TABLE 7.—Smoking regulations reported by Connecticut
hospitals in 1973

1973 survey

Type of regulation (Percent of 41 hospitals)

 

Written smoking policies 8
No tobacco products sold on premises 71
Visitor smoking regulated 7

Employee smoking at duty stations,

offices, desks, prohibited aid

 

SOURCE: Davis, K.M. (17).

patients’ rooms. The most frequent reason given for restricting
patients’ smoking was the danger of fire, and 2 percent of those that
permitted smoking issued fire-resistant clothing to patients who
smoked. Also, 18 percent of the institutions reported they had had fires
caused by smoking. Finally, this survey reported that 7 percent did not
permit visitors to smoke, and in 33 percent, employees were not
allowed to smoke in front of the public.

A study of Canadian hospitals (11), reported in 1976, found that 66
percent had some form of smoking policy. Smoking was prohibited on
47 percent of psychiatric wards, 45 percent of maternity wards, 37
percent of general wards, and 60 percent of out-patient departments.
Depending on the type of hospital, 85 to 90 percent of heart and chest
wards prohibited smoking. In 68 percent of the hospitals, physicians
and nurses on the wards were responsible for enforcing the smoking
regulations; in 25 percent this was the fire marshal’s responsibility.
Fifty-six percent of the hospitals said the regulations were partially
enforced. Forty-nine percent of the hospitals did not sell cigarettes.

In 1977, Crofton (15) reported that 36 percent of Scottish hospitals
sold cigarettes in some way; 28 percent sold them on the wards
through the ward trolley service, and in some cases the trolley service
to maternity wards sold cigarettes.

Another study of Scottish hospitals (16) in 1977 found that they were
more likely to ban smoking by visitors (67 percent) than by patients (12
percent) or nursing staff (44 percent).

In a 1976 survey of 37 hospitals in the Washington, D.C.
metropolitan area to determine smoking policies of hospitals (21), 21
(57 percent) returned completed questionnaires. Nine of the twenty-
one (43 percent) hospitals consistently provided for a nonsmoker’s
preference for a nonsmoking room; 10 hospitals did not sell cigarettes;
and 17 hospitals did not permit staff to smoke in patients’ rooms.

Sangster in 1967 (59) had reported that a no-smoking ward in an
Australian repatriation general hospital was met with enthusiasm by
patients and with cooperation by the staff. Of the first 100 patients

22—21
discharged from the ward, one-fourth said they had stopped smoking
permanently and two staff members also stopped smoking.

Efforts to control smoking in health care settings are not always met
with enthusiasm. A hospital that removed vending machines and
prohibited the sale of cigarettes in the hospital gift shop shortly after
publication of the 1964 Surgeon General’s Report on the effects of
smoking found that the work of hospital employees was interrupted by
trips away from the hospital to buy cigarettes, for themselves and for
patients (60). Some employees were also charging patients highly
inflated prices for cigarettes. As a result, the hospital staff reconsid-
ered their decision not to sell cigarettes.

A more recent study reports on a Massachusetts hospital (74) that
attempted to influence established smokers to change to low “tar,” low
nicotine cigarettes by selling only those types. The hypothesis was that
smoking behavior could be modified in a limited supply situation. Some
employees did try the low “tar”, low nicotine cigarettes, but there was
no indication of any permanent change in their smoking habits. Many
employees expressed resentment at this control of their smoking
habits, although there was no indication that employees were leaving
the hospital to purchase other types of cigarettes.

A number of specific recommendations have been made by health
care providers for the control of smoking in health care settings. The
National Forum on Office Management of Smoking Problems
recommended formally in 1968 (54) that physicians in their offices
should: inquire about the smoking habits of all patients; inform each
patient about the risks involved in continued smoking and the benefits
to be derived from stopping smoking; and advise strongly against
smoking. It was also recommended that, to be maximally effective,
physicians should actively assist smokers in efforts to stop smoking,
create an office environment conducive to cessation, generally prohibit
smoking in the office, and provide signs and literature on the subject to
emphasize the medical concern. The same report recommended
restricting smoking to certain areas of hospitals and prohibiting the
sale of cigarettes. More encompassing recommendations were made by
Fishman in connection with a survey of Metropolitan hospitals in
Washington, D.C. (21).

Two lists of recommendations for the control of smoking by health
care providers were presented in the 1978 report of the National
Commission on Smoking and Public Policy to the Board of Directors of
the American Cancer Society. One was prepared by the Veterans
Administration (VA) and the second was the Commission’s recommen-
dations (47). The following are the VA guidelines:

(1) Forbid the distribution of free cigarettes to patients.

(2) Restrict cigarette sales in hospitals, clinics, and other direct care

facilities to canteens or similar areas where other products are
sold.

22—22
(3) Discourage smoking by professional personnel and staff in the
presence of patients.

(4) Restrict smoking to specifically designated waiting areas,
patients’ day rooms, staff lounges, and private offices.

(5) Eliminate smoking among patients with high-risk diseases
through aggressive and ongoing patient education.

(6) Encourage all personnel involved in public appearances not to
smoke while in the public eye.

(7) Cooperate with community groups in the development and
implementation of community-wide programs concerned with the
hazards of smoking.

The Commission itself recommended that:

(1) Similar guidelines should be adopted by all government and
private hospitals and clinics.

(2) The promotion of healthful lifestyles should be the core of
preventive programs offered by physicians, health departments,
health plans, and voluntary health associations.

(3) Physicians should counsel patients on the risks of smoking and
how to quit smoking or make referrals to various types of
smoking cessation programs offered in the community.

(4) Obstetricians, in particular, should take advantage of the
“teachable moments” that arise when counseling pregnant
patients; expectant mothers are eager to produce healthy infants,
and smoking jeopardizes the chance of normal uncomplicated
delivery and a normal healthy infant.

(5) State Medicaid programs, prepaid health plans, and insurance
companies should either sponsor or pay the cost of smoking
withdrawal methods of beneficiaries.

Conclusions

Most studies of health care providers have focused on health
professionals (physicians, nurses, dentists, and pharmacists). Therefore,
conclusions cannot be drawn regarding the role of others in health care
occupations in influencing the smoking behavior of the public. Even
for health professionals, there are no studies that quantify and
evaluate their impact on smoking practices of the public. However,
studies do indicate that the example set by health care providers plays
some role in influencing the public, a role recognized by both health
care providers and the public.

Health professionals as a group have preceded the general public in
improving their smoking habits—they have stopped smoking, reduced
health risks by smoking less hazardous forms of tobacco, or reduced the
amount smoked. In addition, many who continue to smoke act as
exemplars by not smoking when functioning as health care providers.

22—23
Health professionals, as a group, by and large recognize their
responsibilities as health educators.

Perhaps the most important need at this time is to educate students
in the health professions on the health hazards of smoking and their
own responsibility to act as exemplars and health educators. As
members of the medical hierarchy, their actions will continue to have
an. influence on others in the health field, as well as on the general
public.

22—24
The Role of Health Care Providers: References

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23. THE ROLE OF EDUCATORS.

 

Office of Education
CONTENTS

The Status of Education About Smoking in

 

 

U.S. Schools .......cccccceceecececceeeenseetseceeeeeserseneeereneneeees 5
The Development and Implementation of School Policies
ON SMOKING..........cceeceeeeeeceeeee eee eeeeeeeeenseeeeneseaesueeeees 7
Laws and Regulations Affecting Smoking Practices... 7
Policy Statements...........:cccceeeesesceeeeeeeeeeeeeeeeeeeeeeees 8
State Department of Education Policies................... 9
Institutional Climate and Its Influence on Smoking... 9
Responsibilities for Education About Smoking.......... 12
Contemporary School Programs..........-.::::sssseeseeeeees 13
Recognition of School Responsibility ..............---..+++ 13

School and Community Agencies: Cooperation,
Delineation of Responsibilities, Use of Available

 

ReSOULCES 0.00... .ccc ccc ce eee ee eee et eee n eee eeenteeee ere nena eenias 14
Curriculum ..........c.ccececeeececee een esnessneeseceeeeneeeeeeeeeeteen ees 15
Requirements in Elementary and Secondary Schools.. 15
Development of Curriculum Procedures.................+- 16
Curriculum Foundations...............cececeeeeeeereeeeee ee eees 16
Planning the Curriculum ...........:.cceseeceeeeeeeeeeeeeee ees 17
Curriculum Construction .............0.:sceeceeeeeeeeee ee eenes 17
Some Pitfalls of Curriculum Implementation............ 18
Opportunities for Smoking Education..................56++ 18
Application of Curriculum Procedures to Smoking
Education—Evaluative Comments.........-:.:seessereees 20

 

Development of Demonstration Projects and Identification
of Successful Programs ................ceceeeeeener sree eeeenen ees 22

 

Evaluation of Educational Programs Designed to Prevent

SMOKING .........c eee esc sec ee cnet eee eeeeeeeneeceeesetaeen seen enseees 23
Schoolwide Campaigns............:.ccsceceeereeeeceeesneerteees 24
Youth-to-Youth Programs .............cccceceeseeeneeeeneewees 25
Teaching Methods..............cccseeeeeeeneeeeenseeeseernaeennes 25
Message Themes.............::eececceereenee ence eee ee een eeeeees 26

 

Dissemination and Promotion of Successful Practices and

23—3
 

Teacher Education..............:ccecececeeececeeenceeceneceereseeeeees 28
Certification of Teachers and Consultants................ 28
Preparation of Elementary Teachers and Health

Education Specialists on Smoking Education......... 31

Elementary School Classroom Teacher

Preparation in Smoking Education................ 32
Professional Preparation in Health Education....33
The Effects of Teacher Training and Teaching

 

 

Methodology .................seeceececeeeeeecececereen ees 34
The Teacher’s Role in Smoking and Health...... 35
The Teacher as a Role Model........................- 36
Recommendations ................ccscceeeeencecetenceececsaneceseesees 36
The Status of Education About Smoking in U.S.
Schools ..........c.ccecesceecsceecescescnseaecesceesenseaseeeeees 36
The Development and Implementation of School
Policies on Smoking’..................ceceseceseceeseeesseoees 37
Curriculum ............... ce eeececnecnecececeeeten eee eeneneceeeesaes 37
Development of Demonstration Projects and
Identification of Successful Practices .................65 38
Evaluation of Educational Programs Designed to
Prevent SmokKing...............ccccecceecee este eeeeeseenseoees 38
Dissemination and Promotion of Replication of
Successful Practices and Products ...............:eeeeee 38
Teacher Education ..............ccccecceeesececeeeeeeneeseneeeee 39
References ...........cc cece cece cee ceceeceeeeceneeseeseneneeeeaeeseaeees 40

LIST OF TABLES

 

Table 1.—State school health education programs............ 5

 

Table 2.—A scope and sequence chart for a comprehensive
health education curriculum ...................ccsceeeeceeeeenees 20

 

Table 3.—School health educator certification ................ 29

23—4
The Status of Education About Smoking in U.S. Schools

Most States support education as a potentially important means of
preventing smoking and influencing cessation of smoking, although
results to date are not always highly satisfactory. A recent survey of
State school health programs by the American School Health
Association (ASHA) (14a) found that of all the various subject areas
within health education, instruction on drugs, tobacco, and alcohol is
most frequently required by State legislation. The ASHA report cites
35 States having mandated instruction with respect to tobacco.
However, in a number of States with mandated health education, the
specific subject areas to be taught may be selected by the individual
school systems.

Some States have legislation offering their school districts the option
of providing comprehensive health education programs, while other
States have mandated many individual areas of health education, with
the overall result resembling comprehensive programs. Especially
during the past decade, there has been a trend toward mandatory
health education instruction at the State level. Only three States
appear not to have made provisions for any area of health education. In
some cases, individual school districts may have legislation that takes
precedence over State laws. In such instances provisions for instruction
relating to smoking are generally included in the curriculum. Table 1
provides a synopsis of the present status of State education programs
_ relating to drugs, tobacco, and alcohol in the United States. The table
clearly indicates the current position that in most States instruction in
the area of tobacco is mandated.

TABLE 1.—State school health education programs

 

 

State Drugs, Tobacco, Alcohol
Alabama No formal program at state level.
Alaska Health education is not required; however,

one unit of physical education is required
for graduation of which one half unit
may be health education.

Arizona Optional/Permissive
Arkansas Mandated
California Mandated
Colorado Mandated
Connecticut Mandated
Delaware Mandated
Florida Mandated
Georgia Mandated
Hawaii Mandated

23—5
Idaho
Illinois
Indiana
lowa
Kansas

Kentucky
Louisiana
Maine

Maryland
Massachusetts
Michigan
Minnesota
Mississippi

Missouri
Montana
Nebraska
Nevada

New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio

Oklahoma

Oregon
Pennsylvania
Rhode Island

South Carolina
South Dakota
Tennessee
Texas

Utah

Vermont

23—6

Mandated

Mandated

Mandated

Mandated

Health education is not required; however,
one unit of physical education is required
for graduation of which one half unit
may be health education.

Mandated/Secondary School Level

Subject offerings are option of local school
district.

Mandated

Mandated

Mandated

In grades 1-6, health instruction is
required 30 minutes per day. At the
junior and senior high school levels,
health instruction is optional.

Mandated

Mandated/Secondary School Level

Content selection is local school option.

One half unit of health education is
required for graduation.

Mandated

Mandated/Secondary School Level

Mandated

Mandated

Mandated

Mandated

Mandated

Although no separate program exists,
health education content is taught in
conjunction with other subject areas.

Mandated

One hundred minutes of instruction in
health and physical education per week
is required for all students, K~12.

Mandated

No formal program at state level.

Mandated

Mandated

Mandated

Mandated
Virginia Mandated

Washington Mandated

West Virginia Instruction in physical and mental health is
required at the junior high and high
school levels.

Wisconsin Mandated

Wyoming Health education is taught according to
local education mandates.

District of Columbia Mandated

Unless otherwise noted, programs refer to both elementary and
secondary levels.

 

SOURCE: American Schoo! Health Association. (142).

The Development and Implementation of School Policies on
Smoking

Laws and Regulations Affecting Smoking Practices

In 35 States, school policies on smoking education are based upon State
laws that expressly prohibit minors from smoking on school property.
Jacobs (44), in a review of the effects of State tobacco laws on high
school student smoking throughout the United States, reports that
most States have established the age of 18 as the demarcation point
below which the individual is considered a minor insofar as tobacco
laws are concerned. In those State statutes which indicate an age for
attaining majority, the youngest age is 15. Four States make no
reference to a specific age when using the term “minor” in their
tobacco statutes. .

To a large extent, differences in State laws appear to reflect the
varying mixture of culture and tradition. Review of State tobacco laws
for minors shows wide inconsistency throughout the nation. For
example, 28 States penalize those who supply tobacco to minors. In 13
States, parental consent can render minors immune to tobacco laws,
and two States waive penalties for minors if they divulge their sources.
Four States that have repealed all tobacco laws concerning minors
leave control in the hands of local governments. Thus a myriad of laws
relate to the regulation of smoking practices of school age youth.

In addition to the diversity of State tobacco laws, penalties for both
supplier and minor user vary widely. For a first offense in one State,
the penalties may range from $1 for the user and $10 for the supplier
to $1,000 and/or 1-year imprisonment for both supplier and user in
another. Only two States have involved schools in their codes,
establishing the penalty of suspension or expulsion for those minors
who violate tobacco laws (44).

23—7
Thus, although most States have laws relating to the use of tobacco,
the impact of these laws on behavior is generally believed to be
negligible. The general availability of the product through machines
that dispense it to any consumer, coupled with a cultural norm
militating against enforcement, renders most laws inoperable and
ineffective. Since most reported tobacco violations involving minors
are referred to the juvenile courts, few court decisions deal with the
use of tobacco by minors. In some communities, local fire ordinances
set policy on smoking, leaving the school board without a role in
decision-making on student smoking.

In the absence of such State laws and local ordinances regarding the
school’s legal position on smoking, Ivan Gluckman (11), attorney for
the National Association of Secondary School Principals (NASSP),
states that school boards have the legal authority to regulate smoking
on school property. Much of the case law in this area emanates from
the concept that school administrators have a broad degree of
discretion and can prohibit smoking on the basis of concern for the
health and safety of students.

In most school districts specific rules have been developed to prohibit
smoking on school property. These rules are usually an outgrowth of
local safety ordinances and policies by school administrators in
cooperation with school boards. In recent years, a number of schools
have initiated designated areas as smoking lounges. In his survey of
high school principals, Jacobs (44) found that this approach (along with
suspension and expulsion) was perceived to be an ineffective procedure
for controlling high school smoking problems. Though upheld by some
courts, the legality of this issue is extremely complex and can be
expected to be tested in light of statutes regarding “contributing to
the delinquency” by school administrators.

Specific regulations affecting teacher smoking practices in or on
school property are generally considered within the domain of the local
school administrator. Thus, there is no uniformity among or within
States. The most common policy is to prohibit teacher smoking in other
than specified locations such as teacher lunchrooms and lounges.

Pelicy Statements

A number of national organizations, including health and educational
groups, have issued position statements on school smoking intended for
the guidance of local policy-making officials. For example, NASSP
suggests that intensive educational programs be initiated and that
efforts be undertaken which will lead to the termination of student
smoking (60). A position statement adopted in 1971 by the American
Association for Health, Physical Education, and Recreation (AAH-
PER) (5) is forceful and unequivocating, noting that the research on
smoking has made it abundantly clear that cigarette smoking is a
health hazard. Therefore, the Association recommends that schools

23—8
adopt “no smoking policies” for all groups utilizing school facilities and
that student and faculty smoking facilities be abolished. Like most
health officials, Daniel Horn (11), former Director of the National
Clearinghouse for Smoking and Health (NCSH),' is opposed to
smoking in schools.

State Department of Education Policies

A number of State departments of education have developed their own
policies. Among the leaders in this area are Oregon and Michigan.
Oregon’s policy recognizes that smoking is hazardous, that most public
schools were not designed to accommodate a large number of smokers
of any age, that the health, safety, and educational responsibilities of
schools are factors to be considered in developing a tobacco policy, and
that the rights of nonusers must also be weighed together with the
rights of lawful users (66).

As expressed in the Oregon policy, “Those 18 years of age or older
are allowed to use tobacco in accordance with the times and places
designated by the school board. However, there is the further
stipulation that students are liable for their habits to the extent that
they may preclude their participation in other school activities” (66).

In Michigan, students who are 18 years old may legally purchase
tobacco. However, schools are urged to discourage young people from
taking up the habit. To this end, educational programs are to be
developed which point out the dangers of smoking. In addition,
Michigan laws prohibit smoking in the school building, on ‘he school
premises, or at school functions (55).

Institutional Climate and Its Influence on Smoking

While antismoking campaigns are credited with helping to reduce the
number of adult smokers in the United States, surveys of youth
smoking indicate a consistent pattern of increase over the past decade.
This is especially true of teenage girls from ages 13 to 17. The rate of
smoking by boys of this age group seems to have slowed and begun to
level off (61). However, smoking in schools still represents a major
problem to school officials. According to one State school administra-
tor, the largest single discipline problem faced by public schools is
student smoking (11). Despite the fact that most schools have rules
against smoking in buildings, more and more students seem to ignore
such prohibitions.

Historically, the institutional climate of the schools has been one of
prohibition of student smoking on school property. In most school
districts, this is the present policy. Thus the position of the schools is
quite clear, but there is no evidence that this acts as a deterrent. To the
TT Effective July 1978, all information functions of the National Clearinghouse for Smoking and Health were

incorporated into the Office on Smoking and Health, Department of Health, Education, and Welfare, Rockville,
Maryland.

23—9
contrary, some have maintained that such policies contribute to a
greater incidence of youth smoking. In our society, smoking is a
common, accepted behavior in most settings such as the home, work, or
recreation. The school is one of the few institutions that prohibits this
behavior. Complicating the issue is the fact that the prohibition of
smoking on school grounds generally applies to only one population,
the students. Others, faculty and staff, are allowed to smoke publicly
in designated areas. Thus, the school as an institution is placed in a
position contrary to other institutions in our society and in conflict
with notions of equality. In addition, while the institutional policies of
most schools regarding smoking are somewhat uniform, the individual
behaviors of the teachers and staff of different schools are not. These
differing behaviors may result in varying degrees of enforcement,
which in turn may produce widely differing institutional climates even
though controlling regulations seem similar.

Many school districts have attempted to address the role of their
institutional climate and its influence on smoking. A review of the
literature on school smoking points out the difficulties faced by the
school administrator in attempting to solve the problem. Some have
attempted to enforce strict policies against smoking via suspensions
and expulsions. In an effort to develop realistic and workable policies,
school officials are often placed in the position of having to compromise
the larger purposes of education. While acknowledging that it is the
school’s responsibility to inform students about the hazards of
smoking, school administrators are often faced with the realization
that the prevention of student smoking is beyond their practical power
to control (60). Because of the apparent ineffectiveness of antismoking
policies and the difficulties of enforcement, or because of expediency,
officials “accept reality” and permit smoking, usually out-of-doors or
in some well-defined area, during the students’ free time. This resigned
acceptance on the part of the school administration is illustrated by the
statement: “You either have to put up with smoking inside your
building or outside your building. We’d rather have it outside” (11).

Horn summarizes the basic issue confronting the school regarding
the smoking issue: “Does a school want to sanction smoking by
permitting it, and thus say, ‘We approve of your doing things that will
harm your health’? Or does it want to say, “We will not permit it. We
will not help you do something that is not in your interest’?”’(11).
Although most schools which have adopted a limited smoking policy
have done so out of expedience more than conviction, the result is a
paradoxical one. Such schools include smoking education in their
curriculum yet provide students with smoking areas. Although the
trend has been for schools to become more permissive in their policies,
the more recent emphasis on the rights of nonsmokers, the potential
physical effects of passive smoking, and the increasing limitations
placed on smoking in public places may result in a reversal of present

23—10
patterns. Few directly involved in smoking education efforts advocate
overt or tacit approval of youth smoking by the schools.

In addition to formal policies, attention has been directed toward the
impact of teachers as contributing factors in the institutional climate
and their role in influencing student smoking. A consensus is that since
much of what students learn is gained through observation, it is
essential that school personnel serve as effective models for their
students (25, 30).

NASSP acknowledges the problem in their statement: “There is a
general agreement that it is one thing to assume moral positions and
another to implement those positions” (60). Adopting the policy of
providing outdoor areas for student smoking has been justified on the
grounds that students are going to smoke, and this solution at least
protects the rights of the nonsmokers. One school reported that
enforcement of the no-smoking rule in school lavatories required too
much time and effort on the part of school faculty. However, it was
also reported that the new school policy of permitting outdoor smoking
ealled for a stricter enforcement of the rules against smoking in school
buildings which in turn required increased faculty supervision (32).

School officials of the Niles Township High School, Skokie, Illinois,
have a different solution to the problem of student smoking. The
offender can choose either a 3-day suspension from school or a seminar
composed of four 2-hour sessions on the effects of smoking. The
seminar is conducted by two teachers at the school who use
instructional materials provided by the American Heart Association,
the American Cancer Society, and the American Lung Association. A
follow-up survey was conducted of students who had participated in
the seminars. The results showed that 12 percent of the students had
stopped smoking and another 85 percent stated that they intended to
cut down on their smoking (35).

Del Campo High School in Sacramento, California, employed an
approach similar to that of the Niles Township High School. Students
who were caught smoking were sent to a 5-day clinic conducted by the
county medical society. This program was well-received by both
students and adults and was judged a success (11).

Despite the fact that many U.S. high schools have come to accept
some form of smoking in school, others are prohibiting smoking
anywhere on school grounds. For example, Unified School District 457
in Garden City, Kansas, instituted a policy which banned all smoking
on school grounds. This policy applies to students, teachers, and school
board members. Students who violate this ban receive an automatic 5-
day suspension from school. While enforcing this policy has caused
some difficulty in the community, it appears to be working (64).

A novel and democratic approach to policy development has been
employed by the Edina, Minnesota, school district. Instead of the school
board alone establishing smoking policy, the district has sought the

23—11
active involvement of students, parents, teachers, school administra-
tors, smokers, and nonsmokers. Individual community members were
thus given the opportunity to help the school determine its policy on
school smoking. Citizens were invited to select one of three different
options or to make their own suggestions. The options included (1)
continuation of the current school board policy of prohibiting student
smoking; (2) not only continuation of the existing policy, but also the
hiring of additional personnel to police or enforce the school smoking
ban; or (8) designation of smoking areas for those students 18 years
and older (64).

Teachers have the potential to influence the values and behaviors
established by youth during the socialization process at school. Habits
of lifelong duration are often acquired during the school years and are,
in part, dependent upon the school environment. The attitudes and
examples set by school personnel are factors which should be
considered relevant to student smoking. Teachers gain or lose
credibility depending, in part, on the consistency of their instruction
and their Lehavior. Support for the potential influence of the teacher
as an exemplar model has been observed by Creswell, et al. (22), Chen
and Rakip (17), Mettlin (54), and Downey and O’Rourke (26). A study
by Newman (65) attempted to determine how elementary and
secondary teachers view their own behavior, the.r awareness of the
smoking problem, and whether they would make changes if they
believed it would favorably influence their students. Results showed
that teachers were mindful of their responsibilities and were willing to
restrict smoking as an example to students; they were also more likely
to report a smoking student if they were smokers themselves; and by a
5:1 ratio, they believed that teachers should not smoke where smoking
by students is prohibited. Newman concluded that teachers display a
readiness to assume their exemplar role in smoking education.

In summary, the institutional climate is considered an important
factor in{luencing youth smoking. While peers and parents have been
shown to be more potent as influencing agents, the important role of
the school environment cannot be minimized. According to the Office
on Smoking and Health, the general climate of acceptability of
smoking is probably one of the strongest influences in making smoking
attractive to children. There appears to be a consensus that, faced with
the significant counterforces of advertising and the smoking practices
of parents, other adults, peers, and other people youth admire,
reduction of youth smoking cannot be achieved by the schools alone
(18, 39, 47, 81).

Responsibilities for Education About Smoking

Much of the teaching in today’s schools about the effects of tobacco on
the body had its origins with the Scientific Temperance Movement in
the late 1800’s. The Women’s Christian Temperance Union (WCTU) led

23—12
a highly successful crusade which resulted in the passing of legislation
requiring the teaching about the effects of alcohol, tobacco, and
narcotics. During the 1880’s and 1890's, 38 States and Territories
passed laws requiring the teaching of physiology and hygiene. Every
State passed laws requiring instruction on the effects of alcohol and
narcotics. Many of these same laws also required instruction about
tobacco and the effects of smoking.

In general, schools combined the instruction about specific topics of
alcohol, tobacco, and narcotics with the broader subject of physiology
and hygiene. Despite the success of the WCTU effort in securing the
widespread adoption of its legislative proposals, however, the move-
ment was never considered to be effective in terms of achieving a
successful program of instruction. It has been characterized as the
moralizing and preaching of zeal and negation, with the subject matter
frequently containing inaccuracies, myths, and facts that were
inappropriate to the age group being taught (52).

Contemporary School Programs

In many of today’s schools, yesteryear’s instruction in physiology and
hygiene has led to acceptance in concept and, to a lesser degree,
implementation of a comprehensive program of health instruction. In
theory, this type of curriculum is designed to reach all students at their
various levels of educational development with appropriately graded
activities and materials. Teaching about the effects of cigarette
smoking is planned as a part of many health instruction programs.

As a result of the curriculum reform movement of the early 1960’s
and the issuance of the 1964 Surgeon General’s Report on Smoking and
Health, schools have shown renewed interest in the area of health
education and smoking education. School officials’ awareness of their
responsibilities for smoking education can often be traced to activities
of voluntary health agencies such as the cancer, heart, and lung
associations and to the extensive work with schools sponsored by the
NCSH (now the Office on Smoking and Health).

Recognition of School Responsibility

Stressing the importance of the school’s responsibility for education in
regard to smoking, NASSP (60) has noted the implications to be drawn
from establishing school smoking lounges: Such an action “may well
implicitly promote smoking in the public schools.” In lieu of approving
school smoking, NASSP suggests that an intensive educational
program be designed and instituted to prevent or terminate smoking
among school-age students.

AAHPER urges all schools to take appropriate action to establish
policies that are consistent with current information on the hazards of
cigarette smoking. Specifically, AAHPER recommends that schools
assume “responsibility for curriculum experiences in smoking educa-

23—138
tion which are timely and stimulating and provide accurate content, as
an integral part of the ongoing, unified health instruction program,
kindergarten through the twelfth grade” (4).

School codes and regulations have been adopted by State and local
school agencies acknowledging the school’s obligation to provide
smoking education. In Massachusetts, the school code specifies that
students be taught the adverse effects of smoking. In establishing its
policy governing smoking on school grounds, the local school district of
Montgomery County, Maryland, recognized its educational responsibil-
ities by calling for “a forceful, meaningful program of education
highlighting the hazardous effects of smoking.” The program as
adopted provides instruction for students commencing in the upper
elementary grades and continuing through the senior high school (64).

In 1974, Jacobs (44), using a random sample of high school principals
drawn from throughout the United States, conducted a mail-question-
naire study, “Effects of State Tobacco Laws on High School Student
Smoking.” Questions were directed to the principals on a number of
key points relating to the school smoking issue. In response to the
question, “What is the situation with regard to student smoking at
your school?,” 49 percent of the principals responding said that the
problem was increasing, 29.4 percent reported no change, and 21.6
percent stated that the problem was declining.

If students are permitted to smoke, it is clear that principals would
prefer that they either smoke in an outdoor area (48.8 percent) or that
they smoke off-campus (34.8 percent). Only a small minority of
principals would have students smoke in a designated area of the
school building (11.6 percent). Two questions asked in this survey bear
directly on the school’s role in smoking education. In reply to the
question, “Do schools have a responsibility for discouraging smoking?”
65.3 percent of the principals said yes, 20.5 percent said no, and 14.3
percent were uncertain about this role. -

When principals were asked to select the most effective procedure
for controlling smoking in schools, an educational program was the
choice by a clear majority (49.5 percent), with school athletic events
identified (14.5 percent) as another procedure to help control school
smoking. Less than 1 percent of the principals selected supervision as a
measure for controlling the problem.

School and Community Agencies: Cooperation, Delineation of
Responsibilities, Use of Available Resources

School and community agencies are involved in efforts aimed at the
prevention and cessation of smoking. School programs by their very
nature are focused upon the youth population generally through
planned instructional intervention incorporated into the health curric-
ulum. The major emphasis of the school program is on prevention. A
lesser but emerging effort is also being developed on cessation of youth

23—14
smoking. On the other hand, community agencies concerned with
smoking and health issues often direct their educational programs at
the entire age range, with youth an important component in their total
efforts.

Community agency involvement is most frequently evident in mass
media programs, antismoking education curricula, and smoking-cessa-
tion programs aimed primarily at the adult population. Less evident
are instances where community agencies develop and conduct youth
programs. Such instruction is generally perceived as a function of the
schools. This, however, does not imply a strict dichotomy. Often,
schools utilize materials developed by community agencies or consult
with agency personnel in an attempt to improve instruction. Yet, a
review of related literature shows that most youth antismoking
programs do not involve a direct school-community agency type of
partnership. It is possible that on a local level varying degrees of
cooperation occur, but such efforts are not commonly cited. One recent
program that has attempted to involve both school and community
health agencies directly is the School Health Curriculum Project
(Berkeley Project) developed by NCSH (24) which is examined in
greater detail in another section. Besides providing much of the
materials used, voluntary health- and education-related organizations
have played an active role through their local community agencies with
respect to the Health Curriculum. This type of direct involvement by
school, community, and health agencies is now being incorporated in
numerous school districts throughout the country. The approach seems
to be an operational model reflecting the consensus of those in the area
of smoking education that the problems of youth smoking must be
confronted through a cooperative community effort involving school
and community officials and voluntary health agencies. Such programs
involving active and direct working relationships should be encouraged
and promoted. The alternative would be a fragmented and less
effective approach to the prevention and cessation of youth smoking.

Curriculum

Requirements in Elementary and Secondary Schools

By State law, instruction in the areas of alcohol, tobacco, and drugs is
mandated in at least 35 States with the tendency to incorporate such
programs in States currently without such a requirement (14a). For
example, a 1977 New York State law requires that all schools include
instruction to discourage misuse of alcohol, tobacco, and other drugs.
Mandated instruction is usually required at both the elementary and
secondary levels. Even in States without mandated programs, the
inclusion of some degree of instruction about tobacco is commonplace
at some point along the continuum from kindergarten through 12th
grade.

23—15
Whereas requirements about smoking education are generally
mandated, the amount of instruction actually occurring at one or more
periods of the K-12 cycle varies greatly. Most States leave the decisions
of implementation, such as time devoted to a given area, up to the
teachers. Thus, individual teachers decide how much time and
resources are to be devoted to education about tobacco and health.

It should also be realized that tobacco education is but one of the
many areas included in school health programs and that such programs
are limited during the K-12 cycle. The actual time devoted to this
specific area would appear to be minimal. The extent to which
mandated programs that include tobacco education are actually
conducted is currently unknown.

Development of Curriculum Procedures

The term “curriculum” as employed by specialists in the field usually
means either (1) an educational plan for the learner, or (2) a field of
study. In relating a curriculum to smoking education, it is helpful to
consider some general principles that have derived from work done in
the field of curriculum study and the application of such knowledge to
the specific “plan for action” or “plan which guides instruction” (92) in
the field of smoking education.

Curriculum Foundations

Most curriculum specialists agree that the determinants or foundations
of a curriculum would include some, if not all, of the following areas:

1, Philosophy and the Nature of Knowledge: Basic assumptions about
the nature of knowledge and the philosophy which guides beliefs about
knowledge have particular relevance to the formulation of the
curriculum (92).

2. Society and Culture: The school is the institution invented by
society to transmit the cultural heritage and to assure its survival.
Societal values, assumptions, and concepts of good and bad are
transiated into the curriculum objectives and learning activities.

3. The Individual: The nature of humankind, its biological and
psychological characteristics, needs, and capacity to learn have placed
certain limits on the curriculum, such as the content included, the
organization of the curriculum, and the types of learning activities
selected.

4. Theory of Learning: While some elements of learning theory enjoy
wide acceptance, much difference of opinion exists. Obviously, a
particular theory of learning embraced by the curriculum developer
will exert marked influence upon the design. For example, Dewey’s
well-known theory of “learning by doing” has been applied directly to
certain types of learning activity. The theory of learning and the
importance environment places upon learning have serious implica-
tions for the contemporary curriculum developer.

23—16
Planning the Curriculum

Tyler, in Schaffarzick and Hampson (78), stresses the importance of
conducting a careful preliminary analysis of the curriculum in order to
determine clearly the needs to be met. All too often, curriculum
projects are developed without first making a systematic analysis of
the problem. Such an analysis may call for extensive work with the
loeal community, parents, peer groups, and school officials. If the
curriculum to be developed is to be accepted and used by the teachers,
special efforts must be made to seek their active involvement and to
give careful consideration to their needs.

Curriculum Construction

In his extensive work in curriculum development, Tyler, in Schaffar-
zick and Hampson (78), has developed a series of steps to be followed:

1. Selecting and Defining the Objectives: Curriculum developers must
resist the temptation to write their own objectives and must, instead,
involve many different groups in the selection process, seeking group
deliberation and judgments. Involvement of teachers is essential to
their ultimate commitment to the curriculum. Subject matter special-
ists, curriculum specialists, psychologists, sociologists, and specialists in
human development all offer judgments in this area. The level of
generality for objectives must be considered; objectives that are too
general are nonfunctional, and overly specific objectives are burden-
some.

2. Developing a Philosophy or Point of View: The theory of learning
which is adopted influences the philosophy or point of view of the
curriculum developer.

3. Selecting and Creating Learning Experiences: The purpose of the
learning experience is to meet the curriculum objective, i.e., to perform
and to practice the behavior called for in the objective. Appropriate
learning activities will invite the attention and interest of the learner
and provide satisfaction. Such activities, which can be carried out alone
or with peer groups, should be balanced.

4. Organizing Learning Experiences: The learning activities should
provide maximum impact on the learner. They should be sequenced to
build relationships, so that the student’s learning builds from one
activity to the next.

5. Curriculum Evaluation: Evaluation of the curriculum involves
determining: (a) the effectiveness of the curriculum approach in its
development stage; (b) whether school teachers can, in fact, use the
curriculum at the point of implementation; (c) how effective the
curriculum is in its operational stage; and (d) the extent to which
students have achieved the objectives selected for the curriculum.

23—17
Some Pitfalls of Curriculum Implementation

Experience gained through implementation of the many curriculum
projects developed during the 1960’s indicated some shortcomings. In
some cases, teachers were not sufficiently involved in the curriculum
planning or writing process. Quite frequently, funding was lacking to
train the teacher in the use of the new curriculum.

Two other difficulties have also been identified: (1) the failure to
provide for the dissemination of the newly developed curriculum, and
(2) confusion over the term “experimental” with reference to new
curricula. Hampson, in Schaffarzick and Hampson (78), contends that a
true experimental design is not suitable for the school setting. The
procedure commonly employed in experimental studies of varying the
curriculum and of using control groups raises serious political if not
moral questions for the curriculum developer. Instead, Hampson
suggests that the curriculum developer consider alternative ways of
collecting data by using a method of systematic observation over time,
such as that employed by the astronomer, and by using in-depth
clinical studies.

Opportunities for Smoking Education

The comprehensive health education curriculum has traditionally
included the topic of tobacco and its effects on human health. This
curriculum, as it has been viewed and widely advocated by professional
groups, is designed as a program of health learning experiences
beginning at the kindergarten level and continuing through senior
high school. The curriculum is considered comprehensive in that it is
designed to cover the full range of the subject matter of human health.

A nationwide project, the School Health Education Study (SHES),
emerged from the curriculum reform movement of the 1960's. This
study, with its conceptual approach to curriculum design, gave
renewed emphasis to the comprehensive curriculum plan. One of the 10
major concepts providing the structure of the SHES curriculum
involves the study of tobacco, the effects of smoking, and the
motivations for smoking. In several other areas of this curriculum, the
hazards of smoking are integrated into the conceptual network of the
curriculum structure (80).

Following closely on the curriculum reform movement, several
States enacted legislation calling for comprehensive health education
curriculum programs. New York was the first, in 1967, to enact a law
requiring a statewide program of health education to be implemented
at all levels of instruction. A syllabus developed by the State
Department of Education incorporated a five-strand format that
included the following elements: physical health, sociological health,
mental health, environmental and community health, and education
for survival. Tobacco, alcohol, and drugs are included as topics in the
sociological health strands. Smoking and health are taught at the

23—18