Tobacco Control Program - 1999 Status Report
This is the second Comprehensive School Health Education Tobacco Control Programs Status Report. This report represents an ongoing commitment by the Massachusetts Department of Elementary and Secondary Education to help prevent and decrease tobacco use by students. Tobacco use is the leading preventable cause of death in the United States1, and is responsible for one in every five deaths.2 Tobacco use among young people poses especially serious risks. Adolescent tobacco use not only threatens health, but it is also associated with drinking and illicit drug use and with poor school performance.3 Every year in the United States over one million adolescents begin smoking.4 Four out of every five current adult smokers tried their first cigarette before age 18, and half of these became regular smokers by age 18. 5
Guidelines to Prevent Tobacco Use and Addictions
The first Comprehensive School Health Education Tobacco Control Programs Status Report found that Massachusetts school districts for the most part follow the U.S. Department of Health and Human Services, "Guidelines for School Health Programs to Prevent Tobacco Use and Addictions" 6, which defines the most effective strategies for school-based programs to prevent tobacco use among young people. These 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.
Current Rates of Tobacco Use
The most compelling evidence of the effectiveness of a tobacco control program may be the extent to which youth use tobacco. The Massachusetts Department of Elementary and Secondary Education conducts the Youth Risk Behavior Survey (YRBS), a large, confidential, random survey of student-based behavior every two years with high school students. Many of the questions on the YRBS ask students about their tobacco use over their lifetime, recently (within thirty days of the survey), and daily. The most recent YRBS revealed some progress in the Commonwealth around tobacco use by students.
According to the 1997 Massachusetts Youth Risk Behavior Survey 8:
- Overall, lifetime cigarette smoking, which had risen sharply from 1993 to 1995, has decreased slightly since then, from 72% (1995) to 69% (1997).
- Students in the 9th grade in 1997 had notably lower rates of lifetime smoking (62%) than did their 1995 counterparts (69%).
- Recent cigarette smoking, which had risen significantly from 1993 to 1995, has decreased slightly since then, from 36% (1995) to 34% (1997).
- Recent smoking declined most notably among 9th grade students, from 32% (1995) to 28% (1997).
- Recent smoking stayed level for female students from 1995 to 1997 (36% for both years), but dropped slightly for males (35% to 33%).
- In 1995, rates of recent smoking among Massachusetts students were slightly above those reported by the national YRBS (35.7% vs. 34.8%). Due to slight increases nationally and slight decreases in Massachusetts, the 1997 rates of recent smoking among Massachusetts adolescents dropped below national rates (34.4% vs. 36.4%).9
- The percentage of students who reported smoking cigarettes every day in the month prior to the survey (daily smoking) rose from 1993 to 1995, but has remained level since then at 15%.
- Among students who smoked every day, the proportion of those who smoked more than a half a pack a day (11 or more cigarettes) dropped slightly, from 46% (1995) to 42% (1997).
- The 1997 rates of adolescent smokeless tobacco use were significantly lower than they were in 1993. The sharpest decline has occurred since 1995.
- Among male students (who are almost ten times more likely than females to report recent smokeless tobacco use), the drop in smokeless tobacco use has been substantial and significant, from 17% (1993) to 15% (1995) to the current male rate of 10%.
- One third (33%) of students who had smoked cigarettes in the past month usually obtained their cigarettes by buying them in a store. This represents a significant drop from 1995, when 48% of recent smokers reported that they bought their cigarettes in a store.
- Students were significantly more likely in 1997 than in 1995 to be asked for proof of age if they tried to buy cigarettes in a store (61% compared to 49%).
Comprehensive School Prevention Education and the Health Protection Fund Grant Program
The major initiative of the Massachusetts Department of Elementary and Secondary Education to prevent and reduce tobacco use is the Health Protection Fund (HPF) grant. The grant was established through a 1992 state legislative referendum that directs a portion of tax revenue on tobacco products to the Department of Elementary and Secondary Education for tobacco prevention education and cessation through comprehensive school health education programs. In the 1997-1998 school year, districts reported spending approximately 17% of the HPF grant monies they received exclusively on tobacco prevention education and cessation. The Massachusetts Department of Public Health also has tobacco control programs funded from the Health Protection Fund. These efforts are substantial and focus on pricing, enforcement of laws and policies, and media.
In accordance with the Massachusetts Department of Elementary and Secondary Education Health Protection Fund grant, school districts provide:
- The maintenance of a healthy school climate and environment, with special emphasis on enforcement of an effective tobacco free schools policy. There is to be equitable enforcement of the policy and consequences for students and staff and the provision of cessation programs.
- Tobacco prevention education for all students, including smoking cessation programs.
The findings presented below are compiled from the following Massachusetts Department of Elementary and Secondary Education reports: 1997 Comprehensive School Health Education Tobacco Control Programs Status Report 10, 1996 Massachusetts School Health Education Profile 11, 1998 Massachusetts School Health Education Profile 12, 1998 Year IV Evaluation of the Health Protection Fund 13, 1999 Year V Evaluation of the Health Protection Fund 14, and the Massachusetts Comprehensive Health Education Curriculum Framework. 15 All of these reports, including this report, are or will soon be available on the Department website.
- 100% of districts reported that they have a tobacco free schools policy for students and staff as mandated by the Education Reform Act of 1993.
- The districts' tobacco-free schools policy included the following consequences for student violation:
- 92% include that students are suspended or expelled,
- 72% require students' parents/guardians to meet with school officials,
- 48% include that students must participate in prevention education,
- 29% include that students must participate in a cessation program, and
- 14% include that students are fined.
- 91% of districts include consequences for teachers in the policy.
- 95% of districts enforce the policy during athletic and other special school events.
Tobacco Prevention Education Instruction
- 98% of middle and high schools teach tobacco use prevention.
- Of these, 100% have a tobacco education curriculum that includes refusal skills.
- Tobacco use prevention was a topic on which health teachers were most likely to report expanded coverage due to parental feedback.
- Tobacco use prevention was a topic on which health teachers were most likely to have received in-service training within the last two years.
63% of districts offered cessation programs to students, 29% of districts offered cessation programs for staff, and 23% of districts offered cessation programs for parents and community members.
Districts reported that the average annual number of hours for cessation programs was:
- 10 hours for students, 8 hours for staff, and 9 hours for parents and community members
The number of participants in the last 12 months was:
- For students, 13% of districts that had cessation programs reported no participation. Between 1 and 18 students participating was reported by 51% of districts, between 18 and 38 students by 21% of the districts, and between 40 and 80 student participants by 12%. The remaining 3% of districts reported that the number of participants ranged from 40 to 157 students. For staff, 55% of districts that had cessation programs reported no participation. Between 1 and 12 staff participating was reported by 44% of districts. One district reported that 30 staff participated. For parents and community members, approximately 40% of districts that had cessation programs reported no participation. Between 1 and 23 parents participating was reported by 35% of districts. The remaining 25% of districts reported between 24 and 100 parents and community members participating.
Of those participating in cessation programs, the percent that completed the program was:
- 61% of students completed the cessation program, 33% of staff completed the cessation program, and 47% of parents and community members completed the cessation program.
The number of sessions for students, staff, and parents/community was very consistent. It should be noted that if there were few violations, then there would likely be few participants based on research that shows the ability of cessation programs to recruit and retain members is very low, especially for adolescents.16 However, of the types of participants to whom cessation programs were offered, the participation rates were fairly high for students, while low for parents/community, and quite low for staff. Overall, completion rates were low. Paralleling participation, staff completion rates were only a third, and less than half of the parents/community participants completed the program. Students had the best completion rates; approximately sixty percent of students who participated completed the tobacco cessation program.
Relationships between Comprehensive School Health Prevention Education and Reductions in Student Tobacco Use.
Research shows that school health prevention education can be effective in reducing tobacco use. 17, 18, 19
The Health Protection Fund evaluation, using data from a group of Massachusetts districts in the 1996 and the 1997 school years, found significant relationships between prevention education and reductions in tobacco use. There was substantial similarity of these relationships from Year IV to Year V. The findings from Year V are highlighted here. From 1993, the first year districts received the HPF grant money, to the 1997 school year, the fifth year that the HPF grant has been in place in Massachusetts, the following program practices were found to be significantly related to decreases in tobacco use in high school and middle school students. These findings are associations and not intended to imply cause and effect.
Effective comprehensive school health education prevention education program practices related to decreases in high school tobacco use were:
Exposure to Health Curriculum
- A greater number of health education hours in the 12th grade.
- Having a tobacco policy in place requiring students who violate the tobacco free school policy to participate in prevention education.
- Providing training to teachers to match the comprehensive health curriculum framework with the current health education curriculum.
Involvement of Important Others-Adults
- Parent involvement through the school health advisory council.
- Public health department involvement through the school health advisory council.
Involvement of important others-Peers
- Students being involved through the school health advisory council.
- Students being served by trained health peer educators in health classes.
- Students being served by trained health peer educators in discussion or support groups.
- District's written improvement plan including goals for comprehensive school health education.
- Local evaluation of health-related school policies.
- Local evaluation of staff development in health education.
It can also be useful to know which program practices as a group are related to the decreases in tobacco use and to know the extent to which the decreases can be understood in terms of these groups of program practices. This information is presented below. The program practices are listed in order of their explanatory strength.
High School Tobacco Use
25% of the decrease that occurred from Year I (1993) to Year V (1997) in high school tobacco use can be accounted for by the program practices of:
- Parents being represented on the school health advisory council,
- Peer health educators working with students in discussion/support groups, and
- Training provided to teachers on matching the district's current health curriculum with the Health Curriculum Framework.
Middle School Tobacco Use
28% of the decrease that occurred from Year I (1993) to Year V (1997) in middle school tobacco use can be accounted for by the program practices of:
- A formally documented local evaluation of written goals, objectives, and/or outcomes in health education,
- Peer health educators working with students in health education courses/classes, and
- A greater frequency of interdisciplinary instruction between health education and family and consumer sciences education.
Looking to the Future
The Health Protection Fund grant requires the implementation of a PreK-12 comprehensive health education curriculum using the Comprehensive Health Curriculum Framework, which gives specific goals with measurable objectives. The revised Comprehensive Health Curriculum Framework has a section devoted exclusively to tobacco, alcohol, and other substance use/abuse prevention. Learning standards in the Framework will increase uniformity of instruction in this area and provide students with specific knowledge and skills around tobacco use prevention and cessation. For example:
- In grades PreK-5, students will describe how tobacco and prolonged exposure to cigarette smoke affects the body.
- In grades 6-8, students will describe addictions to alcohol, tobacco, and other drugs, and methods for intervention, treatment, and cessation.
- In grades 6-8, students will list the potential outcomes of prevalent early and late adolescent risk behaviors related to tobacco, alcohol, and other drugs, including the general pattern and continuum of risk behaviors involving substances that young people might follow.
- In grades 6-8, students will demonstrate ways of refusing and of sharing preventive health information about tobacco, alcohol, and other drugs with peers.
- In grades 9-12, students will describe the harmful effects of tobacco, alcohol, and other substances on pregnant women and their unborn children.
- In grades 9-12, students will demonstrate the ability to make informed decisions regarding the use of tobacco, alcohol, and other drugs.
The Council of Chief State School Officers State Collaborate on Assessment System for Health has been made available to districts for use in assessing health education knowledge and skills through the Health Protection Fund Mentor Program and includes questions specific to tobacco.
The 1999 Massachusetts Youth Risk Behavior Survey Report will, as the 1997 report did, have a supplemental report that is specific to tobacco.
Major goals of the Year VI evaluation of the Health Protection Fund will be expansion and a focus on generalizability to school districts across the Commonwealth with movement toward recommendations of effective prevention education program practices for use in helping prevent and reduce tobacco use in Massachusetts students.
Department staff are actively involved in local tobacco control programs as well as the activities of the Question 1 Advisory Council that oversees and contributes to the planning of the HPF monies.
A model tobacco-free schools policy has been developed by the Department and is available in the appendix.
- Public Health Service. (1994). National Household Survey on Drug Abuse: Population Estimates, 1994. DHHS Pub. No 95-3063. Rockville, MD: Substance Abuse and Mental Health Services Administration.
- Centers for Disease Control. (1991). Smoking-attributable mortality and years of potential life lost-United States, 1988. Morbidity and Mortality Weekly Report, 40, 62-63, 67-71.
- Johnston, LD., O'Malley, PM, and Bachman, JG. (1997). National Trends in Drug Use and Related Factors Among American High School Students and Young Adults, 1997-1986. DHHS Pub. No. (ADM) 87-1535. Rockville, MD: National Institute on Drug Abuse.
- US Department of Health and Human Services. (1990). Prevention '89/90: Federal Programs and Progress. Washington, DC: US Government Printing Office.
- US Department of Health and Human Services. (1994). Preventing Tobacco Use among Young People: A Report to the Surgeon General. DHHS Pub. No. S/N 017-001-00491-0.
- Centers for Disease Control and Prevention. (1994). Guidelines for school health programs to prevent tobacco use and addiction. Morbidity and Mortality Weekly Report, 43, 1-18.
- Massachusetts Department of Elementary and Secondary Education. Comprehensive School Health Education Tobacco Control Programs Status Report. (1997). Malden, MA: Author.
- Goodenow, C. (1998). 1997 Massachusetts Youth Risk Behavior Survey Results. Malden, MA: Massachusetts Department of Elementary and Secondary Education.
- Centers for Disease Control and Prevention. (1998). Tobacco use among high school students-United States, 1997. Morbidity and Mortality Weekly Report, April 3.
- Massachusetts Department of Elementary and Secondary Education. (1997). Comprehensive School Health Education Tobacco Control Programs Status Report. Malden, MA: Author.
- Goodenow, C. (1997). 1996 Massachusetts School Health Education Profile. Malden, MA: Massachusetts Department of Elementary and Secondary Education.
- Goodenow, C. (1999-in preparation). 1998 Massachusetts School Health Education Profile. Malden, MA: Massachusetts Department of Elementary and Secondary Education.
- McManis, D. (1998). Year IV Evaluation of the Health Protection Fund. Malden, MA: Massachusetts Department of Elementary and Secondary Education.
- McManis, D. (1999-in preparation). Year V Evaluation of the Health Protection Fund. Malden, MA: Massachusetts Department of Elementary and Secondary Education.
- Massachusetts Department of Elementary and Secondary Education. (1999-in preparation). Massachusetts Comprehensive Health Education Curriculum Framework. Malden, MA: Author.
- US Department of Health and Human Services. (1994). Preventing Tobacco Use among Young People: A Report to the Surgeon General. DHHS Pub. No. S/N 017-001-00491-0.
- U.S. Department of Health and Human Services. (1998). School Health: Findings from Evaluated Programs, 2nd Edition. Washington, DC: Author.
- Botvin, G., and Botvin, E. (1992). Adolescent tobacco, alcohol, and drug abuse: Prevention strategies, empirical findings, and assessment issues. Journal of Developmental and Behavioral Pediatrics, 13, 290-301.
- Glynn, T. (1992). Improving the health of US children: The need for early interventions in tobacco use. Preventive Medicine, 22, 513-519.
Acknowledgement: This report was prepared by Dale McManis, Ph.D.
View the School Health Education Tobacco Control Programs Fact Sheet