Creative Education
2013. Vol.4, No.7, 423-429
Published Online July 2013 in SciRes (http://www.scirp.org/journal/ce) http://dx.doi.org/10.4236/ce.2013.47061
The Impact of a Pharmacist-Conducted Interactive Anti-Smoking
Education Program on the Attitudes and Knowledge of High
School Students*
Man-Tzu Marcie Wu1, Wan-Chen Shen1, Juei-Chia Chang1, Yi-Chun Chiang2,
Hsiang-Mei Chen2, Hsiang-Yin Chen2#
1Department of Pharmacy, Taipei Medical University, Wanfang Hospital, Taipei, Chinese Taipei
2School of Pharmacy, Taipei Medical University, Taipei, Chinese Taipei
Received April 11th, 2013; revised May 12th, 2013; accepted May 19th, 2013
Copyright © 2013 Man-Tzu Marcie Wu et al. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
Introduction: Smoking among adolescents remains a major concern because of its long term health haz-
ards. An effective adolescent-specific anti-smoking education is needed. Objectives: To measure the im-
pact of a school-based tobacco prevention program provided by pharmacists on the attitudes and knowl-
edge of senior high students. Methods: An anti-smoking program specifically aimed at high school stu-
dents was developed by pharmacists and introduced to 354 students in Taiwan. It consisted of a role play
and a lecture. The students were asked to complete a structural questionnaire right before and after the in-
tervention. Results: After the intervention, the average of the total attitude scores increased from 41.7 to
43.2 (p = 0.001), and the total knowledge scores increased from 6.4 to 8.2 (p < 0.001). The average prac-
tice score was 31.2 (maximum score = 50) and the result suggested that the practice score was associated
with attitude rather than knowledge. Conclusion: This pharmacist-conducted anti-smoking program for
high school students resulted in positive changes regarding both attitude and knowledge. This suggests
that further anti-smoking programs targeting students would be effective in helping to prevent youth
smoking.
Keywords: Attitude; High School; Smoking Cessation; Questionnaire; Education
Introduction
Adolescent smoking has a huge impact on global health and
imposes a burden on the economy (“Curbing the epidemic: go-
vernments and the economics of tobacco control. The World
Bank”, 1999; Preventing tobacco use among young people. A
report of the Surgeon General. Executive summary”, 1994).
The smoking rate among adults in Taiwan has declined, while
in contrast the smoking rate among young people has risen
(Taiwan Tobacco Control 2009 Annual Report, 2009). Studies
indicated that many students had their first experience of
smoking in the 5th and 6th grade of elementary school (Esco-
bedo, Anda, Smith, Remington, & Mast, 1990; Minagawa, et
al., 1992). In Taiwan, 23.2% of ever-smoking high school stu-
dents started smoking before reaching the age of 10 (Taiwan
Tobacco Control 2009 Annual Report, 2009). The earlier a
youth begins using tobacco, the more likely it is that they will
continue the habit into adulthood and that it will influence their
entire life (Jackson & Dickinson, 2004; Khuder, Dayal, &
Mutgi, 1999). Tobacco is classified as “Gateway” drug and
research has shown that teens between 13 and 17 years of age
who smoke daily are more likely to use other drugs/substances,
including alcohol, marijuana and cocaine (Summary of Findings
from the 1998 National Household Survey on Drug Abuse,
1999; Takakura & Wake, 2003). Smoking harms nearly every
organ of the body, causing both short-term and long-term ef-
fects (Fagerstrom, 2002). It accounted for an estimated 443,000
deaths, or nearly 1 of every 5 deaths annually in the United
States, and more than 18,800 deaths a year in Taiwan. In this
context it can be seen that reducing the adolescent smoking rate
is a paramount task in nourishing the younger generation (Lyn-
ch & Bonnie, 1994).
Understanding the mentality which leads to adolescent smok-
ing is essential in order to design an effective anti-smoking pro-
gram and escape its harmful consequences. Studies have dem-
onstrated that peer effects, curiosity, anxiety and a feeling of
maturity are important determinants of smoking (Ali & Dwyer,
2009; Wang, Fitzhugh, Westerfield, & Eddy, 1995). The 2009
Youth Tobacco Use Survey in Taiwan also showed similar
results (Taiwan Tobacco Control 2009 Annual Report, 2009). It
revealed that 41.2% of senior and vocational high school stu-
dents had smoked. This figure included 10% who reported be-
ing motivated by peer pressure and 10.8% who said they used
tobacco for stress relief. Almost half (47%) of teen smokers
first acquired cigarettes from their classmates or friends (Tai-
wan Tobacco Control 2009 Annual Report, 2009). This indi-
*Conflict of Interest: This study was supported in part by grant no. 101wf-
eva-09 from Taipei Medical University-Wan Fang Hospital, Taiwan. The
authors bear all responsibility and have no conflicts of interest with regard to
this work.
#Corresponding author.

M.-T. M. WU ET AL.
cates the accessibility of cigarettes through companionship and
underscores the importance of preventing smoking on campus.
An effective adolescent-specific anti-smoking education needs
to provide a fundamental resolution to prevent smoking in ado-
lescents.
Smoking is the leading preventable cause of death, and
health is the most commonly stated primary and overall reason
for wanting to quit (Aung, Hickman, & Moolchan, 2003). As
well-trained health care professionals, pharmacists can be per-
suasive in educating teens about the long-term effects of smok-
ing. The current program, with its attempt to create more inter-
active and effective questioning, discussion and learning, was
designed to measure the impact of a school-based tobacco pre-
vention program provided by pharmacists on the attitudes and
knowledge of senior high students.
Materials and Methods
The anti-smoking education program conducted by pharma-
cists from Taipei Medical University Wan-Fang Hospital was
implemented in four senior high schools (Wan-Fang, Zhong-
Lung, Lih-Ren, and Blessed Imelda’s senior high school) in one
of their military training classes from Sep. 2005 to Nov. 2005.
All students participated in these classes were included into the
study. The program was composed of two educational models:
a drama and a lecture. The drama with role-playing scenes was
used to prepare students for social situations and centered on
how to resist peer pressure and to practice straightforward and
simple refusal skills. The lecture contained 3 main aspects: (1)
the physical effects and disadvantages of smoking, (2) the im-
portance of smoking cessation, and (3) ways to cope with stress
(Table 1). The disadvantages focused on were risks that might
most concern young people: the staining of teeth and nails,
premature aging, and smoker’s breath. However, other impor-
tant smoking-related health issues like chronic lung disease,
cardiovascular diseases and cancers were also addressed. The
participants were asked to provide their demographic informa-
tion and complete the questionnaires before and after the pro-
gram. The total scores of the responses to the knowledge and
attitude questions were analyzed to evaluate the efficacy of the
program.
Table 1.
Program materials and the schedule.
Materials Outline
Script for Role
play
Peer-pressure scenario: how to resist peer-pressure
and practice refusal skills.
PowerPoint
presentation
lectured by the
pharmacists
1. Tobacco related illness
- Tar, nicotine, carbon monoxide and carcinogens.
- Physical effects concern teenagers.
- Chronic diseases.
2. Benefit of smoking cessation
- Lowers the risk for cancer, coronary heart dis-
ease, stroke, and peripheral vascular disease.
- Reduces respiratory symptoms and the risk for
infertility.
3. Ways to cope with stress
- Exercises, hobbies, and family/friend supports.
Schedule of the anti-smoking education program
1. September 28th, 2005: Wan-Fang senior high school
2. October 5th, 2005: Zhong-Lung senior high school
3. October 17th, 2005: Lih-Ren senior high school
4. November 14th, 2005: Blessed Imelda’s senior high school
Questionnaire Development
The surveillance questionnaire was developed and modified
from previously published literature (Hsia & Spruijt-Metz, 2003;
Meier, 1991). The pre- and post-intervention questionnaires dif-
fered only in the practice section, which was exclusive to the
pre-intervention test. The contents were validated by three ex-
perts who majored in nursing, clinical pharmacy, and public
health. The test-retest was given to 40 senior high school stu-
dents to check reliability, which resulted in Spearman’s rho
coefficients of 0.709, 0.805, and 0.715 for attitude, practice,
and knowledge respectively. The internal consistency values,
using Cronbach Alpha, were 0.558, 0.815 and 0.546 for know-
ledge, attitude and practice items.
Knowledge Test. The knowledge questionnaire contained 10
questions to test the students’ general knowledge of tobacco,
common myths surrounding smoking, and the health conse-
quences of smoking (Table 2). Each item had 3 alternatives:
true, false and unknown. Scores were calculated as the sum of
correct answers, with 10 being the highest possible score.
Attitude Measures. The attitude questionnaire comprised of
10 questions with responses given on a five-point scale to mea-
sure attitudes towards personal, social and environmental as-
pects of tobacco use (Table 2). The highest possible score was
50 and the lowest was 10. Higher scores represented a more
positive attitude about avoiding cigarette smoking.
Practice Evaluation. The 10 items in this evaluation were re-
lated to the behavior of the students over the previous six
months (Table 3). Each item was scored on a five-point scale,
with the lowest possible score being 10 and the highest 50.
Higher scores represented better practice in supporting anti-
smoking activities.
Statistical Analyses
Spearman’s correlation was used to identify test and re-test
reliability as well as the correlations regarding the attitude,
practice and knowledge scores. The Wilcoxon signed-rank test
was used to analyze the differences in the correct rates of
knowledge and attitude. All statistical tests were computed us-
ing the Statistical Package for Social Science (SPSS 13.0, SPSS
Inc, Chicago, IL, USA) with significance defined as p < 0.05.
Because the questionnaires were anonymous, two-sample t-
tests were used instead of paired t-tests.
Results
A total of 354 students participated in the education program,
and 304 (86%) students completed and returned both the pre-
intervention and post-intervention questionnaires. The demo-
graphic data of the students can be seen in Table 4. Female stu-
dents were predominant, 208 (68.4%), due to the fact that the
Blessed Imelda Senior High School is a girls’ high school. Com-
paring to male students, female students had higher total atti-
tude scores (40.1 ± 6.39 vs. 42.5 ± 5.8, P = 0.002) and total
practice scores (29.45 ± 4.4 vs. 32.03 ± 3.89, P < 0.001). There
were no significant differences in total knowledge scores be-
tween males and females (6.51 ± 2.15 vs. 6.3 ± 1.86, P =
0.238).
More than half the participants (184 students, 60.5%) had
family members with smoking habits, 37 (12.2%) had some ex-
perience of smoking, and 4 (1.3%) were regular smokers (Ta-
ble 4). Before the intervention, the total knowledge and attitude
424

M.-T. M. WU ET AL.
Table 2.
Knowledge and attitude scores: impact of the intervention.
Categories Items Pre-intervention Post-intervention P-value
Knowledge
Common myth of smoking 3 2.17 ± 0.71 2.78 ± 0.62 <0.001
Smoking with a filter can minimize health damages 0.79 ± 0.40 0.96 ± 0.20 <0.001
Inhaling second-hand smoke does no harm to our health 0.97 ± 0.16 0.92 ± 0.26 0.005
Light or mint cigarettes do less harm to our bodies than general ones do 0.41 ± 0.49 0.89 ± 0.31 <0.001
General knowledge of tobacco 2 0.68 ± 0.73 1.02 ± 0.75 <0.001
There is cholesterol in cigarettes 0.27 ± 0.44 0.47 ± 0.50 <0.001
Tar is the main substrate that causes tobacco addiction 0.41 ± 0.49 0.55 ± 0.50 <0.001
Health consequences 5 3.52 ± 1.36 4.43 ± 0.97 <0.001
Oral cavity cancer is unrelated to smoking 0.79 ± 0.41 0.94 ± 0.24 <0.001
Gastrointestinal ulcers are unrelated to smoking 0.68 ± 0.47 0.89 ± 0.31 <0.001
Smoking will affect efficacy of some medications (e.g. contraceptives) 0.61 ± 0.49 0.77 ± 0.42 <0.001
Smoking will interfere with the menstrual cycle 0.68 ± 0.47 0.91 ± 0.29 <0.001
Pregnant women who smoke will easily give birth to underweight babies 0.76 ± 0.43 0.93 ± 0.26 <0.001
Total 10 6.37 ± 1.95 8.24 ± 1.63 <0.001
Attitude
Personal aspect 3 8.73 ± 2.62 9.35 ± 2.76 0.002
1. Smoking can keep up one’s spirits 2.81 ± 1.10 2.98 ± 1.19 0.048
2. Smoking can make one feel relaxed 2.75 ± 1.12 3.01 ± 1.20 0.002
3. Smoking is a tool to control body weight 3.18 ± 0.98 3.37 ± 0.96 0.019
Social aspect 4 14.11 ± 2.37 14.56 ± 2.17 0.005
4. People can make friends through smoking 3.45 ± 0.80 3.63 ± 0.67 0.002
5. Smoking is a symbol of maturity 3.53 ± 0.76 3.67 ± 0.68 0.009
6. Smoking can make me look cool 3.40 ± 0.86 3.70 ± 0.62 <0.001
7. Smoking may affect others’ health 3.72 ± 0.74 3.57 ± 1.03 0.04
Environmental aspect 3 8.88 ± 2.51 9.27 ± 2.91 0.029
8. Smoking should be forbidden in all internet café and KTV 3.07 ± 1.11 3.11 ± 1.26 0.559
9. Cigarette smells make people uncomfortable 3.34 ± 1.16 3.42 ± 1.12 0.412
10. Advertisements of tobacco should be forbidden 2.46 ± 1.23 2.73 ± 1.25 0.004
Total 10 31.71 ± 6.06 33.18 ± 5.83 0.001
(1) Knowledge scores were calculated as the sum of correct answers, with 10 being the highest possible score; (2) Five point scale for attitude #7, 8, 9, 10: 5 = strongly
agree, 4 = agree, 3 = neither agree nor disagree (neutral response), 2 = disagree, 1 = strongly disagree; (3) Five point scale for attitude #1, 2, 3, 4, 5, 6: 5 = strongly disagree,
4 = disagree, 3 = neither agree nor disagree (neutral response), 2 = agree, 1 = strongly agree; (4) Higher attitude scores represented a more positive attitude about avoiding
cigarette smoking.

M.-T. M. WU ET AL.
Table 3.
Practice: pre-intervention scores.
Categories Items Pre-intervention
Personal aspect 3 4.88 ± 1.47
1. I reported stores selling tobacco to teenagers 0.18 ± 0.54
2. I bought cigarettes for my family, friends or myself 3.68 ± 0.73
3. I joined educational anti-smoking campaigns 1.01 ± 1.03
Social aspect 4 11.03 ± 2.48
4. I dissuaded my family and relatives from smoking 1.79 ± 1.39
5. I dissuaded my classmates or friends who are nonage from smoking 1.55 ± 1.33
6. My relatives or friends have asked me to smoke 3.84 ± 0.47
7. I said yes when other people asked me to smoke 3.84 ± 0.58
Environmental aspect 3 5.29 ± 1.87
8. I dissuaded strangers from smoking in the non-smoking area 0.37 ± 0.67
9. I prefer to go to smoke-free public places 2.24 ± 1.22
10. I have been to places where a lot of people smoke (e.g. Karaoke, pub etc.) 2.69 ± 1.02
Total 10 21.2 ± 4.23
(1) Five point scale for #2,6,7,10: 1 = always, 2 = usually, 3 = sometimes, 4 = seldom, 5 = never; (2) Five point scale for #1, 3, 4, 5, 8, 9: 1 = never, 2 = seldom, 3 = some-
times, 4 = usually, 5 = always; (3) Higher scores represented better practice in supporting anti-smoking activities.
Table 4.
Demographic data of enrolled students.
Demographic characters Number (%)
Grade
11th 220 (72.3)
12th 84 (27.6)
Gender
Male 96 (31.5)
Female 208 (68.4)
Do any members of your family smoke?
Yes 184 (60.5)
No 120 (39.4)
Have you ever smoked?
Yes, and I have smoking habit. 4 (1.3)
Yes, but I don’t have a smoking habit. 37 (12.2)
No. 263 (86.5)
scores between groups of students with and without family
smokers had no significant difference (both P > 0.05). However,
the practice scores of students with family smokers were sig-
nificantly higher in social aspect (15.45 ± 8.0 vs. 14.76 ± 2.5, P
< 0.012) but lower (7.9 ± 2.0 vs. 8.5 ± 1.8, P < 0.004) in envi-
ronmental aspect compared to students without family smokers
(Table 5).
The education program improved the students’ knowledge of
issues surrounding smoking remarkably, with the average total
score increasing from 6.37 ± 1.95 to 8.24 ± 1.63 (maximum
score = 10, p < 0.001) (Table 2). In the post-intervention ques-
tionnaire, question #4 (There is cholesterol in cigarettes) had
the lowest percentage of correct answers (47.97%) and question
#1 (Smoking with a filter can minimize health damages) had
the highest (96.96%).
The mean post-intervention attitude score was 1.47 points
higher than that of the pre-intervention, the scores being 31.71
± 6.06 and 33.18 ± 5.83 respectively (maximum score = 50, p <
0.05) (Table 2). Question #7 (Smoking may affect others’
health) was the only one that failed to show a significant im-
provement following the education program (4.71 ± 0.77 vs.
4.59 ± 0.99, p = 0.097). However, this is because the baseline
attitude score was already high.
The results of the practice section established that the stu-
dents had very low rates of participation in anti-smoking activi-
ties (Table 3). About 25% of the students didn’t conform to the
legal prohibition on buying cigarettes when under 18 years of
age and only 0.3%, 15.9% and 10.8% of students reported that
they always dissuaded strangers, family and friends from smok-
ing. It was also found that about 87% of the students fail to re-
port illegal selling. Moreover, high school students did not ac-
tively support anti-smoking programs, which was indicated by
more than one third of the students (39.2%) never having par-
ticipated in educational anti-smoking campaigns.
A linear positive correlation was found between attitude and
practice (correlation coefficient = 0.329, P < 0.005). However,
no correlations were found between levels of knowledge and at-
titude or practice.
Discussion
The possibility of a pharmacist-initiated education program
having a positive impact was confirmed by this study, which
showed significant improvements in both students’ knowledge
and attitudes toward smoking. The pre-intervention data indi-
cated that students’ knowledge and attitudes were less than sa-
tisfactory and that educational efforts were needed to correct
inaccuracies in their understanding of the subject. Additionally,
the practice assessment demonstrated poor general practice re-
garding anti-smoking activities (Table 3). Whilst over 70% of
the students were aware of the health consequences of the smo-
426

M.-T. M. WU ET AL.
Table 5.
Difference between groups with family smokers or not prior to the intervention. Mann-Whitney test.
Categories Items No family smokers (184) With family smokers (120) P-value
Knowledge
Common myth of smoking 3 2.21 ± 0.73 2.11 ± 0.68 0.176
General knowledge of tobacco 2 0.63 ± 0.76 0.75 ± 0.75 0.150
Health consequences 5 3.58 ± 1.36 3.43 ± 1.35 0.262
Total scores 10 6.42 ± 1.97 6.28 ± 1.92 0.492
Attitude
Personal aspect 3 11.76 ± 2.65 11.7 ± 2.58 0.393
Social aspect 4 17.97 ± 2.52 18.3 ± 2.1 0.699
Environmental aspect 3 11.75 ± 2.56 12.1 ± 2.43 0.347
Total scores 10 41.49 ± 6.19 42.0 ± 5.8 0.517
Practice
Personal aspect 3 7.92 ± 1.32 7.81 ± 1.68 0.529
Social aspect 4 14.76 ± 2.5 15.45 ± 8.0 P<0.012
Environmental aspect 3 8.5 ± 1.8 7.9 ± 2.0 P<0.004
Total scores 10 31.2 ± 4.9 31.2 ± 4.5 0.914
king, they did not actively try to persuade their family or friends
from smoking or report stores for selling cigarettes illegally to
teenagers under 18 years of age. What could be described as
passive and conservative behavior in Taiwanese senior high
school students regarding anti-smoking was observed, which
further emphasizes the importance of making efforts towards
tobacco hazard prevention on campuses.
A mild-to-moderate positive correlation was found between
attitudes and practice. This supports the theory of attitude-be-
havior relations discussed in previous studies (Ajzen, 2001).
However, this study showed no correlation between knowledge
and practice, which suggests that knowledge of smoking does
not guarantee good practice. This finding is also in accordance
with the results of other studies demonstrating a low correlation
between smoking-related knowledge and behavior (Hodgetts,
Broers, & Godwin, 2004; Torabi, Yang, & Li, 2002). In the pre-
sent study, the mean score of the knowledge assessment im-
proved by 28% following the education program, with the atti-
tude assessment rising by 3.6%. Although both improvements
were statistically significant, this indicates that attitude may be
much more difficult to influence. This was also demonstrated
by the “Start to stop” survey conducted in Memphis, United
States, which examined the effectiveness of a school-based
smoking cessation program among students caught smoking at
school (Robinson, Vander Weg, Riedel, Klesges, & McLain-
Allen, 2003). It showed a significant improvement in tobac-
co-related knowledge but left attitudes unchanged. So whilst an
educational program might well be able to raise the level of
knowledge successfully, it does not follow that this will result
in improved practice.
Not all types of education program are successful, and stud-
ies have indicated that programs using cognitive-behavioral
techniques or strategies to enhance motivation lead to signifi-
cantly higher cessation rates (Sussman, Sun, & Dent, 2006).
The present study program attempted to enhance students’ un-
derstanding by acting out the consequences of smoking and a
scenario of what to do when tempted to smoke. It aimed to help
students identify the social and physical consequences of smok-
ing and develop their ability to resist peer pressure. The intro-
duction of cigarette refusal skills, one of which is coping with
peer pressure, has been found to be a successful component in
smoking prevention programs (Nabors, Iobst, & McGrady,
2007). Besides the professional image pharmacists bring, using
a different teaching technique other than simply doing a power-
point style lecture might also have played a role in the success
of the study.
One of the main limitations of this study was its short-term
design as there was no follow-up surveillance to assess the
long-term impact of improved attitude on students’ behavior.
Also, to include a control group in the future that does not get
an intervention or that gets just a power point presentation not
also the role playing should provide a better evidence of the
effect of the intervention. Besides, due to the nature of the sur-
vey, it should be recognized that students might have underes-
timated their tobacco use status. The high proportion of female
participants may also have an impact on the low ever-smoking
rate in this study (12.2% in this study vs. 41.2% in Youth To-
bacco Use Survey in Taiwan). However, the results of the study
did provide some feedback which can be used to improve future
programs. Different strategies focusing on enhancing active
learning should be developed to further improve attitude, as it is
suggested that changes in attitude rather than increased knowl-
edge is the key to modifying behavior.
The current study also showed an interesting result indicating
that students with family members who smoked were more will-
ing to dissuade family and friends from smoking but cared less
about going to places where a lot of people smoke (Table 5,
Practice). It suggested that students who had family smokers
had more opportunities and felt more comfortable asking peo-
ple to quit, however, they tended to be less sensitive to the envi-
ronmental tobacco smoke. Previous studies indicated that smok-
ing within families was a key influence to youth smoking (Hill,
Hawkins, Catalano, Abbott, & Guo, 2005; Keyes, Legrand, Ia-
cono, & McGue, 2008), together with our results, this group of stu-

M.-T. M. WU ET AL.
dents could become important members to be enrolled when we
involve high school education into future anti-smoking projects.
Conclusion
This study demonstrated the efficacy of the school-based
anti-smoking education program was developed by pharmacists.
It also showed that health care professionals such as pharma-
cists can have a positive influence on high school students’ at-
titudes towards smoking and increase their knowledge of the
issues involved. Additionally, the attitude-behavior relationship
was confirmed by the study. However, future efforts with con-
tinued follow-up may be needed to further evaluate the long-
term impact of the program.
REFERENCES
Ajzen, I. (2001). Nature and operation of attitudes. Annual Review of
Psychology, 52, 27-58. doi:10.1146/annurev.psych.52.1.27
Ali, M. M., & Dwyer, D. S. (2009). Estimating peer effects in adoles-
cent smoking behavior: A longitudinal analysis. Journal of Adoles-
cent Health, 45, 402-408. doi:10.1016/j.jadohealth.2009.02.004
Aung, A. T., Hickman, N. J., & Moolchan, E. T. (2003). Health and
performance related reasons for wanting to quit: Gender differences
among teen smokers. Substance Use & Misuse, 38, 1095-1107.
doi:10.1081/JA-120017652
The World Bank (1999). Curbing the epidemic: Governments and the
economics of tobacco control. Tob Co ntr ol , 8, 196-201.
Escobedo, L. G., Anda, R. F., Smith, P. F., Remington, P. L., & Mast, E.
E. (1990). Sociodemographic characteristics of cigarette smoking ini-
tiation in the United States. Implications for smoking prevention
policy. JAMA, 264, 1550-1555.
doi:10.1001/jama.1990.03450120062030
Fagerstrom, K. (2002). The epidemiology of smoking: Health conse-
quences and benefits of cessation. Drugs, 62, 1-9.
doi:10.2165/00003495-200262002-00001
Hill, K. G., Hawkins, J. D., Catalano, R. F., Abbott, R. D., & Guo, J.
(2005). Family influences on the risk of daily smoking initiation.
Journal of Adolescent Health, 37, 202-210.
doi:10.1016/j.jadohealth.2004.08.014
Hodgetts, G., Broers, T., & Godwin, M. (2004). Smoking behaviour,
knowledge and attitudes among Family Medicine physicians and
nurses in Bosnia and Herzegovina. BMC Family Practice, 5, 12.
doi:10.1186/1471-2296-5-12
Hsia, F. N., & Spruijt-Metz, D. (2003). The meanings of smoking among
Chinese American and Taiwanese American college students. Nico-
tine & Tobacco Research, 5, 837-850.
doi:10.1080/14622200310001615259
Jackson, C., & Dickinson, D. (2004). Cigarette consumption during
childhood and persistence of smoking through adolescence. Archives
of Pediatrics & Adolescent Medicine, 158, 1050-1056.
doi:10.1001/archpedi.158.11.1050
Keyes, M., Legrand, L. N., Iacono, W. G., & McGue, M. (2008). Pa-
rental smoking and adolescent problem behavior: An adoption study
of general and specific effects. American Journal of Psychiatry, 165,
1338-1344. doi:10.1176/appi.ajp.2008.08010125
Khuder, S. A., Dayal, H. H., & Mutgi, A. B. (1999). Age at smoking
onset and its effect on smoking cessation. Addictive Behaviors, 24,
673-677. doi:10.1016/S0306-4603(98)00113-0
Lynch, B. S., & Bonnie, R. J. (1994). Growing up tobacco free: Pre-
venting nicotine addiction in children and youths. National Academy
Press, 1.
Meier, K. S. (1991). Tobacco truths: the impact of role models on chil-
dren’s attitudes toward smoking. Health Education Quarterly, 18,
173-182. doi:10.1177/109019819101800203
Minagawa, K.-E., Nishioka, N., Kawabata, T., Takahashi, H., MOChi-
zuki, Y., Nozu, Y., et al. (1992). Tobacco use among Japanese school
children: results from preliminary study of Japan adolescent smoking
survey (JASS). Health Promotion International, 7 , 8.
doi:10.1093/heapro/7.1.37
Nabors, L., Iobst, E. A., & McGrady, M. E. (2007). Evaluation of school-
based smoking prevention programs. The Journal of School Health,
77, 331-333. doi:10.1111/j.1746-1561.2007.00215.x
Executive Summary (1994). Preventing tobacco use among young
people. A report of the surgeon general. The MMWR Recommenda-
tions and Reports, 43, 1-10.
Robinson, L. A., Vander Weg, M. W., Riedel, B. W., Klesges, R. C., &
McLain-Allen, B. (2003). "Start to stop": Results of a randomised
controlled trial of a smoking cessation programme for teens. Tob
Control, 12, IV26-IV33. doi:10.1136/tc.12.suppl_4.iv26
Summary of Findings from the 1998 National Household Survey on
Drug Abuse (1999). Substance abuse and mental health services ad-
ministration. US Department of Health and Human Services.
Sussman, S., Sun, P., & Dent, C. W. (2006). A meta-analysis of teen ci-
garette smoking cessation. Health Psychology, 25, 549-557.
doi:10.1037/0278-6133.25.5.549
Taiwan Tobacco Control 2009 Annual Report (2009). Bureau of Health
Promotion. Chinese Tapei: Department of Health.
Takakura, M., & Wake, N. (2003). Association of age at onset of ciga-
rette and alcohol use with subsequent smoking and drinking patterns
among Japanese high school students. The Journal of School Health,
73, 226-231. doi:10.1111/j.1746-1561.2003.tb06566.x
Torabi, M. R., Yang, J., & Li, J. (2002). Comparison of tobacco use
knowledge, attitude and practice among college students in China
and the United States. Health Promotion International, 17, 247-253.
doi:10.1093/heapro/17.3.247
Wang, M. Q., Fitzhugh, E. C., Westerfield, R. C., & Eddy, J. M. (1995).
Family and peer influences on smoking behavior among American
adolescents: An age trend. Journal of Adolescent Health, 16, 200-
203. doi:10.1016/1054-139X(94)00097-X
428

M.-T. M. WU ET AL.
Appendix
Smoking Cessation questionnaire in Mandarin
Grade: □ Second Year (11th Grade) □ Third year (12th Grade)
Gender: □ Male □ Female
Do you have relatives who smoke? □ No
□ Yes.
Who?
(e.g. mom, dad, brothers, etc.)
Please mark one of the following that best describes your situation.
□ I smoke cigarettes per day
□ I had smoked before, but I am not a regular smoker.
□ I have never smoked before.
Are you anticipated to try smoking in 6 months?
□ Yes □ No
Part 1: Please mark the most suitable answer. True False Unknown
K1. Smoking with a filter can avoid health damage □ □ □
K2. Oral cavity cancer is unrelated to smoking □ □ □
K3. Gastrointestinal ulcers are unrelated to smoking. □ □ □
K4. There is cholesterol in cigarettes □ □ □
K5. Inhaling secondhand smoke is not real smoking, so it does no harm to our health □ □ □
K6. Smoking will affect efficacy of some medications (e.g. contraceptives) □ □ □
K7. Tar is the main substrate for tobacco addiction □ □ □
K8. Light or mint cigarettes do less harm to our bodies than general ones do □ □ □
K9. Smoking will interfere with the menstrual cycle □ □ □
K10. Pregnant women who smoke will easily give birth to light-weight babies □ □ □
Part 2: Please mark the item that best expresses your opinion.
In general, I believe that: Strongly Agree Agree No Comments Disagree Strongly Disagree
1. Smoking can keep up one’s spirits □ □ □ □ □
2. People can make friends through smoking □ □ □ □ □
3. Smoking is a symbol of maturity □ □ □ □ □
4. Smoking should be forbidden in all internet café and KTV □ □ □ □ □
5. Smoking can make one feel relaxed □ □ □ □ □
6. Cigarette smells make people uncomfortable □ □ □ □ □
7. Advertisements of tobacco should be forbidden □ □ □ □ □
8. Smoking can make me look cool □ □ □ □ □
9. Smoking is a method to control body weight □ □ □ □ □
10. Smoking may affect others’ health □ □ □ □ □
Part 3: Please mark the frequency of facing the situations below.
Always: 90% Usually: 75% Sometimes: 50% Seldom: 25% Never: 0%
In the half passed year…
Never Seldom Sometimes Usually Always
P1. I dissuaded strangers from smoking in the non-smoking area □ □ □ □ □
P2. I dissuaded my family and relatives from smoking □ □ □ □ □
P3. I dissuaded my classmates or friends who are nonage from smoking □ □ □ □ □
P4. I reported stores selling tobacco to teenagers □ □ □ □ □
P5. I bought tobacco for my family, friends or myself □ □ □ □ □
P6. My relatives or friends have asked me to smoke □ □ □ □ □
P7. I said yes when other people asked me to smoke □ □ □ □ □
P8. I joined educational anti-smoking campaigns □ □ □ □ □
P9. I prefer to go to smoke-free public places. □ □ □ □ □
P10. I have been to places where a lot of people smoke (e.g. KTV, pub etc.) □ □ □ □ □