporated, adapted or rejected as new information was collected, ensuring reliability of themes. In keeping with qualitative research protocol, these phases were cyclical rather than linear in outline. That is, after each focus group data analysis, the resulting collective reinterpretation was then returned to the larger body of data to generate further analysis. This cyclical process was repeated to the point of saturation or redundancy, that is, no new information or perspectives was being produced.
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Results |
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We present the results in terms of the participants’ own words. We found four main categories: surprise/opportunity, student control/tobacco control, school indifference/individual concern and quitting/isolation. Ages and genders of participants have not been included as we were interested in capturing the general experience of the phenomenon of designated smoking areas from the emic student perspective.
Surprise/opportunity: ‘I'm allowed to smoke here—right in the middle of school!'
The teens participating in this study attended high schools with designated smoking areas, referred to by each student population as the ‘smoke pit'. For those students entering these schools from elementary and middle schools with completely smoke-free environments, the impact of seeing peers smoking with permission on campus appeared to surprise them:
I asked when I came here, ‘Why do they have like a big smoke pit right in the middle of the school?’ It's like, ‘What's this?'
Even students who smoke indicated that they did not expect to be able to smoke on school property:
When I came to ... school and I saw the smoke pit ... I was like, ‘That's kind of odd—I'm allowed to smoke here, right in the middle of school!’ ... it was kind of pointless, but whatever, I just lit up a smoke and started smoking it.
Older students, both non-smokers and smokers, expressed some concern regarding the impact on younger students of having a designated smoking area on school grounds, particularly the ‘optics’ of the location and supervision practices. The stated policy at both high schools is that the smoke pit is reserved for students in Grades 10, 11 and 12 only. However, this restriction appeared to be meaningless in our participants’ experiences:
Like the kids who come out of grade 8 and go into grade 9 at ... school and they have this little skywalk and the smoke pit is right below that, and they see like all the people out there smoking and stuff and so I guess they think it's OK—because it's at school....I see kids out there that are in like grade 9 and stuff and they're smoking just because they see other people are doing it and there's teachers out there supervising, making sure that they're in the lines and within the boundaries and they kind of see that as ok, and if they can't smoke at home, they'll smoke at school with their friends. So, I don't think that it's good that ... High actually has that.
... the teachers don't really come out and go, "OK only the grade 10–12 can smoke. There are kids from grade 9 out there.
Highly visible smoke pits within school property, and supervising staff who appeared to overlook the stated grade restrictions, counters the expectations of students. Further, it appears to encourage the perception that that neither the school nor the staff take student smoking too seriously.
Student control/tobacco control: ‘If there wasn't a smoke pit, there'd be kids out on the street doing drugs'
During our conversations with teens, reference was repeatedly made to the problems surrounding smokers leaving school property to smoke. The assumption was that these were ‘bad kids'; that they would ‘cause a big disturbance', ‘get into trouble’ or ‘do drugs’ if they could not smoke in school. No evidence was provided to back these claims, and it did not seem ironic to them that they were themselves smokers who used the smoking pit, but would not consider resorting to any of these activities if the area was removed:
The teachers and principals would rather have us, like, because there's a lot of bad people go to our school and a lot of people with smokes, so they'd rather have the smokers come to school and like stand in the smoke pit and socialize with their friends instead of getting into trouble if they're going and standing out on the street smoking.Like I can see what the smokers are saying. Like they'd be mad if the smoke pit went out because it's something that they're used to, and you know, if it got taken away, it would leave them more mad at the school system, because it would kind of help them out in one way. Instead of, like say if there wasn't a smoke pit, there would be kids out on the street doing drugs and having a cigarette and feel more free that way. Instead, there is a smoke pit and they're actually smoking and going to class. So, it kinda takes them away from the drugs.
Some smokers, however, remain unconcerned about the apparent logistical issues and are quite content to take advantage of the situation:
So, I'm kinda in high school and kinda saw everyone else smokes ... and you know, it just didn't seem like such a big thing. Yeah, they taught us, you know, how bad it is for you, but it wasn't a big thing.10 min break in classes I go and have a cigarette ... no problem.
School indifference/individual concern: ‘There's nothing really pushing them to quit'
Participants appeared unable to identify any quit or reduction programmes that they could readily access, either in their school or in their community. When pushed, they provided us with vague suggestions. However, the scathing comments within which these suggestions were couched infers that they could not be taken as being something that the student would seriously consider:
I guess you could go to counselling at school, I'm sure they've got magazines and stuff.There are places that you can call in ... but you just don't know what to expect. There may be money involved and I am going to have to sit there and answer 100 questions.
When asked about the programmes they had received at school, participants were similarly negative. While not being able to clearly articulate their expectations for an ideal school programme, their comments suggest that their experiences with existing programmes have been lukewarm at best:
Basically, when someone gets the information (from school), the first thing in their head is, ‘Ok, I want to quit, I want to quit, I want to quit!’ but after that they kinda like forget about it because there's nothing really pushing them to quit.I know we had one program ... like I had a few friends who tried it and said, ‘You know it's not really, it doesn't do much, but if you go you get some free stuff kind of thing'.
Perhaps, the most damning comment came from a girl who told us that ‘They're (school) only doing drugs (programs) ... it's like they don't care about smoking'. However, another girl who had attended a high school with a strong tobacco control policy enthusiastically shared her experience of one of the strategies used there, which had clearly had an impact on her:
When I went to high school in Las Vegas, in the stalls in the girls’ bathroom, like sit down, there's a mirror and then a skeleton face on it. It's like, ‘See—now look at yourself—if you don't start quitting now'... It helped stop smoking ... it was on every single stall.
Although participants could not readily tell us about programmes or how to access them, several could cite teachers who they would approach for help in quitting:
I'd go to Mr ..., or Mrs ... —they're the people who have most effect on me in the school. They're the people who are telling you what to do and when to do it ... and I think they'd have good advice.Like, Mr ... said I could go to him about anything. He kinda bugs me about my smoking every once in a while.
It is interesting to note that participants generically referred to staff members who they saw tolerating policy infringements as ‘teachers', although students who had been in the school for 4 years were surely familiar with them. However, when talking of where they would go for help or support in quitting, they not only named the teacher—complete with title—but also provided us with reasons why they would feel comfortable in approaching these people.
Quitting/isolation: ‘I'll run by the smoke pit and have a couple of puffs from one of my friends'
In this study, we did not find that participants who were non-smokers, or who had been non-smokers when they entered these schools, reported a perceived increase in their susceptibility to smoking. Instead, we found that by far the biggest impact of having a designated smoking area within school property was on those smoking students attempting to quit or reduce:
If they had the no smoking policy at school, then I probably wouldn't smoke now that I'm trying to quit ... but when I switch my classes, I'll run by the smoke pit and have a couple of puffs from one of my friends. But yeah, if they didn't have that then I wouldn't be getting that couple of puffs.If there was no smoking at school it would be harder so I wouldn't really smoke as much, it would be easier for me to stop because there wouldn't be everyone around smoking just outside and everywhere.
For one participant, quitting meant social isolation. Research into teen smoking suggests that the social connectedness experienced by a group of smoking friends carries great importance for each member of that group [17, 19, 20]. That social network, therefore, is likely to exert quite a considerable pull, and the tenuous nature of her success is reflected in her comment:
I haven't gone out to the smoke pit, because I'm trying to quit ... but most of my friends are there.
Another participant, who had tried to sit with his smoking friends during his unsuccessful quit attempt had neatly rationalized his return to smoking:
If you sat around second hand smoke, it would do the same thing to your lungs, so what's it really matter—you may as well smoke, right?
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionConflict of interest statementAcknowledgementsReferences |
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When teens pull together the information, observations and experiences afforded them by the school setting, they create a framework of understanding that not only guides further decision and action but also shapes the constant flow of new information, observations and experiences. We found evidence of this in the rationalizations offered by students struggling to quit, yet accommodating the very situation that was assisting their failure. These students had incorporated the largely administrative concerns of management and discipline into their own personal interpretations, resulting in their downplaying of their own rights and concerns regarding health. At the same time, teens committed to smoking recognized and used any weaknesses inherent in either policy content or enforcement. This finding concurs with those of Turner and Gordon [16].
There is a conflict between the high school tobacco control policies and the need to keep smoking students in school which must be addressed. It must also be acknowledged that the duties involved in implementing, monitoring and enforcing high school tobacco control policy can be interpreted as another instance of yet more demands made upon overstretched schools already struggling with reduced resources. However, the fact remains that tobacco contains acknowledged carcinogens and smoking is prohibited in adult workplaces for good reason. Exposing students to this risk in school, quite apart from the additional problems of ease of access [21], normalizing [22, 23] and social sourcing [24], is clearly unacceptable. Previous research has shown that smoke-free environments decrease the likelihood that teens will be smokers by 25% and increase the odds that they will stop smoking if they have started experimenting [25].
The argument has been made elsewhere that tobacco control policy is a school and not an individual issue [15, 26]. While agreeing with the philosophical rationale behind that argument, based on our conversations with high school students, we would warn against the oversimplification of the underlying assumption of collaborative intent. Obvious examples are the huge discrepancies we observed between espoused tobacco control policy and practices, where the desire to control tobacco use was subsumed by the need to control student discipline.
The success enjoyed by the Florida's ‘Truth’ Campaign suggests that for teens, a sense of personal control is a central component to successful cessation [27, 28]. In our research, we found that even moderately large high schools can assume an institutional anonymity for the individual student against which they can feel both powerless and insignificant in their attempts to quit or reduce their smoking. We found that in these attempts, most students do not look to the school for support, but to friends and to the caring individuals on staff with whom they had formed a relationship, while others assume that they must tackle smoking cessation or control on their own. Existing programmes, either in the school or the community do not appear to be considered as useful tools.
Research on adolescent smokers contains some hopeful signs for cessation: most young smokers want to quit [29, 30]. Unfortunately, research also shows that few adolescents find formal cessation programmes acceptable and ever fewer would be willing to participate in school-based programmes [30, 31], concurring with our own findings.
Teens, even those who smoke, do not expect to be able to light up at school. Although a few may be all too ready to take advantage of this situation, many more remain quietly appalled that administrative expediency appears to trump health. Based on our findings, we would strongly recommend that designated smoking areas in high schools be eliminated. We also recommend that students be included in both the creation and implementation of school tobacco policy, harnessing the strong idealization of teens and their concerns regarding not only their own perceptions of personal empowerment and health but also their protective attitudes towards younger students.
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Conflict of interest statement |
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None declared.
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Acknowledgements |
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This research was funded by the Canadian Tobacco Control Research Initiative and the BC Cancer Foundation.
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References |
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