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2002 Youth Smoking Survey - Technical Report

Table of Contents

Knowledge of Health Risks

William Morrison, PhD
Faculty of Education
University of New Brunswick

Cynthia Doucet, PhD
Research Associate
University of New Brunswick

Alan Diener, PhD
Tobacco Control Programme
Health Canada

Acknowledgements: The authors thank Roberta Ferrence (University of Toronto), Sarah Robinson (University of Waterloo) and Shawna Mercer (Centers for Disease Control & Prevention, Atlanta) who reviewed an earlier draft of this chapter and provided helpful commentary.

Highlights

More than three-quarters of Canadian students in grades 5-9 indicated they had received education on smoking and its impact on health. The percentage of such students varied considerably by province, from 61% in Quebec to 87% in Prince Edward Island and in Newfoundland and Labrador. The overall percentage who reported receiving education increased by 2% from 1994 to 2002.
The most frequently recalled health problems linked to smoking were "lung cancer," "other cancers," "cardiovascular problems," and "respiratory problems". Other less frequently recalled problems were "mouth problems" and "shortening of lifespan/ causing death".
The number of health problems recalled tended to be greater among students in higher grades, females, never smokers, and those who reported receiving smoking-related education.
Of all students in grades 5-9, 35% recalled three or more kinds of health problems related to smoking, 33% identified two problems, and 26% reported one health problem. The remaining 6% did not recall any health problem.
Exposure to cigarette package health warning messages and recall of various health warning messages were associated with greater involvement in smoking behaviours. The most frequently recalled health warning messages were "lung cancer" and "harms fetus/pregnancy."
Of all students in grades 5-9, 17% recalled three or more kinds of cigarette package health warning messages, 23% recalled two health warning messages, and 38% recalled one health warning message. Females, older students, and those who had smoked beyond puffing recalled more categories of health warning messages.
In general, students who recalled specific cigarette package health warning messages cited the same health concerns as those who did not recall specific health warning messages.
The effectiveness of cigarette package health warning messages may be enhanced if greater emphasis is placed on combining positive messages about the benefits of quitting smoking with current content relating to the negative impact of tobacco use.

Methods

This section covers definitions and sample issues specific to this chapter. For detailed methods on the entire 2002 Youth Smoking Survey refer to Chapter 2.

Definitions

The intent of this chapter is to examine the findings of the 2002 Youth Smoking Survey (YSS) related to students' recall of health problems and health warning messages pertaining to smoking. These variables were investigated, taking into account sex, grade, exposure to health education, and smoking category.

Open-ended questions were used to assess students' knowledge of specific health problems related to smoking (Y_Q48). Elicited responses were coded and sorted into one of 10 possible categories (Table 8-A). A similar procedure was also used to code and sort data related to recall of health warning messages (Y_Q50B) (Table 8-B). For recall of both health problems and health warning messages, it is important to note that some categories define specific health problem areas, whereas others represent aggregate health issues that have been grouped together. Categories were developed to reflect similarities in specific health problems and health warning messages and to provide a means for making comparisons with data collected in 1994. As a result, variations in recall rates across categories may reflect to some extent the way in which data were initially organized and sorted.

Students' knowledge of specific health problems and health warning messages was also evaluated by counting the number of different health categories they were able to identify. This analysis was undertaken by creation of a new variable that involved coding students' responses as 0, 1, 2, or 3 or more problems, based on the number of assigned categories recalled.

The outcomes discussed in the chapter are presented according to five items from the student questionnaire, namely, sex, grade, smoking status, whether smoking-related health education was received (Y_Q58), and province (PROVINCE) for receiving education on smoking-related health problems. With respect to smoking behaviour students' responses on various questionnaire items were employed to determine assignment to one of the following categories: Never Smoker; Puffer; Smoked Beyond Puffing (see Chapter 2, Table 2-C). Questions on awareness of brand ingredients, which were part of the 1994 YSS questionnaire, were omitted in the 2002 YSS questionnaire.

Sample and Response

In general, missing data for items discussed in this chapter accounted for less than 10% of the total responses. As such, the data presented are based on those for whom complete data were available. According to Statistics Canada guidelines, data were deemed non-reportable if the sample size was too small (n<30) or if there was high sampling variability. Only statistically significant group differences are reported. These outcomes were determined using coefficients of variance tables as described in Chapter 2.

Table 8-A - Categories and Coding Scheme for Health Problems Recalled, Youth Smoking Survey 2002
Recalled Category	Coding Includes
Lung Cancer	Bronchial or Lung Cancer
Cardiovascular Problems	Heart Problems, Cardiovascular Problems, Heart Disease, Hypertension, Aortic Aneurysm, Vascular Problems, Heart Attack, Heart Failure, Stroke or Cardiovascular Accident, Brain Problems, Coronary/Pulmonary or Rheumatic Heart Disease
Emphysema/Asthma	Emphysema Or Asthma
Other Respiratory Problems	Breathing Problems, Blackens Lung Tissue, Bronchitis, Coughing/Wheezing, Harms/Destroys Lungs, Chest Infection, Pneumonia, Shortness of Breath, Chronic Airway Obstruction, Damaged Cilia, Lungs Only, Respiratory Problems, Swelling of Lung Tissue, Tuberculosis
Other Cancer	Unspecified Cancer, Breast, Brain, Lip, Larynx, Mouth, Skin, Throat, Tongue, Other Cancer
Mouth Problems	Gum Disease, Halitosis, Mouth Problems/Diseases, Taste Buds Affected, Tooth Loss/Unhealthy Teeth
Addiction	Addiction
Shortens Lifespan/Causes Death	Reduces Life Expectancy, Kills
Sexual Problems	Impotency
Harms Fetuses And Pregnancy	Hurts Babies Miscarriage

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Table 8-B - Categories and Coding Scheme for Cigarette Package Health Warning Messages Recalled, Youth Smoking Survey 2002
Recalled Category	Coding Includes
Cardiovascular Problems	Photo of Heart, Strokes "Cigarettes Cause Strokes", Photo of Brain Cut in Half, Clogged Arteries, Heart Problems, "Cigarettes Are a Heartbreaker"
Lung Cancer	"Cigarettes Cause Lung Cancer", Photo of Cancerous Lungs, Picture of a Person in a Breathing Apparatus
Emphysema/Asthma	Reference to Emphysema or Asthma
Other Respiratory Problems	Respiratory/Breathing Problems, Lung Disease Reference, "Cigarettes Leave You Breathless", Picture of Man Coughing
Other Cancer	Cancer (General)
Mouth Problems	Mouth Diseases or Problems, Gum Disease, "Cigarettes Causes Mouth Disease", Blackened Teeth Picture, Tooth Loss/Bad Teeth/Yellow Teeth, Oral Cancer Reference
Addiction	Addiction, "Cigarettes Are Highly Addictive", Hooked on Nicotine, Hard to Quit
Shortens Lifespan /Causes Death	Death/Dying, Picture of Bar Chart: Number Of Deaths, "Each Year the Equivalent of a Small City Dies From Tobacco Use"
Sexual Problems	Sexual Impotence, "Tobacco Use Can Make You Impotent" Reference to Affecting Sex Life, Picture of Bent-Over Lit Cigarette
Second-Hand Smoke	Second-Hand Smoke, "Where There's Smoke There's Hydrogen Cyanide", "You're Not the Only One Smoking This Cigarette", "Idle But Deadly", Picture Of Blue Smoke, Picture of a Single Lit Cigarette, Reference to Smoke Causing Headaches, Weakness, Nausea, Reference to Smoke Containing 50 Cancer Causing Agents.
Harms Fetuses And Pregnancy	Impact of Smoking on Pregnancy and Babies, "Cigarettes Hurt Babies", "Tobacco Smoke Hurts Babies", Picture of Pregnant Woman Smoking, Baby in Incubator Picture, Growth Reduction in Premature Babies, Reference to Infant Illness/Death of Baby
Harms Children	Parents Influence on Kids, "Children See, Children Do", "Don't Poison Us", Picture of Mother Smoking with Child Watching, Picture of Two Boys Arm-In-Arm, Reference to Copying Adults, Reference to Poisoning Kids/Hurting Children

Findings

Education About Smoking-Related Health Problems

More than three-quarters (77%) of Canadian students in grades 5-9 reported receiving education on smoking and its impact on health (Table 8-1a). The overall percentage that reported receiving education increased by 2% from the 1994 YSS to the 2002 YSS (Table 8-1b).

The percentage of youth who reported receiving education on smoking-related health problems increased with grade, from 65% in grade 5 to 85% in grade 9. No variations by sex were noted. Comparisons with 1994 data revealed similar patterns according to grade and sex.

In the 2002 YSS, the percentage of students who reported receiving education on smoking-related health problems varied considerably by province, from 61% in Quebec to 87% in Prince Edward Island and in Newfoundland and Labrador (Table 8-2a and Figure 8-A). Increases from the 1994 YSS were found for Prince Edward Island and British Columbia. In two provinces, New Brunswick and Manitoba , the proportions of students in grades 5-9 who reported receiving education were less than those found in the 1994 YSS (Table 8-2b).

Figure 8-A - Received Education about Smoking and Health, by Province, Youth Smoking Survey 2002 and 1994

Figure 8-A - Received Education about Smoking and Health, by Province, Youth Smoking Survey 2002 and 1994

Awareness of Smoking-Related Health Problems

Of students in grades 5-9 in the 2002 YSS, 49% recalled "lung cancer", and 48% recalled "other cancers" as smoking-related health problems (Table 8-3a). Approximately one-third of students mentioned "cardiovascular" and "respiratory problems." "Mouth problems" and "shortening lifespan or causing death" were recalled by approximately 18% of the sample. The most frequently recalled smoking-related health problems were generally the same in the 1994 YSS analysis (Table 8-3b).

Recall rates were higher among students in grades 7-9 than among those in grades 5-6 for "lung cancer" and "other cancer". In contrast, "shortens lifespan" or "causes death" was recalled at a higher rate among students in grades 5-6.

Recall rates also differed between the sexes in grades 5-9, with females recalling some health problems at higher rates than did males, including "cardiovascular problems," "other respiratory problems," "other cancer" and "mouth problems." In 1994 females also demonstrated a higher recall rate for "lung cancer" than did male students. In comparing the 1994 and 2002 YSS data, analyses revealed that recall rates decreased for "lung cancer" (from 56% to 49%). In contrast, recall rates for other health-related conditions increased: "cardiovascular problems" (from 26% to 30%), "other cancers" (from 32% to 48%), "mouth problems" (from 3% to 18%), and "shortens lifespan/causes death" (from 3% to 18%).

An inverse trend was noted between recall of most health problems and smoking category. In this regard, recall of health problems was greatest among never smokers and least among those who had smoked beyond puffing (Table 8-4a). This trend was evident on a range of health variables including "cardiovascular problems," "other respiratory problems," "mouth problems," and "shortens lifespan/causes death." In contrast to the 2002 outcomes, analyses of the 1994 data revealed no patterns in relation to the category of smoker (Table 8-4b).

Students indicated whether they had received education about smoking-related diseases by responding "Yes," "No," or "I don't know." In the 2002 YSS students who reported they had received education on smoking and health were more likely to recall health problems caused by smoking including "lung cancer," "cardiovascular problems," "other respiratory problems," "other cancer," and "mouth problems" (Table 8-5a). These differences were also observed in 1994 YSS for "lung cancer," "cardiovascular problems," and "other cancer" (Table 8-5b).

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Number of Smoking-Related Health Problems Recalled

Of all students in grades 5-9 in the 2002 YSS, 35% recalled three or more kinds of health problems related to smoking, 33% identified two problems, and 26% reported only one health problem and the remaining 6% did not recall any (Table 8-6a). The percentage of students that recalled three or more kinds of health problems increased from 14% in the1994 YSS to 35% in the 2002 YSS whereas the percentage that did not recall any health warning messages decreased from 9% in the 1994 YSS to 6% in the 2002 YSS (Table 8-6b).

In general, students in grades 7-9 recalled more categories of health problems than did students in grades 5-6. In addition, females tended to recall more problems than did males. The percentage of males (females) who recalled three or more health problems increased from 11% (16%) in the 1994 YSS to 29% (41%) in the 2002 YSS. The mean (median) number of health problems recalled increased from 1.6 (1) in the 1994 YSS to 2.2 (2) in 2002 YSS.

In the 2002 YSS an inverse trend was observed between number of health problems recalled and smoking category. The percentage of students who reported three or more kinds of health problems was higher among never smokers (37%) than among those who had smoked beyond puffing (25%) (Table 8-7a). In the 1994 YSS, no such pattern was evident with respect to type of smoker and number of health problems recalled, perhaps due in part to high sampling variability (Table 8-7b).

In the 2002 YSS students who reported receiving smoking-related education were more likely (39%) to recall three or more problems than were those who were unsure about receiving (24%) or who reported not having received this type of education (23%) (Table 8-8a). This pattern was also evident in 1994 YSS outcomes (Table 8-8b).

Awareness of Cigarette Package Health Warning Messages

Students were asked to indicate if they had ever seen health warning messages on cigarette packages. In the 2002 YSS, compared to never smokers (73%), both puffers and those who smoked beyond puffing were more likely to indicate they had observed health warning messages (86% and 90%) (Table 8-9a). A similar pattern was also evident for data collected in the 1994 YSS (Table 8-9b).

Cigarette Package Health Warning Messages Recalled

For the full sample in the 2002 YSS, the most frequently recalled health warning messages were "harms fetus/pregnancy" (32%) and "lung cancer" (23%) (Table 8-10a). The same categories were also the most frequently recalled in the 1994 YSS analysis (Table 8-10b).

Students in grades 7-9 were generally more likely to recall health warning messages than were those in grades 5-6. This was noted for health warning messages related to "lung cancer," "other cancer," "mouth problems," "second-hand smoke" and "harms fetus/pregnancy." This pattern was also evident in the 1994 YSS analysis for health warning messages regarding "lung cancer" and "harms fetus/pregnancy."

In the 2002 YSS, females were more likely than were males to recall health warning messages related to "lung cancer," "mouth problems," "shortens lifespan," "second-hand smoke," "harms fetus/pregnancy," and "harms children." In contrast, males were more likely than were females to cite health warning messages relating to "shortens lifespan/causes death." For the 1994 YSS outcomes, females demonstrated higher recall than did males for health warning messages related to "lung cancer," "second-hand smoke" and "harms fetus/pregnancy."

In the 2002 YSS, increased knowledge of some health warning messages was associated with greater involvement with smoking behaviours. In this regard, those who smoked beyond puffing demonstrated higher rates of recall compared to other groups for health warning messages relating to "mouth problems" and "sexual problems" (Table 8-11a). Those who smoked beyond puffing were also more likely to recall messages about "second-hand smoke" than were never smokers. In the 1994 YSS those who smoked beyond puffing were more likely than never smokers to recall health warning messages for "lung cancer," "second-hand smoke," "shortens lifespan/causes death" and "harms fetus/pregnancy" (Table 8-11b).

In the 2002 YSS there were minimal differences in recall of cigarette package health warning messages noted among students who reported receiving and not receiving education about smoking-related health problems (Table 8-12a). The outcomes of the 1994 YSS analysis are also consistent with this finding (Table 8-12b).

Number of Cigarette Package Health Warning Messages Recalled

Of all students in grades 5-9 in the 2002 YSS, 17% recalled three or more kinds of cigarette package health warning messages, 23% identified two such messages, and 38% reported one health warning message (Table 8-13a). Since 1994, the percentage of students who recalled three or more kinds of health warning messages increased from 14% in the 1994 YSS to 17% in the 2002 YSS, whereas the percentage who did not recall any health warning messages decreased from 39% in the 1994 YSS to 22% in 2002 YSS (Table 8-13b). The mean (median) number of health warning messages recalled increased slightly from 1.2 (1) in the 1994 YSS to 1.4 (1) in 2002 YSS.

In the 2002 YSS students in grades 7-9 were more likely to recall more categories of health warning messages than were those in grades 5-6. With respect to sex, females tended to recall more cigarette package health warning messages than did males. The percentage of females who recalled three or more kinds of health warning messages increased from 17% in the 1994 YSS to 21% in the 2002 YSS.

In the 2002 YSS the percentage of students who recalled three or more kinds of cigarette package health warning messages was higher among those who smoked beyond puffing (21%) than among never smokers (15%) (Table 8-14a). In the 1994 YSS, this pattern was also evident with those who smoked beyond puffing (27%) being more likely than never smokers (9%) to recall three or more health warning messages (Table 8-14b).

The results of the analysis rendered no significant differences among student groups in the number of cigarette package health warning messages recalled, based on receiving health education related to the effects of smoking (Table 8-15a). Similarly, there was no observed relationship evident in the 1994 analysis between receiving education and recalling more health warning messages (Table 8-15b).

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Relationship Between Health Knowledge and Cigarette Package Health Warning Messages

In general, students who recalled specific cigarette package health warning messages were also more likely to recall associated health problems related to smoking as compared to those who did not recall the various health warning messages (Table 8-C). For example, of the students who recalled the health warning messages related to "cardiovascular problems", 60% also recalled this condition as a health problem related to smoking. In contrast, of those who did not recall this health warning message, only 28% recalled "cardiovascular problems" as a health condition related to smoking. The overall outcomes of this analysis suggest a potential association between health warning label recall and the recall of specific health problems related to smoking. A similar relationship between these variables was also noted in the 1994 YSS (Table 8-D), suggesting that exposure to cigarette package health warning messages was beneficial for informing students regarding health problems associated with smoking.

Table 8-C - Recall of Health Problem, by Recall of Cigarette Package Health Warning Message, Canada, Youth Smoking Survey 2002
Cigarette Package Health Warning Messages	Lung Cancer	Cardio-vascular Problems	Emphysema or Asthma	Other Respiratory Problems
	Percent who Recalled Health Problem
Recalled	66.4	59.7	55.0	60.4
Not Recalled	48.2	28.0	7.4	36.6
Proportional Difference of Cigarette Package Health Warning Messages Recalled / Not Recalled	1.4	2.4	7.4	1.7
	Percent who Recalled Health Problem
Cigarette Package Health Warning Messages	Other Cancer	Mouth Problems	Shortens Lifespan	Sexual Problems
Recalled	64.7	38.1	25.2	13.0
Not Recalled	47.0	18.2	16.7	0.5
Proportional Difference of Cigarette Package Health Warning Messages Recalled / Not Recalled	1.4	2.1	1.5	26.0

Table 8-D - Recall of Health Problem, by Recall of Cigarette Package Health Warning Message, Canada, Youth Smoking Survey 1994
Cigarette Package Health Warning Messages	Lung Cancer	Cardio-vascular Problems	Other Respiratory Problems	Other Cancer
	Percent who Recalled Health Problem
Recalled	82.3	72.8	63.1	59.7
Not Recalled	49.4	22.9	35.6	26.2
Proportional Difference of Cigarette Package Health Warning Messages Recalled / Not Recalled	1.7	3.2	1.8	2.3

Discussion

Education About Smoking-Related Health Problems

The majority of students surveyed in the 2002 YSS indicated they had been exposed to education relating to smoking and its impact on health. Awareness of specific health education targeting the effects of smoking was also higher among students in grades 7-9 compared with those in lower grades (5-6). In addition, there was considerable variability noted among provinces with respect to reported awareness of education relating to health problems associated with smoking. It is conceivable that differences among provinces with respect to health education awareness exist as a result of the diversity of school-based curriculum planning across educational systems. Because decisions related to the development and implementation of educational programming are under provincial jurisdiction, emphasis related to the delivery of health education focusing on tobacco and its effects may be quite different from one province to another. The finding that older students have greater awareness of specific health education related to smoking is also anticipated, given that these students have experienced a wider range of educational programs and learning opportunities over time. Overall, the outcomes of the 1994 YSS analysis are similar to the findings of the 2002 data-gathering effort.

Awareness of Smoking-Related Health Problems

Similar to exposure to health education, in the 2002 YSS students' recall of health problems associated with smoking increased with years of attendance at school. Compared to males, female students tended to demonstrate greater awareness of specific health problems. Of particular interest is the finding that recall of smoking-related health concerns was higher among those who had never smoked and least among students who had smoked beyond puffing. This might be an issue of self-selection in which those who have tried smoking may choose to ignore the health problems. Different messages may be needed for students who have tried smoking. This trend did not occur in the 1994 YSS.

Health awareness programs are often undertaken on a school-wide basis with the intent of educating all students. Given that smokers in this investigation had lower rates of recall regarding smoking-related health conditions, specific efforts to connect with or reach out to students who have smoked beyond puffing may be an important consideration in planning or implementing school-based health promotion initiatives.

Although further investigation is required to clarify the nature of the relationship between awareness of health problems and smoking behaviour, it is encouraging to note that in the 2002 YSS, higher rates of recall regarding smoking-related health problems were evident among students identified as never smokers. Some research outcomes have reported that students often cite the health effects of smoking as a major reason for not using tobacco industry products.¹ Such outcomes provide support for continuing efforts to educate students regarding the consequences associated with the use of tobacco.

Awareness of Cigarette Package Health Warning Messages

The implementation of health warning messages on cigarette packages has been an important aspect of the Federal Tobacco Control Strategy of Health Canada. The purpose of health warning messages is to increase public awareness regarding the consequences associated with smoking. For health warning messages to be useful, they must not only be noticed, but also be informative and credible to those who observe them.²

In the 2002 YSS youth who had smoked beyond puffing were more likely to report they had seen health warning messages than were never smokers. This finding was anticipated, given that students who have direct experience with tobacco packaging would be more likely to have greater exposure to the health warning messages included on cigarette packages. Some research has indicated that adolescent smokers use health warning messages on cigarette packages as a key source of information regarding the health consequences associated with smoking.³ The effectiveness of health warning messages on cigarette packages has been viewed as comparable to awareness gained through television or through educational programming. Research suggests that many youth smokers view health warning messages as not only effective for informing them about health effects, but also for encouraging them to reduce their smoking around others and to enhance their motivation to quit.^4-6

Consistent with the outcomes of the 1994 YSS, in the 2002 YSS the most frequently recalled health warning messages were "harms fetus/pregnancy" and "lung cancer." Health warning messages related to cancer may be among the most memorable because of the extent of health promotion that has focused on this condition through other forms of education or awareness programming. This observation was also noted regarding "lung cancer" in the 1994 YSS report, indicating that this "health consequence of smoking is now common knowledge."⁷ With respect to "harms fetus /pregnancy," such health warning messages may be more memorable than messages that focus on the long-term effects of tobacco use.⁷ It is conceivable that other health information related to physical and social development obtained through school-based health programming may have reinforced students' familiarity with the category "harms fetus/pregnancy."

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Since the 1994 administration of the YSS, more health warning messages were introduced, they were made larger, and visual content was added to increase their potential for attracting the attention of individuals to specific health effects associated with smoking.⁸ These facts may relate to the finding that a greater range of health warning messages was recalled by students in the 2002 YSS compared to the 1994 YSS. In addition, the percentage of students that recalled three or more kinds of health warning messages increased. It is conceivable that the elaboration of health warning messages to include visual content has contributed to some extent to enhanced awareness of smoking-related health conditions among students.

Relationship Between Health Knowledge and Cigarette Package Health Warning Messages

The intent of health warning messages is to have a meaningful influence on the belief system of individuals and ultimately on the decisions they make regarding their health.⁸ For this study, the effect of health warning messages was investigated by examining the awareness of smoking-related health problems among students who recalled and did not recall specific health warning messages. The outcomes supported the hypothesis that students who recalled specific health warning messages were also more likely to cite the associated health concern. This was evident for a wide range of health concerns including "lung cancer," "cardiovascular problems," "emphysema/asthma," "other respiratory problems," "other cancer," "mouth problems," "sexual problems" and "harms fetus/pregnancy." It is important, however, to note that some health conditions were recalled by a large percentage of students regardless of whether they recalled the corresponding health warning messages (e.g., "lung cancer"). These outcomes highlight the potential impact of other means for communicating messages about smoking-related health concerns, such as school health programs, public awareness campaigns, and other sources of personal information that are relevant for students.

Implications for Regulation and Legislation

The outcomes of the 2002 and1994 YSS provide evidence for the importance of health warning messages on cigarette packages as an essential source of information on smoking-related health problems. These findings and the outcomes of other research suggest that health warning messages that pertain directly to youth or that reflect their current life experience may be more meaningful and therefore more memorable for youth.⁹ In contrast, health warning messages that target health effects that are not as familiar to youth may not be as easily retained or recalled by youth. In this regard, health warning messages that deal with more immediate health effects associated with smoking may be more compelling and influential for students. Another key consideration includes the importance of recognizing the education and literacy level of students in the designing of health warning messages. In this regard, written and visual health warning messages should be kept simple and direct, and avoid overly complex content.²

In both the 1994 and 2002 YSS, there were considerable differences among provinces with respect to student reports about receiving education related to the health effects associated with smoking.⁷ Students who reported receiving health education related to smoking were also more likely to recall specific health conditions associated with tobacco use than were those who did not recall health-related school programming. Although diversity in programming across provinces may reflect regional differences in approaches to health education, it is critical that evidence-based practices and the lessons learned from pilot evaluations be used to guide the development and implementation of health education practices across all provinces. Recent innovations in prevention programming in the Canadian context have underscored the importance of applying a Comprehensive School Health (CSH) approach to health education¹⁰. Such programming efforts not only enhance students' awareness regarding the effects of smoking on health, but also assist them in developing the essential skills for resisting tobacco use through creation of an educational environment that facilitates positive behavioural changes. The CSH framework emphasizes the importance of schools undertaking action in four key areas - instruction, support services, social support and a healthy physical environment - to ensure delivery of both comprehensive and effective approaches for tobacco control programming in the educational context.¹¹

Implications for Education and Message Promotion

Although educational programming and cigarette package health warning messages may assist in enhancing students' awareness regarding the health consequences associated with tobacco, such efforts are not always effective in reaching all students who may experiment with smoking. Some researchers have asserted that the effectiveness of health warning messages may be enhanced if greater emphasis is placed on combining positive messages about the benefits of quitting smoking with current content relating to the negative impact of tobacco use. These investigators also reported that such approaches to awareness-building facilitate students' discussion of their beliefs and behaviour pertaining to tobacco use and their personal health.⁹ It may also be beneficial to begin educating youth about the health effects associated with smoking in earlier grades as the percentage of those youth who had stated that they had ever received such education increased with grade. To confirm that all youth learn about the health effects of smoking with a focus on both prevention and cessation, a standardized federal curriculum could be developed, to serve as a guide to provincial authorities responsible for curriculum. This would ensure that all youth are receiving the appropriate education with respect to tobacco use at the same stage in their education even if they change school boards or provinces.

Implications for Future Monitoring and Research

Continued research is required to evaluate the long-term effectiveness of cigarette package health warning messages and school-based education. In particular, it may be helpful to track those specific regions and groups that are receiving and not receiving consistent or specific health education related to tobacco use. Other research efforts could also consider potential differences in health awareness among provincial regions that receive different types of school-based education.

Additional research could be undertaken to investigate potential differences in students' perceptions regarding health warning messages that focus on short-term and long-term impacts of smoking. Such research could also examine the attitudes and beliefs of students who have a family member or who know someone else who has experienced a smoking-related health problem. Finally, further research might also address the potential impact of health warning messages and school-based health education that combine positive messages about the benefits of quitting smoking with current content related to the negative effects of smoking.

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References

1. Manske S, Morrison W. 2003. Interim School Smoking Profile Report for Selected Schools. Unpublished report submitted to the New Brunswick Department of Education.

2. Health Canada 2004. Building on Success : A Consultation Paper.

3. Kaiserman MJ, Makomaski Illing EM, Dasko D. The Evaluation of Canada.s Health Warning Messages: 18 Month Follow-Up . Presented at the12th World Conference on Tobacco or Health, August 2003, Helsinki , Finland

4. Environics Research Group Limited. Wave 8 Surveys: The Health Effects of Tobacco and Health Warning Messages on Cigarette Packages - Survey of Adults and Adult Smokers . Ottawa : 2004a, Health Canada.

5. Environics Research Group Limited. Wave 8 Surveys: The Health Effects of Tobacco and Health Warning Messages on Cigarette Packages - Survey of Youth . Ottawa : 2004b, Health Canada.

6. Hammond D, Fong GT, McDonald PW, Cameron R, Brown KS. Impact of the Graphic Canadian Warning Labels on Adult Smoking Behaviour. Tobacco Control 2003; 12: 391-395.

7. Stephens T, Morin M. Eds (Health Canada ). Youth Smoking Survey, 1994: Technical Report. Ottawa : Minister of Supply and Services Canada. 1996. (Catalogue No. H49-98/1-1994E).

8. Health Canada. Legislation regulation and compliance: Graphic health warning labels . 2004. Retrieved November 7, 2004

9. Strahan EJ, White K, Fong GT, Fabrigar LR, Zanna MP, Cameron R. Enhancing the Effectiveness of Tobacco Package Warning Labels: A Social Psychological Perspective. Tobacco Control 2002; 11: 183-190.

10. Public Health Agency of Canada. Comprehensive School Health. 2004.