Investigating a School-Based Approach to Tobacco Control: The Hampton High School Initiative

July 2004

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Table of Contents

• Executive Summary
• Acknowledgements
• 1.0 Research Overview
  • 1.1 Introduction
  • 1.2 Research Phases
    • 1.2.1 Phase I
    • 1.2.2 Phase II
    • 1.2.3 Phase III
    • 1.2.4 Phase IV
    • 1.2.5 Phase V
    • 1.2.6 Phase VI
• 2.0 Key Informant Interviews
  • 2.1 Introduction
  • 2.2 Methodology
  • 2.3 Results 1: Planning and Development
    • 2.3.1 Key Issues and Concerns
    • 2.3.2 Supportive Influences and Interactions
    • 2.3.3 Tobacco Control Objectives and Preliminary Planning Activities
    • 2.3.4 Challenges Associated with Initial Planning rocesses Debating Approaches for Implementation of Smoke -free Policy Responding to Student Questions about Smoking Locations Persevering with the Intensity of Timeline Commitment and Efforts Obtaining External Support for the Initiative
  • 2.4 Results 2: Overview of Initiative
    • 2.4.1 Pre-planning: Hold Tobacco-Free Committee Meetings
    • 2.4.2 Pre-planning: Set Goals
    • 2.4.3 Pre-planning: Design Timeline
    • 2.4.4 Pre-planning: Document the Process
    • 2.4.5 Planning: Survey
    • 2.4.6 Planning: Develop Policy; Establish Consequences
    • 2.4.7 Planning: Organize Supervision
    • 2.4.8 Planning: Make Announcements to Students and Parents
    • 2.4.9 Implementation: Redesign Smoking Area into Green/Recreational Space
    • 2.4.10 Implementation: Enforce Policy
    • 2.4.11 Implementation: Include Peer Support
    • 2.4.12 Implementation: Liaison with Local Merchants
    • 2.4.13 Implementation: Form Partnerships and Ad hoc Committees
    • 2.4.14 Implementation: Involve Residents
  • 2.5 Results 3: Documented Outcomes and Perceived Impact
    • 2.5.1 Relationships between Students and School Staff
    • 2.5.2 Satisfaction of Parents and Community
    • 2.5.3 Academic Performance
    • 2.5.4 Perceptions of the Environment
    • 2.5.5 Health Behaviours and Attitudes
    • 2.5.6 Student Smoking Behaviour and Disciplinary Tracking
    • 2.5.7 Lessons Learned
  • 2.6 Results 4: Current Challenges and Proposed Responses
    • 2.6.1 Smoking Behaviours
    • 2.6.2 Middle School Smokers
    • 2.6.3 Community Use of School Facilities
    • 2.6.4 Maintaining Momentum
    • 2.6.5 Family and Community Influences
  • 2.7 Summary of Key Informant Responses
• 3.0 School Smoking Profile
  • 3.1 Introduction
  • 3.2 Methodology
  • 3.3 Results
    • 3.3.1 Student Smoking Behaviours
    • 3.3.2 Exposure to Smoking: Peers, Family Members, Work Place
    • 3.3.3 Sources for Obtaining Cigarettes
    • 3.3.4 Cessation Attempts
    • 3.3.5 Comparison with Provincial SSP Results
  • 3.4 Summary of the School Smoking Profile Findings
• 4.0 Initiative Outcomes: Student Perspective
  • 4.1 Introduction
  • 4.2 Method
    • 4.2.1 Participants
    • 4.2.2 Survey Process
    • 4.2.3 Analyses
  • 4.3 Results
    • 4.3.1 Smoking Prevalence
    • 4.3.2 Smoking Behaviours and School Connectedness
    • 4.3.3 Awareness of Tobacco Control Activities
    • 4.3.4 Perceived Impact of the Initiative
    • 4.3.5 Identified Areas of Change
      • Attitudes of Smokers
      • Attitudes of Non-smokers
      • School Safety
      • Students' Attitudes about Health
      • Student Smoking Behaviours
      • School Performance and Behaviour
      • School-based Activities and Teacher-student Relationships
    • 4.3.6 Beneficial Aspects of the Hampton High School Initiative
  • 4.4 Summary of Student Perspectives
• 5.0 Initiative Outcomes: Staff Perspectives
  • 5.1 Introduction
  • 5.2 Method
    • 5.2.1 Participants
    • 5.2.2 Survey Process
    • 5.2.3 Analyses
  • 5.3 Results
    • 5.3.1 Perceived Impact of the Initiative
    • 5.3.2 Identified Areas of Change
      • Attitudes of Student Smokers
      • Attitudes of Student Non-smokers
      • School Safety
      • Students' Attitudes about their School Work
      • Student Smoking Behaviours
      • Student Participation in School Programs and Activities
      • Teacher-student Relationships
      • Staff Relationships
      • Student Behaviours in Class or During Free Time
    • 5.3.3 Beneficial Aspects of the Hampton High School Initiative
    • 5.3.4 Current Concerns and Next Steps
      • Sustaining Tobacco Control Efforts
      • Student Smoking Behaviours
      • Smoking during Community Events
  • 5.4 Summary of Staff Perspectives
• 6.0 Discussion of Key Findings
  • 6.1 Introduction
  • 6.2 Objective 1: Clarification of Issues and Concerns
  • 6.3 Objective 2: Development and Implementation of the Initiative
  • 6.4 Objective 3: Outcomes and Areas of Impact
    • 6.4.1 Current Smoking Status
    • 6.4.2 Tobacco Control Awareness
    • 6.4.3 Health Attitudes and Behaviours
    • 6.4.4 Smoke-free Policy
    • 6.4.5 School Connectedness
    • 6.4.6 School Relationships
    • 6.4.7 Community Interactions
  • 6.5 Objective 4: Current Challenges and Proposed Responses
  • 6.6 Objective 5: Lessons Learned
    • 6.6.1 Establish Clear Goals and Timelines
    • 6.6.2 Document Key Insights From the Process
    • 6.6.3 Design and Carry Out School-based Surveys
    • 6.6.4 Establish Smoke-free Boundaries at the Outset
    • 6.6.5 Plan for Outdoor Monitoring
    • 6.6.6 Limit Opportunities to Smoke
    • 6.6.7 Inform School and Community Regarding Upcoming Changes in Policy
    • 6.6.8 Use Positive Phrasing
    • 6.6.9 Create Smoke-free Meeting Places
    • 6.6.10 Provide Support to Student Smokers
    • 6.6.11 Promote Tobacco Control Through Emphasis on Healthy Living
    • 6.6.12 Facilitate Increased Student Involvement
    • 6.6.13 Attend to Middle School Smokers
  • 6.7 Research Limitations
  • 6.8 Concluding Reflections

Executive Summary

The Hampton High School initiative has served as a model for enhancement of health behaviours and tobacco control in New Brunswick . Three years following the initial implementation of this project, Health Canada in conjunction with the University of New Brunswick , completed a research investigation designed to assist in formally documenting the Hampton High School experience, and the key elements and processes that contributed to the reported outcomes of this initiative. The majority of data for this study was gathered from research participants who had direct experience with or who were part of the implementation of this initiative.

The preliminary development of the initiative was prompted by staff and student concerns regarding environmental tobacco smoke and a renewed commitment to fulfil the mission statement of the school- "to provide a safe and nurturing environment." Critical aspects of the initiative that were reported across participant groups included the role of teacher champions in leading the strategy, the sustained commitment of students and staff, the creation of smoke-free social spaces, and the provision of positive support for student smokers in reducing tobacco use.

At the time of data-gathering, rates of daily smoking among students at Hampton High School were slightly below the documented average rates of other secondary schools in New Brunswick . In this regard, there was general agreement among all research participants that efforts to reduce smoking had contributed to helping students not to smoke and to enhancing the overall health of smokers and non-smokers.

With respect to tobacco control awareness, almost twice as many students at Hampton High School were aware of specific support available to them to reduce tobacco use as compared to other New Brunswick high schools. Teacher participants also affirmed the role of the tobacco control strategy in extending health knowledge among students, and for encouraging increased student openness to discussing a wide range of health-related behaviours and lifestyle issues. The implementation of the school smoke-free policy was also viewed as beneficial for limiting the number of students regularly congregating in smoking areas, and for reducing incidences of oppositional or disruptive behaviours on school property.

With respect to school connectedness, teacher participants provided feedback that the initiative had contributed to strengthening teacher-student relationships and for enhancing the overall learning climate at the school. Consistent with this observation, data collected among students indicated a greater degree of school connectedness in regards to academic study and participation in structured activities among those who had made decisions not to smoke.

The overall results of this research effort provided a range of participant perspectives and feedback supporting the positive outcomes of this initiative. In particular, the lessons learned arising from the initial implementation of the Hampton High School project may provide valuable insights for other educational jurisdictions that plan to undertake similar school-based tobacco control policies or activities.

Acknowledgements

The completion of this final report has involved the collaborative efforts from Health Canada , Hampton High School , and the Research Team. We would like to express our appreciation to the individuals who participated directly in the research project.

Hampton High School and Community Partners

Clary Wilbur
Peter Guravich
Rosemary Southard
Stephanie Lawson
Susan Rourke
Entire staff of Hampton High School
Lynn Ann Duffley: community partner
Marlien McKay: community partner
Mike Bishop
Rod Campbell

Research Team

Dr. Bill Morrison, University of New Brunswick
Dr. Cynthia Doucet, University of New Brunswick
Dr. Steve Manske, University of Waterloo

Health Canada Contact:

Julie Greene

1.0 Research Overview

1.1 Introduction

The Hampton High School project has served as a model for enhancement of health behaviours and tobacco control in New Brunswick. The members of the school-based implementation team have presented their initiative at both national and international health conferences. Informal reports by this team have supported the positive outcomes of this endeavour on tobacco control and on a range of other educational areas related to school climate, learning attitudes and community relationships.

The proposed research project was designed to assist in formally documenting the Hampton High School project experience, and the key elements and processes that interacted and potentially contributed to reported outcomes of this initiative. The intent of this research effort was also to provide practical lessons learned for other educational contexts and to identify key areas for subsequent research and innovation for tobacco control. More specifically, the objectives of this investigation were to:

• Clarify the specific needs, issues and concerns that led to the development of the Hampton High School tobacco control initiative
• Document the implementation of the program activities undertaken as part of the school-based tobacco control project
• Examine the areas of potential impact resulting from this tobacco control project including: health attitudes and behaviours, school policy, academic performance and attitudes, and relationships both within and beyond the school context
• Identify the specific challenges associated with the current implementation of this initiative, and potential responses for addressing these areas of concern.
• Consider the key lessons learned that might assist in the development and implementation of similar pilot projects in other educational settings

1.2 Research Phases

The implemented research program was composed of six research phases. A summary of the various data-gathering stages is presented highlighting the key activities associated with each research effort.

1.2.1 Phase I

The preliminary phase entailed establishment of a working relationship with Project Authorities. An initial conference meeting was held to review the objectives of the research investigation and the proposed methodology. Feedback from this meeting was incorporated into the work plan, and a revised research design methodology was submitted to project authorities.

1.2.2 Phase II

Initial data-gathering activities involved the completion of a document review of key materials, correspondence, and planning protocols related to the development and implementation of Hampton High School's tobacco control project. Other information related to school health and smoking policies was also examined. This initial review assisted in guiding the identification of key questions and additional areas of inquiry that were applied in subsequent research phases.

1.2.3 Phase III

The third phase entailed completion of key informant interviews with participants who played a significant role in the development or implementation of tobacco control activities at Hampton High School. This aspect of the research provided important insights related to the preliminary planning processes and key components the initiative. Key informants also reported valuable feedback with respect to the lessons learned and specific outcomes associated with Hampton High School's commitment to become smoke free.

1.2.4 Phase IV

For this phase students at Hampton High School completed the School Smoking Profile (SSP). The results from this research effort were used as a means for assessing current smoking behaviours and attitudes of students. The results of the SSP were examined in conjunction with previous data-gathering outcomes associated with other regional addiction surveys.

1.2.5 Phase V

The fifth phase included students' and teachers' completion of the Tobacco Control Follow-up Surveys. The intent of these data-gathering efforts was to gain insight into participants' perspectives regarding the impact of the implemented tobacco control activities on various areas of school life, including school policy and routines, student-teacher relationships, academic performance and attitudes, personal health and safety, and overall school satisfaction.

1.2.6 Phase VI

The final step of this investigation entailed examination of the outcomes resulting from the previous research phases. For this aspect of the research, exploration of identified themes and trends arising from the various data-gathering activities was undertaken. This phase culminated in the completion of the final written report together with documented findings to address the objectives of the study.

The final report provides a detailed description of the methodology employed, as well as a presentation of the key outcomes associated with these research activities. The subsequent four sections summarize the results of the key informant interviews, including research descriptions relating to preliminary development of tobacco control activities, overview of the initiative, documented outcomes and perceived impact, as well as current challenges and responses. Next, the outcomes of the School Smoking Profile and the results of the Tobacco Control Follow-up Surveys for student and teachers are presented. The final section of this report includes a research summary along with potential implications for future development and research of school-based tobacco control activities.

2.0 Key Informant Interviews

2.1 Introduction

The purpose of this initial research activity was to document the key planning processes, the major aspect of the initiative, and preliminary outcomes associated with its implementation. For this research effort, data were gathered from key informants who had direct experience with the Hampton High School tobacco control initiative.

2.2 Methodology

For this research phase ten key informant interviews were undertaken to document the Hampton High School tobacco control initiative. Participants included current and past members of the implementation committee, school administration, teaching staff, and local community. The informants were selected because of their background experiences related to the planning and implementation of tobacco control activities at Hampton High School. Areas of inquiry that were investigated included:

• Key issues, needs, and concerns that led to the tobacco control pilot project
• Planned activities and program components of the initiative, and the nature of their implementation
• Quality of school life variables, including health and academic indicators that might have been impacted by the initiative
• Key program and relationship processes that defined and shaped the implementation of this tobacco control strategy and that may have contributed to its outcomes.

A detailed interview protocol was developed and submitted to project authorities for their review and feedback. Upon acceptance of this deliverable, key informants were contacted for potential participation. A letter outlining the intent of the research project and the nature of their participation was forwarded to them for their consideration. Once consent was obtained, interviews were completed with research participants. Interviews took approximately 60 and 90 minutes to complete with various research participants.

Completed individual interview protocols were merged to provide a single data set. Content and descriptive analyses were subsequently employed to identify potential themes and trends arising from the data. At the close of this phase, a research progress update was submitted to project authorities.

2.3 Results 1: Planning and Development

2.3.1 Key Issues and Concerns

Prior to the implementation of the tobacco-control initiative, smoking was permitted in a designated area at Hampton High School. Participants reported that at this point in time staff members expressed ongoing concern about environmental tobacco smoke and its effects. Previous attempts to move the smoking area had not been successful in reducing smoking on the school campus. According to several participants, some New Brunswick schools had attempted to initiate smoke-free policies without implementing concurrent support activities for student smokers, and consequently had not been successful in sustaining a smoke-free school environment.

Respondents described the smoking area at Hampton High School as an arena that fostered oppositional and disruptive behaviour among students. For some students it provided a source of belonging; however, negative peer associations were also formed in this school area. According to participants, the staff collectively felt strongly that it was their "moral responsibility" to oppose smoking, and to cease to provide an area for it. Two years prior to the development of specific tobacco control activities a charismatic and beloved teacher had died from cancer. From several participants' perspectives, this loss had contributed to increased awareness of the effects of tobacco and a sense of readiness among staff, partners, and administration to address the need for change. In particular, staff and community members became more enveloped in the implicit meaning and implications of their school mission statement to provide a "safe and nurturing environment" for students. The importance of taking action was underscored by the fact that many grade 9 students were often easily drawn into the smoking area upon arriving at the school, thus adding to an increasing number of school smokers.

In the Fall of 2000 an informal in-school survey circulated among teachers identified smoking as a priority concern. Follow-up meetings ensued among teachers and administration to discuss smoking issues, culminating in the formation of a school-based committee to develop plans for tobacco control. Support for this effort was also received from the school parent committee and District Education Council.

2.3.2 Supportive Influences and Interactions

Initial development of tobacco control activities was undertaken in the spring and summer of 2001. In conjunction with the committee, other community and agency partners also became either directly involved or offered support to the preliminary plans of the school committee. Many of these partners were active in sharing information or personal insights related to reducing tobacco use among students. Respondents identified a range of key knowledge brokers including: Public Health nurses, Ridgewood Addiction Service workers, Canadian Cancer Society representatives, the New Brunswick Lung Association and the New Brunswick Anti-Tobacco Coalition. Several of the partners identified were viewed as being important sources of encouragement for empowering staff members to address needed areas of change and to reinforce the development of the notion that smoking was not an acceptable social activity or behaviour for students.

2.3.3 Tobacco Control Objectives and Preliminary Planning Activities

As a result of early planning efforts, the tobacco control committee formulated a range of key objectives. These included:

• Removal of the smoking area: Eliminate exposure of staff and students to second-hand smoke; Implement school-wide smoke-free policies.
• Reduction of tobacco use among students: Decrease number of grade nines who begin smoking; Limit opportunities to smoke; Encourage students to quit smoking and provide supportive cessation activities; Provide support to students who desire to remain smoke-free; Increase awareness of health risks.
• Transformation of the smoking area into an inviting green space: Create an environment where all students could enjoy the outside area.

At the outset of preliminary planning activities committee members devoted significant time to identification of specific goals and timelines. They were also cognisant that their proposed activities would require both policy changes and development of supportive measures for encouraging students to reduce their smoking or to remain smoke-free. In this regard, tobacco control plans and changes to school rules would need to be firmly in place prior to any announcement or promotion in the school or community.

Plans for creation of the proposed green space that would replace the smoking area were confirmed in late spring of 2001. Announcements regarding the changes in smoking policy and the upcoming tobacco control activities were made to students, parents, and the community in June 2001. Invitations were extended to both school and community members to assist with the development of the green space project planned for August 2001. Letters were also drafted during the same time period to inform local merchants that Hampton High School was implementing a smoke-free policy, and to request their support for not selling tobacco to youth under 19 years of age.

Additional planning activities also included establishment of boundaries that would become non-smoking areas for the school. The initial area considered extended well beyond the school zone, comprising properties adjacent to the campus. The smoking policy was also elaborated to include a specified approach for enforcement of rules, beginning with warnings and progressing to more intensive measures put in place by the school administration.

Restructuring the timetable schedule was also undertaken to eliminate afternoon breaks during which times in the past students had had opportunity to smoke. Peer educators were also trained with the intent of becoming directly involved in health promotion activities and delivery of smoking cessation programs for the upcoming school year when the policy would be fully enacted. Respondents indicated that staff committed a great deal of personal time and resources in supporting these preliminary tobacco control plans and actions. Resources were also given by members of the community. These included: use of machinery for outdoor renovations, donation of benches, plants, supplies, finances, and volunteer time. Other health service partners also assisted with peer helper training, focusing on smoking prevention and cessation.

2.3.4 Challenges Associated with Initial Planning Processes

Respondents were asked to identify specific challenges that were encountered during initial planning activities. They were also invited to describe their responses for dealing with these areas of identified concern. Four specific challenges were noted:

Debating Approaches for Implementation of Smoke -free Policy

The committee spent considerable time discussing whether to implement an immediate ban on smoking or to pursue a gradual transition of policy over time. As deliberations progressed, there appeared to be widespread consensus across committee members and partners outside the school that the smoke-free policy should be immediate and apply to all students at the school. The notion of condoning smoking and pursuing tobacco control activities at the same time was perceived by some respondents to be incongruent with the health values that helped to shape the initial planning activities. Overall, a strong commitment was evident for a singular implementation of the smoke-free policy for the school.

Responding to Student Questions about Smoking Locations

With the implementation of the policy it was anticipated that some student smokers would ask teachers where they could smoke beyond smoke-free boundaries. According to some respondents, staff members were concerned about how they would answer students. If they identified a specific location, teachers perceived that they would be condoning or even encouraging tobacco use. Teachers' final decision was to refrain from answering these questions and reminding students of the intent of the new policy.

Persevering with the Intensity of Timeline Commitment and Efforts

The initial commitment of time and effort to prepare for announcing and moving forward with the initiative required regular meetings and completion of tasks in the spring and summer of 2001. The scope of the project was described by many as intensive and sometimes "overwhelming." Several respondents highlighted that the demonstrated passion and commitment of teacher champions were critical in sustaining the determination and participation of others during the completion of readiness activities.

Obtaining External Support for the Initiative

According to various participants, some individuals and partners beyond the school context were uncertain whether the adopted plans would be well-received by students and that decisions whether conceivably have to be rescinded. These participants also indicated that the solidarity of the school team and its unified influence played a critical role in addressing these communicated concerns and in eliciting support for the initiative from the wider school district and community.

2.4 Results 2: Overview of Initiative

In addition to discussing the major objectives and preliminary planning activities of the initiative, respondents were invited also to describe in detail the key aspects of their tobacco control strategy. Based on their descriptions, 14 individual program components or actions were identified and organized according to three time periods:

Pre-planning: April - May

Hold tobacco-free committee meetings
Set goals
Design timeline
Document the process

Planning: April - June

Survey
Develop policy; establish consequences
Organize supervision
Make announcements to students and parents

Implementation: August - Ongoing

Redesign smoking area into green/recreational space
Enforce policy
Include peer support
Liaison with local merchants
Form partnerships and ad hoc committees
Involve residents

The profiles that follow present summary descriptions of the various aspects of Hampton High School tobacco control initiative. Areas of elaboration undertaken for each component profile included:

• Goal
• Timeframe
• Description
• Nature of Teacher/Administration Involvement
• Other Key Supports, Partnerships, Influences
• Rationale / Principles of Practice
• Challenges Associated with Action
• How Challenges were Addressed
• Present Status
• Method of Evaluation
• Impact
• Lessons Learned to Date
• Envisioned Future Developments

2.4.1 Pre-planning: Hold Tobacco-Free Committee Meetings

• Timeframe: April/01 - ongoing

• Goal: Enable a planning forum

• Description:
  • Struck a committee
  • Met weekly to see how to address the issue and develop plans to stop sanctioning smoking on school propert

• Nature of Teacher/Administration Involvement:
  • Met weekly

• Other Key Supports, Partnerships, Influences:
  • Recognized that the initiative would need to involve students, parents, and community
  • Ridgewood and Canadian Cancer Society were active and nearby, and provided direction

• Rationale / Principles of Practice:
  • Stop grade nines from starting smoking
  • Meetings were guided by mission statement of school to provide a healthy environment

• Challenges:
  • Some concern that there would be labelling of smokers
  • Some partners reluctant to support

• How Challenges were Addressed:
  • Used positive language
  • Demonstrated support to convince members that plan could succeed

• Impact:
  • Committee is confident that elimination of smoking area has resulted in improved health and safety

• Present Status:
  • Ongoing

• Lessons Learned to Date:
  • Success will feed itself, and result in increased solidarity and determination

2.4.2 Pre-planning: Set Goals

• Timeframe: April/01 - May/01

• Goal: To have a focus, to manage the task.

• Description:
  • Set goals:
    1. Help kids reduce or quit smoking
    2. Remove exposure to second hand smoke
    3. Reduce the number of grade 9 students who begin to smoke
    4. Eliminate a school-sanctioned site for smoking

• Nature of Teacher/Administration Involvement:
  • Tobacco-free committee consists of approximately 20 individuals, representing teachers and administration

• Other Key Supports, Partnerships, Influences:
  • Canadian Cancer Society
  • Incoming/returning School Administration
  • PSSC

• Rationale / Principles of Practice:
  • Take action while there is support

• Challenges Associated with Action:
  • Canadian Cancer Society emphasized the benefits of a comprehensive plan
  • A phase-out approach was considered
  • There was some discussion on relocating instead of eliminating the smoking area

• How Challenges were Addressed:
  • Outlined capacity
  • Kept planning
  • Planned to offer green space in return for removing smoking area

• Present Status:
  • Goals are still revised yearly by revisiting objectives

• Method of Evaluation:
  • Committee examines whether goals are being addressed

• Lessons Learned to Date:
  • Planning is essential to success
  • Setting goals motivates and focuses the planning committee

• Envisioned Future Developments:
  • Set goals that facilitate our own involvement, lessen dependence on partners

2.4.3 Pre-planning: Design Timeline

• Timeframe: April/01 - May/01

• Goal: To strategically plan steps so that all was in place for June and September

• Description:
  • Planned for steps: policy development, announcements, outdoor changes
  • Anticipated the need to monitor boundaries

• Nature of Teacher/Administration Involvement:
  • Part of weekly Tobacco-free committee meetings

• Other Key Supports, Partnerships, Influences:
  • Parent supports
  • Canadian Cancer Society

• Rationale / Principles of Practice:
  • Allow time for preplanning

• Implementation Strategy:
  • Have everything in place when it needs to be for the student handbook and students' return to school

• Lessons Learned to Date:
  • Timelines assist in acknowledging productivity and effectiveness

2.4.4 Pre-planning: Document the Process

• Timeframe: April 01- ongoing

• Goal: Document process and progress

• Description:
  • Keep documents: notes, minutes, programs from assemblies
  • Maintain records: counts of behaviours, student testimonies

• Rationale / Principles of Practice:
  • Be able to inform other schools

• Challenges:
  • Lost data, software changes

• Present Status:
  • SOS 2 binder is available.
  • Continue to keep records

• Impact:
  • Information can be presented to inform others of processes, challenges, and successes

• Envisioned Future Developments:
  • Revision of SOS 2 binder

2.4.5 Planning: Survey

• Timeframe: April/01, coincide with student council voting

• Goal: Survey students to obtain a baseline Poll staff to demonstrate to others that support is there

• Description:
  • Poll staff one question: Do you support the tobacco-free initiative?
  • Survey students with questions on a variety of areas of inquiry

• Lessons Learned to Date:
  • Surveys provide evidence of support, change, and impact

2.4.6 Planning: Develop Policy; Establish Consequences

• Timeframe: April/01 - May/01, ready for June/01

• Goal: Improve health, eliminate exposure to environmental tobacco smoke

• Description:
  • The policy was written for publication
  • Consequences of policy violation were determined
  • Warning letters were developed for violations
  • Boundaries were plotted maps were printed

• Nature of Teacher/Administration Involvement:
  • Committee of 17 developed policy and determined consequences

• Other Key Supports, Partnerships, Influences:
  • Consulted with partners, other schools, and superintendent's office, and decided to use the following format: a proactive warning letter, followed by one warning letter, before enacting in-school suspension

• Rationale / Principles of Practice:
  • Recognized that it needed to be formal, with impact and consequences

• Implementation Strategy:
  • Planned to announce in June that in September, a smoke-free policy would be in place

• Challenges Associated with Implementation:
  • Needed approval by district to implement a policy that had suspension as a consequence
• Required care in choosing words and phrases

• How Challenges were Addressed:
  • Development of appropriate consequences: Concluded that an out-of-school

suspension would be too harsh, given that there were students would will test limits. These students are often at risk in other areas, and do not benefit from being out of school. The policy was amended to include a warning response to a first offence, followed by in-school suspensions for the subsequent offence.

• Lessons Learned to Date:
• Do not allow students to be penalized because of an addiction
• Set large boundaries early in the process, as it is easier than trying to extend the boundaries afterwards

2.4.7 Planning: Organize Supervision

• Timeframe: April/01 - Sept/01

• Goals: Develop a method of monitoring school boundaries
  Be vigilant and consistent

• Implementation Strategy:
  • Increased amount of outdoor supervision duty
  • Boundaries were plotted boundaries and maps were printed

• Nature of Teacher/Administration Involvement:
  • Each of the 17 teachers was given 10 minutes/day additional supervision duty time

• Rationale / Principles of Practice:
  • Recognized need to be vigilant

• Challenges Associated with Implementation:
  • Existing schedule allowed opportunity for smoking

• How Challenges were Addressed:
  • Restructured school day to remove the afternoon break

• Lessons Learned to Date:
  • When mapping boundaries, include areas where students may congregate to smoke

2.4.8 Planning: Make Announcements to Students and Parents

• Timeframe: June /01

• Goal: Announce that in the Fall semester that the campus would be smoke-free

• Description:
  • Held assemblies with each grade, explained why the campus would be smoke-free
  • Communicated with parents via talk-mail, held an evening meeting
  • Placed announcements in local newspaper
  • Held a public meeting where concerns could be expressed.

• Other Key Supports, Partnerships, Influences:
  • Canadian Cancer Society
  • Ridgewood Addiction Services
  • Guest speaker (laryngectomee)

• Implementation Strategy:
  • Increase awareness of the dangers of smoking so it is uppermost in students' minds

• Challenges Associated with Implementation:
  • Public meeting was not well attended

• How Challenges were Addressed:
  • Presentations were, however, well received

2.4.9 Implementation: Redesign Smoking Area into Green/Recreational Space

• Timeframe: Planning in the Spring, implementation in August/01

• Goal: Change smoking area into a space that is healthy and inviting for everyone
  Use it to convince students that campus will remain smoke-free

• Description:
  • Redesigned the former smoking area into a place for recreation and relaxation
  • Teachers, parents, students and friends came for two days in August and landscaped the area

• Implementation Strategy:
  • Planned when the work would happen; selected two days in August; landscaped and planted

• Rationale/Principles of Practice:
  • The smoking area was a defined space. To rid the school of it, it had to be transformed, preferably into something that was inviting for all.

• Challenges Associated with Implementation:
  • Some funding challenges
  • The courtyard needs upkeep and maintenance

• How Challenges were Addressed:
  • Contributions were in place from the district, PSSC, contractors, and the Town
  • People came voluntarily

• Impact:
  • It is a well-used space. On warmer days there are always students there. As the plants grow, the space becomes even more inviting
  • The removal of the smoking area conveyed determination of staff, and established the permanency of the smoke-free environment
  • Enabled us to give something back to the students
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• Lessons Learned to Date:
  • Students need and appreciate space for leisure and recreation

• Envisioned Future Developments:
  • Continue to develop green area (add plants, and benches) and refine the sand of the volleyball court to be more comfortable
  • Use space for ceremonies and hold more activities there

2.4.10 Implementation: Enforce Policy

• Timeframe: Sept/01 - ongoing

• Goal: Monitor and supervise the smoke-free zone and enforce smoke-free policy. Reprimand smokers who break rules

• Implementation Strategy:
  • Increased amount of outdoor duty and monitored bathrooms with periodic visits
  • Enforced policy:
    1. Proactive warnings: identified potential troublemakers, and sent notices home to their parents
    2. Warning letters
    3. In-school suspension

• Nature of Teacher/Administration Involvement:
  • Each of the 17 teachers was given 10 minutes/day additional duty time

• Rationale / Principles of Practice:
  • Recognized need to be vigilant

• Challenges Associated with Implementation:
  • There was potential for students to argue that they were only with smokers, but were not smoking themselves
  • Trouble spot formed just outside a boundary where students gathered to smoke

• How Challenges were Addressed:
  • If students were with a group where smoking occurred, the whole group was considered in violation
  • Added extra duty to monitor trouble spot and tried to discourage congregations
  • Restructured school day to remove the afternoon break

• Lessons Learned to Date:
  • More supervision time will be required.
  • Large boundaries need to be established to make it difficult to go and smoke

2.4.11 Implementation: Include Peer Support

• Timeframe: September/01 - ongoing

• Goal: Have an active working group of students that offer smoking cessation programs for smokers

• Description:
  • Recruited peer helpers in the Spring. Peer helpers presented to middle schools, and led cessation groups. The smoking cessation program was a central component of the initiative.

• Nature of Teacher/Administration Involvement:
  • Advisory role, supporting students

• Student Participation/Accessibility:
  • Students from all grade levels who wanted to support the tobacco-free initiative, including smokers, former smokers, and non-smokers

• Key Supports, Partnerships, Influences:
  • Ridgewood Addiction Services
  • Canadian Cancer Society

• Implementation Strategy:
  • Training: regional training for peer helpers
  • Offering of cessation group programs with peer helper support
  • Peer helpers received training in presentation skills, and upgraded their knowledge of tobacco effects and cessation processes

• Challenges Associated with Implementation:
  • Some non-smoking peer leaders of smoking cessation groups were not credible to smokers
  • Finding a right time to offer the cessation group, avoiding the noon-hour

• How Challenges were Addressed:
  • Teacher-led models were used
  • Students were released from classes
  • Staggered timing so they were not always missing the same class
  • Encouraged peer educators to be confident and take risks to carry their message

• Impact
  • Peer helpers communicated with other youth with sincerity; they were accepting of differences and challenges

• Present Status:
  • Sustainable

• Lessons Learned to Date:
  • Extend the peer helper role with middle school smokers. Some will come to high school as already established smokers.
  • This component needs administrative and teacher support. Regular meetings are required to continue the campaign.

• Envisioned Future Developments:
  • Peer helpers should be used more often for other projects

2.4.12 Implementation: Liaison with Local Merchants

• Timeframe: August of every year

• Goal: Remind local businesses that it is illegal to sell tobacco to those under 19

• Description:
  • A letter was sent to local merchants

• Other Key Supports, Partnerships, Influences:
  • Parents reacted against one store who advertised a sale on cigarettes

• Impact:
  • Students say it is more difficult to purchase cigarettes
  • Increased dialogue between school and businesses

• Lessons Learned to Date:
  • A polite reminder of the law is usually sufficient
  • It is useful to stay in touch with them and give them a voice when problems arise

2.4.13 Implementation: Form Partnerships and Ad hoc Committees

• Timeframe: June/01 - ongoing

• Goal: Disperse and share workload by forming partnerships and ad hoc committees
  Make use of those who have expertise

• Description:
  • Met and consulted with community, concerned citizens, and health agencies
  • Developed partnerships with Canadian Cancer Society, Ridgewood, PSSC
  • Formed ad hoc committees to deal with complaints or issues that arose

• Implementation Strategy:
  • Invited those nearby who were active in tobacco control
  • Discussed with partners how to become involved

• Rationale:
  • Share expertise, reinforce idea that Hampton High School was doing the right thing

• Challenges Associated with Implementation:
  • Support from partners took the form of constructive feedback identifying both strengths and areas for continued development in current tobacco control activities

• How Challenges were Addressed:
  • Persistence by teachers

• Impact on:
  • Initiative gained credibility

• Lessons Learned to Date:
  • Tobacco is an addiction and is often associated with other risk behaviours

• Envisioned Future Developments:
  • Consultation continues through the school committee

2.4.14 Implementation: Involve Residents

• Timeframe: September/01

• Goal: Anticipate concerns of residents
  Respond to residents who were impacted by new congregations of student smokers

• Description:
  • Have groups (student smokers, bus drivers, and neighbours) designate representatives
  • Bring representatives together to share perspectives and discuss concerns

• Other Key Supports, Partnerships, Influences:
  • Town Manager and Canadian Cancer Society as mediators

• Rationale / Principles of Practice:
  • Develop recommendations and proposals for action
  • Dialogue conveys an understanding of the process and the commitment of becoming smoke-free

• Implementation Strategy:
  • Bus drivers were invited to voice their concerns
  • Held several meetings with local residents
  • RCMP attended since they were concerned about the calls they were receiving

• Challenges Associated with Implementation:
  • Upset residents
  • Traffic concerns

• How Challenges were Addressed:
  • Representative students and residents met and shared their perspectives
  • Increased supervision of problem area
  • Re-routed bus traffic

• Impact
  • Residents were more at ease after talking with the students
  • Increased dialogue between students and neighbours
  • Students were more cognisant of the impact of their actions, and reprimanded each other for being disrespectful by littering or blocking the road
  • There was not always a solution, but there was always a better understanding

• Lessons Learned to Date:
  • Establish and maintain contact with neighbours

2.5 Results 3: Documented Outcomes and Perceived Impact

In addition to describing the key aspects of the initiative, respondents were invited to discuss the key outcomes and impact of the overall initiative. For this aspect of the research project, six areas of inquiry were investigated.

• Relationships between students and school staff
• Satisfaction of parents and community
• Academic performance
• Perceptions of the environment
• Health behaviours and attitudes
• Student smoking behaviour and disciplinary tracking

A summary of key informants' feedback relating to the outcomes of the initiative is presented in the subsequent sections.

2.5.1 Relationships between Students and School Staff

According to respondents, both teaching staff and school administration have demonstrated a sensitive and caring attitude towards student smokers over the course of the implementation of the tobacco control initiative. Increased dialogue between students and teachers regarding health issues has also been evident.

2.5.2 Satisfaction of Parents and Community

Several key informants noted that there has been also widespread support for the initiative among students, parents and community members. Even when challenges to policy were encountered, opportunities for information sharing and open dialogue were effective in facilitating greater mutual understanding and identification of practical steps for resolving issues.

2.5.3 Academic Performance

Key informants indicated that they were uncertain as to the impact of the overall initiative on students' academic performance. They also stated that initial goals of the tobacco control strategy were focussed primarily on reducing tobacco use among students and on establishing a smoke-free school environment.

2.5.4 Perceptions of the Environment

According to participants, the removal of the smoking area had been associated with decreased opportunities for students to engage in high-risk behaviours. More specifically, the absence of a smoking area was reported to have contributed to a healthier environment in which there were fewer fights, decreased vandalism, greater respect among students, and increased student interest in school activities.

2.5.5 Health Behaviours and Attitudes

Some respondents noted that students had shown a greater interest in other health behaviours since implementation of the initiative. For example, there had been a reported increase in the number of students involved with fitness classes at the school, and feedback that healthier food choices had been made available at the cafeteria. Some high school students also had the opportunity to speak with younger students about the importance of making healthy choices.

2.5.6 Student Smoking Behaviour and Disciplinary Tracking

According to school-based data gathering, informal counts of students congregating to smoke decreased from over 200 to less than 70 since the first year of the initiative. Disciplinary tracking statistics associated with violation of the smoke-free policy also indicated a decrease over the past three years. Table 1 provides a summary of these results.

Table 1: Warning and Suspension Statistics

	Sept 01 - Jun 02	Sept 02 - Jun 03	Sept 03- June 04
Student enrolment	830	812	753
Warning Letter	82	44	33
First Suspension	25	11	9
Second Suspension	10	9	3
Third Suspension	4	4	0

2.5.7 Lessons Learned

Respondents identified a range of key lessons learned associated with the planning and implementation of policy changes and tobacco control activities at Hampton High School. These insights include both practical operational considerations as well as proactive measures that assisted in supporting the move toward a smoke-free environment.

Establish Clear Goals and Timelines

Given the responsibilities of committee members, specific meeting times should be established on a regular basis for completion of preliminary planning activities. In particular, time should be devoted, early on, to the identification of clear goals, timelines, and corresponding actions. Such preliminary efforts are crucial for ensuring effective co-ordination of planned activities and for providing a sense of accomplishment for both committee members and other stakeholders.

Document Key Insights from the Process

Intentional efforts should be undertaken to record the details of the implementation and outcomes of the school-based tobacco control initiative. In particular, documentation of key insights from committee members during the process of project development and implementation provides a valuable source of information and lessons learned for other school communities that may undertake similar types of initiatives.

Design and Carry out School-based Surveys

The completion of structured surveys and informal data-gathering exercises provide effective means for understanding smoking attitudes and behaviours in specific school contexts. Such data-collection efforts may also be beneficial for increasing awareness among students and school staff regarding key health issues and concerns related to tobacco control. The outcomes of administered school-based surveys may also be used as a baseline from which to measure the effectiveness of implemented promotion or intervention activities.

Establish Smoke-free Boundaries at the Outset

The establishment of the smoke-free boundaries should precede the announcement of the policy to students and the community. Changes to smoke-free boundaries following announcement of the policy may pose considerable administrative challenges for maintaining the integrity of existing expectations and the consistency of supervision practices.

Plan for Outdoor Monitoring

Larger boundaries often require greater outdoor duty time. Preliminary planning should take into account the actual time required to carry out supervision activities and school personnel should be notified well in advance of anticipated changes to existing duty schedules. Contributions from all staff members may assist in lowering the additional efforts required to implement the planned schedule of supervision.

Limit Opportunities to Smoke

Restructuring daily school or classroom schedules may assist in minimizing the amount of unstructured break times during which students may choose to smoke.. Smoke-free boundaries should also be sufficiently large to prevent immediate access to smoking location for students during break times.

Inform School and Community Regarding Upcoming Changes in Policy

Students should be informed early regarding the specific smoke-free boundaries and how supervision and accountability of such policies will be maintained. Similarly, neighbours close by the school should be invited to collaborate in discussions pertaining to the initial development and adoption of smoke free boundaries and policy changes.

Use Positive Phrasing

In describing tobacco control policy or activities, avoid use of terms such as "ban" that emphasize the loss of choices or privileges. In contrast, promote positive aspects of change with phrases such as "creating a tobacco-free school" that highlight healthy decision-making and the opportunity to set new personal directions or goals.

Create Smoke-free Meeting Places

The removal of smoking areas should be accompanied by the development of smoke-free social spaces that are attractive to both student smokers and non-smokers. These meeting places may incorporate organized leisure and recreational activities for students, as well as provide informal opportunities for development of positive peer relationships.

Provide Support to Student Smokers

The implementation of school smoke-free policy should be supported by concurrent activities and approaches that convey support and respect for student smokers. As students are reminded of specific rules or are prompted to comply with smoke-free policy, interactions with them should include expressions of concern for their personal well-being as well as discussion of available options for reducing tobacco use.

Promote Tobacco Control through Emphasis on Healthy Living

In conjunction with the school mission statement, tobacco control plans were undertaken in the context of an emphasis on promotion of healthy lifestyles and relationships. For example, the courtyard plans were aimed, not only at reducing tobacco use, but also for encouraging positive friendship development, physical exercise, and for enhancing a sense of belonging for all students.

Facilitate Increased Student Involvement

Key informants underscored the importance of encouraging credible peer leaders to become involved with school-based health promotion and smoking cessation activities. Such student leadership was viewed as a critical consideration for engaging other students' participation in planned tobacco control efforts.

Attend to Middle School Smokers

The planning of a smoke-free policy and activities was viewed as relevant for both Hampton High School students and those who would attend the school in the future. In this regard, preliminary planning should also consider outreach plans to feeder schools through use of peer-helper strategies that support and reinforce the development of healthy attitudes and behaviours in students even before they arrive at the secondary school level.

2.6 Results 4: Current Challenges and Proposed Responses

Respondents were asked to describe specific challenges they were currently facing in addressing tobacco control in the school setting. Four key challenges were identified, and potential responses for addressing each area of concern were also examined.

2.6.1 Smoking Behaviours

Although the number of students observed congregating to smoke outside the school had decreased, there was still a group of students who continued to smoke beyond the established school boundaries. These students were identified as those who had been smoking over longer periods of time, and who potentially had a greater dependence on tobacco.

Addressing challenge:

Several key informants emphasized the importance of continuing with ongoing supervision practices to support smoke-free zones within school boundaries. They also asserted that teachers on supervision should make efforts to maintain rapport with student smokers and be open to discussing with them potential ways to reduce tobacco use.

2.6.2 Middle School Smokers

Another identified area of concern included the reality that many middle school students come to Hampton High School as already established daily smokers.

Addressing challenge

Many key informants indicated that the existing partnerships between the feeder schools and high school should continue and be strengthened. In particular, the tobacco control presentations provided by peer helpers from Hampton High School to middle school students were viewed as very beneficial for promotion of healthy decision-making.

2.6.3 Community Use of School Facilities

Although the school has implemented a smoke-free policy, such rules are not always respected on weekends or in the evenings when community-based activities are organized.

Addressing challenge:

The importance of informing community partners regarding the smoke-free policy was underscored. Supervision of community activities outside of school hours was identified as a concern for monitoring compliance with the policy. Some informants reported that intentional efforts should be undertaken to facilitate increased community awareness regarding the policy and its implications for planned activities held after-school hours.

2.6.4 Maintaining Momentum

The initiative is currently in its third year of implementation. Key informants reported that there has been strong support among teachers and administration for both tobacco control policies and activities. Several key informants stressed the importance of maintaining the interest and commitment of school personnel in continuing to meet the challenges associated with remaining smoke-free at Hampton High School.

Addressing challenge

Several respondents highlighted the importance of encouraging shared responsibility and leadership for initiative activities among school personnel. Some respondents also suggested that celebrations of success at the school level and beyond were helpful for maintaining both enthusiasm and energy for participation in planned activities. Overall, having key school champions who demonstrate passion for the objectives of the initiative and who motivate others to become involved, was viewed as critical for sustaining tobacco control efforts at the school.

2.6.5 Family and Community Influences

The major emphases of the initiative have focused on the school setting. Even though students have a level of support at school for not smoking or for reducing tobacco use, many are still faced with home and part-time work situations where tobacco use is an accepted activity.

Addressing Challenge

Various key informants indicated that specific time and effort should be given to the development of formalized strategies for impacting families and the wider community on issues related to student smoking and smoke-free environments. From their perspectives, efforts to reduce smoking among students is not solely a school-based area of concern or responsibility, but one that requires meaningful participation from all community members and families.

2.7 Summary of Key Informant Responses

Prior to the implementation of the tobacco-control initiative smoking was permitted at Hampton High School. Respondents described the smoking area as an arena that fostered oppositional and disruptive behaviour among students. According to participants, the staff collectively felt strongly that it was their "moral responsibility" to oppose smoking, and to cease to provide an area for it. The need for change was also underscored by the reality of the loss of a staff member to cancer, the importance of fulfilling the school mission statement to provide a "safe and nurturing environment," and the fact that many grade 9 students were drawn into the smoking area upon their arrival at the school.

Initial development of tobacco control activities was undertaken by a school-based tobacco-free committee in the spring and summer of 2001. In conjunction with the committee, other partners also became either directly involved or offered support to the preliminary planning efforts. Several of the partners identified were viewed as being important sources of encouragement for empowering staff members to address needed areas of change and to reinforce the development of the notion that smoking was not an acceptable social activity or behaviour for students.

As a result of early planning efforts, the tobacco control committee formulated a range of key objectives that included removal of the smoking area, implementation of smoke-free policies, reduction of tobacco use among students, and creation of smoke-free meeting places for students. Plans for creation of a proposed green space, which would replace the smoking area, were confirmed in late Spring of 2001. Announcements regarding the changes in smoking policy and the upcoming tobacco control activities were made to students, parents, and the community in June 2001. Additional planning activities included also the establishment of smoke-free school boundaries, the development of specific steps for enforcement of rules, the restructuring of the timetable schedule to minimize opportunities for students to smoke during breaks, and the organization of peer-educator training to facilitate subsequent student involvement in health promotion activities and smoking cessation programs.

Preliminary planning activities resulted in a strong commitment by the school-based tobacco-free committee to pursue an immediate, non-gradual implementation of a smoke-free policy at Hampton High School. Several respondents asserted that the demonstrated passion and commitment of teacher champions were critical in sustaining the determination and participation of others during the completion of readiness activities. It was also noted that the solidarity of the school team and its unified influence played a critical role in addressing concerns and in eliciting support for the initiative from the wider school district and community.

In addition to discussing the major objectives and preliminary planning activities of the initiative, respondents also were invited to describe in detail the key aspects of their tobacco control strategy. Based on their descriptions, 14 individual program components or actions were identified and organized according to three time periods: 1. Pre-planning (April - May): Hold tobacco-free committee meetings; Set goals; Design timeline; Document the process. 2. Planning (April - June): Survey; Develop policy and establish consequences; Organize supervision; Make announcements to students and parents. 3. Implementation (August - Ongoing): Redesign smoking area into green/recreational space; Enforce policy; Include peer support; Liaison with local merchants; Form partnerships and ad hoc committees; Involve residents.

With respect to reported outcomes associated with the initiative, several key informants reported that informal counts of students congregating to smoke have decreased from approximately 200 to 70 students. Similarly, violations to the smoke-free school policy have also decreased during the past three years of the initiative. In addition, participants indicated that the removal of the smoking area has also limited the development of disruptive and oppositional behaviour that was previously associated with the former smoking zone. Respondents noted also that students have demonstrated a greater interest in discussing and committing to other health-related behaviours such as exercising, as well as to making healthier food choices .

The overall initiative has received positive support from the community and has contributed to ongoing dialogue about tobacco control beyond the school context. According to respondents, the tobacco control activities undertaken at Hampton High School have fostered also an increased understanding among students and school personnel regarding the challenges associated with reducing smoking. In conjunction with the preceding outcomes, key informants also identified a range of key lessons learned related to the planning and action phase of the tobacco control initiative. Their insights included both practical operational considerations as well as proactive measures that assisted in supporting Hampton High School's move towards becoming smoke-free.

In terms of current challenges, respondents highlighted five areas of concern. These included: continued student smoking beyond smoke-free boundaries, grade nine students who are already established smokers, persistent violations of smoke-free policies during community or recreational events at the school, the reality that many students continue to be faced with environments that condone smoking within the family and community contexts, and the need to maintain the momentum of the initiative. Key informants offered a range of potential responses for addressing these areas of identified challenge including: continuing with supervision practices to support smoke-free zones, using peer-led tobacco control presentations to promote healthy decision-making among middle school students, encouraging shared responsibility and leadership for initiative activities among school personnel, and developing formalized strategies for impacting families and the wider community on issues related to student smoking and smoke-free policies. Many participants indicated also that such proposed actions should be considered in subsequent tobacco control planning at Hampton High School.

3.0 School Smoking Profile

3.1 Introduction

The School Smoking Profile (SSP) was used as a means for assessing current smoking behaviours and attitudes of students at Hampton High School. For this aspect of the research the results of the SSP were examined in conjunction with the outcomes of similar data-gathering efforts undertaken in other New Brunswick jurisdictions.

3.2 Methodology

The SSP was used as the main research instrument for this section of the project. Data-collection efforts were co-ordinated between the research team at the University of New Brunswick and the school administration.

Information letters were distributed to parents by mail ten business days prior to administration of the SSP. All information letters included an explanation of the study, the nature of students' participation, and an invitation to become involved in the study. Informed written consent was obtained from students prior to the completion of this data-gathering aspect of the project.

Approximately 81% of students from the total school enrolment consented to participate in this research activity. The questionnaire was completed during a first period morning class in April 2004. Questionnaires were distributed by teachers and later collected by members of the research team. Administration of this instrument took between 10 and 20 minutes. During the data-gathering period four research personnel were available on-site to assist teachers and students in the completion of this survey exercise.

Upon completion of the SSP, collected individual survey protocols were sealed in envelopes and forwarded to the Health Behaviour Research Group at the University of Waterloo for subsequent analysis. In May, the SSP report outlining the findings of this research effort was submitted to project authorities. The following sections highlight some of the key findings from the SSP report that relate to student smoking behaviours and attitudes at Hampton High School. The specific areas of analysis considered are as follows:

• Student Smoking Behaviours
• Exposure to Smoking: Peers, Family Members, and Work Place
• Sources for Obtaining Cigarettes
• Cessation Attempts

3.3 Results

3.3.1 Student Smoking Behaviours

The graphs below (Figure 1) summarize the percentage of students who smoke by grade and by gender. For these graphs a daily smoker is defined as a person who currently smokes cigarettes every day, and an occasional smoker is defined as a person who currently smokes cigarettes, but not every day. Daily smoking ranged from 11% to 16% across genders and grades. These rates were slightly lower than the average SSP rates of daily smoking (12% to 19%) calculated for other schools in New Brunswick. In contrast, the prevalence of occasional smokers was between 9% and 13% for the same student groups.

Figure 1: Student Smoking Rates

Seventy-four percent of student smokers indicated that they smoked off school property, whereas 47% reported smoking on school property during the day. Most students who smoked at Hampton High School noted that they often smoked with friends or student peers. Forty-eight percent of student smokers also reported that they often smoked alone. With respect to when students used tobacco, participants indicated that that they "often" smoked:

• on the weekend - 66%
• in the evening - 53%
• after school - 51%
• during the school day - 53%
• before school - 46%

The majority of students at Hampton High School (88%) affirmed that the school has a clear set of rules and consequences related to smoking on school property. In addition, 83% of students noted that they were supportive of the establishment of smoke-free public places.

3.3.2 Exposure to Smoking: Peers, Family Members, Work Place

All students were asked, "How many of your 5 closest friends smoke cigarettes?" Smokers were far more likely than non-smokers to report that they had friends who smoked. Seventy-one percent of non-smokers indicated that none of their five closest friends smoked cigarettes, whereas 47% of daily smokers identified that all five of their closest friends smoked (Table 2).

Table 2: Smoking Behaviour of Closest Friends

How many of your 5 closest friends smoke cigarettes?	Percentage of Students Responding
	Daily Smokers	Occasional Smokers	Non-Smokers
0	4	14	71
1	5	26	16
2	8	30	7
3	17	14	3
4	19	11	2
5	47	5	1

Students were also asked if their father, mother, or older sibling(s) smoked. For this area of inquiry, smokers were more likely than non-smokers to have an immediate family member who smoked (Table 3). At Hampton High School 45% of students included in this survey reported that they had a job outside of school; 28% of these students reported exposure to smoking on the job.

Table 3: Smoking Behaviour of Family Members

Family Member Smokes	Percentage of Students Responding
	Daily Smokers	Occasional Smokers	Non-Smokers
Father	47	37	23
Mother	49	31	19
Older Sibling(s)	49	28	18

3.3.3 Sources for Obtaining Cigarettes

Most students at Hampton High School are under the age of 19. Despite the fact that provincial law prohibits the sale of cigarettes to anyone under the age of 19, many students reported that they were able to buy cigarettes and in most cases they were not asked their age. In the past month 53% of smokers stated that they were not asked their age when buying cigarettes, another 15% were asked less than half the time. Only 10% were always or almost always asked their age when buying cigarettes. Table 4 provides a summary of the methods employed by student smokers for obtaining cigarettes. For those students who buy their own cigarettes, over two-thirds reported purchasing them at local convenience stores or gas stations.

Table 4: How Students who Smoke Obtain their Cigarettes

How Students Usually Get Their Cigarettes	% responding
Buy them	48
Someone else buys them	22
Friends	23
Home	8

3.3.4 Cessation Attempts

The majority of student smokers (60%) reported that they had tried to quit smoking at least once during the past year. When asked about their plans to quit smoking, many student smokers - 66% of females and 51% of males - planned to quit, but were not sure when. Another 20% of females and 31% of males planned to quit within a week to a year. Of those who smoked 14% of females and 18% of males had no plans to quit.

Students were also asked about support for those who wished to quit smoking. When they were asked if there was help available at their school, 84% said help was available, 2% said there was no help available and 14% were not sure. Twenty-five percent of smokers indicated that they would be open to participating in a cessation program at the school.

3.3.5 Comparison with Provincial SSP Results

In 2003, the University of Waterloo produced an interim profile report highlighting the SSP results of 16 other schools from New Brunswick. The outcomes from this report regarding student smoking rates across grades and genders overlapped considerably with those reported for the Hampton High School SSP findings. For the combined schools profile, the percentage of students smoking on a daily basis ranged from 12% to 19%, whereas for Hampton High School, they ranged from 11% to 16%. In addition, trends in exposure to smoking, cessation attempts, and methods for obtaining cigarettes, were similar for Hampton High School findings and the combined school outcomes. In contrast, noted differences were evident on an area of inquiry related to health promotion. For the combined school outcomes, 44% of students were able to identify specific help available to them at school for quitting smoking, whereas at Hampton High School, over 80% of the students indicated that school-based resources for cessation were accessible to them.

Comparisons were also noted between the SSP findings and previous data-gathering efforts undertaken by regional Addiction Services at Hampton High School in 1999-2000. Combined prevalence rates, taking into account both occasional and daily smoking, were quite similar. Comparisons for other areas of inquiry related to smoking behaviours and attitudes were difficult to ascertain given differences in the type and structure of questionnaires employed for the two research projects.

3.4 Summary of the School Smoking Profile Findings

The SSP was used as a means for assessing current smoking behaviours and attitudes of students at Hampton High School. The specific areas of analysis considered were: student smoking behaviours; exposure to smoking; sources for obtaining cigarettes; and cessation attempts.

With respect to student smoking behaviours, daily tobacco use ranged from 11% to 16% across genders and grades. These rates were slightly lower than the average SSP rates of daily smoking (12% to 19%) calculated for other schools in New Brunswick. In contrast, the prevalence of occasional smokers was between 9% and 13% for the same student groups. Approximately three-quarters of student smokers reported that they smoked off school property, whereas slightly less than half reported smoking within school boundaries. Although some students reported smoking at school, the majority of students affirmed that the school has a clear smoke-free policy and that they support specific efforts to establish smoke-free public places.

Student smokers also reported having a greater number of close friends who moked compared to non-smokers. Similarly, smokers were more likely than non-smokers to have an immediate family member who smoked. According to student smokers, over half indicated that they were not asked their age when buying cigarettes. The most commonly reported means for obtaining cigarettes was to purchase them personally at local convenience stores.

With respect to quit attempts, over half of student smokers reported that they had tried to quit at least once during the past year. The majority of students surveyed at Hampton High School indicated that support for smoking cessation was available in the school context.

The outcomes for student smoking rates on the SSP for Hampton High School overlap considerably with SSP data gathered from other New Brunswick schools. In contrast, students' awareness of school-based resources for cessation was notably higher among Hampton High School students than it was among other New Brunswick students who completed the SSP.

4.0 Initiative Outcomes: Student Perspective

4.1 Introduction

The purpose of this research phase was to elicit feedback from students regarding their present smoking attitudes and behaviours, and their perceptions relating to the outcomes of the Hampton High School tobacco control initiative. Student perspectives from all grade levels were examined with particular consideration given to grade 12 students who had been in attendance at Hampton High School prior to initiation of this school-based intervention project.

4.2 Method

4.2.1 Participants

All students attending Hampton High School were provided with the opportunity to participate in this research. Letters explaining the purpose of the research project were forwarded by mail to parents and invited the potential participation of their children. Signed consent was also obtained from students prior to their involvement in this data-gathering exercise. Overall, 607 students agreed to become participants in this research effort. Table 4 provides a summary of student participants by grades and genders.

Table 4: Number of Student Participants for the Tobacco Control Follow-up Survey

Grade	Gender		Total
	Number of Males	Number of Females
9	85	87	172
10	74	62	136
11	83	81	164
12	73	62	135
Total	315	292	607

4.2.2 Survey Process

Initial consultations were held with Hampton High School personnel and the advisory committee to identify key areas of inquiry to be included in development of the Tobacco Control Follow-up Survey (TCFS). The finalized instrument included both open-ended and rating scale questions. For this measure, the major areas of inquiry included:

• Smoking prevalence (Grades 9-12)
• Smoking behaviours and school connectedness (Grades 9-12)
• Awareness of tobacco-control activities (Grades 9-12)
• Perceived impact of initiative (Grades 9-12)
• Identified areas of change (Grade 12)

The final question segment of the instrument was designed specifically for grade 12 students who had been at the school both prior to and during the initial implementation of the initiative. The questions for this final section were open-ended and required students to complete descriptive responses regarding various areas of potential change in school life associated with tobacco control activities at Hampton High School.

The questionnaire was completed during a first period morning class in April 2004. Questionnaires were distributed by teachers and later collected by members of the research team. Administration of this instrument took between 10 and 20 minutes. During the data-gathering period, four research personnel were available on-site to assist teachers and students in the completion of this survey exercise.

4.2.3 Analyses

The rating-scale and forced-choice responses from the completed questionnaires were coded and entered into an SPSS database. Descriptive and chi-square analyses were subsequently applied to identify key trends and outcomes arising from the data. A level of p<.05 was used to determine statistical significance for the various analyses. Responses to open-ended questions were transcribed and content analysis was then employed to identify potential theme categories arising from the collected data for the various areas of inquiry.

4.3 Results

4.3.1 Smoking Prevalence

Seventy-seven percent of males and 81% of females identified themselves as current non-smokers. With respect to initial experimentation with smoking cigarettes, approximately half of the student sample indicated that they had tried smoking. Figure 2 provides a summary of students' responses regarding their present smoking status.

Figure 2: Present Smoking Status

4.3.2 Smoking Behaviours and School Connectedness

Chi-square analyses were used to examine the relationship of smoking status to various aspects of school-related activity. With respect to significant results noted between smoking status and time spent on homework, over one-half of smokers indicated that they do less than one hour of homework over the course of a week. In contrast, over 60% of non-smokers reported that they exceeded one hour in homework on a weekly basis.

Similarly, smoking status was also related to involvement in after-school programs. Forty-four percent of non-smokers indicated some level of involvement in structured extracurricular activities. In contrast, only 26% of smokers reported current participation in after-school programming. Overall, smokers reported less involvement in structured routines related to school-based activities or academics.

Smoking and non-smoking students were also asked to identify categories of agreement for various statements relating to quality of relationships with administration, teachers, and peers. Chi-square analysis did not reveal any significant associations between smoking status and the nature of specific school relationships.

4.3.3 Awareness of Tobacco Control Activities

Students were asked to indicate when they became aware of specific policies and activities to reduce smoking at Hampton High School. Over 60% of grade nine students reported that they had been cognisant of tobacco-control activities at Hampton High School prior to their attendance at the school. Similarly, the majority of the remaining students in grades 10 through 12 indicated that they had been aware of smoking-reduction activities early on in their high school experience (Table 5). Levels of awareness across grades were consistent with the period of implementation of the Hampton High School initiative. The majority of students also indicated awareness of recent promotional efforts that had been undertaken during the past 12 months to assist students to reduce or stop smoking.

Table 5: Becoming Aware of Tobacco Control Efforts at Hampton High School

Grade	Before I arrived at Hampton	Grade 9	Grade 10	Grade 11	Grade 12	I do not know
9	60.6%	27.1%				12.3%
10	43.6%	40.6%	6.8%			9.0%
11	17.1%	59.8%	14.0%	3.0%		6.1%
12	7.4%	26.5%	49.3%	8.8%	0.7%	7.3%

4.3.4 Perceived Impact of the Initiative

Students were asked to rate a series of statements related to the perceived impact of the Hampton High School initiative on various aspects of school life including health behaviours, scholastic interest and performance, school relationships, and compliance with school rules. In general, ratings were consistent across grade levels for the various areas of potential impact.

Over half the participants agreed that efforts to reduce smoking at Hampton High School had assisted in helping students not to smoke (58%) and had contributed to enhancing the health of both smokers and non-smokers (57%). In addition, 20% of students affirmed that tobacco control activities had assisted at least one of their peers to reduce their smoking. Relatively few participants (4%) noted that school-based smoking reduction activities had played a role in assisting family members to stop smoking. In summary, students' outcomes suggested positive changes in the health status and behavioural choices of students.

With respect to interest in school activities and academic performance, the majority of student participants (between 86% and 90%) did not indicate any specific changes in their scholastic attitudes or behaviours as a result of the tobacco control initiative. Some students did, however, agree that the Hampton High School initiative had been helpful in creating an overall school setting that was more conducive to fostering learning experiences (24%).

In terms of school relationships, the majority of students (81%) did not identify specific increases in tension between smokers and non-smokers as a result of specific tobacco-control activities or policy. In contrast, 50% of students agreed that the implementation of the new smoke-free policy did change the location where students currently smoked.

4.3.5 Identified Areas of Change

Participants in grade 12 were the only students present at Hampton High School prior to the implementation of the tobacco control initiative. For this area of inquiry, students were asked to elaborate in written form on what positive or negative changes they had observed in various areas of school life since the adoption of smoke-free policies and activities. The specific categories on which students were invited to comment were as follows:

• Attitudes of Smokers
• Attitudes of Non-smokers
• School Safety
• Students' Attitudes about Health
• Students' Attitudes about their School Work
• Student Smoking Behaviour
• Student Participation in School Programs and Activities
• Teacher-student Relationships
• Student Behaviour in Class or During Free Time

Table 6 provides a summary of students' responses related to direction of potential change for the preceding areas of school life. These outcomes are organized under three headings: Positive Changes, No Changes, and Negative Changes.

Table 6 : Direction of Change Related to Written Student Feedback

	Number of respondents	% Positive Changes	% No Changes	% Negative Changes
Attitudes of Smokers	94	21	15	64
Attitudes of Non-smokers	93	65	23	12
School Safety	93	35	52	14
Students' attitudes about Health	93	63	26	11
Students' attitudes about their School Work	86	18	75	7
Student Smoking Behaviour	75	56	20	24
Student Participation in School Programs and Activities	84	36	53	11
Teacher-student Relationships	81	35	55	10
Student Behaviour in Class or During Free Time	85	29	58	13

Attitudes of Smokers

Many respondents indicated that initial implementation of smoke-free policies had not been well-received by all student smokers. Several commented that there had been an increase in the level of frustration among many students who regularly used tobacco. In contrast, a smaller percentage of students reported that some of their peers had stopped or had reduced smoking because of the closure of the smoking area.

Attitudes of Non-smokers

The majority of student comments reflected positive changes in the attitudes of non-smokers. Several respondents reported non-smokers were appreciative of the renewed recreational spaces and of the creation of a healthier environment. Several also noted that non-smokers had become more understanding of student smokers and of the challenge of reducing tobacco use. In this regard, some students were identified as playing proactive roles in encouraging others to stop smoking.

School Safety

The majority of students did not identify any specific changes in the level of school safety as a result of the initiative. For those that did indicate positive changes, they reported that social meeting places for students that had become smoke-free were healthier and safer for both smoking and non-smoking students.

Students' Attitudes about Health

Participants associated many positive changes in students' attitudes about health with the implementation of the Hampton High School initiative. Several respondents indicated that development of healthier attitudes had contributed to specific student decisions to reduce or quit smoking and a greater emphasis among students on the importance of making healthy choices. Overall, students were described as being more informed and knowledgeable about the risks and consequences associated with continued tobacco use.

A few participants also indicated that students who used tobacco might continue smoking because they did not perceive that positive changes were possible in their current situations. These respondents underscored the importance of increasing student smokers' level of hope and optimism for pursuing lifestyle changes.

Student Smoking Behaviours

The majority of students reported that there had been reductions in tobacco use among students as a result of the implementation of the Hampton High School initiative. Some respondents also asserted that new students at the school were less likely to begin smoking since the establishment of smoke-free policies and activities.

School Performance and Behaviour

With respect to academic performance, minimal changes in either a positive or negative direction were associated with the implementation of tobacco control activities. Similarly, the majority of respondents did not attribute specific changes in student behaviour during class time or unstructured periods to the Hampton High School initiative.

School-based Activities and Teacher-student Relationships

Over one-third of participants reported that students' interest and participation in school- structured activities had been enhanced since introduction of tobacco control activities. A similar percentage of respondents also highlighted that relationships between students and teachers had been strengthened during the time period of the Hampton High School initiative.

4.3.6 Beneficial Aspects of the Hampton High School Initiative

Respondents were asked to identify the specific aspects of the initiative that had been particularly helpful for creating and sustaining a smoke-free environment at Hampton High School. The three specific areas identified by student participants were:

• Teacher and student commitment to the initiative (40 participants)
• Creation of smoke-free spaces (20 participants)
• Cessation programs or strategies to help students quit smoking (14 participants)

4.4 Summary of Student Perspectives

The purpose of this research phase was to elicit feedback from students regarding their present smoking attitudes and behaviours, and their perceptions relating to the outcomes of the Hampton High School tobacco control initiative. The TCFS was used to investigate five major areas of inquiry: s moking prevalence (Grades 9-12); smoking behaviours and school connectedness (Grades 9-12); awareness of tobacco-control activities (Grades 9-12); perceived impact of the initiative (Grades 9-12); and identified areas of change (Grade 12).

For the TCFS, 77% of males and 81% of females identified themselves as non-smokers. With respect to initial experimentation with smoking cigarettes, approximately half of the student sample indicated that they had tried smoking in the past. In terms of school connectedness, current student smokers reported less involvement in structured routines related to school-based activities or academics.

With regard to awareness of the initiative, over 60% of grade nine students reported that they had been cognisant of tobacco control activities at Hampton High School prior to their attendance at the school. Similarly, the majority of the students in grades 10 through 12 indicated that they had been aware of smoking-reduction activities early on in their high school experience. Approximately half of respondents agreed that the implementation of the new smoke-free policy had changed the location where students currently smoke.

Over half of participants affirmed that efforts to reduce smoking at Hampton High School had assisted in helping students not to smoke, and had contributed to enhancing the health of both smokers and non-smokers. In contrast, the majority of participants did not attribute any specific changes in their scholastic attitudes or behaviours to the tobacco control initiative. A smaller percentage of students (24%), however, did suggest that the initiative had been helpful in creating an overall setting that was more conducive for fostering learning experiences.

Students' qualitative responses suggested that the initial implementation had been frustrating for some student smokers who use tobacco regularly. In contrast, others noted that the creation of smoke-free spaces had assisted various students in reducing their smoking behaviours. Participants also reported that non-smokers were appreciative of the renewed recreational spaces and of the creation of a healthier environment at school. Several respondents indicated that the initiative had assisted students in adopting healthier attitudes and in increasing their knowledge regarding the consequences associated with continued tobacco use.

Over one-third of participants reported that students' interest and participation in school- structured activities had been enhanced since the introduction of tobacco control activities. A similar percentage of respondents also highlighted that relationships between students and teachers had been strengthened during the time period of the Hampton High School initiative.Student participants also identified three specific aspects of the initiative that had been particularly helpful for creating and sustaining a smoke-free environment. These included teacher and student commitment to the initiative, creation of smoke-free spaces, and cessation programs or strategies to help students quit smoking.

5.0 Initiative Outcomes: Staff Perspectives

5.1 Introduction

The intent of this research phase was to elicit feedback from school staff regarding the outcomes of the Hampton High School tobacco control initiative. This research effort was organized as a supplementary data-gathering activity following completion of the Tobacco Control Follow-up Survey with students.

5.2 Method

5.2.1 Participants

All staff members at Hampton High School were invited to participate in this aspect of the research. Signed consent was obtained from participants prior to their involvement in this data-gathering exercise. Overall, 30 teachers and administration personnel agreed to become participants in this research effort.

5.2.2 Survey Process

Initial consultations were held with Hampton High School personnel and the advisory committee to identify key areas of inquiry to be included in development of the staff version of the Tobacco Control Follow-up Survey (TCFS). The finalized instrument included both open-ended and rating scale questions. For this measure, the major areas of inquiry included the p erceived impact of initiative, and identified areas of change.

The questionnaire was completed during an after-school staff meeting in May 2004. Questionnaires were distributed and subsequently collected by a designated member of the school tobacco control committee. Administration of this instrument took between 10 and 20 minutes. Upon completion of this data-gathering exercise the various questionnaires were sealed and forwarded to the research team at the University of New Brunswick.

5.2.3 Analyses

The rating scale and forced-choice responses from the completed questionnaires were coded and entered into an SPSS database. Descriptive and chi-square analyses were subsequently applied to identify key trends and outcomes arising from the data. A level of p<.05 was used to determine statistical significance for the various analyses. Responses to open-ended questions were transcribed and content analysis was then employed to identify potential theme categories for the various areas of inquiry arising from the collected data.

5.3 Results

5.3.1 Perceived Impact of the Initiative

Participants were asked to rate their agreement with a series of statements concerning the impact of the Hampton High School initiative on specific aspects of school life. The various areas for consideration included: health behaviours, scholastic interest and performance, school relationships, and compliance with school rules.

The majority of staff members (90%) agreed that the initiative had shifted the location where students currently smoke. Similarly, participants also agreed that efforts to reduce smoking at Hampton High School had assisted in helping students not to smoke (93%), and had contributed to enhancing the health of both smokers and non-smokers (93%). Over half the respondents also indicated that the initiative had been beneficial for improving students' attitudes towards their academic work (57%) and for enhancing the overall learning climate at the school (57%). Forty-three percent also agreed that tobacco control activities had assisted in developing students' interest in other school activities and clubs. With respect to school policies, 50% of participants also indicated that tobacco control efforts had assisted students in following other school rules.

Over 30% of participants reported that the outcomes of the initiative had been beneficial for enhancing students' attending behaviours and academic performances in specific classes. With respect to school-based relationships, 40% of respondents noted that with the implementation of the initiative there had been a decrease in conflicts among students. The majority of participants (87%) also affirmed that the initiative had not contributed to increased tension among smoking and non-smoking students. Table 7 provides a summary of participants' ratings regarding the various areas of potential impact.

Table 7: Areas of Perceived Impact

Efforts to reduce smoking have ...	Agree	Neither Agree nor Disagree	Disagree
Helped students not to smoke	93	3	4
Increased students' interest in other school clubs and activities	43	53	4
Decreased conflict between students	40	60	0
Improved health of smokers and non-smokers	93	7	0
Increased tension between smokers and non-smokers	0	13	87
Changed where students smoked	90	3	7
Created a school setting where students could learn more	57	40	3
Made a difference in students' attitudes towards their work in my class	57	40	3
Helped students to follow other school rules	50	47	3
Helped students pay more attention in class	33	60	7
Helped students perform better in their daily schoolwork	37	57	6

5.3.2 Identified Areas of Change

Staff members were asked to elaborate in written form on what positive or negative changes they had observed in various areas of school life since the implementation of tobacco control activities and policy at Hampton High School. The specific categories of inquiry investigated and the number of participants who responded to each area are as follows:

• Attitudes of student smokers (15 participants)
• Attitudes of student non-smokers (17 participants)
• School safety (17 participants)
• Students' attitudes about their schoolwork (11 participants)
• Student smoking behaviour (18 participants)
• Student participation in school programs and activities (9 participants)
• Teacher-student relationships (12 participants)
• Staff relationships (14 participants)
• Student behaviour in class or during free time (9 participants)

Attitudes of Student Smokers

Several participants indicated that as a result of the initiative student smokers were more aware of the consequences associated with tobacco use and were more open to exploring options for stopping smoking.

Attitudes of Student Non-smokers

According to respondents, non-smoking students appreciated that the school grounds were currently smoke-free. Other participants also indicated that non-smoking students were more aware of the health risks associated with tobacco use since the implementation of the initiative.

School Safety

Many respondents reported that the removal of the smoking area had contributed to a reduction of oppositional and illegal behaviours at the school (e.g., fighting, vandalism, drug sales). In contrast, the creation of smoke-free meeting places had subsequently resulted in a healthier and safer environment for the full school community.

Students' Attitudes about their School Work

Approximately half the respondents did not perceive any changes in students' attitudes towards their school work as a result of the initiative. In contrast, several participants cited examples of students who were more focused and conscientious since their decision to reduce or quit smoking.

Student Smoking Behaviour s

According to several participants, the number of people congregating to smoke beyond school boundaries has decreased. In particular, fewer grade 9 students have been observed leaving school grounds to smoke with older student peers. A few participants also noted that there are some individual students who continue to challenge the smoke-free policy by smoking in close proximity to the school.

Student Participation in School Programs and Activities

Participants were divided in their responses on student participation in school activities. Almost half of the respondents reported observing no differences. Others indicated that students were more involved in school programs and activities, especially during the noon break.

Teacher-student Relationships

The majority of respondents indicated that the relationships between students and teachers had been strengthened since the implementation of the initiative. In particular, participants noted that students were more cognisant of teachers' genuine interest in improving the health of their students.

Staff Relationships

Participants indicated that staff members are generally supportive of the initiative and of one another's efforts to maintain the smoke-free boundaries. Several respondents noted that implementation of the tobacco control initiative resulted in closer and more collaborative working relationships among staff.

Student Behaviours in Class or During Free Time

Several participants noted that there were few changes in overall student behaviour as a result of the initiative. Other respondents, however, reported that fewer students were late for class, and that student participation in school-based activities had increased.

5.3.3 Beneficial Aspects of the Hampton High School Initiative

Respondents were asked to identify the specific aspects of the initiative that had been particularly helpful for creating and sustaining a smoke-free environment at Hampton High School. Many respondents highlighted the importance of the teacher champions and the role they played in engaging the school community in developing and implementing tobacco control activities and policies. Several respondents mentioned the beneficial outcomes associated with the conversion of the smoking area into a courtyard and green space. Other participants underscored the importance of including cessation programs in conjunction with the implementation of tobacco-free school policy.

5.3.4 Current Concerns and Next Steps

Respondents were asked to describe specific concerns that they were currently facing in addressing tobacco control in the school setting. Three key challenges were identified, and potential responses for addressing each area of concern were also examined.

Sustaining Tobacco Control Efforts

Several respondents expressed concern regarding the capacity to maintain the current momentum in promoting and carrying out the essential activities of the initiative. Various suggestions for sustaining the ongoing tobacco control efforts included: eliciting increased support from community partnerships, holding presentations by guest speakers, creating a newsletter detailing accomplishments of the initiative, and linking tobacco control with other health concerns and objectives in the school context.

Student Smoking Behaviours

Several participants noted that there were students who still continued to smoke beyond the school property. In this regard, respondents emphasized the importance of consistent supervision practices and the need to continue to provide cessation programs for students. A few participants also asserted that addressing the needs of students with tobacco addiction would require a combined community and school-based effort.

Smoking during Community Events

In the evenings and on weekends, sports, recreational events, and meetings were often held at the school. Respondents noted that some adults who attended these after-school events continued to smoke on school property. Several participants asserted the importance of continuing to heighten community members' awareness of the school's smoke-free policy.

5.4 Summary of Staff Perspectives

The intent of this research phase was to elicit feedback from school staff regarding the outcomes of the Hampton High School tobacco control initiative. The staff version of the Tobacco Control Follow-up Survey was used to gather data regarding the perceived impact of the initiative and identified areas of change.

The majority of staff members affirmed that efforts to reduce smoking at Hampton High School had assisted in helping students not to smoke, and had contributed to enhancing the health of both smokers and non-smokers. Approximately half the participants reported that the initiative had been beneficial for improving students' attitudes towards their academic work, and for enhancing the overall learning climate at the school. A similar percentage of staff members also noted that tobacco control efforts had facilitated greater student compliance in following school rules.

According to qualitative responses provided by school staff, both student smokers and non-smokers increased their knowledge of health risks associated with tobacco use since the implementation of the initiative. Many respondents reported that the removal of the smoking area had resulted in reduction of oppositional and illegal behaviours at the school. In contrast, the creation of smoke-free meeting places resulted subsequently in a healthier and safer environment for the full school community.

Participants indicated that staff members had been generally supportive of the initiative and of one another's efforts to maintain the smoke-free school boundaries. Several respondents noted that implementation of the tobacco control initiative has resulted in closer and more collaborative working relationships among both staff and students.

Respondents were asked also to identify the specific aspects of the initiative that had been particularly helpful for creating and sustaining a smoke-free environment at Hampton High School. Three key features of the initiative were noted, including the role of teacher champions in leading the initiative, the conversion of the smoking area into a courtyard and green space, and the inclusion of cessation programs to strengthen the implementation of the tobacco-free policy.

In terms of current challenges, respondents highlighted three areas of concern. These included: continued student smoking beyond smoke-free boundaries, persistent violations of smoke-free policies during community or recreational events at the school, and the need to maintain the momentum of the initiative. Participants described also a range of potential responses for addressing these identified challenges; such as, increasing support from community partnerships, ensuring ongoing availability of cessation programs for students, and increasing awareness of smoke-free policy among community members who attend after-school events.

6.0 Discussion of Key Findings

6.1 Introduction

The proposed research project was designed to assist in formally documenting the Hampton High School project experience, highlighting the key elements and reported outcomes of this initiative. The intent of this research effort was to provide as well practical lessons learned from this tobacco control project that might be helpful for other schools developing or undertaking similar health-related strategies. More specifically, the key research objectives that guided this investigation were:

• Clarify the specific needs, issues and concerns that led to the development of the Hampton High School tobacco control initiative;
• Document the implementation of the program activities undertaken as part of the school-based tobacco control project;
• Examine the areas of potential impact resulting from this tobacco control project including: health attitudes and behaviours, school policy, academic performance and attitudes, and relationships both within and beyond the school context;
• Identify the specific challenges associated with the current implementation of this initiative and potential responses for addressing these areas of concern;
• Consider the key lessons learned that might assist in the development and implementation of similar pilot projects in other educational settings.

The specific findings discussed in the final section of this report reflect the insights provided by research participants who were directly involved with or were part of the Hampton High School experience. For this research study participants were involved in at least one of the following data-gathering phases:

• Key Informant Interviews: members of the school tobacco-free committee, school administration, community partners, and district personnel;
• School Smoking Profile: students in grades 9-12;
• Tobacco Control Follow-up Survey (student version): students in grades 9-12;
• Tobacco Control Follow-up Survey (staff version): administration and teaching staff.

The following sections provide an overview of the key findings of this investigation and are organized according to the major objectives that guided the overall research effort. At the close of these sections specific limitations associated with the research project are outlined and potential developments for future research are discussed.

6.2 Objective 1: Clarification of Issues and Concerns

Clarify the specific needs, issues and concerns that led to the development of the Hampton High School tobacco control initiative

Prior to the implementation of the tobacco-control initiative, smoking was permitted in a designated area at Hampton High School. Key informants reported that at this point in time staff members expressed ongoing concern about environmental tobacco smoke and its effects. Previous attempts to move the smoking area had not been successful in reducing smoking on the school campus. According to several participants, some New Brunswick schools had attempted to initiate smoke-free policies without implementing concurrent support activities for student smokers and consequently had not been successful in sustaining a smoke-free school environment.

Key informants also described the smoking area at Hampton High School as an arena that fostered oppositional and disruptive behaviour among students. For some students it provided a source of belonging; however, negative peer associations were also formed in this school area. According to participants, the staff collectively felt strongly that it was their "moral responsibility" to not condone smoking, and to cease to provide an area for it. Two years prior to the development of specific tobacco control activities, a charismatic and beloved teacher had died from cancer. From several participants' perspectives, this loss had contributed to increased awareness of the effects of tobacco and a sense of readiness among staff, partners, and administration to address the need for change. In particular, staff and community members became more enveloped in the implicit meaning and implications of their school mission statement to provide a "safe and nurturing environment" for students. The importance of taking action was underscored by the fact that many grade 9 students were often easily drawn into the smoking area upon arriving at the school, adding to an increasing number of school smokers.

6.3 Objective 2: Development and Implementation of the Initiative

Document the implementation of the program activities undertaken as part of the school-based tobacco control project

Initial development of tobacco control activities was undertaken by the school-based tobacco-free committee in the spring and summer of 2001. In conjunction with the committee, other partners became either directly involved or offered support to the preliminary planning efforts. Several of these partners were viewed as important sources of encouragement for empowering staff members to address needed areas of change and to reinforce the development of the notion that smoking was not an acceptable social activity or behaviour for students.

As a result of early planning efforts, the tobacco control committee formulated a range of key objectives that included removal of the smoking area, implementation of smoke-free policies, reduction of tobacco use among students, and creation of smoke-free meeting places for students. Plans for the creation of a proposed green space which would replace the smoking area were confirmed in late Spring of 2001. In June 2001 announcements regarding the changes in smoking policy and the upcoming tobacco control activities were made to students, parents, and the community. Additional planning activities included also the establishment of smoke-free school boundaries, the development of specific steps for enforcement of rules, the restructuring of the timetable schedule to minimize opportunities for students to smoke during breaks, and the organization of peer-educator training to facilitate subsequent student involvement in health promotion activities and smoking cessation programs.

Preliminary planning activities resulted in a strong commitment by the school-based tobacco-free committee to pursue an immediate, non-gradual implementation of a smoke-free policy at Hampton High School. Several respondents asserted that the demonstrated passion and commitment of teacher champions were critical in sustaining the determination and participation of others during the completion of readiness activities. It was noted also that the solidarity of the school team and its unified influence played a critical role in addressing concerns and in eliciting support for the initiative from the wider school district and community.

Overall, key informants described 14 individual program components or actions that comprised the Hampton High School initiative. These aspects of the initiative were undertaken over three specified time periods. The following provides an overview of each component in its associated timeframe: 1. Pre-planning (April - May): Hold tobacco-free committee meetings; Set goals; Design timeline; Document the process. 2. Planning (April - June): Survey; Develop policy, establish consequences; Organize supervision; Make announcements to students and parents. 3. Implementation (August - Ongoing): Redesign smoking area into green/recreational space; Enforce policy; Include peer support; Liaison with local merchants; Form partnerships and ad hoc committees; Involve residents.

Student and staff respondents identified four specific aspects of the initiative that they perceived to be particularly helpful for creating and sustaining a smoke-free environment at Hampton High School. These included: the role of teacher champions in leading the initiative, the ongoing commitment of students and staff, the conversion of the smoking area into a smoke-free courtyard and green space, and the inclusion of cessation programs to strengthen the implementation of the tobacco-free policy.

6.4 Objective 3: Outcomes and Areas of Impact

Examine the areas of potential impact resulting from this tobacco control project including: health attitudes and behaviours, school policy, academic performance and attitudes, and relationships both within and beyond the school context.

Research participants identified seven key areas of change or impact associated with the implementation and outcomes of the Hampton High School initiative. These included current smoking status, tobacco control awareness, health attitudes and behaviours, smoke-free policy, school connectedness, staff-student relationships, and community interactions.

6.4.1 Current Smoking Status

Approximately half the students sampled on the TCFS indicated that they had tried smoking in the past. With respect to current smoking behaviours, the SSP results indicated that daily tobacco use at Hampton High School ranged from 11% to 16% across genders and grades. These rates were slightly lower than the average SSP rates of daily smoking (12% to 19%) calculated for other schools in New Brunswick. The SSP results indicated also that student smokers had a greater number of close friends who smoked compared to non-smokers. Similarly, smokers were more likely than non-smokers to have an immediate family member who smoked. With respect to attempts at quitting, over half the student smokers reported that they had tried to quit at least once during the past year.

6.4.2 Tobacco Control Awareness

With regard to awareness of the initiative, the outcomes of the TCFS indicated that over 60% of grade nine students had been cognisant of tobacco control activities at Hampton High School prior to their attendance at the school. Similarly, the majority of the students in grades 10 through 12 reported that they had been aware of smoking-reduction activities early on in their high school experience.

On the SSP, over 80% of students surveyed at Hampton High School indicated that support for smoking cessation was available to them in their school context. This outcome was substantially higher than the average rate for other schools (44%) that completed the SSP in New Brunswick.

6.4.3 Health Attitudes and Behaviours

Approximately half the student participants and the majority of staff respondents affirmed that efforts to reduce smoking at Hampton High School had assisted in helping students not to smoke, and had contributed to enhancing the health of both smokers and non-smokers. Many of these respondents indicated that the initiative also had assisted students in adopting healthier attitudes and in increasing their knowledge regarding the consequences associated with continued tobacco use.

According to key informants, the tobacco control activities undertaken at Hampton High School have fostered also an increased understanding among students and school personnel regarding the challenges associated with reducing smoking. In conjunction with these results, various key informants noted also that since the implementation of the initiative, students had demonstrated a greater openness in discussing and considering other health-related behaviours; such as, exercising and making healthier food choices.

6.4.4 Smoke-free Policy

With respect to outcomes associated with the initiative, several key informants reported that informal counts of students congregating in smoking areas had decreased from approximately 200 to 70 students. Similarly, violations to the smoke-free school policy had also decreased during the past three years of the initiative. In addition, various key informants and staff participants indicated that the removal of the smoking area had also limited the development of disruptive and oppositional behaviour that had been previously associated with the former smoking zone.

According to the SSP results, approximately three-quarters of student smokers reported that they smoked off school property, whereas slightly less than half reported smoking within school boundaries. Although some students reported smoking at school, the majority of students affirmed that the school had a clear smoke-free policy and that they supported specific efforts to establish smoke-free public places.

Students' qualitative responses suggested that the initial implementation had been frustrating for some student smokers who regularly used tobacco. In contrast, others noted that the creation of smoke-free spaces had assisted various students in reducing their smoking behaviours. Participants reported also that non-smokers were appreciative of the renewed recreational spaces and of the creation of a healthier environment at school.

6.4.5 School Connectedness

On the TCFS, over half the smokers sampled indicated that they did less than one hour of homework over the course of a week. In contrast, over 60% of non-smokers reported that they exceeded one hour in homework weekly. Forty-four percent of non-smokers indicated also some level of involvement in structured extracurricular activities. In contrast, only 26% of smokers reported current participation in after-school programming. Overall, smokers reported less involvement in structured routines related to school-based activities or academics.

With respect to the outcomes of the initiative, over one-third of the student participants reported that student interest and participation in structured school activities had been enhanced since the introduction of tobacco control activities. In addition, approximately half of staff participants reported that the initiative had been beneficial for improving students' attitudes towards their academic work and for improving the overall learning climate at the school. A smaller percentage of students (24%) suggested also that the initiative had been helpful in establishing an overall educational environment that was more conducive for fostering learning experiences.

6.4.6 School Relationships

Staff participants indicated that teachers and administrative personnel had been generally supportive of the initiative and of one another's efforts to maintain the smoke-free school boundaries. Several respondents highlighted that the implementation of the tobacco control initiative had contributed to closer and more collaborative working relationships among both staff and students. Approximately one-third of student respondents also reported that teacher-student relationships had been strengthened during the time period of the Hampton High School initiative.

6.4.7 Community Interactions

According to key informants, the overall initiative has received positive support from community members and has contributed to ongoing dialogue about tobacco control in both the school and local neighbourhoods. Several respondents highlighted the importance of continuing to develop a wider range of community partnerships for addressing tobacco control issues that extend beyond the school context. In this regard, the outcomes of the SSP indicated that approximately half of student smokers currently purchase cigarettes from community sources without being asked their age.

6.5 Objective 4: Current Challenges and Proposed Responses

Identify the specific challenges associated with the current implementation of this initiative and potential responses for addressing these areas of concern.

In terms of current challenges, key informants and staff participants highlighted five areas of ongoing concern. These included: continued student smoking beyond smoke-free boundaries, grade nine students who are already established smokers, persistent violations of smoke-free policies during community or recreational events at the school, the reality that many students continue to be faced with environments that condone smoking within the family and community contexts, and the need to maintain the momentum of the initiative. Research participants offered a range of potential responses for addressing these areas of identified challenge including: continuing with supervision practices to support smoke-free zones, using peer-led tobacco control presentations to promote healthy decision-making among middle school students, encouraging shared responsibility and leadership for initiative activities among school personnel, and developing formalized strategies for impacting families and the wider community on issues related to student smoking and smoke-free policies. Many participants indicated also that such proposed actions should be considered in subsequent tobacco control planning at Hampton High School.

6.6 Objective 5: Lessons Learned

Consider the key lessons learned that might assist in the development and implementation of similar pilot projects in other educational settings

Key informants identified a range of lessons learned associated with the planning and implementation of policy changes and tobacco control activities at Hampton High School. These insights include both practical operational considerations, as well as proactive measures that assist in supporting the school's move toward a smoke-free environment.

6.6.1 Establish Clear Goals and Timelines

Given the responsibilities of committee members, specific meeting times should be established on a regular basis for completion of preliminary planning activities. In particular, time should be devoted, early on, to the identification of clear goals, timelines, and corresponding actions. Such preliminary efforts are crucial for ensuring effective co-ordination of planned activities and for providing a sense of accomplishment for both committee members and other stakeholders.

6.6.2 Document Key Insights From the Process

Intentional efforts should be undertaken to record the details of the implementation and outcomes of school-based tobacco control initiatives. In particular, documentation of key insights from committee members during the process of project development and implementation provides a valuable source of information and lessons learned for other school communities that might undertake similar types of initiatives.

6.6.3 Design and Carry Out School-based Surveys

The completion of structured surveys and informal data-gathering exercises provides an effective means for understanding smoking attitudes and behaviours in specific school contexts. Such data-collection efforts might also be beneficial for increasing awareness among students and school staff regarding key health issues and concerns related to tobacco control. The outcomes of administered school-based surveys might also be used as a baseline from which to measure the effectiveness of implemented promotion or intervention activities.

6.6.4 Establish Smoke-free Boundaries at the Outset

The establishment of the smoke-free boundaries should precede the announcement of the policy to students and to the community. Changes to smoke-free boundaries following announcements of the policy might pose considerable administrative challenges for maintaining the integrity of existing expectations and the consistency of supervision practices.

6.6.5 Plan for Outdoor Monitoring

Larger boundaries often require greater outdoor duty time. Preliminary planning should take into account the actual time required to carry out supervision activities, and school personnel should be notified well in advance of anticipated changes to existing duty schedules. Contributions from all staff members might assist in lowering the additional efforts required to implement the planned schedule of supervision.

6.6.6 Limit Opportunities to Smoke

Restructuring daily school or classroom schedules might assist in minimizing the amount of unstructured break times during which students may choose to smoke. Smoke-free boundaries should also be sufficiently large to prevent immediate access to smoking location for students during break times.

6.6.7 Inform School and Community Regarding Upcoming Changes in Policy

Students should be informed early regarding the specific smoke-free boundaries and how supervision and accountability of such policies are to be maintained. Similarly, neighbours close to the school should be invited to collaborate in discussions pertaining to the initial development and adoption of smoke free boundaries and policy changes.

6.6.8 Use Positive Phrasing

In describing tobacco control policy or activities avoid use of terms such as "ban" that emphasize the loss of choices or privileges. In contrast, promote positive aspects of change with phrases such as "creating a tobacco-free school" that highlight healthy decision-making and the opportunity to set new personal directions or goals.

6.6.9 Create Smoke-free Meeting Places

The removal of smoking areas should be accompanied by development of smoke-free social spaces that are attractive to both student smokers and non-smokers. These meeting places may incorporate organized leisure and recreational activities for students, as well as provide informal opportunities for development of positive peer relationships.

6.6.10 Provide Support to Student Smokers

The implementation of school smoke-free policy should be supported by concurrent activities and approaches that convey support and respect for student smokers. As students are reminded of specific rules or are prompted to comply with smoke-free policy, interactions with them should include expressions of concern for their personal well-being, as well as discussion of available options for reducing tobacco use.

6.6.11 Promote Tobacco Control Through Emphasis on Healthy Living

In conjunction with the school mission statement, tobacco control plans were undertaken in the context of an emphasis on promotion of healthy lifestyles and relationships. For example, the courtyard plans were aimed, not only at reducing tobacco use, but also for encouraging positive friendship development, physical exercise, and for enhancing a sense of belonging for all students.

6.6.12 Facilitate Increased Student Involvement

Key informants underscored the importance of encouraging credible peer leaders to become involved with school-based health promotion and smoking cessation activities. Such student leadership was viewed as a critical consideration for engaging other students' participation in planned tobacco control efforts.

6.6.13 Attend to Middle School Smokers

The planning of smoke-free policy and activities was viewed as relevant for both Hampton High School students and those who would attend the school in the future. In this regard, preliminary planning should also consider outreach plans to feeder schools through use of peer-helper strategies that support and reinforce the development of healthy attitudes and behaviours in students even before they arrive at the secondary school level.

6.7 Research Limitations

This investigation represented a case study analysis of the Hampton High School initiative. Several of the data-gathering phases relied upon the past recollections and experiences of research participants for exploring baseline considerations and the nature of the implementation of the Hampton High School initiative. In this regard, there was not any accessible formalized or uniform baseline data that could be used to examine specific changes over time. For this study, the documentation of identified outcomes was based only on post-program evaluation efforts. The findings of this study were also limited to the specific school context that was investigated and may not be generalizable to other school settings or regional educational jurisdictions.

The outcomes of this research effort underscored the importance of the development of research evaluation plans prior to the implementation of specific intervention or prevention programming. Such research plans should include formulation of both process and outcome evaluation designs. The undertaking of program evaluation efforts in conjunction with the preliminary development and piloting of specific health initiatives is critical for providing meaningful insights into both the implementation and actual effectiveness of proposed promotional or intervention programs.

6.8 Concluding Reflections

The purpose of this investigation was to assist in formally documenting the key aspects and reported outcomes of the Hampton High School tobacco control project. The majority of data for this study was gathered from research participants who had direct experience with or who were part of the implementation of this initiative.

The preliminary development of the initiative was prompted by widespread staff and student concerns regarding environmental tobacco smoke and a renewed commitment to fulfil the mission statement of the school to provide "a safe and nurturing environment." Such efforts were also initiated as a result of an increased awareness regarding student health issues and personal experiences of loss within the school community. To date, the implementation of the tobacco control activities has spanned three years since the adoption of a smoke-free policy at Hampton High School. Critical aspects of the initiative that were reported across participant groups included the role of teacher champions in leading the strategy, the sustained commitment of students and staff, the creation of smoke-free social spaces, and the provision of positive support for student smokers in reducing tobacco use.

At the time of data-gathering, the current rates of daily smoking among students at Hampton high School were slightly below the documented average rates of other secondary schools in various New Brunswick jurisdictions. With respect to tobacco control awareness, almost twice as many students at Hampton High School were aware of specific support available to them to reduce tobacco use as compared to other high schools.

There was also a strong consensus among all research participants that efforts to reduce smoking had contributed to helping student not to smoke and to enhancing the overall health of smokers and non-smokers. Participants also affirmed the role of the tobacco control strategy in extending health knowledge among students, and for encouraging increased student openness to discussing a wide range of health-related behaviours and lifestyle issues.

The implementation of the smoke-free policy was also viewed as beneficial for limiting the number of students regularly congregating in smoking areas. Staff observations suggested also that elimination of the smoking area had been helpful in curbing the opportunity for new students to be exposed to smoking, as well as in reducing incidences of oppositional or disruptive behaviours on school property.

With respect to school connectedness, staff participants in particular provided feedback that the initiative had been beneficial for improving students' attitudes toward their academic work, for enhancing the overall learning climate at the school, and for strengthening teacher-student relationships. Data collected among students suggested also a greater degree of school connectedness in regards to academic study and participation in structured activities among those who had made decisions not to smoke.

The overall results of these research phases provide some evidence supporting the positive outcomes of this initiative. In particular, increased awareness among students regarding health risks and strategies for reducing tobacco use were noted. The implementation policy was viewed also as effective for reducing the student and staff members' exposure to environmental tobacco smoke. Although there were specific examples cited of reductions of smoking among students, lack of uniform baseline data collection posed significant challenges for documenting actual decreases in daily smoking rates among students. In addition, the outcomes of this research noted also potential links between student health behaviours and the degree of school connectedness. These observations were based primarily on staff reports relating to the impact of the initiative and reports from students regarding their school involvement. This area of research warrants further investigation given its potential relevance and implications for development and implementation of health-related promotional or intervention programming within the educational context.

In conjunction with the documented outcomes of the Hampton High School initiative, current challenges and areas for potential development were also discussed. These considerations may have immediate implications for continued enhancement of tobacco control efforts at Hampton High School. In addition, the lessons learned arising from the initial implementation of this initiative may also provide valuable insights for other school committees or educational jurisdictions that plan to undertake similar school-based tobacco control policies or activities.