Anti-tobacco education in Spanish schools
M. Barrueco*, M. A. Hernández-Mezquita*, C. A. Jiménez**, M. T. Vega*** and E. Garrido***
*Universitary Hospital, Salamanca (Spain). **De La Princesa Hospital, Madrid (Spain). ***Social Psicology and Anthropology Department, University of Salamanca (Spain).
RESUMEN
Introducción: desde que se hizo la reforma de la educación en España, se han realizado campañas para prevenir el uso del tabaco, pero aún no se conoce su grado de aplicación. El objetivo de este estudio fue averiguar la extensión del uso de este tipo de campaña a través de las opiniones de directores de colegios.
Material y métodos: un cuestionario (para cumplimentar anónimamente) fue remitido a 8.000 directores de colegio (el 43,3% de los colegios de España). Fueron cumplimentados 3.156 cuestionarios, de los cuales 3.050 (16,5% del total) fueron válidos para el estudio. El cuestionario determinó si se habían llevado a cabo campañas de educación sanitaria y contra el uso del tabaco en los colegios respectivos y, en su caso, en que etapa de la enseñanza y el contexto de su aplicación. El análisis estadístico fue realizado en función de las variables comparadas por cada prueba: la prueba de t de Student, x2, el ANOVA (análisis de la variancia) de una vía y la prueba de Scheffé.
Resultados: se impartieron temas transversales (temas impartidos en varias asignaturas -TT) en 2.718 colegios (89,1%) y se ofreció educación para la salud (ES) en 2.655 (87%). Estos temas fueron significativamente más frecuentes (p < 0,001) en los colegios que daban cursos de educación tanto primaria como secundaria. Se ofreció educación contra el uso del tabaco (ECT) en 2.317 colegios (76%), significativamente más (p < 0,001) en los colegios que impartían cursos de educación primaria y secundaria. Las etapas en que se impartió ECT fueron sobre todo la educación primaria y el primer ciclo de la educación secundaria obligatoria. El porcentaje medio de asignaturas que abordaban TT fue 49,66%, la ES se impartió en el 42% y la ECT en el 27,5% de las asignaturas. El 13% de los colegios españoles no impartieron ES y casi el 25% carecieron de ECT.
Conclusiones: no se imparte una formación sanitaria general o específica para prevenir el hábito de fumar a todos los niños españoles. Por otro lado, cuando ésta existe, su aplicación es esporádica y no se mantiene en todas las etapas de formación. La enseñanza diseñada para promover la vida sana entre los escolares aún no está plenamente generalizada en España.
Palabras clave: Educación para la salud. Prevención del tabaquismo. Colegios.
SUMMARY
Introduction: since the education reform in Spain, anti-tobacco campaings are now fought within the context of Health Education, although the true degree of their application remains unknown. The aim of the present study is to gain insight into the degree of implementation of this type of campaign through the opinion of school principals.
Materials and methods: a questionnaire (answered anonymously) was sent to 8,000 school principals (43.3% of the total number of schools in Spain). Of these, 3,156 were returned, 3,050 (16.5% of the total) of them being valid for the study. The questionnaire explored whether Health Education and anti-tobacco campaings were implemented at their schools and, if so, at what stage of the children''s education and in which contexts. The statistical study was conducted using the appropriate tests as a function of the nature of the variables to be compared in each test: Student''s t tests, x2, one-way ANOVA (analysis of variance) and the Scheffé test.
Results: transverse topics (topics spread across the curricular subjects -TT) are imparted in 2,718 schools (89.1%), Health Education (HE) in 2,655 (87%) --significantly more (p < 0.05) in primary than in secondary school--, and Anti-Tobacco Education (ATE) in 2,317 schools (76%), significantly more (p < 0.001) in schools imparting both primary and secondary syllabuses. The stages at which ATE are imparted are mainly in primary education and during the first CSE (Compulsory Secondary Education) cycle. The mean percentage of curricular subjects in which TT are addressed is 49.66%; HE is imparted in 42% and ATE in 27.5% of the curricular subjects. Thirteen percent of Spanish schools does not impart HE and in almost 25% no ATE are implemented.
Conclusions: teaching related to health in general and smoking in particular does not reach all children and, when it does, is sporadic and is not continued consistently through the different stages of schooling. The generalization of teaching practices designed to promote health among children continues to await full implementation in Spain.
Key words: Health education. Tobacco prevention. School.
INTRODUCTION
In developed countries cigarette smoking is the main cause of avoidable morbidity-mortality (1) and its prevention an efficient way of improving public health and the quality of life of the population. Spain is one of the European countries with the highest prevalene of smoking, especially among the young (2-5).
Children start to smoke when they are still at school, a time when they acquire habits and attitudes that persist throughout their adulthood. Most smokers begin the habit in childhood or adolescence, after which it becomes ingrained (6). Exceptionally, children star to smoke when they are as young as 6 or 7, although the usual age is 9-11. By the time they are 14 many are seasoned smokers (7-10).
As is known, 90% of smokers begin the habit before they are 20 (11) ant tobacco consumption at young ages is a risk factor for nicotine dependence at later ages, the risk of suffering from diseases related to smoking increasing (12). If children are able to refrain from smoking during childhood and adolescence, the chances of their smoking at later ages are strongly reduced (13).
It would be impossible to discover all the variables involved in the adoption of a given habit, although in the case of smoking many of them are related to the school environment, such as a peer pressure, the attitude of teachers, or the child''s own family environment (9, 14, 15).
In recent years, the Spanish education system has included a series of contents in its curriculum aimed at promoting a better adaptation of children to their environment and healthy living habits, both for the children and society at large. For professional and economic reasons, it was decided to impart these contents in the form of transverse topics (topics spread across the curricular subjects -TT). Owing to the diversity of their facets and universality, they do not form a "real part" of any given subject; rather they appear in all the different curricular subjects and are considered to be the responsibility of all the teachers in a school.
In this context, school is considered to be an ideal environment for children and adolescents to receive teaching aimed at promoting healthy life styles and it is for this reason that in recent years transverse topics have included health education (HE), aimed at fostering knowledge and attitudes that will allow the children to become responsible for their own health concerns (16, 17).
And it is within the field of health education that one finds anti-tobacco campaigns (ATE), whose aim is to alert young people about the dangers to tobacco consumption, to remind them of the advantages of not smoking and to offer them a critical and objective view that will help them to cope with external stimuli encouraging them to smoke as efficiently as possible (18).
However, in daily practice, such endeavours are fraught with difficulties: although most teachers are prepared to assume this new task, many refer to problems deriving from their lack of training or from the lack of suitable teaching material, teaching overloads and little institutional support (19).
Currently, we are unaware of the real number of schools imparting TT, which of them give HE or which of them address the issue of smoking within HE (19). The aim of this study was therefore to gain insight into the true state of the situation in Spanish schools.
MATERIAL AND METHODS
Methodology
To collect the pertinent information, we designed a questionnaire for anonymous completion designed for automatic correction at the Data Processing Centre of the University of Salamanca. The questionnaire was sent to school principals or --when this was not feasible-- to study supervisors at schools, understanding that owing to their position in the school community (representatives of the administration and at the same time members of the school board and teachers) school principals were in possession of privileged information as regards the analysis we were wishing to make.
The questionnaire contained 27 items referring to the characteristics of the school (type of education imparted, its public/private status, number of pupils and teachers, etc.) and the objectives of the study: does your school impart TT, HE and ATE? In what percentage of curricular subjects are TT, HE and ATE imparted? Once designed, the questionnaire was validated among teachers and school principals from the province of Salamanca until an unequivocal interpretation of the questions was obtained.
Support was requested from the Ministry of Education and Culture (MEC) and from the Spanish Society for Pneumology and Chest Surgery (SEPAR), who requested the collaboration of school principals in an official letter. The MEC provided an official list of school centers in Spain that imparted primary or secondary education, or both simultaneously, in 1996-1997 and also provided the postal addresses of all the schools. The SEPAR provided the necessary funds for the study.
The questionnaire was sent to 8,000 school principals chosen randomly from the total of 18,457 operating in Spain in 1996-1997; that is, 43.3% of the total. Replies were received from 3,156 school principals and after discarding those that were incorrectly completed, a total of 3,050 replies was validated, i.e., 16.5% of the total number of school principals in Spain during the study period.
Statistical analysis
Sample. The value of the study sample was obtained using the equation for finite universes N = (check)2, where "N" is the number of schools in Spain (18,457), it being necessary to obtain replies from 272 school principals. Since we did not know the number of principals who would reply to our questionnaire, to guarantee the greatest number of responses it was sent to 8,000 schools, obtaining replies from 3,157 and validating a final number of 3,050.
With this sample size, the study has a maximum deviation of ± 1.65% for population data for a confidence level of 95% such that the data obtained in the study can be extrapolated to all Spanish schools. Figure 1 plots the percentages of questionnaires sent and replied to with respect to the total population.
Figure 1.--A. Proportion of questionnaires sent with respect to total number of schools in Spain for 1996-1997. B. Proportion represented by the sample studied with respect to the total number of schools in Spain for 1996-1997.
To determine whether the sample and the population were similar as a function of the status of the schools: public, covenant (state-funded semi private schools) and private, and of the type of education imparted in each (primary education, secondary education or both simultaneously), we used the contrast of proportions for dependent samples test, employing as contrasting statistics the typical scores (Z) corresponding to those proportions. The following formula was applied:
where P1 and P2 are the percentages to be compared from the first and second series; Q1 and Q2 (1-P1) and (1-P2) respectively, and N1 and N2 are the absolute values of both series (of the sample being studied and of the universe from which the sample was taken).
From these calculations, we deduced that the sample and the population were comparable for a confidence level of 95% both as regards their composition as regards the public/private status of the schools and the type of education imparted. Accordingly, the sample studied and the population have similar characteristics.
The data were treated with the SPSS statistical package for Windows, using the appropriate statistical tests as a function of the nature of the variables to be compared in each case: Student''s t test for the comparison of means when the dependent variable was quantitative and the independent one qualitative from two categories: x2 for categorical variables when both variables were qualitative and one-way Anova (analysis of variance) when the dependent variable was quantitative and the independent one was qualitative from more than two categories (in the latter case, if significant differences were found, we applied the Scheffé test a posteriori to determine between which categories the differences were significant).
RESULTS
The samples studied comprised 3,050 questionnaires corresponding to the same number of schools. Of then, 2,308 (75.7%) were public, 520 (17%) covenant, and 159 (5.2%) private. 1,032 (33.8%) impart only primary education; 1,299 (42.6%) primary and secondary education simultaneously, and 649 (22.8%) secondary education only. Table I details the main characteristics of the sample.
TT are imparted in 2,718 schools (89.1%), more in primary schools (93%) than in secondary ones (87%; p < 0.05). He is offered in 2,655 schools (87%), there being significant differences between the primary schools (92%) and secondary ones (84.6%; p < 0.05). ATE are offered in 2,317 schools (73%), more in those imparting primary and secondary education simultaneously (85.9%) than in others offering only primary (75.6%) or secondary (71%) education (p < 0.01).
There were no significant differences among the schools as regards ATE as a function of whether the schools were public, covenant, or private (78%, 79.7% and 85.3%, respectively). Neither were any differences seen as a function of the schools'' location or number of teaching staff. Figure 2 plots the percentages of schools offering TT, HE and ATE.
Table IDistribution of the schools in the sample studied as a function of their characteristics with respect to their public/private status ad the type of education they impart | ||||
| Education stages | Public | Concerted | Private | Total |
| Only primary | 945 (31.9%) | 62 (2.1%) | 8 (0.3%) | 1,015 |
| *785 | *176 | *52.4 | (34.2%) | |
| Primary and secondary | 788 (26.6%) | 373 (12.6%) | 112 (3.8%) | 1,273 |
| *985 | *223 | *66 | (42.9%) | |
| Only secondary | 563 (19%) | 82 (2.8%) | 33 (1.1%) | 678 |
| *524 | *118 | *35 | (22.9%) | |
| Total | 2,296 (77.4%) | 517 (17.4%) | 153 (5.2%) | |
*Number of schools expected on the basis of the proportion that it represents out of the whole sample. | ||||
Figure 2.--Percentages of schools imparting transverse topics, Health Education and ATE, overall and as a function of the type of education imparted.
| Table II | |||
| Educational stages at which ATE are offered; percentages of schools offering them as a function of the type of education imparted | |||
| Education stages | Only primary | Primary and secondary | Only secondary |
| Primary | 72.4% (N.S.) | 47.2% (*) | |
| First cycle secondary education | 78% (N.S.) | 27% (N.S.) | |
| Second cycle secondary education | 18.3% (**) | 49.1% (*) | |
| High school | 7.1% (**) | 22.6% (**) | |
| Vocational training | 1.3% (**) | 10.2% (**) | |
| N.S.: no differences among public, concerted and private schools. | |||
| *Higher percentage in public schools. | |||
| **Higher percentage in concerted and private schools. | |||
The education stages at which HE is offered to pupils are mainly primary education and the first cycle of the CSE. In primary school HE is taught significantly more (p < 0.05) in schools imparting only primary education (72.4%) than in schools imparting primary and secondary education simultaneously (47.2%). In the first cycle of the CSE, a higher percentage of schools impart HE if at the same time they impart primary and secondary education than if they only impart secondary education (27%).
In Bachillerato (High School, 15-18 years) and Vocational Training the percentage of institutions imparting ATE is significantly lower than in the rest of the educational stages. Table II details the percentages of institutions imparting ATE in the different stages of the educational system.
The mean percentage of subjects in which TT are offered is 49.66%; HE, 42% and ATE, 27.5%.
DISCUSSION
Tobacco consumption by children and adolescents is an important public health problem whose control should rank high among health and education officials and indeed the WHO has included this task high up on its list of priorities for the next few years (21). Awareness of the problem in Spain is still in its infancy and despite the legal provisions, which foresee the inclusion of HE in the school syllabus, such educational contents are still not a reality in the education of may children and young adults.
According to the school principals, TT are offered in 89% of Spanish schools (which implies that in more than 10% of schools they are not offered) and are taught more in schools imparting primary education than in those imparting secondary education or primary and secondary education simultaneously. This is probably because the programming of primary education foresees that some of these contents should be taught in the basic syllabus; i.e., outside the content of "transversality".
HE is offered in 87% of schools. This means that most schools imparting TT have chosen HE as one of the main contents to be transmitted to the pupils. As is the case with TT, in primary schools the pupils are more likely to receive HE than in secondary schools. As mentioned above, it should be recalled that some aspects of HE, such as those relating to nutrition or hygiene, form part of traditional teaching contents that are transmitted to pupils during the primary education stage (22).
ATE are given in 76% of schools and it is striking that many of the institutions that do give HE fail to pay attention to smoking since this is a voluntarily chosen habit able to produce the greatest number of diseases and the main cause of avoidable morbidity-mortality. Also, it has been demonstrated that it is easier to prevent a given habit in childhood than to attempt to eradicate it when it has already taken root (13, 23). Accordingly, ATE should be implemented during the years of schooling. It is possible that the inclusion of ATE in primary education syllabuses at the same level as teaching the pupils about their own bodies, hygiene, nutrition or exercise could foster teaching about the dangers of smoking in more schools, although this would break with the prevailing concept of transversality.
ATE are imparted above all to the youngest children, in primary education or the CSE, the percentage of schools offering them during other stages being much lower. Thus, most pupils in the last years of secondary education (a period of maximum risk for acquiring the smoking habit) are not in contact with ATE, such that the positive effect acquired during earlier stages is lost (24-28). A large number of young people begin to smoke or become regular smokers between the ages of 15 and 19 and so ATE should be prolonged throughout secondary education (29). Especially worrying is the almost complete absence of training in matters to tobacco prevention in the stages of Bachillerato and Vocational Training, specially during the latter where almost no information at all is transmitted.
Almost three quarters of primary schools impart ATE while in schools offering primary and secondary education simultaneously, in the primary stage these matters are only addressed in half of them. This suggests that when both levels (primary and secondary education) are given at the same school, ATE are delayed for when the children enter the CSE stage. Hence, more than half the schools do not give ATE until the children are 12 or older, precisely the time when many of them have begun to smoke and some, indeed, have already become regular smokers. It has been shown that this kind of education is more efficient if it is given before the children have begun to smoke (30) and that the earlier on the children experiment with the habit the more likely they are to become regular smokers and to smoke more cigarettes (31). Accordingly, ATE should be begun in primary education and should be prolonged throughout secondary education.
TT are addressed in fewer than half of the subjects on the school syllabus. This means that in many schools the principal, the board and the teachers have not understood the concept of transversality or do not feel sufficiently motivated, prepared or in possession of enough authority to transmit these contents. According to the report of the National Institute for Teaching Assessment and Quality (32), which assessed secondary education in 1998, 60% of teachers believe that they did not receive good teacher training and that the main lacunae lie in the transmission of TT. It is to no avail that new pedagogical trends can be validated if in practice those responsible for putting them into practice are insufficiently informed, motivated, prepared for doing so, or if they do not have the requisite materials or time necessary to suitably instruct their pupils in such matters.
HE is only imparted in 42% of curricular subjects. However, bearing in mind that TT are given in less 50% of them, this gives an idea of the importance of HE within TT. By contrast, ATE are only offered in slightly more than one quarter of the subjects. As mentioned above, this low percentage is quite inconsistent with the enormous advantages of tobacco prevention.
HE aims at fostering healthy life styles among pupils and ATE at reducing the number of smokers (33). The awareness and motivation of teachers can enable ATE to reach more pupils and offer them new perspectives, which in turn would serve to reinforce pupil''s knowledge and attitudes that would otherwise slowly dissipate. Accordingly, the generalization of HE will occur when the large majority of teachers are suitable trained, motivated and aware; when they have the appropriate teaching materials, and when they have a sound knowledge of current legislation, which specifically promotes the development of HE (34).
In conclusion, TT, HE and above all ATE do not reach all pupils or all curricular contents and when they do this is sporadic and not followed up over ensuing years. ATE would be more efficient if they were given during all educational stages and in all curricular subjects. It is therefore necessary to improve the training of teachers in HE issues, endow them with appropriate teaching materials and increase their motivation as regards the transmission of healthy life-style habits. With this, we would be ensuring that more young people receive the kind of teaching (knowledge and attitudes) that will help them to avoid risks, such as smoking, deriving from their own conduct.
Until transversality has become something more than merely an innovating teachig concept and until we are able to have these contents imparted at all schools and to all children, the health and education authorities, as well as teachers and physicians aware of the problem (especially paediatricians), should consider the need for specific interventions aimed at preventing smoking at school.
ACKNOWLEDGEMENTS
The authors acknowledge the Ministry of Education and Culture, the Spanish Society for Pneumology and Chest Surgery and the University of Salamanca for the institutional support that enabled this study, and all school principals who answered the questionnaire.
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