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Quit4life - Facilitator's Guide

2005
ISBN: 0-662-38859-3
Cat. No.: H46-2/04-382E

Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.

(PDF Version - 3070 K)

Introduction to Q4L
1. How to Use this Guide
2. What is the Quit 4 Life Program?
3. Getting Ready to Facilitate a Q4L Group
- 3.1 What does a Q4L Facilitator do?
- 3.2 What should a Q4L Facilitator know?
  - 3.2.1 Facts And Figures: Review Your Knowledge About Teen Smoking And Cessation
  - 3.2.2 Facilitation Tips: Review Your Knowledge About Group Facilitation
4. Getting Organized : How to set up a Q4L program?
5. Evaluating the Program
- 5.1 Assessing implementation: Keeping track of goals and activities (Focus on process)
- 5.2 Detecting change in participants: Baseline and Post-Program Surveys (Focus on outcomes)
6. Overview of Sessions
7. Additional Resources

Introduction

To The Quit 4 Life Guide for Program Facilitators

Quit 4 Life is designed to help Canadian youth quit smoking. This facilitator's guide has been created to assist health professionals, educators and youth workers help young people work together and support each other as they participate in the Q4L program. The program has been adapted and tested for over ten years, taking into account emerging research about youth and smoking, and what works best to help them quit. This is the third updated version of Q4L in hard copy. A web-based program is also available at www.Quit4Life.com. This version of Q4L was piloted across Canada in 2003/2004

1. How to Use this Guide

Quit4Life is a 10-week, four-step group program designed to be delivered by an adult facilitator who has experience working with youth, in a school or community centre setting. The target group? Teenagers who want to quit smoking.

This Guide contains the information you need to get started as a Q4L Group Facilitator. Some facilitators may have a lot of prior experience working with youth, although not as much in the area of smoking cessation. Others may have experience in addictions or smoking cessation, but have not facilitated groups with teens. What you all have in common is your commitment to support youth cessation, and your willingness to work within the Q4L program framework.

The Guide is designed to help facilitators deliver the Q4L program consistently. But consistency does not mean uniformity: each Q4L group will have unique features.

"I have to say that all groups are completely different, their priorities are completely different. Some enjoy one thing, and the others want to do the other, so you really have to, the most important is you really have to adapt to the kids. There's no doubt about that" (Q4L Pilot Facilitator).

The national pilot provided an opportunity for Health Canada to incorporate many ideas and suggestions from facilitators and participants who had 'hands on' experience with Q4L. The national pilot not only showed that Q4L works as a group program to help youth quit; it also showed that Q4L can be adapted by experienced facilitators to meet the needs of youth in diverse regions of the country: For example, many facilitators kept closely to the content and order of the session plans; others brought in additional resources, speakers, and materials to complement the Q4L program. Most Q4L groups were held in schools; but some were held in other community locations. Most facilitators found that recruiting students in a school setting worked best; others preferred word of mouth and informal contact in locations where young people hang out.

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As an experienced facilitator, you will find many opportunities to adjust, supplement, and fine tune program activities, to reflect the specific needs and circumstances of each individual group of teens.

In this Guide, you will find session plans with content and suggested activities for each of the ten core sessions that make up the 4-step Q4L program. There are also plans for four optional sessions.

You also will find background information about the Q4L program; facts and figures about tobacco and youth cessation; facilitation tips; ideas and materials for evaluation; and a list of additional resources.

Handouts for each activity are located immediately after the session in which the activity is presented. You can photocopy them for participants. Some information found in the handouts is also found in the Q4L handbook (e.g. Quit Calendar, How to Refuse, Survival Kit items): this information was included in both formats because some youth use the handbook on their own and would not otherwise have access to this information.

The Q4L handbook is an essential component of the Q4L program. Make it available to all participants from the first session. You can obtain additional copies of the handbook at www.Quit4Life.com.

Conclusion - Facilitators are the backbone of Q4L

Quitting smoking can be a challenge at any age, but adolescence is a prime window of opportunity to help youth kick the habit. Group involvement and supportive facilitation, combined with stimulating and skill-building activities can help smokers go smokefree - and have some fun while they're at it!

This guide provides an overview of group facilitation methods, tips and tricks we learned from the national pilot of Q4L and outlines 10 essential sessions, and 4 optional sessions, that reinforce the basic principles of the Q4L program. Each session also includes several "black line masters" hand-outs for photocopying and distribution.

Dedicated professionals like you provide guidance and support to help young smokers learn new quitting skills and fine-tune the strategies that will work for them. You're helping to lower the rate of youth smoking.

Thank you!

Introduction - 2. What is the Quit 4 Life Program?

Q4L exists because smoking is the leading preventable cause of serious illness and death in Canada. In 2003, 18% of Canadian teens 15-19 were smokers, down from the 28% reported in 1999. If teens who smoke have the opportunity to participate in cessation programs that are suitable for them, the rate of teen smoking likely will continue to decline.

The longer a person smokes, the more dangerous it becomes for their health, and the harder it is to quit. Research shows that young people get 'hooked' on smoking more easily than older people. There is also evidence that many teens who want to quit smoking have difficulty doing so. Health Canada is taking steps to help youth quit smoking before it becomes a lifelong habit. And the Quit4Life program has been part of the plan since 1996.

The 2002 version of Q4L was pilot tested with hundreds of Canadian youth who wanted to quit smoking. This Guide includes suggestions from facilitators and participants in Quit 4 Life groups across Canada.

2.1 What are the goals of Q4L?

Quit4Life will help youth:

learn more about why they smoke
prepare for quitting
know what to expect when they quit
increase self-confidence to keep trying - even if they slip
create and follow a step-by-step action plan to quit successfully - for life!

After Q4L, youth will be more informed, confident, committed and clear about trying to quitand succeeding.

See page 19 for an overview of the learning goals for each of the Q4L sessions.

2.2 Does Q4L work?

The Q4L program has been tested and evaluated. It effectively reaches the intended target group of female and male 12-18 year-olds, especially heavier smokers (greater proportion of daily smokers than average).

In a national study, Q4L participants:

Increased their motivation to quit.
Increased the number and the length of their quit attempts.
Increased their skills and knowledge about smoking cessation.
Cut down cigarette consumption in half: Immediately after the program, they were smoking fewer cigarettes daily than the Canadian average for this age group of smokers.
Were able to quit to a greater extent than average: the 11% quit rate was higher than the Canadian average of 6% short term quitters. This number also should be interpreted in light of the higher number of possibly more nicotine dependent youth at program start
Were very satisfied with the program, which met or exceeded their original expectations. Almost all Q4L participants would recommend the program to their friends.

2.3 Why does Q4L work?

The Q4L program was developed in accordance with the principles of social cognitive theory. It uses cognitive-behavioural techniques to promote individual behaviour change in participants in four sequential steps. The Q4L approach:

Provides information about what students need to do to change their behaviour around smoking; gives clear instructions and training or skill practice about what to do, and how to do it.
Models desirable behaviours in others who are respected by and/or considered to be similar to the students, pointing out others' experience, providing concrete understanding of consequences of actions.
Demonstrates that positive outcomes result from recommended actions to change smoking behaviour.
Sets goals, works to attain them, gradually moving towards internal rather than external rewards for meeting goals.
Increases self-efficacy, increases students' confidence in their own ability to act and to persist in taking positive action.
Maintains a positive learning environment for students that encourages them to keep trying instead of judging them or 'punishing' them for failed attempts (something around that, you can say it better).

Introduction - 3. Getting Ready to Facilitate a Q4L Group

3.1 What does a Q4L Facilitator do?

As a Q4L Facilitator, you are the backbone of the program. You must develop a trusting relationship with the participants and help them strengthen their resolve to quit smoking. You will also provide practical guidance and support, giving participants current information about tobacco and helping them develop the strategies and skills necessary to quit using tobacco. You will act as a model for how to make positive choices and work towards successful change.

As a Q4L Facilitator, you will:

Teach skills in small steps
Model, demonstrate and verbalize what is being demonstrated
Provide progressive exercise problems that are challenging
Give feedback, encouragement and correction
Identify and positively reward behaviour change
Encourage self-monitoring
Help students change their behaviour

As well as facilitating each session, you will be responsible for:

Marketing the program
Recruiting participants
Finding a place to meet
Managing all the organizational details
Providing follow-up guidance for participants
Establishing a secure environment in which participants feel free to express themselves honestly

3.2 What should a Q4L Facilitator know?

The National Q4L Pilot confirmed that the following are important qualities for a Q4L facilitator:

a solid knowledge of tobacco issues and specifically teen cessation
group facilitation skills
comfort and experience working with this age group
ability to build relationships with youth that extend beyond implementing the curriculum
flexibility
awareness of students' needs

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Student participants want the Q4L facilitators to be:

non-judgmental
positive
fun
caring
understanding
ex-smokers

3.2.1 Facts And Figures: Review Your Knowledge About Teen Smoking And Cessation

Facilitators are often process-oriented. In Q4L, content is also important. Q4L participants will look to you as a source for correct information about tobacco use and cessation. Take the quiz in Appendix A to check out what's new, and get up-to-date with the latest facts and figures before you start facilitating Q4L. Good teachers know that if they don't know the answer to a question, students will respect them more if you tell them that you will do your best to do some research and provide information during the next session.

For more background information and to keep up to date with the latest information on tobacco and smoking cessation visit: www.GoSmokeFree.ca and Quit4Life.com.

3.2.2 Facilitation Tips: Review Your Knowledge About Group Facilitation

"I saw my role as the person who would help them to go through their steps and give them as much information and as many tools and to make them feel good and motivate them as much as we could" (Q4L Pilot Facilitator). "You are not only curriculum based, the curriculum is a tool, but it is developing that therapeutic relationship with the group and providing that safe space" (Q4L Pilot Facilitator).

"They have the problem but they also have the solution. Asking them where they are at and trying them to come up with the solution. It is amazing, youth could come up with things that we never could think of... it is meeting their needs." (Q4L Pilot Facilitator)

Facilitating Quit4Life is an exciting and rewarding experience. Every profession brings a unique approach and perspective to youth cessation. Quit4Life facilitators come from diverse professional backgrounds. You may be a volunteer; hired to implement the Q4L program, or have added on the task of group facilitation to your regular work activities as a teacher, guidance counselor, community worker, or public health nurse. You may have a lot or little experience with tobacco issues, cessation, and working with this age group. Even if you are an experienced group facilitator, you may find it useful to review the following guidelines for successful facilitation of a Q4L group.

General guidelines for successful facilitating:

Listen more than you talk.
Support everyone to keep thinking. For example, during brainstorming, significant contributions are often made after periods of silence.
Honour every contribution.
Make each session interactive, supportive, and fun for all.

Keys to Effective Facilitation of Quit 4 Life

Each session should be an exercise in discovery. It should be a dialogue, not a lecture. Informality and relaxation are cardinal principles.
Help the participants learn about smoking by relating to their own feelings, beliefs and experiences. Engage, challenge and involve them.
Take into consideration the level of literacy in your group. If your participants do not like to read or use paper and pencil activities, try to act things out, use more role plays, some alternative examples are provided in the session plan.
Presentations must be relevant simple and realistic because youth are more focused on short-term rather than long-term consequences of behaviours and decisions.
Be understanding and informed about the challenges teens face when trying to quit smoking. They are motivated to smoke for many reasons and sometimes express barriers to quit that are different from adults. Allow participants to proceed at their own pace. Vary your support according to each individual's needs.
Be positive and involved. Validate everyone's views and experiences. Offer reassurance that everyone can succeed and make it clear that smoking, not the person, is the problem.
Be organized and understand the topics for each session although sessions may need to be modified to meet the requirements of the group, each topic must be discussed.
Keep your language straightforward and simple - free of jargon and technical terms.
Always be you. As long as you are sincere and interested in their welfare, teens will respect your guidance and value your support.

For more tips on facilitating Q4L, see Appendix C.

Introduction - 4. Getting Organized : How to set up a Q4L program?

4.1 Recruitment and retention

"I would not bother going out just generally in the community as we did in the beginning, I would go right to schools and recruit from there. The other thing that I did not do, but wish I had done is to go right into the smoking areas" (Q4L Pilot Facilitator).

"We all know that something like 85% of kids like to try to quit on their own. So recruiting them for a group program is not necessarily a cool thing, and is tough. Group is not necessarily for everybody, it isn't for every adult and it isn't for every kid" (Q4L Pilot Facilitator).

The literature on youth cessation suggests that teens are reluctant to participate in group programs. Those who decide to participate in Q4L, though, generally are satisfied with the program and find it helpful.

Recruiting participants to any cessation program can be a challenge. When recruiting teens, make sure that:

Activities seem interesting
Sessions are held in accessible, comfortable surroundings
Incentives are offered
Facilitators and peers encourage participation
And... include a sense of fun!

Recruiting teens for Q4L is most effectively done at schools, and through community organizations which are already serving youth. Don't limit yourself to one recruitment activity: multiple strategies work best. Here are some recruitment ideas that worked for Q4L facilitators during the national pilot:

Get the go-ahead from adult stakeholders and institutions:
- Meet with school principals, trustees, administrators, inform them about the program and solicit their co-operation.
- Meet with public health staff and ask their help to access any programs involving youth.
- Meet with staff from community centres, youth addiction programs, youth services, parks and recreation, and solicit their co-operation.
- Present the program at a school staff or home/school association meeting.
- Present the program at a community centre meeting.
- Present the program to educators at professional development days, meetings, and conferences.
Get the word out to youth:
- Use individual outreach to smokers as much as possible: go where the smokers are.
- Get permission to talk directly to youth in school and distribute program information in guidance, health, or physical education classes, or school smoking areas.
- Pass out program information and talk about the program with youth in smoking areas near school grounds.
- Get permission for a booth or to pass out pamphlets in local shopping malls, outside movie theatres, clubs, fast-food outlets, and other areas in your community where young people hang out.
- Invite teens to bring a friend the session.
- Announce the program over the school PA system.
- Hold open information sessions at school.
- Offer a 'no strings attached' first information session, with pizza or other incentives.
- Hold open information sessions at community locations.
Connect with key individuals:
- Involve the student council, or find a student champion on council who might want to take it on to reach out to their smoking peers; have students do one of the announcements over the PA system
- Identify individuals with a previous positive relationship with target youth (e.g., specific teachers, guidance counsellors, cafeteria staff, addiction workers, youth workers) and ask them to approach young people they personally know would benefit from the program.
- Include committed peers (ideally former smokers) in outreach activities, and to approach other youth.
- Meet with youth leaders and ask for their ideas.
- Provide incentives:
- Recruit in a contest format ("bring a friend and win a prize").
- Hand out gum, candies, and stickers along with program information.
- Offer small prize for attending first session (gum, pen, movie ticket, muffins).
- Promise celebration (party, pizza lunch, outing) at the end.
- (See below for more ideas about incentives)
Use 'see and say':
- Use word of mouth: Speak about Q4L wherever you go, and ask others to do the same.
- Send out e-mails or text messages to youth, and ask them to 'pass it on' to others who might be interested.
- Put up Q4L flyers, posters, and announcements as useful reminders of the date and time of the next Q4L group session.
- Post a notice on school, community, or youth group web-site or electronic bulletin boards.

Finally, remember that you cannot measure recruitment success exclusively by the number of participants who attend a program. A school-based program that reaches those students who most need and can benefit from the Q4L is successful, even though they might be few in number. For example, during the national pilot, one program reported that 100% of all the smokers in a small school were registered in the Q4L group: a total of four!

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4.2 Intake

Q4L is designed as a 10-session group program, with fixed start and end dates. This may become an issue if:

new participants want to join the group once it has started;
you want to keep registration open after the start date, to increase overall participation numbers;
you have many drop-outs after the first few sessions.

It is possible to use the material in this guide to deliver a more open, continuous-registration program, but a closed group is essential for Q4L to work as a sequential group cessation program. You will have to decide what works best for your site.

Other Q4L facilitators have suggested the following strategies for successful intake:

Screening participants prior to the first session, to assess if they are serious about quitting.
Identifying participants with other issues (such as drug addiction) and steering them towards the resources needed prior to attempting to quit.
Offering more than one Q4L group programs over the school year, so that 'late' registrations can be placed on a waiting list.
Permitting 'open' registration for a fixed number of entry sessions (i.e., the first three), and closing the group after those sessions are held.
Having an open 'introductory' session, during which the elements of the program are explained; participants make a commitment at that point to continuing with the closed group or not.
Providing one-shot information sessions at which the Participant Handbook and webbased program information are provided to those not ready/interested in committing to the group program.

4.3 Attendance and retention

Retaining participants in any cessation program is a challenge. Attendance may be affected by contextual factors, such as changes in school schedules, weather, examination periods, sports or recreational activities, or personal/life issues (changing schools, moving out, getting a job). On average, one-third to one-half of participants may drop out prior to completion, but this will vary considerably from site to site and from group to group.

Once your Q4L group begins to meet, it is important to keep holding regularly scheduled sessions, even if a small number shows up to a particular session. This shows your commitment to those students who do attend, and is a positive response to their motivation to quit or cut down.

If participants have to miss a group session, you may want to provide additional short 'catch-up' individual sessions, to avoid having to repeat material for those who were present.

To enhance attendance and retention you may want to:

Use incentives (e.g., draws for a gift certificate at each session)
Establish attendance rules (e.g., missing so many sessions leads to expulsion from the group)
Speak with participants who have missed a couple of sessions to encourage them to continue
Use a buddy system
Emphasize the benefits of continued attendance after the quit date, so participants get the support they need during the final sessions of the program.

Finally, as a facilitator you may want to reach out to 'drop-outs', find out why they left, and invite them to try again at the next Q4L session.

4.4 Group size

The maximum recommend size for a group program is 15 participants.

As a facilitator, you will want to ensure full application of the participatory elements of the program (e.g., pair's activities, group discussions). Group size also affects the amount of time you will have to pay attention to, and support, the individual behavioural change plans of each participant.

To reflect particular conditions and fluctuations in the population of smokers and quitters at any site, a minimum group size is not recommended. If you are working with only one or two students, however, you may need to adapt the program considerably and use the materials as a one-on-one individual support program.

4.5 Diversity

Most Q4L groups will include mixed ages. Older teens may be more likely to participate in the program than those 14 and younger. This reflects smoking uptake patterns. Younger teens may be less motivated to quit completely, and may need more information about the impact of nicotine dependency and the increasing difficulty of quitting the longer they smoke. Older teens can provide a positive influence in a mixed age group, since they are living proof of how much harder it is to quit and how much more expensive it becomes over time.

Q4L is designed as a mixed-gender program. Boys and girls can learn from and about each other in a mixed setting. Most participants have friends from both genders, so a mixed group prepares them well for dealing with their social environment when cutting down and quitting. The national pilot shows that females raised weight issues more frequently than males, but both boys and girls were concerned. Males also profit from information about nutrition and exercise in a mixed group. However, during the pilot some groups were facilitated as either all female or all male groups, or had one session, in which girls and boys met separately to discuss their specific issues.

Q4L material is available in both English and French. Linguistically mixed groups (e.g., French and English) are possible, but must be facilitated with care. If members of your group speak a different mother tongue, you may want to pay attention to level of participation and ease of communication in open discussions. You may also want to monitor understanding of written versus orally delivered material.

4.6 Scheduling

Scheduling your Q4L group will depend on the particular needs and context of your site. Try to schedule sessions so they are easily attended, and don't disrupt the daily activities of the target group. For instance, Q4L facilitators for the national pilot recommend integrating the program into the regular school day, rather than before or after school.

Review the needs of your target group of participants, but also keep in mind the constraints of your site and the needs of other stakeholders and institutional supports, such as administrators, recreational leaders, and teachers. If you are facilitating a Q4L program in a school, obtain teachers' commitment to support the Q4L participants ahead of time. Support participants to make proactive arrangements for tests and assignments that might conflict with group attendance, to reduce additional pressures and stresses on young people who are trying to quit.

Be aware of other demands on participants' time, such as examination dates, holidays, major sports events, band concerts, class trips, when you develop your schedule.

Some possibilities for scheduling are:

Lunch hour group meetings in schools: providing food, not conflicting with classes, and being on location increases attendance.
Group meets in school during class time: integrated into the school day, the program is seen as 'important' enough to miss class time, and does not interfere with other activities.
Rotating or alternating schedule during lunch/class time at school: integrated into the school day, but different classes/activities are missed each week.
Program is included as part of the health curriculum: integrated into the lesson plan; no extra bureaucratic requirements (e.g., signing attendance forms, getting signatures from teacher to be permit leaving class to attend program).
Group meets before or after school at a school site: youth are already at school, no additional transportation is needed, does not interfere with class time.
Group meets after school or on week-ends at a community site: youth already attend the site; can be integrated into other programming and/or followed by recreational activities; is distinct from 'lessons' or 'school'.

You may want to think about the advantages and disadvantages of different possibilities. For example, a lunch hour meeting in a school may also be seen as eating into students' free time; or, they may feel it is keeping them from having a smoke break. If food is not provided, participants may be late since they have to eat first. Similarly, if a group program is included as part of the health curriculum, you will have to be very flexible to meet the needs of any non-smokers in the class, without losing the integrity of the Q4L experience for those who are smokers.

4.7 Incentives

Many Q4L Facilitators during the National Pilot used a range of different 'incentives' (items provided to participants for free) to

assist recruitment
enhance retention
reward behaviour change
help with stimulus control

Items might include: gum, candy, stickers, hacky sacks, yo-yos, muffins, pizza, sandwiches, water, water bottles, movie theatre passes, gift certificates, CDs.

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If you choose to use incentives in your Q4L program, here are some ideas:

Your home/school association or school council may be able to provide a small budget for incentives.
You could approach local businesses for gift certificates.
Service clubs may be able to finance small incentives, or help you to obtain the minimum 'ingredients' for a cope kit.
If no material incentives are available, get creative with no-cost incentives, such as:
- public announcements at school recognizing successful completion of the program;
- articles in school newsletters or community newspapers about successful quitters;
- certificates of attendance;
- certificates awarded during school assemblies;
- being allowed to leave school early to attend a special celebration.

Introduction - 5. Evaluating the Program

As a Q4L Facilitator, you may want to know how your program worked, and find out ways to improve it the next time you facilitate a group. This guide includes some tools to help you evaluate your program.

5.1 Assessing implementation: Keeping track of goals and activities (Focus on process)

Keeping track of your own learning goals for each session

It is useful to review the learning objectives prior to each session, and to add your own, based on the observations of your group and unfinished business from previous session. You can ask yourself the following questions, and note down some of the answers before and after each session:

What are the goals outlined for the up-coming session?
What do I want to achieve?
What do I want participants to know after the session?
What do I want participants to be able to do after the session?
How will I know that they learned the information and skills?
How did I do to facilitate this process?

Try to be as specific as possible, because that will make it easier for you to assess if you reached your objective. For example, "What do I want participants to be able to do after the session?" Answer: "I want each participant to tell me their concrete plan to postpone smoking the first cigarette of the day. I want them to put the plan into practice at least twice before the next session."

If you formulate your objectives as outcome objectives, it may be easier for you to find out if they were achieved. Continuing with the above example, during the next session, you can ask how many of the group were able to implement their plan, what worked, what didn't, and talk about how to make a new plan.

Experienced facilitators or teachers frequently share their objectives with their participants and discuss with them, to assess whether these objectives are realistic. As a result participants know what to expect. Clarifying expectations can be a motivating factor for many youth, because they feel that they are being taken seriously, and that the facilitator believes in their ability to reach the objectives.

Keeping track of learning goals for the program

Formulating very concrete, observable objectives, however, sometimes can distract from the overall outcome goals. It is also important to review the long-term goals each time you prepare or debrief a session. You can ask yourself the following questions:

How does this session contribute to the long-term outcome goals? (reducing smoking, practicing quitting, quitting for life?)
Did we advance in the right direction?

Again, it can be useful to debrief these questions together with participants, collect their feedback and make adjustments for the up-coming session.

Keeping track of the core: what goals and tools can be modified?

Responding to the needs of the youth in your program will require you to be flexible and adapt the program to some degree. It is important, however, to return to the key program elements of Q4L which have been tested and found to be helpful over the years. Q4L will also benefit from your input, as all facilitators for the revised program can provide Health Canada with information about program gaps and needs that surfaced.

5.2 Detecting change in participants: Baseline and Post-Program Surveys (Focus on outcomes)

Baseline data tell you where the participants were at before they began the Q4L program. Post-Program data tell you where they are at when they finish.

Administer the Baseline Survey at the start of the first session.

Ask the youth to fill out the Baseline Survey (handout found at the end of Session One) during the first session, or even at registration - before you provide in-depth information about the program.
The Baseline Survey helps determine who the Q4L participants are, and what their smoking status is. It assesses their motivation to participate in the program, and the level of knowledge each person has prior to starting the program.
When you compare baseline data with the Program Evaluation Survey, it will tell you how well the Q4L program achieved its goals in the short-term.

Motivate participants to complete the Baseline Survey

It's not always easy to get young people to fill out forms. Make sure that participants know they are not 'tests': there are no right and wrong answers, and they won't get a mark. Explain why you are collecting the baseline information, how it will be analyzed, and who will benefit from it. Some participants respond well when they know that they are contributing to evaluation research. Others like the idea that the information they provide will help improve the program for others in the long run.
To increase response rates, you can also provide little incentives (such as handing out gum to people who complete the surveys).

Administer the Program Evaluation Survey during the tenth session.

The post-program survey is designed to evaluate program success, and should be filled out during the last session.
Explain why you are asking participants to answer yet another survey. Refer back to the first (Baseline) survey, and explain the need to compare results with the first set of data.

Motivate participants to complete the Post-Program Survey

In programs such as Q4L there is a natural attrition. Some participants may drop out of the program over time. Since the participants attending the last session did 'stick with it' to the end, you can tell them how important their feedback is to improve the program.
Incentives work - for example, having a pizza party at the end, or watching a movie together - after the surveys have been filled out.
Again, make sure that participants know this is not a 'test' : there are no right and wrong answers, and they won't get a mark.

Include the drop-outs

Encourage youth who dropped out of the program to fill out the Program Evaluation Survey. Their insights are as important as information from those who stayed with the program until the end. Dropouts can offer valuable input to improve the program, and can identify ways that might have kept them from dropping out.
Incentives, such as inviting them to participate in a final pizza party or movie, may also work to bring drop-outs back to fill in that last survey.

Compare baseline and post-program data

Add up the answers for the baseline surveys. Calculate averages.
Add up the answers for the post-program surveys. Calculate averages.
Review the open-ended answers, look for patterns, differences, similarities.
Compare baseline and post-program data.
Compare all data with your original program goals.

Introduction - 6. Overview of Sessions

The four Q4L steps are:

Step 1 - Get Psyched: Motivate Yourself To Quit And Stay Smoke-free
Step 2 - Get Smart: Know Yourself And What To Expect When You Quit
Step 3 - Get Support: Create A Positive Environment For Yourself
Step 4 - Get On With It: Know What To Do When You Quit.

Q4L is conceived as a sequential program. Maintain the steps in sequence as much as possible.

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Each step contains a number of sessions (each about 1 hour long). The sessions are designed to create positive learning experiences for youth participants, and equip them to make the positive lifestyle change of quitting smoking.

6.1 Q4L program objectives

Below is an overview of the objectives for each of the ten core sessions, and how they fit within the four Quit4Life program steps.

Step I : Get Psyched: Motivate Yourself To Quit And Stay Smoke-free

Session 1. What Are the Advantages of Quitting Smoking?

Get to know each other and the facilitator
Explore their current smoking habits
Learn more about the Q4L program
Provide input into group rules
Increase their knowledge about the benefits of quitting smoking
Calculate the amount of money they spend on cigarettes
Practice diverting attention from smoking

Session 2. Why Do You Smoke?

Increase awareness about own smoking routine
Explore in more detail the reasons why they are smoking
Learn more about addiction
Increase their motivation to quit smoking
Increase their awareness about their values and/or goals
Know more how smoking interferes with achieving their goals and being true to their values.

Step II : Get Smart: Know Yourself And What To Expect When You Quit

Session 3. What Do You Know About Smoking? How Do You Deal with the Challenges of Quitting?

Increase knowledge about health facts and smoking
Know more about how smoking impacts on women and men
Increase awareness about their smoking behaviour
Know their own reasons or roadblocks that keep them from making changes to their smoking behaviour
Increase their commitment to cut down smoking

Session 4. What is Withdrawal and How Do You Deal With It?

Increase awareness about routines and what it is like to change them.
Report back on their successes in cutting out cigarettes that they do not need to smoke.
Review and change or adjust their plan to cut out certain cigarettes.
Increase knowledge about withdrawal, temptations, and cravings and how to deal with them.
Increase knowledge about how to use alternative activities to decrease feeling of boredom

Session 5. How Can You Deal With Stress?

Identify own level of stress
Increase knowledge about what causes stress nd how the body experiences it
Identify own coping style
Practice skills how to prevent stress
Increase relaxation skills

Step III : Get Support: Create A Positive Environment For Yourself

Session 6. Get Support

Identify small changes in relation to reduced smoking
Increase knowledge about impact of second hand smoke
Identify potential supporters
Know more about the role of supporters
Increase response repertoire and skills to deal with non-supporters

Step IV : Get On With It: Know What To Do When You Quit

Session 7. How to Prepare for Your Quit Date?

Identify items to use instead of smoking
Identify their supporters
Review their learnings and apply them to a quit plan
Identify smoking cues and know why it is important to remove them
Set a quit date

Session 8. How Can You Stay Smoke-free?

Identify successes and acknowledge them.
Know how to interrupt negative self-talk and replace it with positive messages.
Reflect on their experiences with quitting.
Learn how to deal with slips.
Identify difficult situations and develop and refine coping strategies.

Session 9. How to Socialize Without Smoking

Increase knowledge about alcohol use and smoking
Develop strategies that can help avoid smoking in social situations
Practice refusal skills
Increase and maintain motivation to stay

Session 10. Living Smoke-free: A Celebration!

Assess the progress they have made in reducing or quitting
Celebrate their own and each other's success
Know how and where to go for support when they need it

6.2 What's in a Session Plan?

Each session is structured in a similar way. Here is a summary of what you will find:

Theme

Provides a focus, and situates the session within the Q4L framework.

Session title

Provides you and participants with an idea of what the session is about

Objectives

Formulated as outcomes, they help you and the participants focus on what is to be achieved at each session

Before you start this session

Provides a brief overview of the session, including other Q4L facilitators' and participants' experiences about what worked and what was challenging. Includes options for varying implementation of some activities according to the preferred learning style of your group. Each group is different, and you may have to experiment at the beginning to find out how your group likes to learn. For example, some groups enjoy paper and pencil activities, others prefer to discuss or act things out, and most groups are somewhere in between. You may also want to consider group characteristics such as level of literacy when choosing methods.

Materials

The materials needed for each session are listed. Black line masters for handouts are found at the end of each session plan. Many handouts are also included in the Q4L handbook for youth. Some participants may forget to bring their handbooks to some sessions. Make sure to have extra copies available. Alternatively, collect the handbooks at the end of each session, and distribute them again at the beginning of the next. Students can take them away at the last session.

Warm-up

Each session opens with a fun activity that introduces the main learning component of the session, and gets participants back into the topic.

Activities

Most sessions have a number of activities designed to have participants learn about tobacco use and nicotine addiction, gain insight into their own thinking, and design strategies to quit using tobacco. Each activity described includes "Notes to the facilitator" and instructions for implementation.

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Cool-off

Q4L facilitators found that many participants were anxious to smoke immediately after each session, "after all that talk about smoking". They found it useful to help students divert their attention from smoking at the end of each session. This is also a way to practice distraction from thoughts about smoking. Suggestions for a brief 'cool-off' activity are included at the end of each session, with the purpose of taking participants' mind off smoking as the leave the session.

6.3 Other things to consider in planning your group program

Length and timing

All sessions are designed for a 60-minute period, assuming a group of 8-12 participants. You can adapt the content for shorter or longer sessions. The time each activity will take depends on the size of the group, level of engagement, group dynamic, and group composition.

Setting up

Set up the chairs in a circle, to facilitate a sense of equality, foster participation, and ensure you and all the participants can see each other.

Have flip-chart paper, markers, and tape available each time the group meets. This will help you capture and validate young people's ideas during each session. Keep the flip-chart to help you refer to responses and questions in later sessions.

Wrapping up

It is important to summarize and reinforce the main learnings for each session prior to the cool-off activity. The first session provides one example of how this might be done. Use your own style and approach to 'wrap up' each of the sessions in a way that meets the needs of each group.

Tasks between sessions and written 'homework'

Q4L Facilitators have found that youth are often reluctant to complete extra tasks between sessions. Limit written 'homework' between sessions to two key tasks: filling out the Smoke Detector Tracking Form and getting supporters to sign the pledge form. Participants don't usually perceive other types of tasks as 'homework', and are more willing to work on modifying behaviour between sessions, such as cutting down on cigarettes, or sticking to a quit date.

Introduction - 7. Additional Resources

Many organizations provide additional support to people who have quit smoking. Contact the Lung Association, the Canadian Cancer Society , and your local health department to find other group programs in your area.

Doctors, school nurses, local health centres or health departments may also be able to provide individual counselling to support quitting after completion of Quit4Life.

e-Quit
Health Canada's free, quit-smoking e-mails will support you through the process, one day at a time. Subscribe and try it!
On the Road to Quitting
This proven program gets you off to a running start after you've spent a few minutes to complete a questionnaire and create your own personal profile.
Inventory of Tobacco Cessation Programs and Resources
This inventory is a listing of various cessation programs and services that are currently available nation-wide or province-wide.

Check out these other helpful sites.

Some of the following hyperlinks are to sites of organizations or other entities that are not subject to the Official Languages Act. The material found there is therefore in the language(s) used by the sites in question.

Plans For The 10-session Program

Step 1 - Get Psyched : Motivate Yourself To Quit And Stay Smoke-Free

Session 1. What Are the Advantages of Quitting Smoking?

Theme: Program Introduction and Motivation

Objectives:

Participants will

Get to know each other and the facilitator
Explore their current smoking habits
Learn more about the Q4L program
Provide input into group rules
Increase their knowledge about the benefits of quitting smoking
Calculate the amount of money they spend on cigarettes
Practice diverting attention from smoking

Before you start Session 1

The first Q4L session has many purposes. Your most important objective is to motivate students to come back! You also will provide a taste of how other sessions will be run, and set the tone for the group. Most facilitators try to maintain a balance between fun activities and contentladen activities, with an emphasis on providing new information that students find interesting.

Plan this first session carefully. You will be 'marketing' the program, and at the same time explaining organizational details such as scheduling, location, attendance requirements. A checklist can help you deliver essential information succinctly, without boring participants with unnecessary details.

Do you want to know if participants cut down, quit or developed new skills after Q4L? If so, you will need to distribute the pre-program questionnaire (Baseline Survey) at this first session, so you can compare with data at the end (Q4L Program Evaluation Survey). Read more about evaluation on pages 15-17, and use the surveys provided on 33-34 & 143-145.

The Baseline Survey can also help you tailor the program to participant needs. It is a way of collecting information on how many cigarettes participants are smoking, how often they have tried to quit in the past, and what motivated them to attend Q4L.

Facilitator's Checklist

Attendance requirements (school, your expectations)
Session schedule (which day of the week does the group meet, at what time, might this change)
Length of each session (will any be longer or shorter)
Food and drink (will you bring lunch, snacks, drinks? Can participants bring their own?)
Number of sessions (10; possible follow-ups?)
Importance of attending all sessions (your expectations, any incentives)
Non-smoking supporters (can friends attend, until which session, what's their role)
Between-session support (will you be available, when and where? If not, is there someone in counselling or administration available for support?)

Materials

Pencils
Q4L handbooks
Calculator(s)

Handouts

Baseline survey
Q4L Program Overview
Benefits of Quitting Quiz
Benefits of Quitting Answers
How Much is Smoking Costing You?

Please Note: The introductory section of the Q4L handbook contains images and information about the health effects of smoking. When Q4L was tested with youth across Canada, they asked for gross pictures to help psych them up about the negative health effects of smoking so that they would be more motivated to quit. These images are provided for participant's information, and are not part of an activity included in the Facilitator's Guide. More information on these images can be found at: http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/legislation/label-etiquette/graph/index_e.html

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Activity 1. Warm-up: Getting on the Bus

Type of activity: Highly interactive, active, large group and small groups

Notes to the facilitator

This first ice-breaking activity will take longer than warm-ups for other sessions. It will set the tone for a high level of participation. Since it is the first session, it may take a few minutes for the participants to get to the room and figure out what's going on. If there are fewer than 8 participants, reduce the number of 'buses'. You might remind youth that this activity is more fun if people don't just follow their friends, but take a chance to get to know other 'passengers'. Be attentive to mobility impairments, and adapt your instructions accordingly.

How to implement this activity

Clear space in the room to permit easy circulation.
Tell participants that there are four imaginary buses in each corner of the room, but not enough room in any one of the buses for everyone. Different people will be asked to get on and off buses pretty quickly, as you try to organize the trip. They will know when they have to change buses by listening to your instructions.
For example: "How did you get to school today? Those people who walked to school, get on bus No. 1; those who came on bus or subway, get on Bus No. 2. Bus No. 3 is for bikers, roller bladers, and skate boarders. If you came by car, motorcycle, scooter, or boat, get on Bus No. 4. Find out the names of the other passengers on your bus, and ask them what they like and don't like about the way you all get to school".
Time this so it does not last more than 30 seconds (it should feel lively, even a bit chaotic at first!) then tell them they will have to switch buses.
Use another characteristic to mix participants up in a different way. For example: "Now, people who have a dog or a cat, will get on Bus 1; those who have no pets, will get on Bus 2, those with a fish or a bird, on Bus 3; those with iguanas or snakes, on Bus 4."
Continue assigning students to buses according to other characteristics, such as:
- physical activities they enjoy (dancing, riding, swimming, other);
- favourite desserts (chocolate, fruit, pie, cake);
- languages spoken at home (English or French only; English and French;
- English and another language; another language only);
- music style preferred (rock, rap, country, pop);
- grade in school;
- having brothers or sisters;
- places visited... etc.
emember to present four options each time.
Ask people to briefly chat about what they have in common with the other 'passengers' each time they get on a 'bus'.
If some 'passengers' don't get on any 'buses', have them talk to each other while they wait at the 'bus stop' for the next set of 'buses'.
Not all 'buses' will have 'passengers' each time, and sometimes, everyone will get on the same bus. Create sub-categories when that is the case.
After three or four general themes, move into some smoking related topics: age they tried their first cigarette; number of cigarette smoked last week, or yesterday; who lives with smokers; number of years they have smoked; favourite brand; where they smoke the first cigarette of the day; how many of their friends smoke (none, all, a few).
You may want to 'get on the bus' at times yourself; for instance, if you want the participants to know your smoking status, you could include yourself in some of the smoking-related items.
At the end of the activity, ask what they have learned about each other; something they learned about someone new; or something new about a friend.

Activity 2. Baseline survey

Type of activity: Individual paper/pencil, followed by large group discussion

Notes to the facilitator

Being able to compare group members' smoking habits at the beginning of the program (Baseline Survey) with their patterns at the end (Q4L Program Evaluation Survey) will help you assess how the program helped students to change their smoking behaviours.

This activity is not only for collecting data. It provides the opportunity to take a fist step in self-awareness about own smoking patterns. It also leads into the next activity, building up the expectation/ motivation that by the end of the program participants will have a different smoking pattern.

This information also can help you tailor the program to the groups' needs. For example, knowing how much and how long students have been smoking can tell you something about possible extent of dependency, and how long smoking has been a part of their daily lives.

How to implement this activity

Explain the purpose of the survey
Hand out the "Baseline Survey" and answer questions
Give students the choice to use either their own name or a nickname that they need to remember for the last session, to be able to compare baseline and evaluation surveys at the end of the program.
Collect the survey
Tell students that they can look at their answers again at the last Q4L session
Begin to discuss smoking patterns, based on survey items, leading into the next activity.

Activity 3. Introduction and Overview of Q4L

Type of activity: Presentation with questions and answers

Notes to the facilitator

With this activity, you present the goals for the entire program, making reference to the previous activity. Keep it lively, interesting, and motivating.

Some participants may forget to bring the handbook to each session, or may misplace it. Consider possible options: participants take handbook with them to consult between sessions/ leave their handbooks with the facilitator between sessions/have a double set of handbooks available.

Verify access to internet prior to mentioning Q4L website. ( www.Quit4Life.com)

Make sure that your own rules are laid out openly and included, as well as school/setting rules. This is the time to clarify any expectations about permission to participate, confidentiality, absences.

Sample Group Guidelines

We will begin and end on time
We will keep what happens here in confidence
We will take turns speaking
We will never put down anyone in the group
We will inform the group facilitator if we cannot come to a session
We do not have to participate in an activity if we do not want to
We do not have to speak if we do not want to.

How to implement this activity

Provide an overview of the Q4L program, including the 4-Steps involved and the goals. You may want to use visual aids and give each participant the "Q4L Program Overview" Handout.
Tell participants that the program has been tested and improved with input from youth like themselves for over 10 years.
Mention the success of the program, and mention the website: www.Quit4Life.com (verify access to internet first).
Explain how the Q4L handbook will be used.
Go around the circle, asking for expectations and individual goals.
State your own expectations.
Lead a discussion on group rules and why we need them, following up on 'expectations'.
Collect group rules on flip chart and make sure that there is consensus on those that are 'negotiable'.

Activity 4. Benefits of quitting

Type of activity: Individual or pair exercise followed by large group discussion

Notes to the facilitator

Knowing some of the benefits of quitting motivates students to commit to participate in the program. Since saving money is an important motivator, you can combine this and the next activity.

How to implement this activity

Introduce the activity with a question such as "Almost everyone knows that smoking is bad for your health, but do you know all the benefits of quitting?"
Ask participants to brainstorm some advantages of quitting, and list them on the chart
Form pairs, or have students complete activity individually
Hand out "Benefits of Quitting Quiz" to each individual/pair to complete (no more than 3 minutes)
Hand out "Benefits of Quitting Answers" after/during discussion.
Facilitate discussion using 'myths and partial truths' approach.

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Activity 5. How much is smoking costing you?

Type of activity: Demonstration followed by individual practice

Notes to the facilitator

Young people may have an idea that smoking is costing them money, but they may not have calculated how much money. Realizing the amount that goes up in smoke each week, and visualizing how that can be transformed into money used to buy something they want, is an important motivator to quit.

Increasing cigarette prices has been called the best smoking cessation program there is. Studies show that increases in cigarette taxation that increase costs have a direct effect on youth smoking.

One Q4L participant stated: "The biggest issue to quit is the cost issue. I've got bills that I have to pay. I have to save up for my university. I can't afford to smoke." [Q4L participant]

How to implement this activity

Provide information about cost of cigarettes, increased taxation, and how this influences youth smoking rates.
Ask participants to guess and discuss: How much do Canadian teenagers spend on cigarettes each year? Correct answer is: 330 million
How much does the Canadian tobacco industry spend on marketing cigarettes to all Canadians? Correct answer is: 20 million.
Ask for a volunteer or use your own ex-smoking history to calculate the cost of smoking. Use the Cost Calculator formula from the handbook or use the "How Much is Smoking Costing You?" Handout. Present on flip-chart or on the board:
Ask participants to do the same calculation, or do it for/with them (depending on math skills in group).
Talk about what they would like to have that money for, if they have ever tried to save money for something, and if they succeeded.

"You have already spent (xx) on cigarettes since you started smoking. If you smoked for another 10 years, that would be an additional (xx)."

Wrap-up

Invite students to summarize what they have learned during the session.
Ask if they have any questions.
Tell them what they can expect during the next session.
eview organizational details; make sure they know where and when the next session will take place.

Activity 6. Cool-off: If I had a million dollars...

Type of activity: Guided group conversation

Notes to the facilitator

Ideally, you don't want the youth to leave this session desperate for a smoke. Taking one's mind off smoking is an important skill to learn in the quitting process. Keep this final activity light, lively, and short.

How to implement this activity

Explain the purpose of the cool-off activity: to take their mind off smoking and to focus on something else after talking about smoking throughout the session.
Ask participants what they would do if they won or inherited a million dollars.
Final reminder: time and place for next session, any other housekeeping details.
Finish on a positive note, give positive feedback to participants about their involvement in this program and thank them for their participation.

Baseline Survey

Name (or Nickname):
Date:
Age:
Grade:

Male
Female

About Smoking

1. In the last 30 days, did you smoke at least one cigarette?

Yes
No
I used to smoke but I quit

2. Do you usually smoke every day?

If Yes , choose one of the options below

A few puffs (drags, hits) every day
1 to 4 each day (a pack usually lasts me all week)
5 to 9 each day (less than a pack a day)
10 to 19 each day (around a pack a day)
20 or more every day (around a pack a day or more)

3. Do you usually smoke every week?

If Yes, choose one of the options below

A few puffs (drags, hits) every week
1 to 6 every week
7 to 14 every week (around half a pack a week)
More than 15 cigarettes every week (around a pack a week)

4. I want to:

Quit smoking now
Quit smoking in the next month
Cut down the number of cigarettes that I smoke
Quit smoking some time, not sure when

5. Have you ever tried to quit smoking before?

6. How long have you smoked regularly?

Less than one year
1-2 years
3-4 years
5 years and longer

Who else smokes?

7. About how many of your friends smoke?

None
A few
About half
Most
All

8. Do you live with any people who smoke?

9. How often do people smoke inside your home?

Most of the time
Sometimes
Never

10. How much does second-hand smoke bother you?

1 - A lot
2 - A little
3 - Not at all

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Q4L Program Overview

The four Q4L steps are:

Step I : Get Psyched: Motivate Yourself To Quit And Stay Smoke-free

Session 1. What Are the Advantages of Quitting Smoking?
Session 2. Why Do I Smoke

Step II : Get Smart: Know Yourself And What To Expect When You Quit

Session 3. What Do I Know About Smoking? How Do I Deal with the Challenges of Quitting? Session 4. What is Withdrawal and How Do I Deal With It? Session 5. How Can I Deal With Stress?

Step III : Get Support: Create A Positive Environment For Yourself

Session 6. Get Support

Step IV : Get On With It: Know What To Do When You Quit.

Session 7. How to Prepare for My Quit Date? Session 8. How Can I Stay Smoke-free? Session 9. How to Socialize Without Smoking Session 10. Living Smoke-free: A Celebration!

Benefits of Quitting Quiz

Do you know the facts on smoking?

Take this quiz to find out how much you really know about smoking.

1. Your health doesn't begin to improve until several years after you quit smoking.

True
False

2. Quitting smoking can improve your looks.

True
False

3. Quitting smoking can improve your social life.

True
False

4. Quitting smoking may help you get and keep a good job.

True
False

5. The earlier you quit smoking, the greater the benefits.

True
False

6. Quitting smoking can reduce your risk of injuries

True
False

Benefits of Quitting Quiz- Answers

1. Your health doesn't begin to improve until several years after you quit smoking.

The correct answer is 'False'

Your health improves within hours after your last smoke. Within 8 hours of your last smoke, carbon monoxide (the stuff found in car exhausts) levels drop and the oxygen level in your blood increases to normal. Within 2 days of quitting, your sense of smell and taste will begin to improve. Within 4 days, it gets easier to breathe and your lung capacity increases. Between 2 weeks and months, blood flow throughout your body improves. Your chances of developing serious health problems such as a heart attack or trouble breathing also starts to go down only one day after quitting. Don't be fooled into thinking that heart and lung problems happen only to older adults. Early signs of heart disease and stroke can be found in teens who smoke. Did you know that teens who smoke suffer shortness of breath almost three times more often than teens who don't smoke? Smokers are more likely to have problems with their teeth and gums. Every cigarette does you damage, no matter how old you are.

2. Quitting smoking can improve your looks.

The correct answer is 'True'

People who smoke tend to have more and deeper wrinkles in their skin. Over time, smoking yellows your teeth, destroys your gums (which causes tooth loss and bad breath), and stains your fingers. Smoking may also cause eye problems (cataracts).

3. Quitting smoking can improve your social life.

The correct answer is 'True'

More and more people are non-smokers. More and more public places are becoming smoke-free, including coffee shops and restaurants. So, smoking may actually reduce your chances of meeting new and interesting people. Prospective dates may find smelly clothes and bad breath a real turn-off. People admire someone who has overcome a difficult challenge like quitting smoking.

4. Quitting smoking may help you get and keep a good job.

The correct answer is 'True'

Smokers take more breaks from work. It's getting worse since more offices and workplaces are going smoke-free. Smokers also tend to miss more work due to illness. Having designated smoking areas also costs employers money for cleaning and insurance. Employers, like everyone else, admire people who can overcome a difficult challenge like quitting smoking. It shows maturity and perseverance when you set a difficult goal and are able to meet it.

5. The earlier you quit smoking, the greater the benefits.

The correct answer is 'True'

The earlier a person quits smoking, the less damage is done and the faster you will enjoy the benefits that come from being smoke-free. It's not just your health that will improve. Think of all the extra money you'll save each week you're smoke-free. While it's never too late to quit, the sooner you quit, the better.

6. Quitting smoking can reduce your chances of getting injured.

The correct answer is 'True'

Even smokers who are physically fit break bones and sprain ankles more often that similarly fit non-smokers. And the more the people smoke, the more likely they are to develop blisters on long walks. People who smoke 10 cigarettes or less a day had a 35% chance of injuries, compared to only 20% for those who do not smoke. For those who smoke 10 cigarettes or more per day, injury rates increase up to 40%.

How Much is Smoking Costing You?

Let's say you are 15 years old right now. By the time you finish high school you could spend over $10,053 on smokes!

Think about it.

You can buy a car for that kind of money, or pay 2 years tuition at most schools.
And the money saved each year from not buying cigarettes will pay for the insurance, gas, maintenance, and fuzzy dice.

Cost Calculator: How much does it really cost to smoke?

How much do you spend on cigarettes each week?

$

Multiply by 52, the number of weeks in one year.

x 52

Multiply the cost per year by the number
of years you expect
to smoke.
x

This is how much you'll spend over the years you expect to smoke.
= $

*this will probably be a low estimate because it doesn't include how much the price of cigarettes goes up each year. But it gives you an idea.

From now...	Events	Cost for 1 pack/day
1 day	tomorrwow	$9
1 month		$270
1 year		$285
3 years	finished high school	$10,053
10 yrs	you'll probably get married!	$35,970
15 yrs	you'll be 30!!	$56,809
30 yrs	you'll be your parents' age!!!	$133,266
50 yrs	you'll be... your Grandparents' age?!	$277,843

*assumes the price of cigarettes goes up 2% every year.

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Session 2. Why Do You Smoke?

Theme: Dependency, Values and Goals

Objectives:

Participants will

Increase awareness about own smoking routine
Explore in more detail the reasons why they are smoking
Learn more about addiction
Increase their motivation to quit smoking
Increase their awareness about their values and/or goals
Know more how smoking interferes with achieving their goals and being true to their values.

Before you start Session 2

This session will help students begin the process of monitoring their smoking behaviour, which will continue through many sessions. Becoming more aware of certain patterns in smoking behaviour will make it easier later to begin changing this behaviour. Youth will discover in which situations they are most likely to smoke and what triggers them to light up. Seeing smoking in the context of their own values and goals in life, and how their smoking behaviour might interfere is an important step in increasing motivation to change.

In this session, you will introduce a key activity in the Q4L program: the Smoke Detector Tracking Form. Some students enjoy filling it out and find it immediately useful. Others may see it as a tedious task, and be reluctant to use it on a regular basis. Avoid presenting the Smoke Detector Tracking Form as 'homework'; rather, as a step towards self-awareness. Encourage participants to use it at least a few times: by monitoring smoking, they will gain a lot of insight about their smoking patterns.

Some facilitators have used incentives (e.g., a draw among all completed forms for a small prize) in the subsequent session, to motivate participants to complete the Smoke Detector Tracking Form.

You may find it useful to show a motivational movie to students at this point in the program, or to use a resource person who is able to talk about the effect that smoking or quitting has had on her or his life. Your challenge in facilitating will be to ensure that those students are emotionally touched by other peoples' experiences without being overwhelmed. Sensitive facilitation will alert you to reactions that may trigger feelings of helplessness that reduce motivation to make changes: the "I will die anyways, what's the point" reaction.

Many participants are likely to have close relatives that smoke, or may have lost a family member to smoking-related illness. As the facilitator, remind them that it is not their responsibility to change adult behaviour. You can encourage them to set a good example for others, and tell them that many adults do quit when they realize how smoking impacts on others. For example, during the National Pilot, an elder who was approached to become a support person for a native youth trying to quit, decided also to quit to become a good role model.

Materials

Popsicle sticks, or some other small items (straws, pebbles, candies... )
TV and video/DVD machine, video

Handouts

Your Smoking Profile
Your Smoking Profile - Answers
My Values Worksheet
My Goals Worksheet
How to Use the Smoke Detector Tracking Form

Activity 1. Warm-up: My first cigarette of the day...

Type of activity: Visualization, interactive, large group

Notes to the facilitator

This activity can replace the paper and pencil activity (below), and is designed for groups that prefer moving and acting rather than writing things down. You could use a combination of Activity 1 and 2 or move back and forth between the two.

How to implement this activity

Ask people to stand up or sit in a circle.
As you read the following script, individuals will either sit down or move out of the circle when you reach the moment at which they have their first cigarette.
Keep playing, providing each person with 5 Popsicle sticks (or other item) which they put in a container (or ash tray) when they have smoked their first, second, third cigarette, until the five are used up.
"Imagine your morning routine: You wake up... you are still in bed... you get up... go to the bathroom... get dressed... go into the kitchen... (Check: Has anyone had their first cigarette by now?)... you have a cup of coffee or tea... you have breakfast... (Check: Has anyone had their first cigarette by now?) you grab your stuff... you leave the house... (Keep checking periodically, until all have had their first cigarette); you get to the bus stop (into the car, on your bike, walk to school)... ; you meet your friends); after the first class... ; at lunch... ; after school... ; at the bus ... during homework... when you get to work... during your work break... on your way out with friends... at a coffee shop... watching TV... getting ready for bed..."
The idea is to see who uses up their 'cigarettes' fastest.
Encourage students to be honest with themselves. If you have time and interest, you can play the game out fully, encouraging those who have no cigarettes left to try to bum one from those who still have some. How do those being asked for one react? What does that tell them about their own and other person's level of dependency? How easy is it to share, if you only have one left?
Discuss smoking rules at home, whether their parents know that they are smoking, and how that influences where and when youth smoke their first cigarette.
Talk about how week days and week-ends might be different. You can play out a week-end day, if you think it will help students to realize their patterns better.

Activity 2. Your Smoking Profile

Type of activity: Paper and pencil with group discussion

How to implement this activity

Hand out "Your Smoking Profile" questions, or use the questions in the handbook.
Ask students to fill out questions and to reflect on their answers.
Discuss with reasons why each person smokes, and help them identify situations in which they are most likely to smoke.
Categorize the reasons for lighting up into feelings, situations, environment.
Ask: "Do you think knowing why you smoke will help you quit when you're ready? In what way?"
'Score' with them their level of dependency, using the "Your Smoking Profile - Answers".
Discuss what makes someone nicotine-dependent.

Activity 3. Other smokers' experiences

Type of activity: Video or resource person presentation, followed by group discussion

Notes to the facilitator

Videos, films, and presentations from 'real live people', can have long-lasting effects on youth, and increase their motivation to quit. A character in a video or an external resource person serves to reinforce the quit message you are providing. Using videos and resource people also offers additional role-models for behaviour change.

You may want to choose a film from the resource list, or contact local organizations for their recommendations. Pre-view the film yourself before you show it to the group.

As an alternative, consider inviting a resource person to speak to your group, such as someone who has struggled with nicotine dependency and suffered the consequences; a person who is knowledgeable about addiction; a youth who has successfully quit. If you invite a resource person, share with them what you hope to achieve with this activity (session and activity goals). They may be able to suggest additional questions for the discussion.

How to implement this activity

Show the video and/or introduce the resource person.
Provide time for questions and answers, if a resource person is present.
Questions to start a discussion about a presentation or video might include:
- How has smoking affected this person?
- Why did she or he quit, or did not quit?
- What made it hard for them to quit?
- How did this affect the people around her or him, such as other family members or friends?
- What would you suggest to her or him to do immediately, in the long run?
- How does smoking affect people beyond family and friends?
- What is the cost of smoking to society (absenteeism due to smoking-related illnesses, increases in health costs, doctor visits, etc.)

Activity 4. What's important to you?

Type of activity: Individual paper-and-pencil followed by group discussion with flip-chart

Notes to the facilitator

With this activity, you bring the focus back on to the students, while keeping in mind the messages from the film/ resource person and their growing insight about when and why they smoke.

Choose either 'Goals' or 'Values', depending on group characteristics and the time available.

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How to implement this activity

Pass out either the "My Values Worksheet" or "My Goals Worksheet".
Ask students to reflect on their goals or values individually or in small groups. They can make notes on the handout.
In the large group, discuss how goals or values might be compromised by continuing to smoke: What does smoking have to do with it?
Collect answers on flip chart.
Invite students to summarize how they might be truer to their own values or how their own goals might be achieved more easily, if they quit.

Activity 5. Introduction of the Smoke Detector Tracking Form

Type of activity: Demonstration followed by individual practice

Notes to the facilitator

Selling the Smoke Detector Tracking Form is important for the success of the program. Use your motivational speaking skills to get buy-in from teens. You could share the following comments from other teens that used the Smoke Detector Tracking Form:

"It told me when was the ones where I did not mostly need it, and the other ones that would be harder for me to quit off". (Q4L participant).

"Tracking helped me. I cut out all the number ones and number twos, and kept to the number fives and then slowly ... it worked" (Q4L participant).

How to implement this activity

Ask participants to take Smoke Detector Tracking Form out of their handbook and review how to use it, or pass out the "How to Use the Smoke Detector Tracking Form" Handout.
Make sure that everyone understands how to use the form. Provide an illustration or example that everyone can see.
Ask them to monitor the next 25 cigarettes (or as much as they smoke between sessions), as a minimum for the next session. You can offer incentives.
emind them of the ice-breaker activity and how important it is to know exactly when and why they're smoking each cigarette.
Tell participants that besides knowing their values and goals, another significant piece of information that will help them quit smoking is knowing WHEN they have a cigarette and HOW they feel before they smoke it.
Inform students that the filled out form will help them cut down and quit, that this has worked in the past. Refer to previous successes of other Q4L participants.

Wrap-up

Highlight the main issues discussed during this session
Tell participants that you are looking forward to seeing them next week and hearing about anything they have learning about their smoking habits.
Confirm the time and place for the next session.

Activity 6. Cool off: One thing that I have changed...

Type of activity: Guided group conversation

How to implement this activity

Go around: Ask students to think of something that they were able to change about themselves that they're pleased with; or some health or environmental or family/ community-related accomplishment. It can be a very small thing, like brushing their teeth every night, not biting their nails, or starting an exercise routine. How did they manage to do this? What or who helped them? What did that feel like?
If students are reluctant, start with one thing that you have managed to change in yourself, to get them going (i.e., getting up earlier; not using the car all the time; watching less TV; eating more fruit; not chewing gum during meetings; listening more before reacting; remembering to recycle paper, etc.).

Your Smoking Profile

The following questions are excerpts from the 30 question profile available at www.quit4life.com , beginning in March 2005.

Some people see smoking as part of their identity or self-image. They feel that they are more 'themselves' when they smoke, and they can't imagine themselves as a non-smoker. Some people become dependent on nicotine, a substance in tobacco that causes a short-term boost to the body. Find out about your own patterns. There are two ways you can get hooked on smoking: physical addiction and habit. Smoking can also be triggered by emotions or self-image.

My Smoking Identity

1. Is smoking a part of your identity?

2. Do you like the way you think it makes you look?

3. Is it part of how you want others to see you?

My Level Of Dependency

4. Do you ever have a craving for a cigarette (a feeling that you really need a cigarette at that time)?

5. If Yes: How soon after you wake up do you crave your first cigarette?

Less than 15 minutes
15-30 minutes
1/2 an hour to one hour
1 - 3 hours
More than 3 hours but less than a day
More than a day
I don't crave cigarettes

6. Do you avoid places where you can't smoke (movies, classes, church) because you find it hard to spend more than a couple of hours without smoking?

7. Do you worry that you will run out of cigarettes?

8. If you're low on cigarettes, do you spend a lot of time thinking about how you're going to get more cigarettes?

9. Since you first started smoking cigarettes, how much have you increased?

A lot
A little
Not at all

10. Can you function better after you've had your first cigarette of the day?

Smoking Habit

11. Is smoking a habit for you?

12. Is smoking something you do without thinking, in response to certain activities, when you're with other smokers or part of your routines?

13. What usually makes you light up?(Check all that apply to you)

Getting up in the morning
Hanging out with friends
Having coffee or tea
Drinking alcohol
Being at a party
Before or after a meal
During breaks (at school or at work)
Relaxing at home or watching television
Talking on the phone
Driving
Feeling happy, great
Feeling stressed or nervous
Feeling bored
Feeling angry or sad
Working or concentrating
Finishing work or completing a task
Being with other smokers
Waiting around (bus, mall, etc.)
Other moods or activities

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Your Smoking Profile - Answers

My Smoking Identity

If your answers were YES to either question 1, 2, or 3:

Your answers to the questionnaire suggest that smoking has become part of your identity. It might be hard to admit that you smoke partly to create, express or connect with a certain image, but many smokers do. It's not always a conscious choice. In fact, the "picture" or sense you may have of yourself as a smoker probably comes from images you're not really aware of or that influenced you a long time ago. Over time, smoking has become part of your identity -- your sense of who you are.

Did you know that, contrary to what the advertisers tell us, most people find smokers to be unattractive? Many people are repelled by the smell of smoke, never mind the taste of a smoker's kiss. Throughout your life, you have probably been exposed to images of smoking -- in movies, on television, in advertising and in your daily life. And if you liked certain things about the characters or people you saw smoking, you probably learned to link those qualities with smoking itself. You likely formed a lasting, emotional connection between smoking and how you also wanted to be, feel, look and be seen.

Stained fingers, yellow teeth, stinky breath... If you're tired of this look, Quit4Life can help you make a plan to change your image.

If your answers were NO to questions 1 to 3.:

Your answers to the questionnaire suggest that being a smoker has not yet become part of your identity. This will make it easier to quit! The "picture" or sense you have of yourself does not include the image of 'smoker'. You probably know that many people are repelled by the smell of smoke, never mind the taste of a smoker's kiss. Take a hard look at the real image of the smoker: stained fingers, yellow teeth, stinky breath... is this really you? If you don't identify with this look, the Quit4Life program can help you make a plan to change your image.

My Level Of Dependency

4. Do you ever have a craving for a cigarette (a feeling that you really need a cigarette at that time)?

Yes (1)
No (0)

5. If Yes: How soon after you wake up do you crave your first cigarette?

Less than 15 minutes (3)
15-30 minutes (2)
1/2 an hour to one hour (2)
1 - 3 hours (1)
More than 3 hours but less than a day (1)
More than a day (0)
I don't crave cigarettes (0)

6. Do you avoid places where you can't smoke (movies, classes, church) because you find it hard to spend more than a couple of hours without smoking?

Yes (1)
No (0)

7. Do you worry that you will run out of cigarettes?

Yes (1)
No (0)

8. If you're low on cigarettes, do you spend a lot of time thinking about how you're going to get more cigarettes?

Yes (1)
No (0)

9. Since you first started smoking cigarettes, how much have you increased?

Yes (1)
No (0)

10. Can you function better after you've had your first cigarette of the day

Yes (1)
No (0)

Your level of dependency : Highest Score possible: 13

a) 0 to 3 very low dependence
b) 4 to 6 medium dependence
c) 7 to 9 high dependence
d) 10 to 13 very high dependence

a) 0 to 3 very low dependence

Your answers to the questionnaire suggest that your level of nicotine dependency is relatively low: You likely don't smoke every day; you don't feel cravings when you stop smoking for more than a couple of hours; you don't worry about where your next cigarette will be coming from, and you can wait hours or days between smokes. In general, the more cigarettes you smoke, the shorter the time between waking and your first smoke, and the more intense your withdrawal symptoms, the more addicted you are. But don't be fooled. Addiction develops over time. So, just because you don't have signs of high dependency now, doesn't mean you won't develop them in a few months. The good news is that you may find it easier to quit when you know what to expect, prepare, and make a good plan. The Q4L program can help you to do that.

b) 4 to 6 medium dependence

Your answers to the questionnaire suggest that your level of nicotine dependency is moderate: You likely smoke every day or almost every day; you feel some cravings when you stop smoking; you worry a bit about where your next cigarette will be coming from; you can wait a couple of hours after you wake up before your first smoke. In general, the more cigarettes you smoke, the shorter the time between waking and your first smoke, and the more intense your withdrawal symptoms, the more addicted you are. But don't be fooled. Addiction develops over time. The longer you delay quitting, the more dependent you will become. But the good news is that no matter how dependent you are, you can quit smoking. Did you know that about half of all the people in Canada who have ever smoked have already quit? You can deal with nicotine withdrawal and get past it in a few days. You will need to know what to expect, prepare, and make a good plan. The Q4L program can help you.

c) and d) 7 to 13 high to very high dependency

Your answers to the questionnaire suggest that your level of nicotine dependency is relatively high: You likely smoke every day; you feel strong cravings or withdrawal when you stop smoking for more than a couple of hours; you try to smoke soon after you wake up; you spend time worrying about where your next cigarette will come from; and you feel the urge to smoke even when it is inconvenient. In general, the more cigarettes you smoke, the shorter the time between waking and your first smoke, and the more intense your withdrawal symptoms, the more dependent you are. But the good news is that no matter how high your level of dependency, you can quit smoking. Did you know that about half of all the people in Canada who have ever smoked have already quit? You can deal with nicotine withdrawal and get past it in a few days. You will need to know what to expect, prepare, and make a good plan. The Q4L program can help you. You may also want to review some of the other options for programs to help you quit.

About Nicotine Dependency

Since the effect only lasts a few minutes, you need to absorb more and more nicotine to make the effects last. Over time, people find they need to smoke just to feel "normal", and feel bad when they go a few hours without smoking (withdrawal). Once they quit for good, withdrawal symptoms will pass within a few days.

You may be dependent on nicotine if you feel a strong urge to smoke or begin to feel uncomfortable after only a few hours without it; or if you worry about running out of cigarettes and spend time figuring out how to get more. Some other signs include feelings of frustration, restlessness, worry, or difficulty in concentrating.

Your level of dependency can depend on things like your genes and how long you have smoked. Physical addiction occurs when your body needs nicotine to relax, get a temporary boost of energy or to prevent cravings and withdrawal (e.g. irritability, tension, sadness, sleeping problems, headaches).

My Smoking Habit

You may be smoking as a habit if you consistently associate smoking with certain places, people, actions, or feelings. For example, whenever some people drink coffee, they crave a smoke. Even smelling coffee makes them think about smoking. Some people associate smoking with going to a party, and hanging out in a particular place, driving, or being with a friend.

If you checked any of the items in question 13, smoking likely is a habit for you. Smoking is something you have learned to do. It's a powerful habit that has become part of your routine. Most regular smokers don't even think about lighting up. Reaching for a cigarette is a reflex -- an automatic reaction to specific activities or moods. You have learned to associate smoking with some activities, situations, and feelings.

These are just some of the activities and feelings you may have learned to respond to by smoking. They are the "triggers" that make you want to smoke. To break your smoking habit, you need to practice connecting them with other things -- not cigarettes. The Quit4Life program will help you learn more about your own triggers, and find ways to handle them so you can break the habit of smoking.

If you checked that you often smoke when hanging out with friends or at parties, or when you are with other smokers. Smoking may help you connect with your family and friends, but it isn't the only thing you have in common. They won't lose interest in you just because you quit. You may have many friends who smoke. But think about the number of non-smokers you also see everyday. Today, most people do not smoke. Chances are, more and more non-smokers are an important part of your life. How would you react, as a smoker, if someone told you they were trying to quit? Would you be upset or supportive? Next time you are with some of your friends, ask them how they would feel if you decided to quit smoking. Ask them if they would support you. True friends will respect -- not reject -- your decision. The Quit4Life program will help you learn more about getting the support you need to quit from family and friends.

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If you checked that you often smoke when you feel certain emotions, such as sadness. If you sometimes feel a little depressed or are facing a crisis in your life that makes you tense or sad, it's easy to say: "So what if I smoke?" Don't be fooled. You have more compelling reasons to stay healthy. Learn more about how to deal with feelings without smoking in the Q4L program.

If you checked that smoking is something you do when you want to take a break, relax, or deal with stress. One reason for this is that smoking provides you with an opportunity to take a short break from stressful or daily tasks.

The relaxation you associate with smoking comes more from other things you do when you smoke. Think about it: When you smoke, you are probably taking a break from your work, thoughts or activities. You may meet briefly with other smokers or friends to chat. You probably connect it with many other relaxing things like finishing work, being at a party or enjoying a good meal. And guess what? People who don't smoke enjoy all these things too!

In fact, smoking actually increases your heart rate and breathing. It may also increase your blood pressure. Smoking can cause sleep problems, which may increase your level of stress. So, even though smoking may briefly help you to relax, over the not-so long term it may actually increase your level of stress.

Stress is a part of life. Smoking may make it worse. There are better ways to cope and, in spite of your stress, there is no better time than now. Learn more about other ways to relax and about positive ways to deal with stress in the Q4L program.

If you checked that you often smoke when you are working or trying to concentrate, to get more energy. Smoking may make you feel energized, but the feeling doesn't last. The damage can! When you smoke, nicotine passes quickly from your lungs to your blood to your brain. Since nicotine is a stimulant (like caffeine), it makes you feel a bit more energized and alert. In time, however, your brain adjusts to these temporary "boosts" by actually "turning down" your normal energy level. After a while you may feel the need to smoke just to feel "normal". Learn how to find other ways of boosting your energy level with the Q4L program.

If you checked that you often smoke before and after a meal. You may think that smoking helps you control your weight. However, it's important to keep in mind that most adults gain weight over time whether or not they smoke. It's also important to remember that if you stop smoking you will not necessarily put on weight. In fact, about one third of people do not change their weight after they quit. People who put on weight gain an average of 3 kg (about 5 to 7 pounds). So, the effect of smoking on weight is relatively small for most people.

Ex-smokers are sometimes tempted to eat more for a variety of reasons. You may be, too. You may feel hungrier. Food will definitely smell and taste better. It may replace the feeling of a cigarette in your hands and mouth. Learn how to prepare for this before you quit with the Q4L program.

If you checked that you usually light up when you are bored, waiting around, driving, or talking on the phone. Many young people smoke because they feel that they have nothing else to do, or to kill time. These also are the 'automatic' cigarettes, the ones that you just light up without thinking about it. You've taught yourself to automatically pick up a cigarette at these times, without even asking yourself if you really need it. When you are bored, your brain tells you that it needs something to do, to get some energy... But smoking is not the only answer! Did you know that people who smoke a lot are less likely to be physically active, and also have less energy because they're smoking? It becomes a vicious circle: You don't have much energy to do anything, you get bored, you smoke, and you lose more energy. Are you still bored after you light up that cigarette? The Quit4Life program can help you quit being bored... get your energy back!

If you checked: When you complete a task, or when you are relaxing Like many other smokers, you probably associate smoking with relaxing after doing something, taking a break. Why not be honest with yourself? Admit it when you need or want a short break and just take it -- instead of hiding that need behind a cigarette. The Quit4Life program can help you find ways to relax and enjoy your life...but get rid of the cigarettes!

You're not alone in noticing that there is a link between drinking alcohol and smoking. Heavy drinkers tend to be heavy smokers. You've probably learned to associate having the fun of having a drink with smoking. But most people can have a couple of drinks without lighting up... you can learn to do it too. Researchers also have found that people use both alcohol and tobacco to help them cope with stress, anxiety, frustration, or depression. Alcohol can loosen your inhibitions, and make it harder to stick to a quit plan, especially at first. The Q4L program can help you find different ways of coping with feelings of stress, so that you do what you planned to do: quit successfully.

What's Important to You? - My Values Worksheet

Write down your values on this worksheet. Next, put a star * next to your top values, the ones that are most important to you. Then, write down how quitting smoking fits with the things you value.

These are the things I value:	My most important values	How quitting smoking fits with my values:

My Goals Worksheet

Write down your short term and long-term goals on this worksheet. Then, write down how quitting smoking will help you achieve those goals.

	My goals	How quitting smoking will help me achieve those goals:
My goals for the short term






My goals for medium term






My goals for the long term

How to Use The Tracking Form

* Put this form in your cigarette package or other convenient place
* Record every cigarette you smoke until the chart is complete

For the column on mood put

G= if your mood is good or happy before you smoke]
B=if you're in a bad mood, angry or sad before smoking
?=if you're not sure how you feel before smoking

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For the column marked "Rate", put in a number between 1 and 5 where

1=I could have done without this smoke
5=I really had to have this cigarette

Cig. #	Time	Place	Who with	Mood (g/b/?)	Rate (1-5)
Example: 1	8:40	Bus stop	Karen, Mark, the usual	G	2
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.

Step II- Get Smart : Know Yourself And What To Expect When You Quit

Session 3. What Do You Know About Smoking? How Do You Deal with the Challenges of Quitting?

Theme: Health Knowledge and Roadblocks

Objectives:

Participants will

Increase knowledge about health facts and smoking
Know more about how smoking impacts on women and men
Increase awareness about their smoking behaviour
Know their own reasons or roadblocks that keep them from making changes to their smoking behaviour
Increase their commitment to cut down smoking

Before you start Session 3

This session is about increasing or solidifying participants' knowledge about health and smoking. In this session, you will begin to address the 'roadblocks', and excuses that keep many people from taking the big step to quit. Students will also start to monitor their own smoking behaviour. You will motivate students to practice cutting down.

Although most youth will tell you that they've 'heard it all a million times', they may not have all the facts about tobacco, dependency, and quitting. The "Jeopardy" game is a fun way to confirm and expand participants' knowledge. Some of the information (for example, on sex and smoking) might also be new to them. You can adapt the quiz to your site: for example, include questions about smoking bylaws in your town/city/region; or smoking rules in your school or on school property.

Debriefing the Smoke Detector Tracking Form will be an important activity in this session. The discussion will help you assess the level of trust that is developing among group members, as they share what triggers them to smoke specific cigarettes, and how 'necessary' each one was. In facilitating the discussion, ensure that participants respect each others' experiences and feelings, emphasizing that these are unique to each person.

Materials

Facts & Figures Quiz For Facilitators (see Appendices A and B)
Buzzers or funny noise-makers (bells, squeaky toys, whistles)
Stop-watch or a watch with a second hand

Handouts

Your Roadblocks to Quitting and How to Face Them
Quit Calendar

Activity 1. Warm-up: Jeopardy Game

Type of activity: Small groups, interactive game

Notes to the facilitator

Since this is a fun activity, it also works as the session warm-up. You can make it as 'real' a quiz show as you like, and set up the room accordingly. You might want play the role of a quiz show host (choose one that most students will recognize!). Using 'gruesome' pictures when appropriate can make the activity even more interesting (see Health Canada posters, websites in resource list on page 23.

You may want to use gum, candy, or other 'silly' and inexpensive prizes.

How to implement this activity

Divide participants into two or three small groups.
Select questions from various areas of the Facts and Figures Quiz, according to the specific characteristics of your group.
Determine the rules the quiz show: ask participants to decide whether they can discuss their answers in the group, or if they will have individual answers; either taking turns answering questions, or using buzzers or other noisemakers when they know the right answer.
Explain how much time they will have to come up with an answer (not more than 20 seconds); and how points will be assigned to each group for correct answers.
You may want to offer 'bonus points' for asking questions when they weren't sure, taking a chance, being willing to change their minds in view of new information, etc.
To make this a deeper learning experience, spend time between questions, or at the end of the 'game', providing more detail for both the 'wrong' and 'right' answers.

Activity 2. Smoke Detector Tracking Form

Type of activity: Demonstration, individual practice of paper-and-pencil activity, group discussion

Notes to the facilitator

Not all students find it easy to complete the Smoke Detector Tracking Form. Those who have not done so need your continued support. Make sure they don't feel as if they 'failed' because they 'didn't do their homework', but encourage them to try again.

How to implement this activity

Find out if participants completed the Smoke Detector Tracking Form for 25 cigarettes.
If not, review how to do it, and ask them to fill the form out in class, counting back from their last cigarette, the one before..., as well as they can remember.
Or, use one student's Smoke Detector Tracking Form (with their permission) as an example.
Flip the Tracking Form over to review the Smoke Detector questions and scores.
Ask each student to complete the Tracking Form with the Smoke Detector scores (e.g. Mood good or bad, rate cigarettes from 1-5)
Discuss: What did you find out about yourself? About the time, place, and mood for each cigarette? Who were you with for each one? Did your mood change after each cigarette, or not? Did you really need this cigarette, if it did not make a difference?
Ask students to count up how many number #1, 2, 3, 4 or 5 cigarettes they had, and talk about them in relation to the above.
You can take a group inventory on a previously prepared group Smoke Detector Tracking Form (on flip chart).
If the group responds well to paper and pencil activities, use the Quit Calendar.

Activity 3. Roadblocks

Type of activity: Brief lecture, followed by flip-chart-guided group discussion

Notes to the facilitator

Review the information from the handout below. When discussing roadblocks, you also can talk about the importance of decision-making and 'excuses' that can block people from changing anything in their lives. If you have used a video or resource person in a previous session, remind them of the roadblocks that held them back and kept them from changing their behaviour earlier in their lives. Most of us can find a reason not to make changes (too much stress; after such and such a date it will be better; as long as someone else smokes I won't be able to quit... ), unless there is a crisis. You may want to discuss with students whether they feel they need a crisis before taking the big step to quit, and why.

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How to implement this activity

Summarize key learnings from this session so far: increased health knowledge; tracking which smokes they don't really need.
Ask: With all we know, what keeps us from changing our smoking behaviour?
Collect replies on flip chart.
Add additional reasons from the handout "Your Roadblocks to Quitting and How to Face Them".
Ask: What would you tell someone who is concerned about.... [discuss each of the roadblocks]?
Encourage students to come up with ways to address each roadblock, and write them all down, realistic or not.

Activity 4. Making a plan for cutting down

Type of activity: Individual paper-and-pencil; flip-charted group discussion

Notes to the facilitator

Starting small, cutting out the 'easy' cigarettes, is an important step in the process of quitting. Participants are more likely to experience success cutting out these non-essential cigarettes, which promotes self-efficacy.

At this point in the program, you may find that some youth are ready to quit 'cold turkey'. Tell them that you admire their motivation; however, most people find it useful to prepare really well for this step to ensure success. You can compare this process with practicing for a marathon: you start with running 5k and increase gradually, to build up the stamina you need. If you do it this way, you don't feel discouraged and you do achieve your goal.

Nevertheless, if a group member wants to try quitting, do not hold them back. Focus on motivating them to stay in the group, to reinforce their success, get support with withdrawal. Communicate that you and the group will not pass judgment if they cannot stick to their plan at this time.

How to implement this activity

Ask: After having reviewed your roadblocks, are you ready to make a plan?
What would it take to cut out the #1 cigarettes?
Go around and ask each participant: What will you do to cut out the first #1? How many of your #1s are you planning to cut out?
Take notes, or collect each person's plan on flip chart.
Hand out "Quit Calendar", or use the calendar in the handbook, and ask students to make a plan for the upcoming week.
Tell youth that the next time you meet as a group, you will review how well each person's plan has worked. Emphasize that you will assess their plan together with the group.

Activity 5. Cool-off: Changing something in my routine, try something new

Type of activity: Guided group conversation

How to implement this activity

Ask students to come up with ideas for one thing that they will do differently, one change from their usual routine, next week. Emphasize: nothing to do with smoking.

Go around: Have students describe one thing they'll do to break their routine, to surprise themselves, their friends, or their family members.

Be prepared with a suggestion from your own life, if they need help to get started. For instance: walk to work instead of taking the bus; take a different route to get home; buy flowers for someone; bring lunch for a friend; change the furniture in your room; listen to someone else's favourite CD; have a nap after school; paint your nails a different colour; carry a water bottle; read the sports section of the paper instead of the horoscopes, etc.

Your Roadblocks to Quitting and How to Face Them

Choose the reasons that keep popping up when you think about really quitting:

I might lose friends, everyone in our group smokes, my boyfriend/girlfriend smokes.
I might not be able to do it, what if I fail?
What's the point? We're all going to die some day.
What if I get really irritable, will I be able to handle my feelings?
I'll probably gain a lot of weight.
Quitting is more stress than I can handle right now, I have enough on my plate.

Fear of losing friends

Some people smoke because they are afraid of losing friends if they quit. But real friends care about you. They respect your wishes and they will respect your decision to quit smoking. Don't let your fear block the road to your friends. Many people find their friends are happy to support them when they are trying to do something hard, like quitting. In fact, they might want to quit as well, but are worried they might lose your friendship!

Fear of failure

No one likes to fail. But people who try difficult challenges aren't a failure. Don't you admire people who try to do things they believe in? Everyone who seriously tries to quit is a winner. Even if you don't quit for good, each quit attempt allows you to learn something important about yourself and your smoking. You can use each quit attempt to figure out how you will do things differently on your next quit attempt. What seemed to be a roadblock can become just another giant step forward.

Sense of immortality

"We're all going to die sometime" is an excuse to avoid quitting. While it is true we're all going to die, it's not an excuse for continuing to smoke. A long time before they die, most smokers get sick. Many smoking-related illnesses get worse over time. So, long before you die your quality of life will get worse. You won't be able to do the things you like. For example, teenage smokers produce much more mucus in their lungs than non-smokers or former smokers. You may find it more difficult to breathe while biking, hiking, or swimming. Teen smokers also get more colds and other nagging illnesses. Who needs that? Finally, your health is only one good reason to quit smoking. Check the benefits of quitting again for other reasons, and don't let this excuse block your way to a healthier life.

Feeling sad or angry

Sometimes, people feel sad or get the blues right after they quit smoking. If you are very dependent, you may experience feelings of irritability as the nicotine starts to leave your body. But these feelings don't last for long: they will pass within the first few days. Eventually, feelings of sadness will be replaced by the pride and the sense of freedom you feel from quitting. Remember that this roadblock won't be there for long.

Weight gain

Some people keep smoking because they are afraid they will gain weight if they quit. But did you know that many people don't gain weight after they quit? Even people who do gain weight put on only 2 or 3 kg (4 to 6 pounds) on average. People who are physically active are less likely to gain weight. Also, most people put on weight as they get older. In other words, you may put on weight whether or not you quit smoking. Don't believe ALL the stories you hear about how quitting smoking caused someone to gain weight. You can reduce or eliminate weight gain after quitting by making sure you eat healthy food and remain physically active. That's one way to deal with this roadblock.

Feeling too stressed out

Sure, quitting might seem like adding stress to your life. But quitting can also help you reduce your stress level. And, there are lots of other ways to help you deal with stress without smoking. Session 5 in this program is just about that: how to deal with stress. So try out some of those activities before you let this roadblock get in your way.

Quit Calendar

Make your plan to practice quitting next week. Write it down on the Quit Calendar. Use the "Savings Calculator" to find out how much money you will save when you don't have those unnecessary cigarettes.

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This is my plan for next week:

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday	$ saved

Want some ideas? Check out another smoker's Quit Calendar.

Week	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday	$ saved this week
1			Cut out 1s	The same	Cut out 2s	Avoid triggers. Try different pool hall.	Keep 1s and 2s out	Insert savings for 10 cigarettes
2	Tackle the 3s			Avoid triggers		Avoid triggers: Go dancing, not playing pool.		Insert savings for 20 cigarettes
3	Smoke only the three I really need	Smoke only the three I reall need	Try to delay first smoke	Delay first smoke	The same	Avoid triggers: don't drink be the designated driver for after the party.	Smoke only the two I really need	Insert savings for 30 cigarettes
4	Add up all the money I saved	Quit date	Try out some of the stress-buster activites in the program. Tell everybody to not offer me any more smokes!!	Call Q4L support buddies and check how they're doing - maybe go out to non-smoking club	Find out when summer soccer tryouts are- get to the gym?	Practice saying no to smokes with drinks- look at the 'scenarios' in the program	!Call Kim and get to the gym for sure.	Insert savings for 50 cigarettes

Session 4. What is Withdrawal and How Do You Deal With It?

Theme: Withdrawal, Cravings and Temptations

Objectives:

Participants will

Increase awareness about routines and what it is like to change them.
Report back on their successes in cutting out cigarettes that they do not need to smoke.
Review and change or adjust their plan to cut out certain cigarettes.
Increase knowledge about withdrawal, temptations, and cravings and how to deal with them.
Increase knowledge about how to use alternative activities to decrease feeling of boredom

Before you start Session 4

After Session Three, participants who are cutting down on cigarettes may experience withdrawal symptoms, cravings, and temptations.

This session will help them to become more aware what it is that they are experiencing. Not all youth experience withdrawal symptoms. Each person's responses to reduced smoking might be quite different from that of their friends. Most youth will experience 'temptations', however. You can help them to develop concrete plans to deal with these situations.

Boredom has been found to be a trigger for smoking with youth. Realizing that smoking will not fill the void can help youth to develop a new set of action plans.

Stress is also a major 'trigger'. The following session (Session 5) is devoted to stress.

Materials

Handouts

What Can You Expect When You Quit?
How Can You Cope?
How to Break the Boredom Cycle

Activity 1. Warm-up: Try something new

Type of activity: Experiential, group discussion

Notes to the facilitator

This activity follows up on the cool-off from the previous session. Before the group arrives, set the room up differently from how it is usually set up. For example, close the curtains if they are usually open; set up the chairs in rows, if they are usually in a circle; bring a snack, if you don't usually have one; play loud music, if the room is usually silent. You can also change something about your own appearance: wear only one glove; roll up only one pant leg to the knee; or put on a big hat or large sunglasses.

How to implement this activity

Let students speculate about what is different in the room, and why. For instance, why you are wearing only one glove? (hurt your hand, lost the other one, forgot to take it off...)
Discuss briefly: How long did it take them to notice that something different was happening? What was it like to experience and to do something different? How did it feel: exciting, unfamiliar, confusing, fun? Did it make you aware of what normally happens, things or routines that you don't usually notice?
Go around: Each person reports on the novel activity they tried last week. As facilitator, make sure you also have something new to report on.
Discuss briefly: What was it like? What were the reactions of people around you? Did they notice?

Activity 2. Reviewing success and refining plans

Type of activity: Motivational lecture; group discussion

Notes to the facilitator

Referring to the warm-up, point out how changing smoking behaviour involves breaking with what you do almost without thinking; deliberately changing some part of your familiar routine. Youth may be resistant to believing that they have a routine (sounds boring); or, may be equally reluctant to any suggestion that they could or should try to change anything.

Not all youth will have been able to cut out the Number 1s. Encourage the group to help them to maintain a positive outlook, to keep trying, and remain motivated. Tell them you know that they will succeed in making that first change, taking that first step.

How to implement this activity

Refer to the Number 1 cut-out plans of the previous session as each participant reports how often s/he was able to cut out the number 1 cigarettes in the previous week.
Discuss: Was it harder, easier than expected? What made it harder, easier? How did your plan work? What would you do differently next week?
Elicit suggestions and ideas from those who were more successful, or share your own experience.
To keep up the good work, ask: Who is ready to go for the number 2?
Reinforce for participants: they are in the process of preparing to quit by practicing skills in cutting down. Remind them that they are aiming for a quit date after the 7th session (3 more weeks to go).

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Activity 3. Withdrawal, Temptations, and Cravings

Type of activity: Group discussion with flip-chart

Notes to the facilitator

Every young person experiences different degrees of each of the three sensations. Many will experience a combination of the three. Social smokers are most likely to experience temptations. Those who are nicotine dependent are more likely to experience withdrawal symptoms and cravings. Help them become aware of which one is harder for them to deal with at this point.

How to implement this activity

Mention that withdrawal, temptations, or cravings may have made it hard for participants to cut out cigarettes.
Ask students to provide examples for each of the three reactions. Collect on flip-chart.
Discuss the different types of reactions.
Encourage students to talk about which they experienced most and least; and how they know that.
Lead a discussion about withdrawal, temptations, and cravings. Use information in the Q4L handbook or the Handouts: "What Can You Expect When You Quit?" And: "How Can You Cope?"
Summarize: withdrawal experiences are individual; not everyone has physical difficulties (from nicotine dependence) when quitting smoking, but all will have to break the habit of smoking.

Activity 4. Dealing with boredom

Type of activity: Experiential; pairs or small groups; large group discussion

Notes to the facilitator

Boredom can become one of the temptations to smoke. Some youth find it interesting to learn about the physiology of boredom. Others relate to a discussion of the social dimension of boredom. Once participants begin to see boredom as a sign that they need to become active and use their creativity, boredom becomes a motivator for action.

What is boredom?

In our society, boredom tends to be categorized as something 'bad'. We think that we need and should be entertained and stimulated non-stop. Is this true?

Boredom is the reaction that your brain has when it needs to get some energy. Feeling bored stimulates the body to do something... anything... to bring up those oxygen levels and get some positive energy going. People who smoke a lot are less likely to be physically active, get less oxygen, and also have less energy, because they're smoking. It becomes a vicious cycle: You don't have much energy to do anything, you get bored, you smoke, and you have even less energy. Ask yourself: Am I still bored after I light up a cigarette? Probably nine times out of ten you are... So... stop being bored and get your energy back!

How to implement this activity

Begin as an 'experiential' activity. Ask all participants to keep perfectly still, and not do anything at all for 60 seconds. When the time is over, ask how it felt. Some may tell you that all they could think of was their next cigarette; others, that it took much longer than one minute; or that they were feeling sleepy, or restless. Share how boring it was to do nothing, and how bored you also started to feel.
Go around quickly: what's the most boring situation you've ever been in (be prepared to include this boring conversation with this bored group... )
Ask youth to share whether they have ever smoked because they were bored (refer to #1 and #2 cigarettes in the Smoke Detector activity).
Form pairs or small groups to come up with activities they can do to relieve boredom, instead of smoking.
Collect on flip chart and add ideas from other Q4L participants (see Handout: "How to Break the Boredom Cycle").

Activity 5. Cool-off

Type of activity: Experiential

Since physical activity is one of the ways to deal with boredom, have a yawning contest: get everyone to stand up and yawn really loud and long, stretching out their arms, rubbing their eyes, bending over limply, rolling their eyes, to show how terribly, terribly bored they have been... and, at the same time, getting oxygen to their brains!

Finish by reminding youth that, strangely enough, too much boredom can be stressful, and that the next session will be about stress and how to deal with it.

What Can You Expect When You Quit?

When some people quit, they experience withdrawal from nicotine, temptations and cravings to smoke and/or the habit of smoking. It's important to know whether you will have to learn to deal with these. Remember, not everyone will experience these things. These reactions can be very mild or very strong.

Short-term physical withdrawal

This may include feeling grouchy or irritable, bored, hungry, tired, depressed, or nervous. Some people also have trouble sleeping or cough more than usual. Some people don't feel anything or have only one symptom. Other people feel a lot of symptoms. Withdrawal occurs because nicotine is leaving your body. The symptoms will last less than two weeks after quitting.

Cravings to smoke

The urge to have a cigarette is called a craving. Certain smells (e.g. the smell of someone else's cigarette or the smell of fresh coffee) or sights (watching your friends gather in a familiar spot to smoke) may remind you how much you miss smoking. You may miss the taste, smell or feel of a cigarette. Cravings can last for a few days or a few months after quitting.

Temptations to smoke

Temptations cause you to have a craving. Seeing, smelling or touching something familiar can be a temptation. The most powerful temptation is seeing a cigarette or watching someone else smoke. You can also be tempted to smoke because a friend offers you a cigarette (they may not realize you have quit smoking). You may be tempted to smoke before, during or after stressful situations, or to help you feel better.

Breaking old habits

There are many habits or routines associated with smoking. For example, some people like to hold onto a cigarette or lighter and play with them in their hand. When they quit, they miss having something in their hand. You may also miss having something in your mouth. Review your tracking form to see what are your 'triggers' for habitual smoking.

How Can You Cope?

Dealing with short-term physical withdrawal

Yes, these symptoms are short-term. In about two weeks after quitting, these symptoms will disappear or you will feel them with much less intensity. Check the symptoms that you either already have experienced or are worried about:

Withdrawal Symptoms

Feeling grouchy or irritable
Bored
Hungry
Tired
Stressed
Depressed
Nervous
Trouble sleeping
Coughing (more than usual).

Headaches, nervousness, irritability

Try some relaxation exercises
Take a hot bath or shower
Listen to some relaxing music.
Drink lots of water and juice
Make a sign for your door to warn people: Grouch trying to quit; Give me 2 weeks!
Find something funny to do, something that will make you laugh!
Ask a friend for a neck rub or a back rub.

Boredom

Stay active.
Find new things to do.
Play a game of cards.
Check out the Internet;
Play the piano. Play the drums. Bang on a pot with a stick.
Read a book.
Do a crossword.
Go for a walk.
Go to the movies or to a mall where you can't smoke.

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Hungry

Try drinking lots of water.
Eat low calorie snacks like fruit or veggies.
Offer to cook dinner (some people find that they are less hungry when they cook or prepare food themselves).
Get a piece of gum.
Ask yourself: Are you hungry or are you bored?

Trouble sleeping

Temporarily eliminate coffee, black or green tea, cola or other sources of caffeine.
Drink herbal tea instead
Get some exercise during the day (not before bedtime).
Try doing some relaxation exercises before bedtime.
Open the windows and let in some fresh air.

Constipation

Eat more fruits and vegetables.
Drink plenty of water and juice.
Avoid white bread, try some whole grain instead
Go for a walk, or do some other exercises.

Cough

This is your body trying to clear your lungs. It will pass in a few days. If it gets too bad, try a mild cough syrup or cough drops to soothe your throat.

Dealing with cravings

When a craving hits, try to distract yourself by doing something that requires concentration.

Do some deep breathing - get more oxygen into your brain!
Try a game
Write a letter to a friend
Shoot some hoops
Play with a stress ball or hackey sack
Watch a video
Paint your nails
Talk to your quit buddy
Try chewing sugarless gum.
Go to the bathroom and put on your makeup
Do something to relax yourself like reading a book, walking around the block or taking a hot shower.
Dance to brilliant music.

Fortunately, most cravings pass in a few minutes. Play the mind game and stay in control! Tell yourself that your mind can be stronger than your urges.

"Whenever I wanted to have a smoke, I chewed spits (sunflower seeds). It really worked to take my mind off it." (Q4L participant)

Dealing with temptations to smoke

The best way to cope with temptations is to avoid them.

Remove cigarettes, lighters, matches and ashtrays.
If other people in your house smoke, ask them to put away their cigarettes.

Scan your calendar or agenda every day to identify situations that may tempt you to smoke and then prepare for them. Review your tracking form and your quit calendar.

Let's say you like to smoke when you go to parties. If you can't avoid going to a party, then you will need to practice various ways of saying no when someone offers you a cigarette. For example, you could say, "No thanks, I'm trying to quit." You could say, "You go ahead without me, I'm just going to go to the washroom," or you could ask a friend to go with you to offer support. The key is to learn to recognize potentially tempting situations, and then prepare three or more strategies you can use if a situation comes up.

Breaking old habits

There are many habits or routines associated with smoking. For example, some people like to hold a cigarette or lighter and play with them. When they quit, they miss having something in their hand. You may also miss having something in your mouth.

There are at least two ways to deal with habits -- either replace the feelings you got from smoking (e.g. relaxation) with something else, or find a way to break the connection with smoking.

Keep your hands busy by drawing, playing cards, working at the computer or video game or doing a craft.
Work on things that require you to concentrate.
Do something that makes it harder to smoke, such as taking a shower, brushing your teeth, sitting in a no-smoking section, eating a carrot, or chewing gum.
Temporarily stop drinking coffee or meeting with the people you most associate with smoking.

How to Break The Boredom Cycle

Make a point of noticing when you are bored: Being bored is not something bad in itself. It is a signal from your brain. Your brain tells you that it needs 'brain food'. Obviously, smoking will not feed your brain.
You are the only one who can stimulate your brain. This will require investing a little energy on your part. You have to decide what you are going to do. You have a choice to let boredom control you, or to take action. Easier said than done... but it's the only way out of the boredom cycle.
Start with something small, but DO IT. Next time you're about to light a smoke because you're just bored, plug into a different source for energy. Stretch, go for a walk, do some deep breathing. Put on new lipstick. Catch up on e-mails. Try a different hairstyle. Sit in another chair, change your view. Start a chain letter. Call a friend you haven't spoken to for a while. Chat with a friend you just saw an hour ago. Study for a test (OK, bad suggestion). Do the crossword. Invent new lyrics for your favourite song. Practice a dance step. Send someone a snail mail postcard (go to the store, buy the postcard, write on it, go to the post office, buy a stamp, lick it, put it on the card, put the card in the mailbox...). Open the window, breathe some fresh air. Make a list about why you're so bored. Make a list of times when you weren't bored. Make a paper airplane with the list...
Make longer-term changes in what you do for your brain. What other youth have done: Got involved in something they thought is important Helped somebody, volunteered Found a job Checked out school clubs Started a new club Joined a sports team/club Wrote an article for student or community paper Got out that bike or skateboard Set a goal, and made a plan to go after it (planning a trip, getting better marks, running 10k, learning to play guitar) Checked out activities at a community centre Started a new hobby (cooking, drawing, taking photos, learning to build something) Learned to dance Got involved in environmental campaigns Picked up that book and started reading again
You will have to try more than once to break the boredom rut. Make it happen! If there is nothing to do where you live, it's about time to get that changed. Talk to your friends, write to the newspapers, talk to your mayor, councillor, or other representative, start a campaign. Get something going... you can do it!
And the next time you get bored, whatever you do, try to get your brain off automatic replay. That boredom cigarette? You really don't need it.

Session 5. How Can You Deal With Stress?

Theme: Stress

Objectives:

Participants will

Identify own level of stress
Increase knowledge about what causes stress and how the body experiences it
Identify own coping style
Practice skills how to prevent stress
Increase their relaxation skills

Before you start Session 5

Most youth say they started smoking regularly because of stress. Stress is also one of the main triggers that gets adolescents to reach for a cigarette again when they try to quit. As one Q4L participant said:

I cut down a lot. I was smoking about a pack and a half a day. Now I am down to about 3 to 4 packs a week, and I only smoke when I am stressed out or after I eat now" [Q4L participant].

Many people find that smoking temporarily helps them relax. However, smoking increases their heart and breathing rate. The body gets used to being a little "high" all the time. Eventually, it becomes difficult to relax. Therefore, smoking can actually cause stress. Research shows that once people stay smoke-free for a while they feel less stressed than when they were smoking. If youth can remember how they used to relax before becoming a smoker, they may be able to cut back even more and eventually quit.

If you feel unprepared or uncomfortable to lead a session on relaxation, find a resource person in your school or community to do so. It is really important, not only to 'talk' about relaxation, but to actually practice it and develop some skills in this area. Relaxation skills improve with practice, just like musical or sports skills. Learning relaxation techniques may help student during exams, job interviews, tests, and other stressful situations.

Your group may want to continue practicing relaxation skills at the beginning or end of each session after this introduction, to replace the warm-up or cool-off activities. Some Q4L facilitators have distributed copies of relaxation tapes, encouraging youth to use these before going to bed to make it easier to sleep.

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Materials

Tape recorder, music tape

Handouts

Take The Stress Test
Stress Test Results
Understanding Stress
Preventing Stress
What's Your Coping Style?
What's Your Coping Style? Answers
Progressive Muscle Relaxation

Activity 1. Warm-up: Visualization or Imagery

Type of activity: Experiential, guided visualization

Notes to the facilitator

This activity may take longer than the usual 'warm-up'. Become familiar with the visualization script before leading this activity. Read it out loud several times, to work out an appropriate pace. Leave pauses. Change the script to reflect your own way of saying things, your own expressions and vocabulary. You may want to try doing the visualization yourself!

How to implement this activity

If you can, set up the room to encourage relaxation: mats or pillows on the floor; soft lighting; not too cold. Have relaxing music playing softly in the background.
As students arrive, encourage them to sit down comfortably, or even lie down. Briefly explain they are going to do a relaxation exercise as a warm-up. Ask them to close their eyes, and focus on breathing gently in and out, while they imagine being in their favourite place.
Once participants have come in, begin to read the visualization script, below.

Imagery Instructions

Make sure you're sitting or lying comfortably. Close your eyes and try to clear your mind for a moment. Breathe deeply two or three times.

Now, imagine that you're at a really comfortable, relaxing place.

You might be on a sandy beach, at the banks of a river, gazing up at a mountain, by the shore of the ocean or lying in a large open field... You might be watching the clouds drift across blue skies on a beautiful summer day, or lying on the dock, gazing at the moon and its reflection in the water... You might be taking a warm bubble bath by candlelight... lying on a soft warm rug in front of the fireplace... having a sauna after a day snowboarding... or curled up in your bed under a nice soft blanket on a day you don't have to get up early...

Have you chosen a place? Imagine that's where you are...

Try to imagine what you are experiencing with each of your senses... What do you see... what do you feel... what do you taste... smell... hear...

Your skin is warm... from the sun, from the fire, from the warm water... but cooled by a gentle breeze.

You are surrounded by comfort, softness, warmth.

Take a deep breath, and imagine your lungs filling with clean, fresh air, with a subtle perfume of fresh spring flowers...

Take another deep, cleansing breath, this time, your lungs fill with air that carries the scent of pine trees...

Imagine you hear the sound of waves gently lapping against a sandy shore... Take another deep, slow breath, and this time, imagine your lungs are filling with air that smells of the ocean breezes... Spend a couple of minutes creating your own private fantasy world. Take another deep, slow breath.

Now, start to come back to reality: slowly move your fingers, toes, stretch your arms.

Gently open your eyes and notice how relaxed you are.

Activity 2. Stress Test

Type of activity: Individual paper-and-pencil, group discussion

Notes to the facilitator

In this activity, students will look at their stress levels. Most youth enjoy quizzes. Be attentive to literacy levels, and modify the activity accordingly.

If any participants score in the highest category (16 and above), you might want to refer them for some extra support: school guidance department, counselling services, or other options available in your area.

How to implement this activity

Hand out copies of the "Take the Stress Test" quiz to each student to fill out individually.
Score together using the "Stress Test Results".
Discuss: what did each person find out about him/herself?

Activity 3. Understanding and Preventing stress

Type of activity: Interactive presentation/lecture; role plays in pairs

Notes to the facilitator

Prepare an interactive presentation about understanding stress. The amount of detail and length of the presentation depends on the interest of the group. You might include some of the following points:

Stress reactions are very individual. The things that cause stress for you may not be a problem for your friend, and things that bring stress to your friend's life may not worry you at all.
Not all stress is bad: for example, some stress can help you perform better, e.g., if you are too relaxed about a certain test, you might not be mobilizing enough energy to perform well.
Some of us have physical signs of stress, such as muscle tension and difficulty sleeping (insomnia). Others may react more emotionally with outbursts of crying or anger.
Both having too much to do and having nothing to do can be stressful!
Your feelings about the events in your life are very important. By understanding their own reactions to stressful events, people can learn to handle stress effectively.

How to implement this activity

Present information on stress, using the "Understanding Stress" Handout.
Ask students to share examples of what stresses them out, and what they do to prevent stress.
Collect suggestions on flip-chart. Try to group these into the five Stress-Prevention skills from the "Preventing Stress" Handout: > Problem solve or make decisions > Avoid putting things off (procrastination) > Ask for help > Use positive self-talk > Don't take on more than you can handle
Select a couple of the 'stressed out' examples.
Encourage pairs of students to role play different ways to handle these situations, using any of the skills in the Preventing Stress Handout.

Activity 4. What's Your Coping Style?

Type of activity: Small and large group, discussion

Notes to the facilitator

Increasing participants' awareness about the kind of coping style they tend to use in stressful situations, helps them to prepare for the consequences that each style brings with it. It also will help them to realize that there are different ways of dealing with the same situation, and that they might not be locked into one type of reaction.

How to implement this activity

There are two options:

Option 1: Read the scenarios in "What's Your Coping Style?" out loud for the whole group, and ask each student to choose one of the three solutions, writing it down.
Option 2: Divide the group in two, pass out "What's Your Coping Style?" Handout, let them discuss the scenarios, and decide which style each person would use. Emphasize they don't have to agree.

Tabulate (on flip chart) how many chose A, B, and C. Read out loud the description of each of the three coping styles from the "What's Your Coping Style?-Answers" Handout.

Discuss: Can you relate to this? Do you usually use this style of coping, or do you use other styles as well? What are the advantages and disadvantages of each style?

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Is your coping style related to how you're dealing with quitting smoking? (e.g., taskoriented might find it easier to do careful planning and stick to their plan, emotional might find it easiest to motivate themselves by remembering experiences of other smokers; and distracters might need to make a special effort to face the issue).

Summarize: There is not necessarily a right or wrong style. All three styles might work and can be applied in different situations.

Activity 5. Cool-off: Progressive Muscle Relaxation

Type of activity: Experiential

Alert students that some of them might find the following activity funny or strange, but that it does not hurt to try. Many people have found this a very useful skill to learn, including actors, politicians, athletes, and musicians.

As with the earlier guided visualization, read it out loud a few times, checking the pace, before using it with the group. You may want to try it yourself!

How to implement this activity

Using the script from "Progressive Muscle Relaxation" guide students through the exercise
Make sure you give students enough time to 'come back into reality'
Discuss briefly what it felt like to do this activity. You can pass out copies of the script; some people tape the script and play it back when they want to practice.

Take The Stress Test

(Adapted from TeenNet, www.cyberisle.org)

Check all the boxes that apply to you. The more honest you are with yourself the better the results!

Do you tire more easily?
Are you working harder and accomplishing less?
Are you easily frustrated?
Is it hard to relax, fall asleep, or get up?
Do you frequently feel sad, frazzled, or overwhelmed?
Are you forgetting and / or losing important things?
Are you more irritable than usual?
Are you seeing your friends or family less?
Are you too busy to do routine things and social activities?
Are you suffering physical symptoms (headaches, stomach aches)?
Do you feel drained and unmotivated at the end of the day?
Is it hard to feel happy and enjoy life?
Is it hard to laugh at yourself and at other's jokes?
Do you have little to say to other people?
Is it hard to find time for significant others?
Do you feel like you just want to lie around watching TV?
Do negative thoughts keep running through your head?
Do you get angry easily?
Do you feel like you never have time off?
Do others tell you that you are stressed?

Stress Test Results

5 and less checked: You're doing fine! Keep using your current strategies for coping with stress. Make sure you turn to them later if you find yourself feeling stressed as you cut down and quit smoking. Read about preventing stress and find out what else you can do to stay stress-free.

6-15 checked: You're beginning to stress out! Start making changes in the way you work and play. Find out more about how to prevent and deal with stress, especially when you cut down and quit smoking. Check out the section below on understanding stress and find out about some coping strategies for some ideas.

16 and more checked: You might need some help now to deal with your stress! You are in danger of stressing out. Stress can create many health and other problems. You need to make some changes in your life, not only quitting or cutting down on smoking. Ask a professional or your family doctor for some help. It might help to find out more about how stress works on your body understanding stress and what coping strategies others have used to reduce stress.

Understanding Stress

Everybody talks about stress... but are you really clear about what it is? Many people aren't. This is because both good and bad things that happen to us actually can create stress. Stress becomes a problem when we are not sure how to handle an event or a situation. Then worry sets in, and we feel "stressed."

The Stress Response

When you find an event stressful, your body undergoes a series of changes, called the stress response. There are three stages in the stress response.

Stage 1 - Mobilizing Energy

At first, your body releases adrenaline and you feel a 'rush'; your heart beats faster, and you start to breathe more quickly. Both good and bad events can start this reaction: For example, a good event that causes stress might be a first kiss with someone you really like; a bad event might be finding out you've failed an exam. Believe it or not, your body may react the same way to both situations! Usually this first stage doesn't last too long - your breathing, heart rate, and adrenaline level come back down to normal.

Stage 2 - Consuming Energy Stores

If, for some reason, you stay in the first stage for a longer period of time, your body begins to use up its resources of stored sugars and fats. At Stage 2, you will feel driven, pressured and tired. You might drink more coffee, smoke more, and consume more alcohol than is good for you. You may also experience anxiety, memory loss, catch colds or get the flu more often than normal.

Stage 3 - Draining Energy Stores

If you do not resolve your stress problems, your body goes into Stage 3. It will need more energy than it can produce. You can become chronically stressed. At this stage, you may experience sleep problems (insomnia) and personality changes. You might misjudge situations around you. Some people also develop serious sickness, such as heart disease, ulcers or mental illness.

Preventing Stress

The best way to cope with stress is to prevent it! Regular physical activity and eating healthily has been found to prevent stress. Some other good ways are:

Make Decisions.
Avoid putting things off (procrastination)
Ask for help
Use positive self-talk
Don't take on more than you can handle

Make Decisions

Here are two techniques: Sit down with a pencil and paper and make some lists.

List your options.
List the consequences of each option.
Write your response(s) to this question: What will happen if I don't choose at all? If you don't make a decision, that's a decision in itself and it also has consequences. Once you realize that something is going to happen whether you make a decision or not, you may find the decision easier to make.

Can't make up your mind? Maybe your subconscious can help you: Sleep over it!

Before going to bed, think about your problem and the various choices you could make. Think about each choice clearly in your mind. Tell yourself you're going to make the decision while you sleep.

You may not name the solution the next morning but if you keep trying, you will eventually awaken with your mind made up.

Avoid putting things off (procrastination)

If procrastination causes stress in your life, learn to stop putting things off. Most people don't do their best work under pressure, no matter what they say. To avoid 'last minute deadline' stress, practice planning ahead for work... and for recreation. Make a weekly schedule and fill it with lots of time for fun and relaxation, as well as work. That way, you'll enjoy your playtime because you'll be doing it at the time you've decided will be best for you, not when you think you should be working. And when you are working, you won't resent it because you'll know that your leisure time is coming up soon. Set goals, rather than wander in life.

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Ask for help

People who haven't learned how to ask others for help often feel needlessly stressed. Asking people to help you is not a sign of weakness, it is actually a sign of strength: you know your skills, abilities, and limits. You have gone as far as you can on your own and now it is time to involve others. Think of the times your friends or family members were stuck and asked you for help. Did that make you feel good? Helping others and being helped makes us human. Try it in a situation when it is not so urgent, to practice asking for help, and see what it is like. You may find this is one of the best ways to reduce your level of stress with day-to-day things.

Use positive self-talk

Much of our stress is due to the conversations which we have with ourselves, in our own minds. This is called 'self-talk'. Some self-talk is useful and constructive (e.g., planning your day, congratulating yourself on a job well done). However, some self-talk is negative and can contribute to your stress level ("I know I will fail again"; "I'm not smart enough to do that"; "Nobody will like me any more"). Negative self-talk can lead to stress and even make you behave in ways that are not in your best interest. Being aware of negative thoughts is the first step in dealing with it. Once you recognize it as negative, ask yourself: "Is this really true, or reasonable?". You may want to visualize a stop sign, or some other sign, that tells you to STOP talking to yourself negatively. Then,practice talking to yourself in a more positive way. For example, instead of saying to yourself, "I screwed up, I smoked a cigarette, I really blew it, forget it, all that trying for nothing, now I can't even stay quit for a day", tell yourself "I know that I will be able to say no the next time someone offers me a cigarette. I have done it before!" or: "I am learning how to handle this better and better. The more times I practice, the easier it will get"; "It is hard to be perfect all the time, but I am getting there."

Don't take on more than you can handle

The next time you say 'yes' to do something, stop yourself and think: "Do I really have time for this?" You have the following choices:

Say: "No", and explain why it is hard for you right now to make a commitment to do something.
Say: "I will think it over, I am not sure if I will have the time, but I will let you know" This way, you give yourself some breathing space to make a decision.
Say: "I might be able to do it, but not until (next week, the summer, I have got my marks straightened out)"

If this is really important to you and you really want to do it, think about what you might want to drop.

Reality check: it is impossible to have a completely stress-free life! Stress, good and bad, is part of what happens to everyone. Learn how to deal with stress so that it doesn't control you: thay's the key.

Coping With Stress

How do you deal with stress now?

There are three main ways to resolve a stressful situation. You can avoid it, you can alter it, or you can accept it.

Many of us try to avoid stress. This isn't always the best thing to do. For example, going out instead of studying for a test may help for a while, but eventually you'll be more stressed than ever. A different way to handle this situation is to alter it, by studying hard for the test. You will have done about as much as you can do. You could even reward yourself for putting in the work, by going out with friends after. The next time you're faced with a stressful problem, think about whether it's best to avoid, accept, or alter the situation causing the stress.

Problem-Solving Skills

You can learn to use problem-solving skills to deal with stressful problems, instead of trying to deal with stress by smoking...which can create more stress for you and your body. Here is a list of some skills that work. Practice these skills with some of the 'smaller' problems you face first, and see how they help you deal with some of the more stress-creating parts of your life. This long-term way of reducing stress in your life is something everyone, sooner or later, will need to do. Try one or a couple of the following ideas to see what might work for you.

Identify the pieces of the problem.
Write it down.
Brainstorm solutions.
Talk about your problems.
Take your mind off your problems.
Get more help.

Identify the pieces of the problem. Sometimes you just feel stressed and need to figure out what the problem actually consists of. Is it your schoolwork, your job, your relationship with someone, or money worries that are causing you stress? Are unimportant, little things covering up real, deeper ones? Once you know what the problem actually is, you can start to do something about it. You can also figure out what parts of the problem you can deal with right away, to reduce the overall level of stress you face.

Write it down. Keeping a journal can help you figure out what it is that is stressing you out, what the situations are that you find it hard to deal with. It can also help you notice what positive steps you have been taking to cope with stress. You may want to use a journal to help you 'brainstorm' or explore solutions, instead of dwelling on your problems. Some prefer to talk things over, though, rather than writing them down.

Brainstorm solutions. Start thinking about solutions. Be imaginative. Is there anything that you can do to change the situation, and what will happen as a consequence? Are you doing too many things (school, job, other regular activities) and is there anything that you can cut out? Who might be able to help you out? What will happen if you do nothing? If you follow this problem-solving strategy, you might be able to come up with ideas for changes that will help take the pressure off yourself. You can brainstorm by yourself or with others.

Talk about your problems. You may find it helpful to talk about your stress. Friends, family members, and even teachers may not realize that you are having a hard time. Once they understand, they may be helpful in two ways: first, by just listening to your feelings and second, by suggesting solutions to your problems. If you need to talk with someone outside your own circle of friends and relatives, think of the professional people you trust or you have a good relationship with (guidance counsellor, teacher, coach, youth worker, school nurse, family doctor, somebody at work). They also may be able to refer you to another person who can help.

Take your mind off your problems. You may be able to get rid of stressful feelings temporarily by getting busy with something. If you get involved in hobbies, sports or work, you can give yourself a "mental holiday" from your stress. Deciding that you won't think about your problems for a fixed time period can give you a little mental distance and make it easier to get back to them with a solution. Tell yourself you won't think about what is stressing you for the time it takes you to....walk to school; play a video game; fix a snack; work out at the gym; listen to a CD; take a hot bath... This is only a temporary solution, but getting some distance can help reduce the stress for a while.

Get more help. There are many helpful books, films, videos and courses to help you cope with stress. There are also counsellors who specialize in stress: ask your family doctor for a referral. There may also be courses and stress management workshops available in your community or school.

What's Your Coping Style?

Situation 1: Two of your best friends are having a huge fight and are not talking to each other. You all bought expensive tickets for a concert of your favorite band. You had to work overtime to earn the money. All three of you have been looking forward to going to this concert together for quite some time. The concert is tomorrow. What do you do?

You phone each of your friends and get their perspective about what is going on. You tell them that you were looking forward to going to the concert with both of them, and how important it is to you. You ask them to work it out between them, because it affects you too. You say you will speak with both of them again later in the evening so you can make plans for tomorrow.
You are really disappointed and down about the whole thing. You feel hurt and wonder why they are not thinking about how you might feel in this whole situation. You start to remember lots of times that you went out of your way to keep the friendships going, and feel upset that they're not trying. You phone another friend who knows all of you well, and ask for his/her support.
You decide to go for a jog, then go home and write a couple of e-mails which you'd been putting off for some time. Then you call another friend and go to the movies, not mentioning anything about the situation. You decide not to think about the whole thing again until the time comes to go the concert tomorrow.

Situation 2: Friday after school: You have a ton of homework including a big assignment that is due on Monday. Your friend has a birthday party that night, and you are working Saturday and Sunday at your weekend job.

You get right down to it and try to get as much done on your assignment as possible. You decide that you might go to the party a bit later than originally planned. You also decide to call your co-worker to see, if she can take on half of your shift on Sunday.
You feel really stressed out. You pick a fight with your sister and she blows up at you, which makes you really mad and does not help you either. You phone up your friend and talk about how miserable you feel and how much you have to do this weekend. This seems to make you feel a bit better.
You think: "I'm glad it's the weekend. Doing homework on Friday sucks." You go through your CDs to see which ones you want to take to the party. Then, you decide to go over early to your friend's house to see if she needs any help with setting up for the party.

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What's Your Coping Style? - Answers

Your coping style to solve a situation seems be Task-oriented: you may feel comfortable analyzing the situation and deciding what to do to deal directly with the situation.
Your coping style to solve a situation seems be Emotion-oriented: you may prefer to deal with your feelings and find social supports.
Your coping style to solve a situation seems be Distraction-oriented: you may use activities or work to take your mind off the situation.

Remember: There is not necessarily a right or wrong style. All three styles might work and can be applied in different situations.

Progressive Muscle - Relaxation

This is a technique to help relax tense muscles.

Select a comfortable position, sitting or lying down.
Loosen tight clothing, uncross legs and arms.
Close your eyes and focus on your body.
Begin by tensing your toes and feet, hold the tension for a second... and then let go, relaxing. Feel the difference between the tensed and relaxed state.
Now tense your lower legs, knees and thighs. Hold the muscles tensed for as long as you can and then release, relaxing the legs.
Tense the buttocks hold and then relax. Continue moving up your body.
Tense the abdomen, hold the tension and then release.
Now tense your chest area, hold and feel the tension. Then let go, release, and relax.
Now move to your arms and shoulders. Tense, hold, hold, hold... and relax.
Now tense your fingers and hands, creating two fists and holding them tight... and then relax again.
Move towards your back now. First tense the upper back and hold, then release.
Do the same for the lower back: tense and hold, release, relax.
Remember to focus on the difference between your muscles being tensed up and then being relaxed.
Now move to your neck, tense the area of the neck with your shoulders, hold and then let go.
Move towards your face now. Tense your whole face, squeeze your eyes and mouth shut, hold the tension... and then let go.
Finally: tense up your entire body, all the parts that you tensed up before, from head to toes... Hold the tension for as long as you can, and then release, letting go... and feeling fully relaxed and refreshed.

Step III - Get Support : Create A Positive Environment For Yourself

Session 6. Get Support

Theme: Importance of Support

Objectives:

Participants will

Identify small changes in relation to reduced smoking
Increase knowledge about impact of second hand smoke
Identify potential supporters
Know more about the role of supporters
Increase response repertoire and skills to deal with non-supporters

Before you start Session 6

Some Q4L facilitators have chose to deliver this session earlier in the program. Assess how important it is for your group to develop a support system beyond other Q4L group members. Some youth may find it challenging to receive support for quitting at home. If parents are heavy smokers, don't believe in quitting, or don't know that their child is smoking, it may be difficult for them to provide the necessary support. One Q4L participant recalled:

"My mum would go, like, 'Good thing that you're not smoking', and then she is lighting up a cigarette! So, it was that that made it a little bit harder. And even if she meant well, she still has her addiction to smoking..." [Q4L participant].

It may be important for some students to find a supportive friend to call; or to get additional support from adults other than their parents. Many participants will find that having friends that smoke is a great challenge; on the other hand, friends are the source of greatest support for most participants who try to quit.

"It has a little bit to do with my friends, 'cause it's the friends that I bum the smokes off, but that is only because I ask. And they don't be like, 'No, you can't smoke, so they let me have one" [Q4L participant].

"The group support was great, because all my friends were in there [in the Q4L program], and that helped, because they were not smoking either" [Q4L participant].

You may want to mention that one never knows who will be supportive until you try. It might require a little risk-taking for students to find out who will support them.

Materials

Scarves to use for 'blindfolds'

Handouts

Who Will Support You?
Support Pledge
How Can You Deal With Non-Supporters? - Scenarios
What Would Other Young People Do?

Activity 1. Warm-up: You can lean on me

Type of activity: Experiential, group discussion

Notes to the facilitator

There are many types of games and activities similar to the one described here, in which some sort of support or assistance is needed from another person to achieve a goal. The one below is offered as a suggestion. Use any from your own repertoire, or any that might fit the needs of the group. Keep the activity relatively short, and the debriefing focused.

How to implement this activity

Students form pairs.
One person is blindfolded, and leans on a second person who helps them walk around the room, or through an 'obstacle course' (chairs and desks placed in an unusual formation).
When they reach the end of the obstacle course, or after one or two minutes, they reverse roles.
A quick debrief follows:
- How did it feel to be supported and having to trust another person?
- How did it feel to have someone lean on you and depend on you for support?
- What would have made it easier/harder

Activity 2. Review of 'practice' cutting down

Type of activity: Guided individual reporting to group, motivational feedback, group discussion

Note to the facilitator

Introduce the session picking up on the debrief comments from the warm up: this session will be about getting support. Remind participants of the previous session, and how they learned that asking for help is a key ingredient to reduce stress. Asking for help also is important when quitting

Make sure that participants have some sense of 'success', even if it is small. Help them avoid negative self-talk. Keep the discussion and the feedback positive.

How to implement this activity

Go around: Review how participants have been able to cut down the 'boredom' cigarettes, the number 1 and 2.
Discuss in relation to each participant:
- What has worked and what has been hard?
- What has become easier?
- Can you drop the number 3s?
From Smoke Detector Tracking Form review, "who with", and how they rated these cigarettes.
Give positive feedback, celebrating every success, even if small.
Reminder: in the next session, they will be setting their quit dates.

Activity 3. Build your support network

Type of activity: Individual paper- and-pencil; demonstration to group; individual practice

Notes to the trainer

Tell participants that getting support is very important, and therefore, some participants likely rated the 'Who With' cigarettes high, as those cigarettes that they really 'had to have', as a 4 or 5.

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How to implement this activity

Encourage participants to think about all their different environments when making their support list: home, school, work, clubs, sports, or other places.
Individually, participants make a list of people they might ask to help them quit smoking in their different environments.

Demonstrate how to create a support web using the Handout: "Who Will Support You?"

Give each participant a flip chart page and markers.
Ask participants to create webs how people can help them quitting.
Ask each participant to put a star beside the idea that would be most important to them, and write it into their handbook or on the handout.
Distribute the "Support Pledge" Handout and discuss importance of getting it signed by next week by at least 3 people from their different environments.

Activity 4. How Does Second-hand Smoke Effect Us?

Type of activity: Lecture, group discussion

Notes to the facilitator

Most people do not want to harm others when they are smoking. As we learn more about how harmful second-hand smoke is, the general public has become more concerned. In many parts of the country smoking restrictions in public places are increasing. Being knowledgeable about the harm of second- hand smoke can motivate youth to reduce their smoking around non-smokers, and become more assertive in asking others not to smoke around them.

How to implement this activity

Provide overview of facts about second hand smoke (review facts from the quiz, or www.gosmokefree.ca.); or, use the quiz questions to assess group knowledge.
Remind participants that when they become non-smokers, they will have to protect themselves from second-hand smoke, which will also protect others.
Asking others not to smoke around them will reduce their 'temptations' to smoke.
Discuss: In which places will you have the most control about exposure to second hand smoke (e.g., own bedroom)? In which will you have less control (e.g., workplace; or living room where parents smoke)?
Summarize: this will lead into the next activity, how to deal with non-supporters.

Activity 5. Dealing with non-supporters

Type of activity: Small group role-plays, large group discussion

Note to the facilitator

To avoid polarization between smokers, non-smokers, and quitters, it might be useful to discuss why some friends might be unsupportive. In many cases it has to do with their friends' own problems (fears, insecurities, inability to quit themselves), rather than not wanting to help.

It may help to remind participants that when someone chooses to try to quit, this does not mean that they are better people, or need to feel superior to those who haven't made that choice. The decision to quit is not a decision against your friends; but a decision for yourself.

How to implement this activity

Form small groups of 3-4 participants.
Give each group two scenarios from "How Can You Deal With Non-Supporters? - Scenarios" Handout.
Ask each group to play out the scenario with a number of alternative solutions.
Participants should try to be realistic but avoid overly aggressive reactions.
Each small group presents their role play and discusses the solutions in the large groups. Discuss some of the reactions and responses from the "What Would Other Young People Do?" Handout (optional).
Model positive feedback, ensuring proposed solutions are not mocked or dismissed, emphasizing there are many ways to deal with non-supporters.

Activity 6. Cool-off: Random acts of kindness

Type of activity: Guided group conversation

Talk about a situation in which someone has helped you, one in which you asked for help, and one situation in which you helped someone. Or, report on random acts of kindness. Or, perform a random act of kindness for the youth: hand out small gifts, chocolate bars, flowers; let them leave early; give each one a decorative card on which you've written something special about each one, etc.

Who Will Support You?

This is a technique to help relax tense muscles.

Here is a list of people youth might ask to help them quit smoking:

Your best friend
Your brother or sister
Your girlfriend or boyfriend
Another Q4L group member
Your parents
Another close relative, grandma, uncle...
Your doctor
Your guidance counsellor
The school nurse
A coach or other trusted adult
A co-worker
An elder
Someone like you who has recently quit smoking

Who Will Support You

Support PLEDGE-Q4L- Supporter

1. Supporter

I, ___ will support you, in your effort to quit smoking.

I will

Be understanding and patient with any mood changes
Be available to talk
Not offer cigarettes or other tobacco products
Not smoke in front of you
Give you lots of praise
Not nag
Not make you feel bad if you don't succeed this time
Help avoid situations where you might be tempted to smoke
Help celebrate each day, week, or month that you are smoke free

2. Supporter

I, ___ will support you, in your effort to quit smoking.

I will

Be understanding and patient with any mood changes
Be available to talk
Not offer cigarettes or other tobacco products
Not smoke in front of you
Give you lots of praise
Not nag
Not make you feel bad if you don't succeed this time
Help avoid situations where you might be tempted to smoke
Help celebrate each day, week, or month that you are smoke free

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3. Supporter

I, ___ will support you, in your effort to quit smoking.

I will

Be understanding and patient with any mood changes
Be available to talk
Not offer cigarettes or other tobacco products
Not smoke in front of you
Give you lots of praise
Not nag
Not make you feel bad if you don't succeed this time
Help avoid situations where you might be tempted to smoke
Help celebrate each day, week, or month that you are smoke free

How Can You Deal With Non - Supporters? - Scenarios

1) Imagine that... You know that alcohol is a 'trigger' for you (it makes you want to smoke!). You've finally quit (yeah!) and have managed to stay away from parties for a couple of weeks. Your boyfriend/girlfriend, who was supposed to quit smoking with you, started up again during exams. S/he says s/he doesn't see the point, especially since you're so moody when you're not smoking. It's been pretty hard to resist temptation, but you've managed, mostly because you've been stuck at home studying every evening. But today is the last day of exams, and you plan to really celebrate. Your boyfriend/girlfriend comes to pick you up and you drive to a friends' house for a barbecue. Everyone's there, everyone's in a great mood, and you've had a couple of beers. Your boyfriend/girlfriend opens up a new pack, and offers you one, casually, almost without thinking about it.

What do you say, what do you do? Really visualize yourself in this situation. Figure out what you would say to resist the cigarette. Practice actually saying it out loud.

2) Imagine that... You are walking up to your usual meeting spot, in front of the corner store near school. A bunch of your friends are already there. You kind of are in a bad mood, since you lost your keys again, for the second time in two weeks. Your best friend says: "Aaww, what's wrong? Here, have a smoke."

What do you say, what do you do? Really visualize yourself in this situation. Figure out what you would say to resist the cigarette. Practice actually saying it out loud

3) Imagine that... You can't wait for the lunch break. This teacher is just the most boring you have had in years, nothing but lectures, and you're just bored out of your mind. On top of that he just announced another test for tomorrow, and the English assignment is also due which you haven't even started yet. Oh, and you just remembered that you agreed to take on Kelly's evening shift at the store. Finally, the lunch bell rings, and you get outdoors, still feeling really stressed out. You had decided to cut those lunch break cigarettes out, but when you get to your usual smoking spot, two of the regulars are already smoking, and say "Hey, want a drag?".

What do you say, what do you do? Really visualize yourself in this situation. Figure out what you would say to resist the cigarette. Practice actually saying it out loud.

What Would Other Young People Do?

Check out the replies below, from the Quit4Life Youth Reference Group

Scenario 1

"Naa, I'm quittin' for real. You said you were, too, remember? Put them away and let's gohave a burger instead... to keep your mind off it."
"C'mon, honey. I quit, remember? I know I've been irritable lately, but I need to stick with it. Hey, I really need you to understand and help me with this."
"Hey, I'm the one actually sticking with quitting, did you forget? Please try and respect that." (Just make sure you don't sound sarcastic or rude when you're saying this, your partner maybe just forgot. Don't take your anger out on them.)
"Yeah, I think I'm gonna pass! I wanna see if this whole quitting thing can work. I just wanna stick to it for my own sake, cause I want to prove to myself that I'm not flakey. Believe me, I'm dying to have one, but I want to see how long I can last. Who knows? Right, I'll just finish my drink, and let's go have fun!"
"Aaaah, have you seen me smoking in the last little while? Keep those away from me, pleeeaase! I'll go grab us a drink"
Other ideas from young people:
Break out the gum and pass that around!
Be the chef and BBQ stuff, so your hands are busy.
Get her/him to come up and dance, put on some music, jump in the pool, play ball, whatever is going on at the party, keep occupied.
I'm the type of person who would likely rationalize my reasons for having one more smoke. I know I can't resist a situation where my boyfriend is smoking and we're having a beer. I would avoid any situation where I'd be tempted until I was totally finished with smoking. (Q4L participant).

Scenario 2

"I lost my bloody keys again, and no, don't give me a smoke, I'm trying to quit."
"Thanks, but you know I'm trying to quit. I'm just not having a good day. I will make it, though. Anybody have a piece of gum?"
"Thanks, but that's not gonna help me out too much. I just need you to be there, I'm having a lousy day."
"Ummmm, ya, sure, NOT. That would help me out sooo much, since not only would I be pissed off with myself for constantly losing my keys, but that I smoked in a time of iweakness. That's not the kind of help I need from you, right now."
"No thanks, I'm OK, it's just that I lost my stupid keys again. And, trust me, having a smoke on top of that would not really help me! I think there's something wrong with my mind that I keep on losing my keys!"
"Nah, man. I quit, remember? I'm just bummed, but don't worry about it."
"No, I'm fine. I think I just need to vent. Can we go for a walk?"
"No way, man. I quit. Dr. Angotiffius informed me that smoking gives you diseases like alphbrakiutis that damages the sector of your brain that lets you think that girls are hot!"
"Having a smoke is only going to make things worse for me in the long run. It sure is not gonna bring my keys back. Come help me find them so we have something to do!"
Other ideas from young people:
Try to laugh about it, or just ask my friends to let me get mad about the situation and then get over it.
Try to change the subject so they don't offer you another smoke, and focus on those keys, ask people if they remember when they saw you with your keys for the last time, ask someone to come with you to see if they can help you find them.
Steer the conversation away from smoking and get into something else.
Go into the store, where you're not allowed to smoke.

Scenario 3

"Naa, but you smoke away. I don't have time for this. Plus, I can't afford to start again. I need the money, that's why I'm working. Anyway, I need to get back inside and get working."
"No thanks. Did you take English last semester? What the heck do I have to do to pass this course?"
"No, I'm fine. I'm just stressed about a bunch of stuff and came out for some fresh air. But I guess I'm not gonna find it here (laugh while you say this so nobody is offended)!"
"You know what, I think I'm just gonna pass! I've gotta get something from my car now, anyways. Anyways, thanks guys."
"Thanks, but maybe what I need is to go for a walk... I'll go get something to eat... or even better, get something to drink!(laughing about this)"
"I would if I could, but I can't, I have a bunch of work to do and I have to get started right away, but thanks anyway, maybe later."
"Thanks, I'm trying to quit, so don't tempt me! Hey, does anybody know what we're supposed to be studying for on that stupid English test tomorrow?"

Step IV- Get On With It : Know What To Do When You Quit.

Session 7. How to Prepare for Your Quit Date

Theme: Quit date preparation

Objectives :

Participants will

Identify items to use instead of smoking
Identify their supporters
Review their learnings and apply them to a quit plan
Identify smoking cues and know why it is important to remove them
Set a quit date

Before you start Session 7

This session is your chance to review all the elements and skills that participants have learned so far, and acquire some new ones. Students will have a look at how to: set a quit date; create a plan; check out their environment and remove cues; create a survival kit; assess social context (who to tell and not tell), and prepare specific strategies for dealing with social situations. The group will also find out what to expect when they quit (withdrawal).

Materials

Survival kit items

Handouts

What Have Others Put Into Their Survival Kit?
Quit Day Plan
Quit contract

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Activity 1. Warm-up: Memory Game

Type of activity: Experiential, small group or individual, large group reporting

Notes to the facilitator

You might already have introduced some 'survival' kit items as incentives, e.g., gum, suckers, or bottled water. If you have the resources, provide an assortment of inexpensive items to replace cigarettes, so that each participant can assemble a small 'survival kit' right then and there. Receiving the kits will increase participants' motivation and give them a feeling of being rewarded. Other Q4L facilitators have suggested that each student should choose those items that will work best for them, since individual preferences vary.

How to implement this activity

On a table, lay out about 15 different survival kit items (see list below).
Divide participants into 2 or 3 groups.
Tell students that these are some 'survival kit' items.
Let them look at the items for 2 minutes.
During that time the group can talk about how the items might be used instead of smoking. They might have their own ideas about other items they would like to use.
After 2 minutes, cover the items with a sheet of paper.
Provide each group with a sheet of flip-chart paper, and ask them to list all the items that were on the table, within 30 seconds.
The group with the greatest number of items right, can have first choice in selecting an item, explaining to the whole group how they will use that item to avoid smoking.
Each participant is encouraged to develop an individual 'survival kit' list. Provide youth with "What Have Others Put into Their Survival Kit?" Handout for additional ideas (also available in the handbook).
You can also do this activity individually: ask students to recall items from the covered table display and write them down individually.
Finish off as a go-around during which each students describes their 3-5 preferred items: "Instead of a cigarette I will take out a... to deal with... ; a ... etc."
If possible, have enough items to have students actually assemble their kits right away.

Activity 2. Who are Your Supporters?

Type of activity: large group, modelling/instruction of paper-and-pencil activity

Notes to the facilitator

This is a follow-up to the previous session. Be sensitive to the fact that some students might not have been able to get a supporter at home. Make sure that each student has at least one supporter, ideally including an adult. Emphasize the group as potential supporters.

How to implement this activity

Remind students that they will make a quit plan today, and part of this quit plan involves having their 'supporters' help them.
Review support pledge forms.
Encourage students to share whether they were able to get their pledge forms signed, and what reactions they received.
If not all students have been able to get forms signed, encourage those who were more 'successful' to describe their strategies and ideas.

Activity 3. Make a Plan and Set Your Quit Date

Type of activity: Paper-and-pencil, individual, pairs or small groups; followed by large group discussion

Notes to the facilitator

The purpose of this activity is to emphasize that successful change requires planning. Encourage reflection on previous experiences the students may have had that required preparation and planning: e.g., packing for a move; organizing a trip, both require prior preparation and planning, and setting a date for 'taking off'. The activity can be done individually, in pairs, or in small groups prior to sharing ideas in the large group, depending on the level of trust among group members. Other Q4L facilitators have found that encouraging students to share ideas and exchange strategies at this stage is very useful: they are well aware of what a realistic plan is and what will be hard to accomplish for youth in their particular situation. Model ways to give constructive feedback, and remind students of being positive and supportive of each other as they provide input into each others' quit plans.

Some students might not want to set a quit date. Some simply might not feel they are ready. Some may have been heavier smokers, and have cut down enough so they feel content about what they have achieved. Sensitive facilitation is needed to ensure that these students do not feel negatively judged by others or the facilitator. Encourage them to try at least not to smoke for 24 hours, to make that their first step. Remind them that setting a quit date is part of the program. Be very positive if they agree to at least give it a try.

Some Q4L facilitators have used a signed quit contract; others have not. The seriousness of signing a contract may help some students to stick to the plan. Other students may feel negatively judged if they break a contract. Some facilitators have expressed concern that breaking a quit contract has no negative consequences, and is a misleading example of what happens to people who break contracts 'in real life'. Use your own judgment about what will work with your group, and what you feel comfortable doing. You may choose to substitute a 'petition' format, which all group members are encouraged to sign, indicating they will stick to their plans as best as they can, rather than individual quit contracts.

How to implement this activity

Distribute copies of "Quit Day Plans"
Explain how this will help put everything the students have learned so far into practice.
Review the overall plan, and review the different sections again: withdrawal, cravings, temptations, old habits and the short-term benefits
Have students fill out their own plan, or do this in pairs
Encourage students to be as realistic as possible, e.g., if they never jogged in their lives, going for a run might not be a realistic alternative to smoking
Review how supporters can help.
Share quit plans in the large group.
Write down on a flip chart each person's quit date.
Discuss: Is it possible for them to avoid 'tempting' situations, like a party? If not, how can they prepare for this situation?
Remind students of what they have learned about coping with stress, and about relaxation.
Present additional ideas, e.g., throw out all the ash trays; throw out their lighter, etc. to remove smoking cues.
Optional: Discuss the elements of the quit contract and review the seriousness of putting a signature to something.
Or, have participants sign a group form (similar to a petition), that they will try their best to stick with their quit date.

Activity 4. Cool-off

Type of activity: Experiential

Use one of the previously presented relaxation activities (a stretching exercise, visualization, or progressive muscle relaxation).

What Have Others Put Into Their Survival Kit?

sugarless gum
low calorie snacks (carrot sticks, celery, yogurt, sunflower seeds)
lollipops, suckers
toothpicks
stress ball
computer game
doodle pad and pen
comic
hackey sack
yoyo
a deck of cards
cell phone
paper clips or anything else that will keep your hands busy
lipstick
nail file, nail polish
card with all the reasons you want to quit smoking and then read it when you feel temptation coming on
tracking form
picture of someone who will be proud of you when you quit smoking
pledge card
your quit plan.

Quit Day Plan

I commit to quit smoking on

My top 3 reasons for quitting smoking are:

These are the names and phone numbers of my supporters:

At school:
At home:
At work:
Other places:

This is what I will do on my quit day:

This is how I will deal with

Withdrawal:
Cravings:
Temptations:
Old Habits:

This is what I will put into my Survival Kit:

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Quit Contract

I commit to do my best to quit smoking on

Signature

Witness Signature

Session 8. How Can You Stay Smoke-free?

Theme: Maintenance

Objectives:

Participants will

Identify successes and acknowledge them.
Know how to interrupt negative self-talk and replace it with positive messages.
Reflect on their experiences with quitting.
Learn how to deal with slips.
Identify difficult situations and develop and refine coping strategies.

Before you start Session 8

Setting a positive tone is extremely important for this session. Focusing on why some students' plans might have not worked, rather than on students' 'failure' to maintain their quit date, is crucial. It is important for students to not give up, and to continue to believe in themselves, and that they will be able to quit in future. If you can, invite an ex-smoker into this session or for session 9 as a resource person, to provide input and share experiences. Or, you might want to share your own experiences with successful quitting.

Materials

Handouts

Give Yourself a Pep Talk
What to Do When You Slip: Don't Panic!

Activity 1. Warm-up: Give your self a pep talk

Type of activity: Large group, individual practice/modelling

Notes to the facilitator

This activity incorporates the warm-up component. Although it might seem artificial to some students, learning to interrupt negative self-talk and replacing it with positive talk can be a useful skill to deal with discouragement. Tell the group your group that athletes, for example, are taught this skill to be able to keep performing under pressure. Encourage youth to assume the role of a 'coach' in the next activity. Since coaches also need to be able to apply what they teach others to themselves, they also will need to learn to 'brag' about what they are good at. Set a very positive tone for this session. Examples of positive selftalk are included in the handout.

How to implement this activity

Go around: each person says one positive thing about the person immediately to their left.
Alternatively, to make it more interactive and 'fun', no speaking allowed: each person has to 'mime' something positive about the person immediately to their left.
Briefly discuss: What was that like?
Go around again: say something positive about yourself.
Briefly discuss: Was this harder or easier to do? Why did it feel different?
Explain: the second round is a coaching technique called 'positive self-talk'. Handout "Give Yourself a Pep-Talk"

Activity 2. How did my quit plan work?

Type of activity: Large group, guided individual reporting

Notes to the facilitator

Focus on keeping the sharing of experiences as positive as possible. Avoid judgment, and instead, talk about a plan that might not have worked, instead of a person having 'screwed up' or failed. Remind students that quitting is a process, and that each and every cigarette that you decide not to smoke is a step in the right direction.

How to implement this activity

Go around: How did you do with your quit date?
Discuss each participant's experience with quitting:
- what worked well?
- what was hard?
- how did you adjust your plan to make it work better for you?
- how did your supporters help you?
Encourage sharing of strategies, suggestions, plans.
How long was each person able to stay smoke free?
Record who is still smoke free.

Activity 3. What Happens if You Slip?

Type of activity: Lecture, group discussion

Notes to the facilitator

Keep modeling positive and supportive feedback. Avoid negative judgment.

How to implement this activity

Provide information about relapse: many people have relapses when they try to quit
smoking, this is natural. The important thing is to explore why they slipped, rethink their
strategies, and try again. Most will eventually be successful.
Facilitate a discussion among group members: how did you feel, or how might you feel,
if you relapse and hand out "What to Do When You Slip: Don't Panic!"
Discuss possible solutions, leading into the next activity.

Activity 4. Handling difficult situations

Type of activity: Flip-charted group discussion; small or large group role-plays

Notes to the facilitator

You can use additional examples for dealing with non-supporters from Session 5, above; however, group members may be able to identify many situations that are hard for them. You may want to use some of these as your role playing situations. Model positive feedback to all the role players. Be prepared to discover many creative solutions!

How to implement this activity

Ask students to identify situations that have been particularly difficult.
Collect in point form on flip chart.
Identify situations in which there are other people involved, and ask students to take on the roles of the people involved in the scenario, including the 'quitter'.
Role play these situations, either in small groups, or all together.
Encourage role players to come up with alternative solutions that might work for different individuals.
In the debrief, review and distinguish between assertive and aggressive behaviours, leading into the following activity.

Activity 5. Cool-off: Assertive behaviour

Type of activity: Individual, pairs, or small group role-plays

Keep this one short, focused, and lively.

How to implement this activity

Briefly role play any or all of the following non-smoking related scenarios, in which assertive behaviour is required:
- Asking for a change in your work schedule so you can go to the dentist, write an exam or attend a wedding.
- Saying no to a friend who wants you to go out on Friday night when you have to work Saturday morning.
- Standing up for someone who has been treated unfairly.
- Dealing with a teacher who has wrongfully accused you of cheating.

Give Yourself a Pep-Talk

Most of us talk to ourselves in our minds. We say things like, "Why does the teacher always pick on me?" or "How come I can't do this right?" Often, we talk in a negative way to ourselves. It's negative because it doesn't change our situation, it only makes us feel worse. Did you know that if we start saying positive things to ourselves instead, that can actually make us feel better? Saying encouraging things to ourselves can motivate us to do what we are tying to do: quit smoking.

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Sometimes, smokers who are trying to quit say negative things to themselves such as, "I feel really miserable", "It's too much stress for me to handle this now" or "I don't think I can do this." Saying these things doesn't help you quit; rather, it increases the chances that you will start smoking again.

To increase your chances of quitting for good, pay attention to your self-talk. If it is negative, silently say "STOP" then replace it with positive self-talk. Some people visualize a giant stop sign when they want to stop saying negative things to themselves.

Examples of positive self-talk include:

"I've beaten tougher problems than this."
"I am stronger than this."
"This feeling will pass in a few minutes."
"I'm well prepared and I can handle anything that comes my way."
"This withdrawal is a sign that my body is healing itself."
"I can handle this. Urges to smoke are normal for all people who are trying to quit".

*Write down three positive things that you want to tell yourself:

Practice telling yourself these three things and remember them, the next time you feel down or stuck.

What To Do When You Slip : Don't Panic!

All of us mess up sometimes. If you give in to temptation and smoke a cigarette or two, don't panic. All your hard work isn't wasted. A slip is not a failure. The important thing is to get back on track as quickly as possible and to learn from the slip. Think about what led you to smoke and then figure out how you will handle the situation differently if it happens again. Be kind to yourself and think positively.

Sometimes, it takes several tries to quit. Most people have to practice a few times, so if you didn't quite make it to be totally smoke-free yet, just keep on! You'll get there soon.

Just under half of all youth quitters (49%) reported making more than one attempt before they successfully quit smoking, the average being 2.7 tries before finally succeeding.
Young women aged 20-22 seemed to be able to quit most readily, averaging 1.9 attempts, whereas young men aged 23-24 had to make the most tries (4.2) before quitting successfully.

But, if you smoke on more than 3 days in a row, or at least one day for three straight weeks, it's a good idea to go back and review all the steps in this program, beginning with Step 1. Remember that every time you make a serious quit attempt, you can use it to learn some important information that you can use the next time you try to quit. Everyone who seriously tries to quit smoking is a winner.

Session 9. Socializing Without Smoking

Theme: Alcohol or socializing and smoking

Objectives:

Participants will

Increase knowledge about alcohol use and smoking
Develop strategies that can help avoid smoking in social situations
Practice refusal skills
Increase and maintain motivation to stay smoke-free

Before you start Session 9

Session 9 is designed as a 'maintenance' session. You might want to shift the content, depending on how your group is doing and what they need to review. Maintaining motivation to stay smoke-free, or to try again to quit, is important and requires 'work', especially when the novelty wears off. A resource person or a film might help at this stage to keep motivation high level. Make sure people feel re-energized, and ready to continue with their quit plan.

Materials

Calculator
Cost calculator handout from session 1

Handouts

How to Refuse
Practicing Refusal Skills

Activity 1. Warm up: Overcoming obstacles

Type of activity: Experiential, large group discussion

Notes to the facilitator

Choose the warm-up that will work with your group: some get tired of 'just talking', and want to do something more active for part of the session; others are happy to start to engage in group discussions right away.

How to implement this activity

Option 1: Obstacle course

Set up an 'obstacle course' in the room, with chairs, desks, flip chart, whatever items you have handy. Use your ingenuity in the set-up!
Instruct students to go over, around, through, or under the different obstacles, without touching or moving the obstacles, one at a time.
When all students have completed the 'obstacle course', tell them they can no go through the same course again, but this time, they can have another person help them.
Ask: what was easier, what was harder? Did they plan differently for the second time around?

Option 2: Group discussion

Go-around, asking each student to talk briefly about:
- What is the most difficult thing I ever have done in my life?
- How does quitting compare (on a scale of 1-10) ?
Lead discussion of how the group has been doing during the last week, referring to quit plans.
Invite people who slipped or went back to smoking to make a new plan, or set a new date.

Activity 2. What do we know about drinking and smoking

Type of activity: Lecture/resource person presentation, question-and-answers

Notes to the facilitator

Youth participants in Q4L groups often want to talk about the difficulty of staying smokefree at social events, especially if alcohol is involved. You may want to invite a resource person with a background in addictions to deliver some of the content of this session.

How to implement this activity

Brief presentation, possibly by a resource person, including the following content:
- Information about how alcohol lowers inhibitions
- What research has shown about drinking and smoking
- Alternatives to drinking and smoking
- Emphasis: non-smokers also have fun
Question-and-answer period

Activity 3. How to socialize without smoking

Type of activity: Individual reports back to group; flip-charted group discussion; pairs or small group role plays

Notes to facilitator

The success of this activity will depend on how much trust has been built in the group, especially in relation to students describing under-age drinking and/or illegal substance use. While you need to be alert to indicators of substance use or other issues, during the group meeting continue to model non-judgmental attitudes, and provide positive feedback for smoking-control strategies that emerge. If drug use (e.g., substituting marijuana for tobacco) is an issue, here is the time to provide facts and alternatives. For more information on this topic, visit the Canadian Health Network's website at: www.canadian-health-network.ca. If issues emerge that you feel require follow-up, approach the students individually and confidentially, outside of the context of the group, and suggest appropriate resources/referrals.

How to implement this activity

Lead group in review of what's happening with each person; strategies for working on staying smoke-free in difficult situations
Collect situations and strategies on flip-chart.
Select a couple of examples.
Encourage pairs of students to role play different ways to handle these situations, using any of the skills previously learned.
Provide positive feedback, identifying, as a group, successful strategies.

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Activity 4. Refusal Skills

Type of activity: pairs or small group role plays; large group debrief

Notes to the facilitator

Most youth find it useful to have a repertoire of refusal responses available, to feel ready to handle situations in which they feel pressure to smoke. Being able to think in terms of prepared categories will help some youth to stay in control. The following activity is designed to help participants develop a repertoire of possible responses using specific categories.

How to implement this activity

Pass out the "How to Refuse" Handout (also available in the Q4L handbook) and go over each skill and the examples.
Divide youth into pairs. One takes on the role of the friend who wants them to smoke, the other 'plays' herself or himself. Ask them to try out the different responses.
Reverse roles and come up with a new response that fits each 'refusal skill' category. They can write out their responses on the "Practicing Refusal Skills", or present them verbally for you to collect on flip-chart.
Instruct each pair to play their scenario in front of the whole group. Ask other group members to guess which of the refusal skills they were using, and provide reasons for their observation.
Discuss in the group which of these skills will be the most difficult for each person to implement, which ones they think will be easier.
Talk about variations in the group: what comes easily to one person may be harder for another.
To wrap-up, find out from each participant their favourite refusal skill, the one that they will definitely want to use.

Activity 5. Staying motivated

Type of activity: motivational lecture/presentation from resource person; individual reports to group

Notes to the facilitator

This is a good time to again invite an ex-smoker, especially a successful Q4L program quitter, an older teen or a young adult, to talk about quitting experiences. If you are an ex-smoker, talk about what quitting was like for you in more detail, if you have not done so already.

How to implement this activity

Resource person presentation (optional)
After the resource person speaks, use the cost calculator introduced in Session 1 to review how much money that person has saved since they quit.
Use the cost calculator to determine how much money each group participant has saved since they quit or cut down.
Review the health benefits for each participant according to how long they have stayed smoke free.

Activity 6. Cool-off: What Do You Want to Do to Celebrate?

Type of activity: group discussion/planning

Note to the facilitator

Involve the students in planning next week's final activity. Check the policies of your location about leaving premises or bringing in food. It may be possible to find a movie or restaurant that will donate part or all of the cost of admission/meals.

Depending on available resources and policies of your setting, you may be able to take the group to a restaurant, go bowling, attend a movie, or do some other fun activity together ... in a non-smoking environment. Lower-cost alternatives include ordering food (pizzas, subs are usual favourites!) and eating together; having a picnic; having cake, ice cream and balloons, or renting a movie that has nothing to do with smoking.

How to implement this activity

Remind students that the next session is the last of the 10 Q4L program sessions. It's time to celebrate!
Point out that the group has come a long way, and achieved a lot.
Find out from students what they would like to do to celebrate their success.
Present options (see above) and discuss pros and cons.
Decide through show of hands, written ballot, placing stickers on a flip chart, loudest cheers, drawing items from a hat, or any other method that you choose.

How To Refuse

Refusal skill	He or she says - or does	You say - or do...
a) Reverse pressure	"Hey, lets go out for a smoke!"	"No, thanks, how about watching the basketball game in the gym. We need to support our team, and I'm sure they will win this time".
b) Cold shoulder	"Take a puff!"	Ignore person, and have a sip of water
c) Walk away	"Haven't seen you for a while here..."	"Got to go..."
d) Broken record	"Here, try one... Have a puff... One won't hurt..."	... Forget it ... Forget it ... Forget it
e) No thanks	"What's the matter, you look like you need a smoke..."	"Thanks for the offer, but no."
f) Give a reason or excuse	"Are you one of these health freaks now? Here's a smoke, come and relax..."	"Not today, thanks, my taste buds have changed ...;" "I got to get to my job..."
g) Avoid the situation	Many of your friends are hanging out in the smoking area	Stay away from the smoking areas
h) Strength in numbers	Observe where people hang out who do not smoke. They might need your support too.	Find some other quitters and hang around with them

Practicing Refusal Skills

Refusal skill	He or she says - or does	You say - or do...
a) Reverse pressure	"Hey, lets go out for a smoke!"
b) Cold shoulder	"Take a puff!"
c) Walk away	"Haven't seen you for a while here..."
d) Broken record	"Here, try one... Have a puff... One won't hurt..."
e) No thanks	"What's the matter, you look like you need a smoke..."
f) Give a reason or excuse	"Are you one of these health freaks now? Here's a smoke, come and relax..."
g) Avoid the situation	Many of your friends are hanging out in the smoking area
h) Strength in numbers	Observe where people hang out who do not smoke. They might need your support too.

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Session 10. Living smoke-free: a celebration!

Theme: Celebrating successes and what's next?

Objectives

Participants will

Assess the progress they have made in reducing or quitting
Celebrate their own and each other's success
Know how and where to go for support when they need it

Before you start Session 10

As well as celebrating, this final session will help you determine how students can continue the process of staying smoke-free or quitting, and inform them of the type of support you will be able to provide beyond this date. Holding a few follow-up sessions is ideal, but if you are unable to do so, suggest alternatives. These might include a weekly lunch-time drop-in; e-mails; network among group participants; a peer helper or counsellor that can be contacted for support. Setting up some sort of support system shows youth that you care about their progress beyond the program. This is reinforcing and motivating. This is also a good time to review available resources, such as local tobacco help lines, and the Q4L Online program.

Take some time for students to reflect on the program, and provide feedback about what they liked and what they did not like, so you can improve Q4L in the future. If you distributed a baseline survey, this is the time to collect post-program evaluation data.

Remind participants that in Canada people who have quit outnumber those who still smoke. It's their choice, and they can decide which group they want to belong to.

Finish with some really positive feedback for each of the students, emphasizing one of their individual strengths, something each one taught you, or something that you have enjoyed about having them in the group. You may want to award certificates to students as official recognition of successful completion of Q4L, emphasizing that ALL who stayed with the program are successful, whether or not they have totally quit yet.

Materials

Handouts

Q4L Program Evaluation
Q4L Certificate

Activity 1. Q4L Program Evaluation Survey

Type of activity: Individual paper-and-pencil

Notes to the facilitator

Since most of this session is devoted to some sort of celebration, start by getting the 'serious' stuff out of the way first, and quickly.

How to implement this activity

Remind participants of the Baseline Survey that they completed in the first session, and explain the purpose of this survey.
Hand out the "Q4L Program Evaluation" survey to be filled out.
After completion, pass out each student's Baseline Survey, and ask them to compare their before-and-after scores.
Discuss changes, expectations, successes.

Activity 2. Program satisfaction

Type of activity: Individual reports to group, flip-charted

Notes to the facilitator

If you plan to facilitate Q4L programs in future, you may want to ask whether any 'graduates' are interested in providing assistance, helping recruit others, or being a resource person to talk about quitting.

Especially if you are not doing a formal evaluation, this is a good way to discover what students liked and did not like, and how to improve the program for the next time.

How to implement this activity

Go around: each student shares one thing they liked, one thing they did not like, and what could be done differently the next time.
Make sure each participant has the opportunity to say something about the program.
Collect all suggestions, positive and negative comments, on flipchart.
Thank participants for their suggestions, including any negative comments.

Activity 3 . Recognition of Success and Celebration

Type of activity: Group fun!

You can hand out certificates of participation, or 'awards' for each person, telling them what you liked about their participation and program success.

Proceed to the celebration part of the program!

Activity 4. Cool-Off: Saying goodbye.

Type of activity: Motivational lecture

Notes to the facilitator

If you can, give each participant a card with phone numbers and addresses for support (e.g., www.Quit4Life.com).

How to implement this activity

Review with participants what you are planning in terms of supporting them to stay smoke free (other follow-up session, drop-in, email contact)
Provide them with other resources that they might be interested in, refer them to the website: www.Quit4Life.com
Explain again how they can use the handbook to remind them about what they can do.
Congratulations to everyone!

Quit4Life Evaluation

Name (or Nickname):
Date:
Age:
Grade:

Male
Female

About Smoking

1. In the last 30 days, did you smoke at least one cigarette?

I used to smoke but I quit
Yes
No

2. Do you usually smoke every day?

If Yes , choose one of the options below

A few puffs (drags, hits) every day
1 to 4 each day (a pack usually lasts me all week)
5 to 9 each day (less than a pack a day)
10 to 19 each day (around a pack a day)
20 or more every day (around a pack a day or more)

3. Do you usually smoke every week?

If Yes, choose one of the options below

A few puffs (drags, hits) every week
1 to 6 every week
7 to 14 every week (around half a pack a week)
More than 15 cigarettes every week (around a pack a week)

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4. I want to:

Stay smoke-free
Quit smoking now
Quit smoking in the next month
Cut down the number of cigarettes that I smoke
Quit smoking some time, not sure when

5. Since you started the Quit 4 Life program, what was the longest time that you went without smoking?

I quit completely
A few hours
1 full day
2 - 6 days
1 week
2 weeks
Longer than two weeks, please specify
Can not remember

Who else smokes?

6. About how many of your friends smoke?

None
A few
About half
Most
All

7. How much does second-hand smoke bother you?

1 - A lot
2 - A little
3 - Not at all

Usefulness of the Program

8. How many sessions of the Quit 4 Life Program were you able to attend?

all sessions
most sessions
only a few sessions

9. Would you recommend Quit4Life to a friend?

Yes
No
Maybe

10. How much did Q4Life help you to do the following?

The Q4L Program…	1 Not at all	2	3 A little	4	5 A lot
Motivated me to quit and stay smoke free
Informed me about what to expect when I quit
Provided me with ideas about how to create a positive environment for myself
Taught me skills for how to quit
Helped me to relax and not think about smoking after each of the sessions
Helped me to postpone smoking the next cigarette after each session

11. Do you think the number of sessions was:

Too few
Just right
r Too many

12. Do you think the length of each session (about 1 hour) was:

Too short
Just right
Too long

13. How much did you like the following aspects of the program?

The Q4L Program…	1 Not at all	2	3 A little	4	5 A lot
Overall Q4L program
Program materials
Style of the program (group
discussions, own work)
The group, the other participants
The facilitator

14. What do you suggest to make the program better?

Q4L Certificate

Name

Has completed the Q4L program successfully and is on her or his way to have Quit4Life

Signature

Date

Four Optional Sessions

Four optional sessions are available to Facilitators who may wish to run them as booster sessions after the program has ended, or to add these sessions to their regular Q4L program. The optional sessions cover topics including:

Optional Session One - Follow Up Session
Optional Session Two - Media and Youth Advocacy
Optional Session Three - Traditional Tobacco Use
Optional Session Four - Healthy Living

Optional Session 1 : Sample follow-up session

Objectives:

Participants will

increase awareness of their own fears and hopes in relation to quitting or staying quit
Identify and address difficult situations or issues related to staying smoke-free, quitting, or reducing.
Review skills and content areas

Before you begin the follow-up or maintenance session

If at all possible, try to offer a few follow-up or maintenance sessions after the 10-session plan. A sample session plan is outlined below.

Some Q4L pilot facilitators offered maintenance sessions as long as participants needed them. Others have offered one or two sessions; or a shorter group encounter; individual drop-in support; or e-mail follow-up.

Follow-up and maintenance sessions require very flexible facilitation, and an ability to respond to respond to participants' needs on the spot. These needs might include: reviewing certain topic areas, practicing specific skills, providing some emotional support, increasing motivation to stay smoke-free, and encouraging those who relapsed to try again and again.

In keeping with the Q4L program philosophy, maintaining a positive group climate will be key for these sessions. This goal is even more important if the group includes both quitters and not-yet-quitters. Sensitive facilitation will help to transcend some participants' feelings of discouragement into hope and new motivation to continue the process of quitting. The warm up activity is designed to help you do that.

Activity 1. Warm-up: Biggest Fears (or concerns) - Highest Hopes

Note to the facilitator

This activity is a bit longer than most warm-ups, and could take 15-20 minutes to implement, depending on the size of the group. Depending on your group, you can do this as a paper and pencil activity.

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Some participants may react to 'hopeful talk' with scorn: they may see it as self-delusion, unrealistic, or lying to oneself. Emphasize that this is a recognized psychological skill that can be learned. It can lead to a more positive attitude and is worth trying.

Material:

2 index cards for each participant (optional)
tape
flip chart

How to implement this activity

Ask participants to sit quietly for a minute, and think about their biggest fear in relation to smoking and quitting.
Next, ask them to think about their highest hopes in relation to smoking and quitting.
Hand out index cards to each youth. Youth write their biggest fear or concern on one card, and their highest hope on the other.
Ask youth to pin all their hopes on one flipchart labelled "hopes", and all their fears on another labelled "fears".
Ask someone to read them out loud.
Debrief: Ask students if they noticed anything about the hopes and fears.
Can they make some connections?
If they haven't, start drawing lines between fears and hope, to see inverse relationships, e.g.,

Fear

Not being able to resist temptation
Die of lung cancer
Harm others with second hand smoke
Be addicted
Waste all that money

Hope

To keep up their will power
Live a healthy life
Set a good role model for others to stay smoke-free
Become independent from nicotine
Save a lot of money

Summary presentation:
Fear frequently immobilizes people, makes them not to be able to act or change any thing. Fear commonly sparks the following reactions: "It is useless anyways"; "I will fail again...".

Ask: has anyone had these experiences, how does that feel? Be ready to provide example from own life.

Hope, in contrast, most often mobilizes people to want to do something, to work towards achieving a goal or change. Ask: has anyone had these experiences, how does that feel? Be ready to provide example from own life.
Model and practice 'hopeful talk', translating fears into hopes. Ask youth to try to do the same, and talk about how that feels.

Activity 2. What I want help with...

Notes to the trainer

This activity will take up to half an hour, depending on the size and stage of the group.

Model non-judgmental responses and respect for everybody's concerns: make sure nobody's 'issues' or suggestions are discounted or dismissed.

You might suggest that you can try to invite a resource person or show a film about a specific topic that has come up during a subsequent session (if offering more than one)

Materials

Flip charts
Markers

How to implement this activity

Go around: ask participants about one thing they have found difficult, or would like to review again or practice.
Collect all issues on a flipchart, note similarities.
If all issues can't be addressed in one session, offer a second session if possible. If not, prioritize with the group the issues or concerns with which they would like to begin.
In group discussion, develop plans for addressing each person's needs.
Write them on flip chart.

Activity 3. Cool-off

By now you know your group and have noticed what works well to loosen them up or to have fun. Some ideas:

party games
watching a short cartoon
dancing to a good beat
or any of the cool-off activities suggested in previous sessions.

Activity 4. What's next

If you are planning to offer more sessions, provide details: where, when, how 'optional'; any organizational details.
If not, provide information for additional individual support (yourself, guidance, quit line, other resources).
Encourage students to also stay in touch with each other.

Optional Session 2. Media and Youth Advocacy

Objectives:

Participants will

Increase awareness about tobacco advertising.
Learn more about how the tobacco industry promotes its products.
Know some of the steps involved in anti-tobacco advocacy.

Before you start Optional Session 2

Many youth want to go beyond quitting or individual behaviour change and want to address tobacco as a social or community health issue. They may feel misled by the manipulation of the tobacco industry and the resources it spends on targeting them. Some feel angry or helpless. To channel these feelings in a positive way, it can be useful to provide youth with information and tools about tobacco advocacy initiatives.

If your school or community is currently changing smoking policies, adopting smoking bylaws, or campaigning against second-hand smoke, this may be an ideal time to motivate youth to participate. A youth advocate involved in any of these community campaigns would be an ideal resource person to invite to this session.

To analyze how the issue is presented in the media, the group could be encouraged to follow the local media for a few weeks prior to this session: recording newscasts or interviews; taping radio commentaries; collecting newspaper articles and advertisements from various interest groups. If you have not done this prior to the session, you can also encourage students to follow the media coverage in the weeks after the session.

This session provides only an introductory overview of the issue, with an example of analysing advertisements and some ideas to get involved in anti-tobacco advocacy. Choose where you want to focus this session depending on the specific situation of the group and your community.

Consult additional resources prior to offering this session, for more information and ideas, such as:

Materials

Tobacco ads and anti-tobacco ads (e.g., downloaded from above web-sites)
Video and TV
Movie clips involving smoking
Handout: Steps in advocacy
Handout: Smoking in Movies

Activity 1. Warm-up: How brainwashed are we?

Notes to the facilitator

This is a word-association activity that will help illustrate the penetration of tobacco advertising.

Keep this activity moving quickly, short and focused. Prepare your 'flash cards' ahead of time, if you are using them; otherwise, you can just write the names of cigarette brands and the other information on the flip chart. 154

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How to implement this activity

Have six to eight 'flash cards' ready, each with the name of a brand of cigarette (e.g., DuMaurier; Export A).
'Flash' each card to the group for a fraction of a second.
Ask participants to call out: colours of the package; slogan; an image associated with the brand.
Alternate, or follow with, a few 'Flash' cards that have questions about other important "facts" (depending on the age group), such as the name of the second Canadian Prime Minister; the date of the last day of school; the scientific formula for salt; the names of the Great Lakes; how old you have to be to legally get married, etc.
Compare speed and accuracy of replies to both types of cards.

Activity 2. Media analysis: Tobacco advertisements and anti-advertisement.

Notes to the facilitator

Some students take courses in media analysis during high school. Assess the level of sophistication in your group and tailor the information accordingly. You may want to involve more skilled participants in the planning and delivery of this session.

Introduction

Provide students with copies of tobacco advertisements and also anti-advertisements (examples can be found on websites listed above).
Discuss in large group:
- How do the ads appeal, or not appeal, to you?
- How do they appeal to other young people?
- What images do the companies choose?
Select one pro-tobacco and one anti-tobacco advertisement for detailed comparison.
Discuss in large group:
- What is similar, what is different?
- Do you think that anti-ads work, why or why not?
Or: create your own 'Badvertising'; or make existing ads 'true' in 'Badvertising' form. http://www.badvertising.org/
Play a clip from a movie in which the lead actor smokes.
Discuss in large group:
- In what situations do people in movies smoke? (e.g., when they are stressed, nervous, bored, alone, with others... )
- What are the subtle messages?
- Might these be role models for you? For other youth? For younger kids?
Review the statistics about smoking in movies (see quiz, or facts below).
Discuss:
- What else has the tobacco industry done to promote its product?
- Why does tobacco promotion work?
- What can you/we do about this

Activity 3. Anti-tobacco Advocacy: What you can do...

Notes to the facilitator

Sensitive facilitation is needed so students feel positive about the possibility of contributing to change, despite the enormity of the industry. Not all students will be interested in getting involved in advocacy, or think that they have the skills or time to do so. Model respect for this choice, ensuring they don't feel under pressure to become involved in advocacy.

Be as concrete as possible when working through ways to become active on tobacco issues. If your group wants to become active in an anti-tobacco initiative, refer them to appropriate community organizations and leaders.

How to implement this activity

Ask: How has the smoking culture changed: in Canada, your province, your community and municipality, school, your home?
Collect replies on flip chart.
Discuss: Why do you think it changed?
Share information about how advocacy has led to change in relation to issues other than tobacco (e.g., changing laws about racial or gender discrimination).
Using an example suggested by the group, work through the steps that might be involved in taking this on as an issue.
Find out if your group wants to participate or start an initiative.
Go on-line for more! Order the Smokefree Spaces Activist Toolkit from Health Canada. This bilingual CD ROM is full of facts, ideas and information to help youth to speak up about second-hand smoke where they live.

Cool-off:

Use any of the cool-off activities from the main sessions.

Smoking in Movies

(Source: http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/youth-jeunes/scoop-primeur/indust_cinema_e.html)

When was the last time you went to see a movie and one of the stars pulled out a cigarette on screen?

When you stop and think about it, lighting up on screen is like showing a celebrity endorsement the size of a billboard. And it works. According to Stanton Glantz of Smoke Free Movies, nonsmoking teens whose favourite stars smoke frequently on screen are 16 times more likely to develop positive attitudes toward smoking.

Why movies are even better than TV advertising

Smoking in movies is much more effective than TV ads -- any kind of paid advertising, really -- because viewers are not aware that there may be a sponsor. And movies live on and on through repeated showings on home video and on television.

Most tobacco advertising on TV ceased in the early 1970s. In the US, tobacco companies started looking for other ways to advertise including paying to place their brands in Hollywood movies. Unlike commercial breaks on TV, these situations occur at a time when your attention is sharply focussed on the plot and your mental guard against advertising exaggerations and misrepresentations is down. You have no reason to believe that there is an underlying motive to sell cigarettes.

One big star was paid $500,000 to smoke a certain brand of cigarettes in three of his action films. In 1989, the movie industry payola scandal was exposed and tobacco companies "volunteered" to stop it. (Payola is bribery of any influential person in exchange for the promotion of a product or service.) But more than a decade later smoking in movies is more prominent than even before the ban.

A youth-led American Lung Association study found that in 1997/98, 88% of the top 50 box office movies contained tobacco use, and in 74% of them, it was the lead actors who were smoking.

Smoke Free Movies also contends that of America's 25 top-grossing movies in 2000, nine in ten dramatize use of tobacco... more than one in four show a particular brand... actors now display or smoke these featured brands ten times more than before the 1989 payola ban.

The World Health Organization points out that "No warning label is required when actors or actresses light up. What the young person sees [is a star with an enviable lifestyle]... using tobacco." That means many young people see smoking as a "highly desirable activity", because movies don't show the realities: addiction, disease and death.

In Titanic (which received a PG-13, rating in the U.S.), Leonardo DiCaprio and co-star Kate Winslet both light up, equating cigarettes with romance and rebellion for perhaps 100 million viewers around the world. This kind of celebrity endorsement is virtually priceless. And it will live on for years with repeated showings on home video and television.

5-year study: Hollywood delivered 8.2 billion tobacco impressions to children and teens
Three studios released over half the youth-rated (G/PG/PG-13) movies with smoking.
Three studios account for 56% of the 8.2 billion tobacco impressions delivered to U.S. children and teens ages 6-17 in 1999-2003.

Estimated Number of New Smokers Delivered to the Tobacco Industry by Smoking in Movies (per year)

Producer	Kids Delivered
Time Warner	98,000
Disney	66,000
Sony	55,000
Universal	43,000
Viacom	39,000
News Corp.	35,000
D’Works &Indies	35,000
MGM	20,000
Total	390,000

Source: First-Run Smoking Presentations in U.S. Movies 1999-2003 by Jonathan R. Polansky and Stanton Glantz, PhD, University of California-San Francisco Center for Tobacco Control Research and Education, March 2004.

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This comprehensive study of every live-action movie released by the U.S. motion picture industry between 1999 and 2003 finds:

80% of the 776 Hollywood and independent movies included tobacco use -- almost 90% of R-rated films, 80% of PG-13 films and half of movies rated G/PG.
First-run movies in theaters delivered an estimated 32.6 billion tobacco impressions to audiences -- 1.7 billion to children 6-11 and 6.5 billion to teens 12-17.
Three media conglomerates -- Time Warner, Disney and Sony -- accounted for more than half of all movies releases with smoking and 55% of all estimated tobacco impressions delivered to children 6-11 and teens 12-17.
Adolescents, the age group most susceptible to smoking initiation, receives 75% more tobacco impressions than children and 20% more than young adults 18-34.
Individual R-rated films with smoking have twice as many tobacco incidents on average as PG-13 movies with smoking.
88% of Disney's PG-13 movies included smoking over the past five years, the highest among all major studios. Disney and News Corp. led all major studios with 91% of their R-rated movies including smoking. Sony led major studios with 45% of G/PG films with smoking.
The U.S. movie industry delivered an estimated 32.6 billion first-run theatrical tobacco impressions to audiences of all ages over the past five years. A quarter of these impressions -- 8.3 billion evenly divided between youth-rated and R-rated movies -- were delivered to children and teens. Time Warner alone delivered a quarter of child and teen tobacco impressions. Applying these percentages to the 390,000 youth estimated to start smoking each year because of smoking in the movies, allows us to estimate the number of new smokers each studio "delivers" to the tobacco industry each year (see table).
An R-rating for on-screen tobacco use effectively would have reduced children's and teens' first-run exposure to tobacco imagery by half over the last five years.

Optional Session 3. Traditional Tobacco Use

Objectives:

Participants will

Increase knowledge about the traditional use of tobacco among Aboriginal communities.
Increase knowledge about what constitutes ceremonial use versus abuse of tobacco.
Increase respect for Aboriginal traditions and histories.

Before you start Optional Session 3...

Regardless of their own backgrounds, many Canadian youth will be interested in learning more about the traditional use of tobacco in Aboriginal communities. If there are Aboriginal youth in your group, it is especially useful to provide this context. If you can obtain the assistance of an elder with experience in ceremonial tobacco use, you may wish to turn the entire session over to them, reserving time for introduction and questions and answers. An alternative would be to show a film on traditional tobacco use.

The information and handouts for this session are based on resources developed by several First Nation organizations to combat smoking among Aboriginal populations. (See: Cessation Programs in Action at end of session).

Activity 1. Warm-up: What does my name mean?

Note to the facilitator

Bring a 'name your baby' book. Be sensitive to possibility that students may not have been named by the parents/guardians with whom they are living; or may not know who named them or why. The idea is that students will find variations: some are named after a relative, others after a popular film character or star, others don't know. Everyone has a name but the traditions that led to that name can be very different.

How to implement this activity

Go around: Ask students if they know the meaning of their name.
Consult the 'name your baby' book for other meanings. Likely you will find that the names contained in the book are mostly traditional English or French names.
Go around: why/how did you get this name?
Talk about 'traditions of naming' a baby; whether and how we get nicknames; if anyone has changed his or her name.
Led the discussion to the meaning of 'traditions', and the topic of traditional tobacco use, in the next activity.

Activity 2. Images and stories about tobacco use

Notes to the facilitator

If you have an invited resource person who will be speaking about traditional tobacco use, you may choose to skip this activity 161

How to implement this activity

Ask students to 'brainstorm' the topic of Aboriginal (Indian) people and tobacco. "What do you think of when I say "Aboriginal people" or "Indians" and tobacco?"
Capture all ideas, images, words on flip chart. Identify if possible negative, neutral, and positive images or words.
Discuss: How similar is this to what we each knew about tobacco before? What ideas did we have about Aboriginal (Indian) people and tobacco? Are they the same now? Were there any surprises, anything you did not expect?

Activity 3: Presentation on uses of tobacco

Note to the facilitator

If there are Aboriginal students in your group, offer them the choice of assisting you in the preparation or presentation of this activity ahead of time. Be very attentive to the degree of comfort and knowledge that any participant may have, and respectful of their choice not to focus on their Aboriginal heritage or status. Model positive regard for Aboriginal communities and their strengths, rather than negative or judgmental attitudes towards difficulties encountered with tobacco.

Your challenge in facilitating will be to ensure that students that are emotionally touched by other peoples' experiences without being overwhelmed; and aware of the richness and diversity of Aboriginal cultures, without falling into stereotypes.

How to implement this activity

Option 1: You may find it useful to invite an Aboriginal resource person who is able to talk about the traditional or ceremonial use of tobacco, and/or the effect that smoking has had on her or his life. Leave time for questions and answers.

Option 2: Deliver a presentation based on the information provided in the handouts (found at the end of this session) for this session. Choose your focus: traditional use; contemporary misuse. Begin with myths and truths format. Leave time for questions and answers.

Option 3: Show a film, encouraging questions and answers/discussion after.

How to implement this activity

Choose one of the three options:

Invite an Aboriginal elder to share information about traditional tobacco use
Deliver a presentation based on the Fact Sheets (Handouts at end of session)

Activity 4. Cool-off

Ask the group to design their own 'ceremony' to help close the session. It could be a special type of handshake, a way of saying good bye, a group cheer, a series of dance steps on the way out the door...

Fact Sheet on Traditional Use of Tobacco

Adapted from: "Building and Sustaining Partnerships: A Resource Guide to Address Non- Traditional Tobacco Use", prepared for the First Nation and Inuit Health Branch, Health Canada. October (2003).

Traditional Use of Tobacco

Tobacco has been used in Aboriginal communities for thousands of years before contact with Europeans and the rise of recreational smoking. Tobacco was grown and cultivated with other natural herbs such as sweet grass and lavender.

Not all Aboriginal populations across Canada use tobacco as a traditional, sacred part of their culture. This is because of the differences in culture, climate and geography. Plant products such as willow bark, sweet-grass, cedar and sage were smoked in pipes and used instead of tobacco by some nations.

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There are two varieties of tobacco:

Nicotania rustica or Indian Tobacco - traditional
Nicotania tabacum or commercial tobacco - non-traditional

Traditional tobacco was:

cultivated separately from other crops
burnt over the fire
thrown on water
left on the ground
smoked in a pipe either by an individual or passed around a circle of people
chewed

Generally, traditional tobacco or the above substitutes were an important component of
Native cultures in two main aspects:

Ceremonial

communication with the spirits (smoke)
thanking the Creator
praying for a good harvest or better fish catch
rites of passage ceremonies (birth, weddings, funerals)
sealing the peace with enemies (peace pipe)

Medicinal

To treat earaches and snakebites
To purify the mind and heal the body

Some nations have a "pipe carrier", a special medicine person who uses tobacco the traditional way to communicate with the Creator.

Today, traditional tobacco is still regarded as sacred by most Aboriginal groups and retains its spiritual and, in some cases, medicinal value. However, because tobacco has been a vital part of Aboriginal culture for so long, its traditional use is sometimes given as a justification for smoking or chewing commercial tobacco. Such confusion can hinder efforts to reduce the consumption and deal with the harmful effects of non-traditional tobacco use.

Using traditional tobacco is part of the Aboriginal heritage - Addiction and disease brought on by abuse of non-traditional tobacco is a post contact legacy.

Tobacco Misuse in Aboriginal Populations

Three national surveys documenting Aboriginal tobacco misuse were conducted between 1991 and 2001. While these surveys document different results, they all concur that smoking rates in Aboriginal populations are unacceptably high, and are often double the rates found in the non-aboriginal populations.

Highlights from these surveys are summarized below:

The Aboriginal Peoples Survey (APS) was conducted in 1991 by Statistics Canada and repeated in 2001. The 1991 survey included 341 of 600 First Nations Communities, covering all provinces and territories.

57% of Aboriginal adults are current smokers. Daily smoking rates within the Aboriginal community are double the current smokers in the general Canadian population.
Smoking prevalence is higher among the Aboriginal population for every age group compared to the Canadian Population. Smoking rates are highest among young adults aged 20-24 at 35% and 25-44 at 61%, while over half of aboriginal teenagers are smokers at 54%.
Smoking rates among Aboriginal adults tended to decrease with increasing education levels. Those with less than a grade nine education are almost twice as likely to smoke as university graduates (57% vs. 29%).
Among Aboriginal adults, Inuit people have the highest smoking rates at 72%, while 57% of Metis are current smokers and 56% of First Nations people are current smokers.
The First Nations and Inuit Regional Health Survey (FNIRHS) was conducted in 1997 by Health Canada. This survey collected data from First Nations people living on reserves and Labrador Inuit communities.
62% of First Nations and Inuit populations are smoker.
78% of Aboriginal adults reported misusing tobacco at some point in their lives.
The smoking prevalence for First Nations and Inuit people are double that of the general Canadian population in many age groups.
Smoking rates are highest among young adults aged 20-24 at 72%.
Smoking rates decreased as education levels increased, but the smoking rate of 53% in the highest education group is still almost double the general Canadian population smoking rate.
57% of First Nations and Inuit indicated that smoking occurred in their homes.

Canadian Community Health Survey (CCCH) was conducted in 2001 by Health Canada. Aboriginals were surveyed in the Territories or outside of First Nations and Inuit communities.

51.4% of Canada's off-reserve Aboriginal population are current smokers, almost double that of the general Canadian population.
The smoking rates of off-reserve Aboriginal people are significantly higher than those of the non-Aboriginal population in both urban and rural areas.

Health Canada also commissioned Ipsos Reid to survey 800 Aboriginal people in 2002 and Aboriginal smoking rates and trends have been surveyed in the North West Territories in 1999 and in British Columbia in 1997.

Contact your local Community Health Representative or local health official to determine if local data on smoking behaviours has been collected in your community.

Source: Balancing Act: Aboriginal Adult Tobacco Cessation Strategies: Implications for Social Marketing. Prepared for Health Canada. (2002)

Cessation programs in action

Aniqsaattiarniq - Breathing Easy is a Community Resource Kit designed to reduce and prevent tobacco use in Inuit communities. The cessation portions of the kit consist of a video on the health effects of tobacco use and ways of quitting with supporting pamphlets, posters and a resource manual. Developed by the Pauktuutit Inuit Women's Organization, the materials are intended for use by Inuit youth, pregnant women, adults and elders.

NASAWIN is a community approach to tobacco education for Aboriginal peoples. It is best suited to smokers who are in the earlier stages of change rather than smokers in the action stage. The program combines posters, pamphlets, a program manual and a 15-minute video, and can be delivered as either a group or self-help program. The role of tobacco in traditional ceremonies and gift giving is incorporated in the program.

Sacred Plants, Sacred Ways has been developed with the input of Elders to raise awareness of the sacred uses of tobacco in traditional ceremonies, in spiritual communication and as a gift symbolizing appreciation and respect. It is intended for Aboriginal Peoples living in urban settings, and combines information on prevention, cessation and protection.

Integrated Tobacco Recovery for Urban Aboriginal Adults and Adolescents is an adaptation of the Smoker's Treatment Centre's New Tools for Survival. The Nechi Institute has reworked the original document to make it culturally suitable for Aboriginal youth and adults living in urban communities. The adaptation includes acknowledging the traditional use of tobacco's spiritual and healing role for Aboriginal Peoples.

A Tribe Called Quit
The 'Tribe Called Quit' is an online tool to help youth resist smoking and to help those to quit smoking. The Tribe are four young people who share their stories with you about smoking and tobacco. http://ayn.ca/quit/

Sacred Use Not Abuse

Source: http://www.ncidc.org/tupe/home.htm

"Sacred" is our Theme

Sacred Tobacco...

Tribal, tradition, that teach us our heritage.
Of sacred tobacco.
Be brave, tell others 'No'.
Actions speak louder than words. Don't smoke.
Cancer is the end result of smoking.
Custom use not abuse.
Offer sacred tobacco.

Use Tobacco In:

Prayer
Offering
Purification
As a Sign of Respect

Sacred Tobacco has been used for thousands of years by our ancestors.

It is sacred.
It is a gift.
It is used as a medicine.

When used in a correct way with respect and honor it can promote good health and assist with spiritual guidance and growth. Each tribe across this United States has their own way of ceremonial use. Learn it, use it, respect it. Our people all have a common knowledge of sacred, respect, and honor. Tribal Elders are dedicated to keeping tobacco sacred. Tobacco is offered to the creator of the earth, for our land, our fish, our acorns, our life. The creator gives us many gifts. These gifts must be respected and used in their proper way. Tobacco is a gift to be used in a sacred way with respect. So many of our cultural ways have been lost. We thank the Creator of Mother Earth for our life. We offer her sacred tobacco in our ceremonies with respect.

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Invest your time and your talents in something besides the tobacco industry! It takes approximately 10 minutes to smoke a cigarette. So if you smoke a pack a day that is 3.3 hours you spend just on smoking cigarettes. Each cigarette cost about 25 cents each. Each cigarette cost 15 minutes of your life. If you pay $5.00 a pack for your cigarettes it will cost $150 a month and $1800 a year.

Just think of all the things you could do with your time and money:

Beading your own necklace.
Making your own drum.
Exercising so you can dance longer and well.
Catching and smoking your own fish.
Gathering acorns and fresh mushrooms.
Hike up that trail smell the fresh air.
Learn your own heritage.

Don't let commercial tobacco trick you into thinking it's something great. You aren't going to get slim, you won't win a marathon, you won't hike that trail with ease.

Help you and our people keep the use of tobacco sacred. It's our medicine. It's what our ancestors believed and so should we. Say this to yourself; "Tobacco is a medicine it is a gift from the creator it is sacred, it should not be misused it is a medicine for healing."

The Use of Sacred Tobacco Is Our Tradition...

Sacred sacred (say-krid) adj.

Dedicated to or set apart for worship.
Worthy of religious veneration.
Made or declared holy.
Dedicated or devoted exclusively to a single use, purpose, or person.
Worthy of respect; venerable.
Of or relating to religious objects, rites, or practices.

Tribal Elders are dedicated to keeping tobacco sacred. Tobacco is offered to the creator of the earth, for our land, our fish, our acorns, our life. The creator gives us many gifts. These gifts must be respected and used in their proper way. Tobacco is a gift to be used in a sacred way with respect.

http://www.ncidc.org/tupe/sacred.htm

Optional Session 4. Healthy Living

Objectives:

Participants will

Increase their knowledge about the importance of healthy eating and physical activity.
Know how to prevent weight gain when stopping smoking.

Before you start Optional Session 4

This session will focus on two healthy living components: nutrition and physical activity. Tobacco-free living is also a component in healthy living. There are many others, such as having a clean environment, good mental health, relaxation, reduced danger of injury, a life free from violence, and access to health care.

You may want to involve a specialized resource person for this session, such as a nutritionist or dietician from your local public health unit; or a physical education or health teacher.

Some Q4L facilitators have incorporated smoking cessation in an overall lifestyle change focus. Others offer information about nutrition and physical activity when participants request it. Find out ahead of time what interests the members of your group. Some may feel they have been bombarded with healthy living information in health classes already.

Many youth are concerned about how to avoid eating more when they quit, and how to avoid weight gain. If you have the facilities, preparing a healthy lunch together might be more fun (and more effective) than just talking about grains, fruits and vegetables. You might be able to use kitchen facilities; if not, bring an assortment of vegetables and fruits to class and prepare a snack together; or go on a picnic with 'healthy' foods.

If youth are most interested in physical activity, then trying to do something active might be a more effective way to deliver the message of this session. You could invite a resource person with sports or games expertise to deliver a session; or, invite one of the participants to lead a 'warm-up' or stretching activity. Other Q4L facilitators have arranged for participants to try out a local health club for free; or obtained free YM/YWCA passes for a few months; or offered memberships as an incentive. Going to a gym or club with a group can help youth overcome the barrier of feeling insecure, not knowing what to do or how to do it.

Additional information and tips on health living is available from many health organizations: see nutrition, healthy eating, and becoming physically active.

Materials

Canada Food Guide
Canada Physical Activity Guide
Healthy snacks or fruit, vegetable, cheese to prepare it (optional)

Activity 1. Warm-up: Just do it!

Start off this session doing something physically active. Some ideas:

Bring skipping ropes and skip in the hall or outdoors.
Hop on one foot, then on another, then on two feet.
Time how long each person is able to skip or hop.
Point out that if they do this again after quitting, they will likely be able to skip for a long time.
Blow up a balloon. Do 50 jumping jacks. Blow up a balloon immediately after.
Talk about lung capacity.

Activity 2. Presentation: What we know about physical activity and smoking.

Notes to the facilitator

Keep the presentation short. Ideally, include some physical activity during or immediately after the presentation- it might be something as easy as standing up, walking around your desk, and stretching.

How to implement this activity

Option 1. You may find it useful to invite a resource person present and discuss facts about physical activity and smoking, e.g., youth who are physically active are less likely to be smokers; becoming physically active can reduce the urge to smoke; being physically active will help prevent weight gain (transition into Activity 3). Leave time for questions and answers.

Option 2. Deliver a presentation based on the information provided in the handouts (Fact Sheets in Appendix?) for this session. Begin with a 'myths and truths' format. Model some of the 'fun' physical activities in the handout, and have the group participate. Leave time for questions and answers.

Incorporating physical activity into your classroom activities and learning programs can be fun!

Ideas for fun physical activities

Classroom physical activity circuits - place signs around the room to create stations for students to work on components such as all-jump, chair sit-ups, line jumps, wall push-ups, and groin stretch.
On-the-spot hip hop - create hip hop dances by moving in place. Teach a few moves like the "Wave" with arms, foot tap, sky reach, hip push. Encourage the students to make up their own moves.
Body-part stretch - name a body part and each person does their own stretch. Encourage youth to learn stretches from each other. Remind them to maintain the natural curve in their lower back while stretching.
Do the wave - one person starts an activity, either stretches or cardio-vascular, then it moves around the room like a wave.
Do a variety of desk exercises such as knee lifts, arm reaches, straddle stretch, desk push-ups, lunge with foot on chair and side bending reaching over the desk.
Four-way mirror - follow a person near the front of the room leading some stretches. As the leader turns all the students turn to follow a new leader at the new front. Turn to follow a new leader in each direction.

Activity 3 - Interactive presentation: What we know about healthy eating and smoking.

Notes to the facilitator

If possible, invite a resource person to talk about nutrition and smoking. If not, prepare a presentation: review parts of the quiz (session 2) about smoking and weight, and dispel the myths around smoking leading to weight loss.

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How to implement this activity

Review the quiz items, and talk about the many alternatives instead of smoking:
- Having vegetable, fruit and yogurt snacks ready in the fridge (ideal also to increase fruit, vegetable and calcium intake)
- Chewing sugarless gum
- Chewing sunflower seeds (spits)
- Drinking water
- Becoming physically active (see above)
Provide information about body image issues in a 'myths and truths' format. Emphasize research findings about girls with normal weight.
Facilitate a discussion that includes:
- Sharing individual strategies and ideas for improving nutrition and avoiding weight gain when quitting
- who benefits (at a societal level) from using an unhealthy habit (smoking) to justify a fashion trend?

Currently, Health Canada advises that all Canadians should consume between 5 to 10 servings every day. Yet a Heart and Stroke Foundation survey of 500 Canadian tweens showed only 14% consume four or more servings of fruit, vegetables, or pure fruit or vegetable juice daily.

The findings from the Nurses Health Study, a landmark study of nearly 75,000 nurses aged 38-63 years, found women who consumed more fibre had half (49%) the obesity risk of those who consumed less fibre. You can boost your daily intake of fibre and whole grains by simply adding a couple of slices of whole wheat toast and a serving of high fibre cereal to your diet which can help cut your risk of obesity and may even aid weight loss.

Liu S, Willett WC, Manson JE, et al. Relation between changes in intakes of dietary fibre and grain products and changes in weight and development of obesity among middle-aged women. American Journal of Clinical Nutrition 2003;78:920-927

Excerpts from Health Canada:

Teacher's Guide to Physical Activity for Youth

http://www.phac-aspc.gc.ca/pau-uap/paguide/child_youth/resources.html#2

Over half of young people are not active enough for healthy growth and development.

Ask the class why they think this is true. Discuss with them what they do with their time and how much of their day is devoted to physical activities.
Ask the class what types of physical activity they like and why they like those particular activities.
Ask the class what has changed in their generation to make them less active than their parents were at the same age. This will likely start a discussion about television, computers, etc. Some youth may also raise the issue of a "lack of time."

Health benefits come from doing the right variety of physical activities.

Ask the class what types of activities they should be doing. Start a chart with each type of activity as a heading at the top of a column.
Ask them what these activities are like and what effect they have on the body. Add these notes to the chart under the appropriate heading.
Here is an outline to help you guide discussions:

There are many good activities from which to choose.

Ask the class to help you build a list. Add all the suggestions to the chart you have started, putting each activity in the correct column. Some examples are included in Canada's Physical Activity Guide for Youth for your reference and to help trigger discussion.

Canada's Guidelines for Increasing Physical Activity in Youth

Increase the time currently spent on physical activity starting with at least 30 minutes more per day.
Reduce "non-active" time spent on TV, video, computer games and surfing the Internet, starting with at least 30 minutes less per day. You need to encourage youth to build up their physical activity throughout the day in periods of at least 5 to 10 minutes.

This increase in physical activity should include:

Moderate activities like brisk walking, skating, or bike riding
Vigorous activities like running, supervised weight training, basketball or soccer.

Note: Youth who are already quite active should record all their moderate and vigorous activities for a few days. They can total up the minutes, then progress gradually from there until they reach at least 90 minutes of daily physical activity.

Healthy Eating Quiz

Adapted from Heart and Stroke Foundation (Canada): How does your family score?

1. Do you eat breakfast before going to school?

Always
Most of the time
Rarely

2. During an average day, how many servings of fruits and vegetables do you eat? (1 serving = 1 orange or apple or 1/2 cup fruit juice or 1/2 cup vegetables or 1 cup salad)

Less than 2
2 to 4
5 or more

3. What type of breads and breakfast cereals do you usually eat?

Pick the answer that best describes your child.

White bread and presweetened cereals
Brown bread and unsweetened cereals
High fibre bread and whole-grain cereals

4. In a typical week, how many evenings will you or your family pick up, or eat food from, a fast food restaurant?

3 or more times a week
Once or twice a week
Less than once a week

5. Which of the following best describes the sort of dairy products your usually consumes?

Whole milk, whole-milk cheeses, and regular (high-fat) ice cream
Some lower-fat dairy products such as 2% or 1% milk or cheese
Nothing but low-fat milk, low-fat cheeses and low-fat frozen desserts

6. Compared to most of your friends, how would you rate your weight?

About normal
Underweight
Overweight

What's my score?

a)=2 b)=1 c)=0
a)=0 b)=1 c)=2
a)=0 b)=1 c)=2
a)=0 b)=1 c)=2
a)=0 b)=1 c)=2
a)=2 b)=1 c)=0

If you scored between:

0 - 4 (Two Thumbs Down) As you are becoming independent, you take charge of how much and what you eat. When you are buying groceries or are picking up prepared foods, include vegetables and fruits, higherfibre cereals and lower-fat dairy products. If you are not in charge, ask your parents if they could do so as well.

5 - 8 (One up, One Down) You might be a picky eater, lack time, or lack of information to ensure that you are eating a healthy diet. Don't despair - there are resources out there to help you. For example, did you know that popcorn - without the butter - is a healthy, high-fibre alternative to potato chips?

9 - 12 (Two Thumbs Up) Your hard efforts are paying off - you have healthy eating habits that should last a lifetime. Healthy eating is important at all stages in life and you will benefit from following Canada's Food Guide.

Activity 4. Cool-off

Go around: Ask students to choose one new thing that they are going to try out next week in terms of increasing physical activity and eating more healthy. Finish with one of the 'fun'-
physical activities described in the Fact Sheet.

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Appendices

Appendix A - Facts & Figures Quiz for Facilitators

(Also to be used in Session 2)

1. The majority of Canadian teens don't smoke.

True
False

2. What is the average age at which Canadian youth try smoking for the first time?

a) 10.4 years old
b) 12.8 years old
c) 13.5 years old
d) 14.6 years old

3. By age 14, one in four Canadian youth will have tried smoking.

True
False

4. More than a third of students who try smoking become smokers.

True
False

5. Over 80% of smokers started smoking before age 18.

True
False

6. The main reason children and teenagers start smoking is:

a) to fit in with their peers
b) to be like adults or feel more like an adult
c) to explore and experiment
d) to rebel or get attention
e) to deal with stress and depression
f) to try to control their weight
e) all of the above
f) none of the above

7. Children of smokers are less likely to smoke themselves.

True
False

8. Parents who smoke, but disapprove of smoking, can help their children not to become smokers.

True
False

9. To be safe, limit exposure to second-hand smoke to one hour per day.

True
False

10. How many kids are regularly exposed to second-hand smoke in Canada?

a) 100,000
b) 400,000
c) 600,000
d) 800,000

11. In which province are children and teens least likely to be regularly exposed to second hand smoke in their homes?

12. If you limit smoking to a few puffs a week it doesn't do you any harm.

True
False

13. How many Canadians are killed every year due to smoking?

a) 4,500
b) 47,500
c) 475,000
d) 1,000,000

14. On average, how much longer will non-smokers live?

a) one year
b) three years
c) eight years
d) ten years

15. All smokers do permanent damage to their lungs, even if they quit.

True
False

16. Quitting early reduces the risk of dying early.

True
False

17. It takes a long time to get addicted to tobacco.

True
False

18. Young teens who are only occasional smokers are not dependent on nicotine.

True
False

19. Smoking scenes in movies are more effective to get teens to start smoking than tobacco advertising.

True
False

20. The Canadian tobacco industry earns half a billion dollars per year from sales of cigarettes to teens.

True
False

21. Studies prove that smoking can help you lose weight.

True
False

22. Teens who don't smoke usually eat a healthier diet.

True
False

23. Starting to smoke will help you to lose weight.

True
False

24. How many adolescents believe that smoking can help control weight?

a) 5%
b)25%
c)40%
d)65%

25. Teens are more likely to try quitting than adults

True
False

26. What are the top three motivators for teens to quit smoking?

a) Bad breath
b) Long term health concerns
c) Not wanting to be out of breath (short term health concerns)
d)Yellow fingers
e) Smelly clothes
f ) Cost
g)Parents nagging

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27. Which cessation or quit method is most preferred by youth?

a) Quit contracts with friends
b) Group programs
c) Nicotine patch or gum
d) Independently
e) Self-help programs

28. Repeatedly telling people to stop smoking is the most effective way to help them quit.

True
False

29. Most teens who smoke don't really want to quit.

True
False

30. 95% of high school students believe they will quit after high school. How many are still smoking five years after graduation?

a) one quarter
b) half
c) two-thirds
d) three-quarters

31. Knowing the facts about quitting, being aware of what to expect, and learning skills to deal with the effects makes a difference to quitting successfully.

True
False

32. Teens find it easier to quit than adults.

True
False

33. Which of these are typical symptoms of nicotine withdrawal?

a) Irritability, frustration, anger or anxiety
b) Difficulty in concentrating
c) Restlessness
d) Increased appetite
e) Problems falling asleep or frequent waking
f ) Slight depression or feeling down
g) All of the above.

34. Symptoms of nicotine withdrawal usually diminish after:

a) 1 day
b) 3 days
c) 15 days
d) 28 days

35. Research shows that nicotine replacement therapies (patch, gum) are effective to help teens quit smoking.

True
False

36. More teen boys smoke than teen girls.

True
False

37. Teen girls smoke more cigarettes a day on average than teen boys.

True
False

38. Teen boys are more likely to be daily smokers than teen girls.

True
False

Appendix B - Answers to The Facts & Figures Quiz

The Facts About.....teen Smoking Rates

1. The majority of Canadian teens don't smoke.

True
False

True.
In 2003, 79% Canadian teens aged 15-19 reported to never have smoked, an additional 3% said that they had quit for good, and only 18% indicated that they were smokers. Source: Canadian Tobacco Use Monitoring Survey (CTUMS) 2003).

2. What is the average age at which Canadian youth try smoking for the first time?

a) 10.4 years old
b) 12.8 years old
c) 13.5 years old
d) 14.6 years old

The correct answer is: b).
On average, young Canadians first try a cigarette when they are 12.8 years old. Source: Canadian Lung Association: http://www.lungsareforlife.ca/

The Facts About.....starting Smoking

3. By age 14, one in four Canadian youth will have tried smoking.

True
False

True.
In 2002, according to the Youth Smoking Survey, 25% of youth in grades 5 through 9 reported that they had tried a tobacco product at least once - mostly smoking a cigarette. This figure is down from 1994, when 42% of teens in this age group indicated that they had tried tobacco.

Source: Health Canada, Go Smoke Free

4. More than a third of students who try smoking become smokers.

True
False

True.
Among students who had ever tried cigarette smoking, 36% went on to smoke daily.

Source: Centre for Disease Control and Prevention, 1997.

5. Over 80% of smokers started smoking before age 18.

True
False

True.
More than 80% of adult smokers started before they turned 18--hardly anyone starts using tobacco as an adult. People who make it through their teens tobacco-free, are most likely to remain tobacco-free for life.

Source: Canadian Lung Association: http://www.lungsareforlife.ca/

6. The main reason children and teenagers start smoking is:

a) to fit in with their peers
b) to be like adults or feel more like an adult
c) to explore and experiment
d) to rebel or get attention
e) to deal with stress and depression
f ) to try to control their weight
g) all of the above
h) none of the above

The correct answer is: e).
Children and teenagers start smoking for lots of reasons including all of the above.

Source: Talking to Children About Quitting - Health Canada Tobacco Control Programme

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The Facts About... Parents And Teen Smoking

Smokers who live in homes where smoking isn't permitted are almost twice as likely to quit smoking as a smoker who lives in a home where smoking is permitted.

7. Children of smokers are less likely to smoke themselves.

True
False

False.
Children of smokers are twice as likely to smoke themselves.

Source: Health Canada Quit4Life Website Text.

8. Parents who smoke, but disapprove of smoking, can help their children not to become smokers.

True
False

True.
Children with parents (both smokers and non-smokers), who voice strong disapproval of smoking, are less likely to take up the habit.

Source: Eisenberg, M.E. and Forster, J.L. (2003); Sargent and Dalton, 2001

The Facts About...second-hand Smoke

9. To be safe, limit exposure to second-hand smoke to one hour per day.

True
False

False.
There is no known safe level of exposure to second-hand smoke.

Source: Health Canada, Go Smoke Free

10. How many kids are regularly exposed to second-hand smoke in Canada?

a) 100,000
b) 400,000
c) 600,000
d) 800,000

The correct answer is: d)
800,000 Canadian kids under 12 were regularly exposed to second-hand smoke in their home from cigarettes, cigars or pipes.

Source: Health Canada, Go Smoke Free

11. In which province are children and teens least likely to be regularly exposed to second hand smoke in their homes?

The correct answer is: BRITISH COLUMBIA.
In B.C., only 8% of children and youth (age 0-17) are exposed to cigarettes in their home regularly. Figures for each province are:

Quebec 26%
New Brunswick 20%
Nova Scotia 19%
Saskatchewan 19%
Prince Edward Island 18%
Newfoundland and Labrador 18%
Manitoba 17%
Alberta 14%
Ontario 12%
BC 8%

Source: CTUMS, 2003

The Facts About....some Health Consequences Of Smoking

12. If you limit smoking to a few puffs a week it doesn't do you any harm.

True
False

False.
Even a few puffs a week is enough to increase carbon monoxide levels in your blood and affect various tissues in your body - there is no safe level of smoking.

Source: Blitstein et al. (2003).

13. How many Canadians are killed every year due to smoking?

a) 4,500
b) 47,500
c) 475,000
d) 1,000,000

The correct answer is: c).
Smoking kills 47,500 Canadians every year. That is the population of a medium size Canadian town, such as Cornwall (Ontario); Chilliwack (B.C.); Shawinigan (Quebec), Charlottetown (P.E.I.), or Wood Buffalo (Alberta)

Source: Health Canada, Go Smoke Free, Census Canada, 2001

14. On average, how much longer will non-smokers live?

a) one year
b) three years
c) eight years
d) ten years

The correct answer is: c).
The average smoker will die about 8 years earlier than a similar non-smoker. Life expectancy improves after a smoker quits

Source: Health Canada, Go Smoke Free

15. All smokers do permanent damage to their lungs, even if they quit.

True
False

False.
In general, the longer you don't smoke, the greater the reduction in risk of lung cancer. The risk levels among long-term (10+ years) ex-smokers approach those of non-smokers.

Source: Health Canada, Go Smoke Free

16. Quitting early reduces the risk of dying early.

True
False

True.
Compared with those who continue to smoke, people who quit before the age of 50 have half the risk of dying in the next 15 years.

Source: Ontario Lung Association.

The Facts About...nicotine Dependency

17. It takes a long time to get addicted to tobacco.

True
False

False
The nicotine in tobacco is one of the most addictive substances known. About eight out of every ten people who try smoking get hooked.

Source: Health Canada, The Scoop.

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18. Young teens who are only occasional smokers are not dependent on nicotine.

True
False

False.
Studies on teen smokers have found that even occasional smokers crave cigarettes and show signs of dependency on nicotine.

Source: Lantz et al., 2000; Colby, 2000. In another study, researchers followed more than 600 12- and 13-year-olds from seven schools in central Massachusetts for a four year period. Even teens who only smoked a few cigarettes a week became strongly addicted.

Source: DiFranza, J. 1999

The Facts About...the Tobacco Industry

19. Smoking scenes in movies are more effective to get teens to start smoking than tobacco advertising.

True
False

True.
A number of studies have shown that now movies account for more than half (52%) of new adolescent smokers. This means smoking scenes in movies are more powerful than conventional cigarette advertising.

Source: http://smokefreemovies.ucsf.edu/godeeper/Landmark_Study.html

20. The Canadian tobacco industry earns half a billion dollars per year from sales of cigarettes to teens.

True
False

True.
The teen market is an important source of revenue for Canadian tobacco companies.

Source: Tobacco Program City of Ottawa, 2000

The Facts About...smoking And Weight

21. Studies prove that smoking can help you lose weight.

True
False

False.
Smoking does not lead to a healthy weight. Research conducted at the University of Memphis (USA) with 4000 young people (18-30 years old) showed that smokers gained as much weight as non-smokers in the same age range.

Source: http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/youth-jeunes/scoop-primeur/index_e.html. Being physically active, switching to a healthy diet and stopping smoking will help you
avoid weight gain.

Source: Klesges, R.C., Ward, K.D., & Ray, J.W., Jacobs, D.R.Jr., Cutter, G. Wagenknecht, L.E. (1998). The prospective relationships between smoking and weight in a young, biracial cohort: the coronary artery risk development in young adults study Journal of Consulting and Clinical Psychology, Vol. 66, No. 6.; Fulkerson, J.A., & French, S.A. (2003). Cigarette smoking for weight loss or control among adolescents: gender and racial/ethnic differences. Journal Of Adolescent Health, 32, 306-313.

22. Teens who don't smoke usually eat a healthier diet.

True
False

True.
Adolescents who smoke are less likely to eat a healthy diet that includes fruit and vegetables.

Source: Strauss and Mir, 2001.

23. Starting to smoke will help you to lose weight.

True
False

False.
There is no evidence that smoking initiation leads to weight loss.

Source: Strauss and Mir, 2001.

24. How many adolescents believe that smoking can help control weight?

a) 5%
b)25%
c)40%
d)65%

The correct answer is: c)
40% of adolescents have this mistaken belief, although research has shown that there is no indication that smoking helps to reduce weight.

Source: (Strauss and Mir, 2001; Klesges RC, Elliot VE, Robinson LA (1997). Chronic dieting and the belief that smoking controls body weight in a biracial population-based adolescent sample. Tobacco Control, 6, 89-94.

The Facts About...quitting

25. Teens are more likely to try quitting than adults

True
False

True.
92% of teens 15-17 had tried to quit one time or more in the past year and 84% of the 18-19 year olds, compared to 67% of adults 25+.

Source: CTUMS, 2003.

26. What are the top three motivators for teens to quit smoking?

a) Bad breath
b) Long term health concerns
c) Not wanting to be out of breath (short term health concerns)
d)Yellow fingers
e) Smelly clothes
f) Cost
g) Parents nagging

The correct answer is: b), c), and f).
Studies have identified health concerns (long term and short term) and cost as the most important reasons that motivate teens to quit. In an evaluation of the Quit4Life pilot program, 328 teens from across Canada reported that the most important motivator for participating in the Q4L program was "wanting to be healthier", (rated at 2.9 on average on a scale from 1 to 3, 3=very important and 1=not at all important) followed by "not wanting to be out of breath" (2.8), and not wanting to spend all that money on smokes (2.8).

Source: Meyer & Estable, 2004. A US study found similar results: the main motivator for adolescents in an inner-city school in Memphis to quit long term health concerns (76%), followed by short term health concerns (65%), physical appearance (59%), and cost of cigarettes (52%).

Source: Riedel et al., Drug and Alcohol Dependence 2002; CDC Vol 14, No.3, Fall 200, page 14.

27. Which cessation or quit method is most preferred by youth?

a) Quit contracts with friends
b) Group programs
c) Nicotine patch or gum
d) Independently
e) Self-help programs

The correct answer is: a)
In a Canadian study with 1,340 adolescents aged 13 to 20, 28% chose quit contracts with friends as their preferred method from a list of 13 quit options; followed by 8% self-help programs; 5% nicotine replacement therapy (although they have not been confirmed as a safe method for teens yet); 4% group programs; and 1% web-based programs.

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Source: Lawrance, 2001.

28. Repeatedly telling people to stop smoking is the most effective way to help them quit.

True
False

False.
Support and encouragement are essential parts of helping people manage their addictions. Open-ended questions, empathetic listening, and role modeling are very important factors in smoking cessation.

Source: Minimal Contact, PTCC, 2000 Background from #1. Minimal contact with youth increases the chances of quitting, as the constant reinforcement, even if limited, has been proven to work (serial contacts). Randomized controlled trials have shown that among smokers who are subject to brief intervention by their physician, group leader or teacher, the quit rate doubles from 6% to about 12% each year. Motivational messages and support from medical and non-medical providers, particularly if the smokers are not yet addicted to nicotine, can be beneficial.

Source: Info-Pack, PTCC, 2000

29. Most teens who smoke don't really want to quit.

True
False

False.
The desire to quit seems to come earlier now than before, even prior to the end of high school. In fact it often seems to take hold as soon as the recent starters admit to themselves that they are hooked on smoking. However, the desire to quit, and actually carrying it out are two quite different things, as the would-be quitter soon learns.

Source: WHO Fact Sheet # 197 May 1998.

30. 95% of high school students believe they will quit after high school. How many are still smoking five years after graduation?

a) one quarter
b) half
c) two-thirds
d) three-quarters

The correct answer is: d)
In this study, only 5% of high school students believed that they would continue smoking after high school. When surveyed again 7 years later, almost 75% were still smokers

Source: Trends in Tobacco Use Among Youth, "CDC, March 1994; www.smokefreekids.com/facts03.htm"

31. Knowing the facts about quitting, being aware of what to expect, and learning skills to deal with the effects makes a difference to quitting successfully.

True
False

True.
These are essential elements for successful adolescent cessation programs, and they are incorporated into the Q4L program.

Source: McDonald et al., 2002. Better Practices for Youth Tobacco Cessation: Findings of an Evidence Review Panel. Health Canada; Sussman 2002; Mermelstein, 2003

32. Teens find it easier to quit than adults.

True
False

False.
If they do make a serious attempt to quit, most are surprised at how hard it is. Their confidence may come from the fact that kids tend to be better able to regulate how much they smoke and where they smoke. For example, many are forced to stop smoking when they are away from friends or family who supply them with tobacco or when they do not have money to buy their own cigarettes.

Source: Talking to Children About Quitting - Health Canada Tobacco Control Programme

33. Which of these are typical symptoms of nicotine withdrawal?

a) Irritability, frustration, anger or anxiety
b) Difficulty in concentrating
c) Restlessness
d) Increased appetite
e) Problems falling asleep or frequent waking
f ) Slight depression or feeling down
g) All of the above.

The correct answer is: g)
All of the above are typical. Not all smokers go through withdrawal, however. What's more, not all individuals who go through withdrawal experience the same number or intensity of symptoms.

Source: Health Canada, The Scoop.

34. Symptoms of nicotine withdrawal usually diminish after:

a) 1 day
b) 3 days
c) 15 days
d) 28 days

The correct answer is: b)
For many people, withdrawal is at its worst for the first few days after they stop smoking. It begins to lessen after 3 or 4 days. After a week to 10 days all withdrawal symptoms should be gone. Because the symptoms are most intense in the first few days after you stop, this is when you are most likely to start smoking again.

Source: Health Canada, The Scoop. http://www.hc-sc.gc.ca/hecs-sesc/tobacco

35. Research shows that nicotine replacement therapies (patch, gum) are effective to help teens quit smoking.

True
False

False.
Nicotine Replacement Patches can help adults quit smoking. However, as of January 2002, 188 not enough scientific studies have been done to show if patches can help teen smokers to quit. Like patches, nicotine chewing pieces can be very effective in helping adults quit smoking. Unfortunately, there has not been enough research done to show if nicotine chewing gum can help teen smokers to quit smoking.

Source: Health Canada, The Scoop.

The Facts About...gender Differences

36. More teen boys smoke than teen girls.

True
False

False.
The rate of teens aged 15-19 smoking in 2003 was 18%: 20% females and 17% males.

Source: CTUMS, 2003

37. Teen girls smoke more cigarettes a day on average than teen boys.

True
False

False.
In 2003, Teen boys smoked 13.0 cigarettes a day on average compared to 11.7 of teen girls.

Source: CTUMS, 2003

38. Teen boys are more likely to be daily smokers than teen girls.

True
False

True.
13% of teen girls said that they did not smoke every day, compared to 10% of teen boys.

Source: CTUMS, 2003

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Appendix C - Tips For Q4L Group Facilitation

(Many of the suggestions in the following section are adapted from: Auvine, Brian, et al. (1978). A Manual for Group Facilitators. The Centre for Conflict Resolution. Madison, WI; and Estable, Meyer and Pon (1997) A Training Manual for Anti-Racism Trainers. Ottawa: From the Margin/Canadian Labour Congress.)

Group function

As a facilitator, you can adapt your facilitation style according to the purpose of a group. Keep in mind that your Q4L group has several functions:

Becoming more informed - educational, shares facts and theories, knowledge-focused
Learning and practicing new skills- practical application of information, emphasizes improving abilities
Becoming more aware- self-awareness, values clarification, feelings
Providing support to each other- establishing trust, links, connections.

The Q4L Session Outlines offer a range of activities to help meet each of these functions.

Group characteristics

As you begin to facilitate your group, and during the first few sessions, you may also want to think about:

Group size and composition: What is the number of participants, ages, gender, language, cultural/ethnic mix?
Cohesion: How well do the participants know each other? Are they connected outside the group? Are they talking to each other when you first walk into the room? Do seating patterns change?
Dynamics: Are any participants emerging as leaders? Is anyone consistently silent? Are there any tensions? Is everyone equally comfortable participating?
Style: What learning styles are evident? How do different participants respond to different types of activities?

Review the Q4L Session Outlines to select a mix of activities and facilitation options to reflect the characteristics of your group.

Role of facilitator

Facilitation usually involves:

making it easy for participants in a group to engage in 'horizontal' discussions
encouraging participants to bring in their own ideas, experience, and knowledge
respecting the direction which the group wants to take
assisting the group to meet its own goals.

As a Q4L facilitator, your role has additional dimensions: leading and training. As well as the facilitator, you are also the leader of the group, with a responsibility to ensure that specific goals are achieved. Your role is also an educational one: you will work towards achieving a set of specific learning goals during the course of each session, and overall.

Introducing yourself as a Q4L facilitator

Many Q4L facilitators are also teachers or guidance counsellors. When you introduce yourself to the participants, you may want to:

Set the scene: Describe the role you will play, and distinguish between your role as teacher and your role as Q4L facilitator
Explain your own motivation for being a facilitator for Q4L: Why is youth cessation important to you? Why is it important to you that these kids quit?
Establish your credibility: Have you successfully managed to change a negative health behaviour in your own life (e.g., smoking)?

Facilitation style

When facilitating a Q4L group, you may want to become aware of your own facilitation style, and adapt it to the unique challenges and characteristics of each session and each group. For example, you could:

explain the reasoning behind the things you do; what the goals of each activity are; what you hope to accomplish
provide additional factual and knowledge-based information
share your own experiences with smoking or quitting
solicit feedback from participants about your own participation, and pay attention to it
take time to explain interactive and cooperative style of participation that is expected in a group, compared to a classroom
share your expectations about the group's rights and responsibilities, and about your own
of the group
be openly attentive to group process and aware of the cycles the group is going through
inform participants about additional supports and refer them if they need more help.

Group process

Facilitators have a double focus: they must be aware of both content and process simultaneously. As a Q4L Facilitator, you will need to balance your own interest in the content and your observation of how the group is working.

To facilitate effectively,

before the meeting, focus inward: take time to prepare the content well, make a plan for how you will deliver each session, be ready with answers to possible questions
during the meeting, focus outward: observe how the group members are interacting help the group work together well

Some signs that group process needs your attention include:

Restlessness
Uncomfortable silences
No eye contact with facilitator/each other
Closed body language (posture, facial expressions)
Off-topic conversations, bilateral conversations
Persistently unequal participation

Group cycle

Most group meetings go through a number of predictable phases. These are:

Social interaction
Information seeking
Establishing structure
Constructive work
Completion

The Q4L Sessions are designed with this cycle in mind. If you find the group is going back to an earlier phase (e.g., social interaction in the middle of constructive work), this might be a hint that:

the group rushed into the next activity too soon
the activity may not be well enough defined
the activity may not be well structured
the group may be ready to move to the next activity

Group communication

Good communication is essential to good group process. As a facilitator, you may want to:

adapt your language and style to the group, but remain authentic to your own age group and experience
listen more than you speak, and listen from the other person's perspective
model the type of communication you want in the group
give feedback that is specific, tentative, suggestive, and tied to behaviour
openly test your assumptions
show commitment and concern for the group.

To help facilitate communication during a discussion, you may want to:

explain what the discussion is about, why it is important to discuss at this time
give room for participants to be involved
model a relaxed, conversational style for the discussion
use questions to get things started
use lists (of topics, ideas, reasons, views, pros and cons) to summarize where the discussion is at
go around the room asking for input
use flipcharts or blackboard to write down key points
relate discussion to experiences
use humour.

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Quit4life - Facilitator's Guide

Table of Contents:

Plans For The 10-session Program

Four Optional Sessions

Appendices

Introduction

To The Quit 4 Life Guide for Program Facilitators

1. How to Use this Guide

Conclusion - Facilitators are the backbone of Q4L

Thank you!

Introduction - 2. What is the Quit 4 Life Program?

2.1 What are the goals of Q4L?

2.2 Does Q4L work?

2.3 Why does Q4L work?

Introduction - 3. Getting Ready to Facilitate a Q4L Group

3.1 What does a Q4L Facilitator do?

3.2 What should a Q4L Facilitator know?

3.2.1 Facts And Figures: Review Your Knowledge About Teen Smoking And Cessation

3.2.2 Facilitation Tips: Review Your Knowledge About Group Facilitation

Introduction - 4. Getting Organized : How to set up a Q4L program?

4.1 Recruitment and retention

4.2 Intake

4.3 Attendance and retention

4.4 Group size

4.5 Diversity

4.6 Scheduling

4.7 Incentives

Introduction - 5. Evaluating the Program

5.1 Assessing implementation: Keeping track of goals and activities (Focus on process)

Keeping track of your own learning goals for each session

Keeping track of learning goals for the program

Keeping track of the core: what goals and tools can be modified?

5.2 Detecting change in participants: Baseline and Post-Program Surveys (Focus on outcomes)

Administer the Baseline Survey at the start of the first session.

Motivate participants to complete the Baseline Survey

Administer the Program Evaluation Survey during the tenth session.

Motivate participants to complete the Post-Program Survey

Include the drop-outs

Compare baseline and post-program data

Introduction - 6. Overview of Sessions

6.1 Q4L program objectives

Step I : Get Psyched: Motivate Yourself To Quit And Stay Smoke-free

Step II : Get Smart: Know Yourself And What To Expect When You Quit

Step III : Get Support: Create A Positive Environment For Yourself

Step IV : Get On With It: Know What To Do When You Quit

6.2 What's in a Session Plan?

Theme

Session title

Objectives

Before you start this session

Materials

Warm-up

Activities

Cool-off

6.3 Other things to consider in planning your group program

Length and timing

Setting up

Wrapping up

Tasks between sessions and written 'homework'

Introduction - 7. Additional Resources

Check out these other helpful sites.

Plans For The 10-session Program

Step 1 - Get Psyched : Motivate Yourself To Quit And Stay Smoke-Free

Session 1. What Are the Advantages of Quitting Smoking?

Theme: Program Introduction and Motivation

Objectives:

Before you start Session 1

Facilitator's Checklist

Materials

Handouts

Activity 1. Warm-up: Getting on the Bus

Notes to the facilitator

How to implement this activity

Activity 2. Baseline survey

Notes to the facilitator