Tobacco Control Programs
1997 Status Report Findings
In order to organize the findings generated from the Self-Evaluation Tool for School-Based Tobacco Control Programs (SETT)1 and the Massachusetts School Health Education Profile (MSHEP)2 as related to tobacco, this report uses the U.S. Department of Health and Human Services "Guidelines for School Health Programs to Prevent Tobacco Use and Addiction".3 These guidelines consolidate the most effective strategies for school-based programs found to prevent tobacco use among young people.
The components of the guide are:
- Develop and enforce a school policy on tobacco use.
- Provide instruction about the short- and long-term negative physiologic and social consequences of tobacco use, social influences on tobacco use, peer norms regarding tobacco use, and refusal skills.
- Provide tobacco-use prevention education in kindergarten through 12th grade. This instruction should be especially intensive in junior high or middle school and should be reinforced in high school.
- Provide program-specific training for teachers.
- Involve parents and community in support of school-based programs to prevent tobacco use.
- Support cessation efforts among students and all school staff who use tobacco.
- Assess and evaluate the tobacco-use prevention program at regular intervals.
Note: Unless otherwise indicated, the results are from the Self-Evaluation Tobacco Tool (SETT) (see Appendix).
1. Policy Implementation
Findings from a 1988 National School Board Association (NSBA) random mail survey of U.S. public school smoking policies revealed that school districts that had policies banning smoking completely had better adherence to their policies than districts with less strict smoking restrictions. 4
- 100% of Massachusetts districts have Tobacco-Free School Policies. (see Figure1)
- 93% of districts list consequences for student violation of the Tobacco-Free School Policy. (see Figure 1)
- 58% of districts include an option for tobacco education, e.g., Tobacco Education Group (TEG), instead of suspension or other punishment for students violating the Tobacco-Free School Policy. (see Figure 1)
- This option for tobacco education is offered in 60% of urban districts, 52% of suburban districts, and in 49% of rural districts.
- 99% of districts adhere to Rule 14 of the Massachusetts Interscholastic Athletic Association which treats tobacco use the same as other drugs and requires that any student found in violation of the policy be prohibited from playing two consecutive games.
- 91% of districts include consequences for teachers in the Tobacco-Free School Policy.
- 95% of districts enforce the policy during athletic and other special school events.
- 78% of districts have active enforcement of the policy when school is not in session and community organizations are using the school building, and
- 54% have organizations sign an agreement to adhere to the Tobacco-Free School Policy.
2. Instructional Elements
The Surgeon General's 1994 report on Preventing Tobacco Use Among Young People 5 reiterates the findings that peer influences, peer smoking, and peer approval of smoking are strongly related to tobacco use initiation and are especially powerful in the early stages of tobacco use. The report urges that tobacco prevention programs engage peer role models who do not use tobacco. Adolescents who are able to resist peer offers appear to be at lower risk for tobacco use initiation.
- 100% of districts have a tobacco education curriculum that includes refusal skills.
- 83% of districts have peer leadership programs that include tobacco prevention activities.
- 96% of middle school and 95% of high school teachers have tried both to increase student knowledge and to improve attitudes on tobacco use prevention in required health education course(s) in any of grades 6 through 12. (MSHEP)
- There has been a significant increase from 1994 to 1996 in the percentage of health educators teaching tobacco use prevention, from 73% to
- 95%. (MSHEP)
- 89% of middle school and 83% of high school teachers have taught analysis of media messages in required health education. (MSHEP)
3. Education Provided
Research shows that adults believe that smoking-related education to grade school children is effective in discouraging smoking, 6 and that there should be an increase in school-based anti-tobacco education.7 Direct intervention is most important in adolescence when there is the highest commencement of smoking. Continued booster sessions into the upper grades are vital as the short-term positive effects of intervention become diluted over time.8
- The percentage of schools requiring a health education course for graduation or promotion went from 69% in 1994 to 82% in 1996 for high schools, a significant increase.(MSHEP).
- Required general health education courses (which include tobacco education) are most often scheduled in the 6th, 7th, and 8th grades, with a rapid decrease in the percentage of schools scheduling required health education courses after the 9th grade. (MSHEP)
- The greatest amount of tobacco prevention education is received by students in grades 5 through 9, and there is a decreasing amount offered during the high school years. (see Figure 2)
4. Teacher Training
Research shows that enhanced implementation and delivery of health education is associated with teacher training. 9
- 82% of K-12 teachers received training in tobacco prevention education.
- 57% of middle school and 60% of high school health teachers received four or more hours (at least day) of inservice training on tobacco use prevention. The only health education topics on which they attended more inservice trainings than on tobacco were conflict resolution, sexual harassment, and HIV prevention. (MSHEP)
- Tobacco use prevention was one of the topics on which health educators would like to attend future inservice training (40% of middle school and 51% of high school teachers). (MSHEP)
5. Community And Parental Involvement
Research shows that the capacity of school-based programs to prevent tobacco use seems to be improved and sustained until the end of high school by the addition of coordinated community programs. Further, while tobacco use by parents does not seem to be as powerful a risk agent as does peer use, parents who are disapproving of smoking may exert a positive effect on their children.10
- 81% of districts are part of a tobacco coalition aimed at reducing the use of tobacco in the entire community.
- 96% of districts have involved students, staff, and parents in tobacco related policy/program development and implementation.
- 97% of districts have discussed tobacco control formally with the School Health Advisory Committee.
- 75% of districts' tobacco control programs are linked to community programs.
- 97% of districts notify parents about tobacco policy violations by students.
- 56% of districts provide tobacco education to parents. Parental feedback prompted teachers in 22% of middle schools and
- 27% of high schools to expand coverage on tobacco use prevention in required health education courses. This topic was the third highest on a list of 25 topics. (MSHEP)
6. Cessation Program Availability
Research has found that smoking prevention programs have little influence on quitting smoking. Adolescents often resist involvement in smoking cessation programs because they are less concerned about long-term health consequences, but they are more concerned about parents and authority figures finding out they are using tobacco. Community-based supplemental strategies can benefit school-based programs.11
- 33% of urban districts, 30% of suburban districts, and 7%of rural districts offer cessation to high school students only; 37%of urban district, 34% of suburban districts, and 70% of rural districts offer cessation to both middle school and high school students. (see Figure 3).
- 67% of districts with high schools have a cessation group for high school students and 32% of districts with middle schools have a cessation group for middle school students. (see Figure 4)
- 50% of districts have a tobacco cessation group for teachers. (see Figure 4)
- 37% of districts have a tobacco cessation group for the community. (see Figure 4)
- 28% of districts have a tobacco cessation group specifically for parents. (see Figure 4) Figure 4
7. Program Evaluation
Research shows that changing the behavior of tobacco use is very difficult for young people. Adolescents who are current smokers are already addicted. Their addiction is experienced in a manner similar to adult smokers with respect to the severity. The withdrawal symptoms reported by adolescents match those reported by adults. The majority of adolescent smokers want to stop smoking and have made numerous and most often unsuccessful attempts to quit. A great deal of them report that they plan to stop using tobacco in the future, but then they are not able to quit. To further aggravate this situation, it is difficult to recruit and retain adolescents in cessation programs.12
- Districts track the success of the school-based cessation program by the number of participants enrolled, number who have cut down and by how much, and the short- and long-term quit rate.
- Districts collect information about the incidences of tobacco use on campuses.
- The Massachusetts Youth Risk Behavior Survey (MYRBS) 13 is administered every two years to identify risk behaviors such as smoking. In addition, many districts administer a local YRBS to assess risk behaviors and attitudes of their student population.
- The Massachusetts Department of Elementary and Secondary Education requires evidence of a Comprehensive K-12 Needs Assessment for the Health Protection Fund Grant Application.
- Districts use this evaluation information to further refine their tobacco prevention education and cessation programs.
The Health Protection Fund for comprehensive school health education has been in place for three and a half years. Policy development and implementation, tobacco prevention education for all students, and the development of cessation programs for students, staff, and community are gains in tobacco prevention and cessation that have been made in Massachusetts school districts. Districts have moved forward with comprehensive school health education and tobacco prevention and cessation despite yearly funding decreases of 12% for the Health Protection Fund Grants.
The commitment of the state to health education is shown by the completion of the Health Curriculum Framework. As school districts use the Health Curriculum Framework and begin locally assessing health education, more informed decisions about tobacco prevention education and cessation will be possible.
HPF is guided by evaluation and uses findings to enhance health education programs. In an ongoing process of improvement, tobacco prevention education and cessation will need to be strengthened. Districts are challenged to increase the prevention education effort in the upper grades. Many districts run cessation programs, but the necessity for more cessation programs is recurrent. A commitment to a cessation program is critical tor the success of the participants and for commitment to occur, the cessation program must be dynamic, exciting, and include peer and community leaders where possible. The community will need to play an active role in prevention and cessation in order to present an effective message to young people about the benefits of a tobacco-free life.
Many agencies and organizations, such as the Massachusetts Department of Public Health, are also working to decrease the risks of tobacco use among young people. While there is a decrease in the number of young adults smoking, an emphasis needs to be placed on adolescents to counteract the past increase in smoking in this age group.14 School programs reach young people in the place they spend the majority of their time and thus are a vital component of the work to prevent and alleviate smoking behaviors. The 1994 Surgeon General's report states that "These [tobacco] interventions may be enhanced if they are embedded in a more comprehensive school health education program. The comprehensive school health approach needs further evaluation but is promising as an effective prevention tool." ( p.225). 15
1 Self-Evaluation Tool for School-Based Tobacco Control Programs(SETT). The SETT was developed by the Massachusetts Department of Public Health (DPH) to gauge school-based tobacco policy development and implementation, tobacco prevention education, and tobacco cessation programs. 216 (62%) school districts responded.
2 Massachusetts School Health Education Profile (MSHEP). The School Health Education Profile (SHEP) was developed by the U.S. Centers for Disease Control and Prevention (CDC) to assess the impact of state and federal resources on the implementation of comprehensive health education. The survey was conducted in the Spring of 1996 with 90% of principals (393) and 87% of teachers (383) responding out of 439 schools. Results from the 1994 MSHEP are also used for across time comparisons.
3 Centers for Disease Control and Prevention, 1994. Guidelines for school health programs to prevent tobacco use and addiction. Morbidity and Mortality Weekly Report, 43(No. RR-2):1-18.
4 National School Boards Association, 1989. Smoke-free schools: a progress report. Alexandria, VA: National School Boards Association.
5 Centers for Disease Control and Prevention, 1994. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Public Health Service; DHHS Publication No. S/N 017-001-00491-0.
6 Marcus, S, Emont, S., Corcoran, RD, Giovino, GA, Pierce, JP, and Waller, MN, 1994. Public attitudes about cigarette smoking: results from the 1990 smoking activity volunteer executed survey. Public Health Reports, 109(1):125(10).
7 California Department of Health Services 1991. Tobacco use in California, 1990: a preliminary report documenting the decline of tobacco use. Sacramento, CA: California Department of Public Health Services.
8 Centers for Disease Control and Prevention, 1994. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Public Health Service; DHHS Publication No. S/N 017-001-00491-0.
9 Connell, D, Turner, R, & Mason, E, 1985. Summary of findings of the school health education evaluation: health promotion effectiveness, implementation, and costs. Journal of School Health, 55(8), 316-21.
10 Centers for Disease Control and Prevention, 1994. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Public Health Service; DHHS Publication No. S/N 017-001-00491-0.
13 Massachusetts Youth Risk Behavior Survey (MYRBS). Developed by CDC to monitor behaviors of high school students related to the leading causes of illness and death. The MYRBS was conducted in the Spring of 1995 in 59 high schools with 4,159 students in grades 9 through 12 participating (94% response rate).
14 Massachusetts Department of Public Health, 1995. Independent Evaluation of the Massachusetts Tobacco Control Program: Second Annual Report, January 1994-June 1995. Cambridge, MA: Abt. Associates, Inc.
15 Centers for Disease Control and Prevention, 1994. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human
Services, Public Health Service; DHHS Publication No. S/N 017-001-00491-0.
Commissioner's Letter || Executive Summary || Findings || Appendix