Assessing School Policies Related to Tobacco and Other Health Issues

1
Assessing School Policies Related to Tobacco and
Other Health Issues
Kathy Begley, BA Data Management
Coordinator Tobacco Policy Research
Program Carol A. Riker, RN, MSN Provosts
Distinguished Service Professor
2
Youth Tobacco Statistics, 2003 (KY)
Prevalence of Smoking Grades 9-12 32.7
Numbers of Smokers Grades 9-12 53,000
Projected to start Smoking (KY) 334,000
Projected to Die from Smoking (KY) 107,000
CDC Data Highlights 2006 http//www.cdc.gov
3
Costs of Not Intervening

• Kentuckys 1998 annual total smoking-attributable
  direct medical expenditures were 1,171,000,000,
  or 298 per capita. (CDC, 2002)
• About 15 of all KY Medicaid expenditures in 1998
  were spent on smoking-related illnesses and
  diseases (CDC, 2002).
• Kentuckys gross cigarette tax revenue in 2007
  was 179,100,100. (CDC, 2007)

4
Why Is School Policy Important?

• Prevents secondhand smoke exposure
• Prevents role-modeling of smoking by teachers,
  staff, and other students, thus setting a
  tobacco-free norm
• (Lovato, 2006 Barnett, 2007 Pointek, 2007)
• Decreases chance of experimentation and
  progression to addiction (Goldstein, 2003).

5
Prevention of Secondhand Smoke (SHS) Exposure

• SHS exposure is
• linked to respiratory illness, new and
  exacerbated cases of asthma, heart disease,
  cognitive deficits and risk of breast cancer in
  pre-menopausal women
• associated with increased respiratory-related
  absenteeism, especially in students with asthma
  (Gilliland, 2003)

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Air Pollution in a Rural Kentucky High School
Student Restroom is 19 Times the Federal Outdoor
Air Quality Standard and Over 2 Times Higher than
Lexingtons Bars, Pre-Law
PM2.5 (microgram per cubic meter)
Note. The National Ambient Outdoor Air Quality
Standard (NAAQS) for PM2.5 is 35 µg/m3
for 24 hours. There is no Indoor Air Quality
Standard.
7
Experimentation Can Quickly Lead to Addiction
(DiFranza, 2002)

• Symptoms of tobacco dependence develop rapidly
  after onset of intermittent smoking
• Development of a single symptom
  strongly predicted continued tobacco
  use
• Median frequency of use at onset of symptoms was
  2 cigarettes, one day per week

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What Constitutes Model School Tobacco Policy?

• Prohibits tobacco
• - On all school property
• In school vehicles
• At school-sponsored events on and off school
  property (even fundraising)
• For students, staff, and all visitors

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Model School Tobacco Policy

• Additional components for prevention
• Tobacco ads and event
  sponsorship prohibited
• Brand name apparel prohibited
• Tobacco education mandated for violators and
  voluntary cessation classes offered as
  Alternatives To Suspension
• Research-based curricula provided for all
  students by trained staff
• Signage communicates policy

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Kentucky School Policy Interview, 2007

• 52.1 of schools ban smoking on school grounds
  for employees (97.2 for students) compared to
  46.6 in 2005
• 49.7 prohibit smoking at outdoor events,
  compared to 49.1 in 2005.
• Only 8.1 of schools do fundraising in Bingo
  halls where smoking is allowed, but 29.1 of
  those allow students to work there.
• 3.6 have access to a tobacco base and almost 56
  of those have students participating in tobacco
  production, many for Ag Ed.

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Additional Areas for Improvement

• 73.2 have signs posted (69.7 in 2005 68 in
  2003)
• Only 12.6 post signs in/near restrooms
• Only 7.9 of schools refer to a smoking education
  class on first offense, yet nearly 50 of schools
  have such classes
• 38.0 refer for in-school suspension on a first
  offense brief interventions could be offered
  there

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School Policy Interview Purpose

• To collect school policy data for planning and
  monitoring change over time
• To lay the groundwork for helping schools with
  tobacco policy change
• To recruit partners for your tobacco prevention
  and cessation coalition
• NOTE Train all helpers
• in this protocol!

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School Policy Interviews An Overview

• Recruit middle and high schools, public and
  private
• Phone interview with principals /or others
  knowledgeable about school policy and curricula
• Document data on interview form or online
• Submit data forms online (preferred method) or
  FAX to 859-323-1033
• Send data forms to UK in tracking mailer provided
• Follow-up with interested school personnel

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Elements of the School Policy Interview, 2009

• Where and when students, teachers, staff, and
  visitors are banned from using tobacco
• How the policy is communicated
• How the policy is enforced
• How violators are handled
• Existence of cessation resources
• Existence of research-based curricula
• Student advocacy regarding tobacco
• Other environmental factors related to tobacco,
  nutrition and exercise
• Interest in policy change

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Contacting Schools

• Check list of schools for accuracy
• Call the school and ask for the principal
• Introduce yourself
• Explain purpose of interview
• Explain that all KY middle and
• high schools are being asked to participate
• Say interview will last 25-30 minutes
• Explain how information will be used
• Schedule a convenient time for the interview

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Conducting the Phone Interview

• Choose a convenient time with
  minimal opportunity for interruption
• Avoid beginning end of school and meal times
• Verify contact information on School List
• School name and address
• Contact name
• Phone number

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Conduct the Phone Interview

• Get complete informationask clarifying questions
  if needed
• Dont offer the I dont know option
• If person being interviewed is uncertain about an
  answer, complete the interview and ask for
  another school contact who may have the missing
  information
• You may need to talk with more than one person to
  get the correct information! In this case, make
  sure you adjust the end time to reflect the total
  time of the interview
• Wait until AFTER the interview to discuss issues
  or further comments about the questions

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Averting Refusals

• If hesitant to participate
• You sound busy.when is a more
  convenient time to call?
• There are no right or wrong answers. We are
  interested in what you are doing, so that we can
  be more effective in planning our health
  programs
• The information will be kept confidential. The
  information will be summarized by health
  department service area, not by individual school

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Proper Phone Etiquette

• Find the most convenient time
• Know the school schedule
• Avoid beginning, ending,
  and meal times
• Be sensitive to time constraints
• Be polite
• Use nonjudgmental approach

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Human Subjects Protections

• Voluntary participation
• Minimize barriers to participation
• Understanding the benefits of participation
• Right to withdraw or refuse to answer
• Confidentiality
• Do not include names of the interviewees on the
  actual interview form!
• Be sure to communicate the importance of Human
  Subjects Protections with any helpers!

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Located On the Websitehttp//www.mc.uky.edu/tobac
copolicy/

• 2009 School Tobacco Policy Interview Guide
  on-line version this is the preferred method
  for data collection
• 2009 School Tobacco Policy Interview Guide PDF
  version (to print and submit by fax)
• Blank disposition sheet
• School list and county code for each county
• Cheat sheets for conducting interviews

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Located On the Website (cont.)http//www.mc.uky.e
du/tobaccopolicy/

• 2009 School Tobacco Policy Protocol
• Follow up sheet
• Letter to schools

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Preparing for the Interview

• Go to our website http//www.mc.uky.edu/tobaccopo
  licy/ and click on Data Collection Forms once
  you log in, you will select 2009 School Tobacco
  Policy
• Print your school list (see example, next slide)
• If more than one person will be conducting the
  interviews, please assign schools to avoid
  interviewing a school twice.
• Read the 2009 School Policy Protocol and print
  the Cheat Sheets to keep at your fingertips
• Print one Disposition Sheet for every school
  (needed for both online fax)
• Determine which method of data collection you
  will be using there are two methods for
  collecting data online (preferred method) and
  FAX

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School List
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Submitting Forms Online

• Select responses by clicking on the circles and
  checking the boxes.
• When a response is different than the available
  choices, click the other box AND type in the
  response in the space provided. Please do not use
  the OTHER box to provide comments about choices
  selected.
• Type any clarifications in the space provided at
  the end.
• The school ID, school name, county, county code,
  type of school, title of person being
  interviewed, your name, and start/end times are
  required before you can submit the survey.

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Submitting Forms Online (Cont.)

• Check over entire form before clicking submit
  to see that all responses are checked.
• Make sure the school ID matches the school
  name. The school ID s are 6 digits long and
  should be entered exactly as they appear on the
  school list. (The School Code consists of your
  3-digit county code and the school code.) Please
  include all zeroes when you enter the school code
  Ex 002, not 2.
• If you collect the information on a paper version
  of the form and then submit online, send the
  paper forms to UK in the mailer provided.
• If you submit online as you conduct the
  interview, youll only have disposition sheets to
  send to UK.

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Submitting Interviews Using the FAX Method

• Click on the Interview Guide pdf on the website.
• Type in the School Name and School Code on the
  first page of the Interview Guideone letter or
  number per box. The school code will duplicate on
  all pages!! You must type this information to
  eliminate transcription errors and pages without
  school codes.
• The School Code consists of your 3-digit county
  code and the school code Please include all
  zeroes when you enter the school code Ex 002,
  not 2.
• Once you have entered the school name and school
  code, print the form.
• Using an ink pen (preferably black ink), place a
  diagonal line / in the boxes to mark responses.
  PLEASE BE CAREFUL TO PLACE THE LINE WITHIN THE
  BOX. TELEFORM WILL NOT PICK UP MARKS PLACED TO
  THE SIDE. (See example next slide)

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Examples of Errors From Actual Surveys in 2007
The data audit revealed that 57 of the errors
occurred because boxes were not being checked
properly.
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Completing the PDF Forms

• When an alternative response is given, mark the
  other choice and print the response neatly in
  the space provided. Do not use the other space
  to elaborate on responses clarifications should
  be written in the box at the end of the survey.
  Do not write in the white spaces on the form
• Make sure the form ID code at the bottom
  right-hand corner is free of any marks. Teleform
  uses this number to read the form, so it must
  remain intact.
• Mark only ONE box per question unless it says,
  Mark all that apply.

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Completing the PDF Forms (cont.)

• If you make a mistakeplace a large X through
  the incorrect information, and write Error next
  to it. To make sure that the incorrect response
  is not counted, please email Kathy at
  kathy.begley_at_uky.edu when you fax the survey and
  include the School ID and Question .
• Pay attention to SKIP patterns.
• Write clarifications only in the Comments box
  on the last page of the form. (Comments noted
  anywhere else cannot be read electronically.)

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AFTER Each Interview

• Check interview form for completeness making sure
  that the responses are marked INSIDE the boxes.
• FAX forms to UK as you complete them
• (859-323-1033).
• It is better to fax forms one at a time rather
  than in a group.
• Contact Kathy(859-323-8539) or kathy.begley_at_uky.ed
  u if you are having difficulty FAXing the forms
  or have questions.

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When ALL Interviews are Complete

• When all interviews are completed, mail a copy of
  the Disposition sheets and any completed
  interview forms to UK in the mailer provided. If
  you interview while submitting online, just send
  disposition sheets to UK.
• Everyone sends Disposition Sheets!
• Keep a copy of the School List for future
  contactsindicate which schools are interested in
  more information.
• Do not keep copies of the interview forms send
  to UK.

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Follow-Up Contacts with Schools

• Gather materials requested (i.e. policy info,
  cessation resources, prevention curricula)
• Send information packets along with a thank you
  letter.
• Initiate follow up on areas needing improvement
• Involve coalition partners to advocate for policy
  improvement

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Use data for Policy Change

• Present data at school boards, site-based
  decision-making councils, PTAs, Local ASAP
  Boards, Prevention Centers.
• Use data as a media opportunity, if appropriate
• Specify targets for planning from baseline data
• Base all policy changes on Best Practices
• Recommend evidence-based prevention curricula and
  cessation activities

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How Can Effective School Policy be Adopted?

• Key Strategies Used in North Carolina
  (Summerlin-Long Goldstein, 2008 Goldstein,
  2003)
• Leadership from organizations and individuals
• Letters from Governor and successful districts
• Technical Assistance
• Forums on Leadership and Policy

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Key Strategies in North Carolina (cont.)

• Grassroots organizing
• Strong community coalition - multiple
  stakeholders influenced School Board
• Youth Groups key informants felt that hearing
  from trained students was effective
• Communication Strategies Key Messages
• Adult role modeling affects youth smoking
• Health effects of smoking and secondhand smoke
  (short-term long-term) were personalized (band
  members, kids with asthma)

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Key Strategies in North Carolina Key Messages

• Demonstration of Local Support
• Opinion polls provided political cover
• Students did surveys presented to Board,
  including
• Data from Principals re cost/benefits
• Data from parents at football games
• These messages addressed perceived barriers (i.e.
  that teachers would quit and visitors to athletic
  games would complain).

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Key Strategies in North Carolina Key Messages

• Success of policy in other districts
• Policy succeeded
• Fears unfounded
• Staff/concessions not lost
• Diminishing economic role of tobacco
• Jump on the bandwagon dont be last!

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What Do We Know About School-based Prevention
Programs (Thomas Perera, 2006 Cochrane review)

• There is little strong evidence that
  school-based programmes are effective in the
  long-term in preventing uptake of smoking.
• Little evidence that information alone is
  effective
• Some evidence for multimodal approach including
  community initiatives

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Prevention Programs (Thomas Perera, 2006
Cochrane review)

• Conflicting evidence about effects of social
  influence models
• Hutchinson (highest quality and longest trial)
  showed no sustained effect, yet some researchers
  criticize the study.
• Half of high quality studies showed shortterm
  effects on smoking behavior.
• Sussman (TNT) found effects into high school, as
  did Botvin (Life Skills Training)

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Prevention Program Recommendations (Thomas
Perera, 2006 Cochrane review)

• Cost should be considered
• Weigh costs of implementation as well as
  effectiveness.
• Complex school-based interventions may not be
  sustained because of unrealistic demands on the
  teacher time.

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Find Programs that Work

• National Registry of Evidence-based Programs and
  Practices (NREPP), a service of the Substance
  Abuse and Mental Health Services Administration
  (SAMHSA).
• NREPP is a searchable database of interventions
  for the prevention and treatment of mental and
  substance use disorders. SAMHSA has developed
  this resource to help people, agencies, and
  organizations implement programs and practices in
  their communities.
• http//nrepp.samhsa.gov/find.asp
• http//modelprograms.samhsa.gov/model.htm

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What Do We Know About Cessation? (KYTS, 2004)

• 69 of high school smokers in Kentucky think they
  could quit smoking if they wanted to.
• 60 tried quitting at least once in the past year
• Only 8 have ever participated in a program to
  help them quit.

44
School Policy Success Strong Policy Help

• Schools using education/counseling along with
  disciplinary measures for violations had lower
  smoking rates (Hamilton, 2003).
• Especially important in high schools, where
  strong enforcement loses its protective effect
  (Reitsma, 2004)
• Strictness of monitoring reduces smoking in
  middle school (Kumar, 2005)
• Recommendation Monitor policy carefully while
  maintaining a holistic environment which includes
  tobacco dependence treatment (cessation).

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Success of School Policy Cessation

• Most youth smokers with intentions to quit would
  not join a school-based program, but
  sub-populations were more likely to be interested
  if they were aware of the programs. (Leatherdale,
  2006)
• Recommendations (Horn, 2008)
• Make more youth aware of the program.
• Target youth most likely to use the program
  (early initiators, high daily smoking, made quit
  attempts)
• Recruit using face to face communication with
  facilitators and graduates of cessation programs
• Program should address confidence issues early

46
What Works in Cessation?(Grimshaw Stanton,
2006 Cochrane Review)

• There is not yet sufficient evidence to test the
  effectiveness of smoking cessation programmes for
  adolescents, although some approaches show
  promise.
• Barriers to implementation should be considered
  (researchers found many difficulties working with
  youth and organizations).

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What Works in Cessation?(Grimshaw Stanton,
2006 Cochrane Review)

• Use of the Transtheoretical Model (TTM) (Stages
  of Change) achieved moderate long-term success.
• Cognitive-Behavioral Therapy trials showed some
  effectiveness.
• Studies with Motivational Interviewing (MI) as a
  component also showed some effectiveness, but MI
  could not be isolated from other components of
  the intervention.

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What Works in Cessation? Possible Interventions
Tips

• Train school personnel to use the 5As to provide
  brief, tailored interventions (counselors, FRYSC
  personnel, social workers, coaches).
• Refer to stopping smoking
  (rather than quitting)
• Persons conducting the intervention should
  personally recruit teen smokers.
• Be explicit about no alcohol while stopping.

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School Policy Success

• Synergistic impact of policies, prevention and
  cessation programs may impact prevalence
  (Lovato, 2007 Kayaba, 2005)
• Recommendations
• Train engage youth to advocate for
  well-monitored smoke-free school policy
  (Summerlin-Long, 2008 Tencati, 2002)
• Advocate for
• evidence-based prevention and cessation programs
• strict enforcement of purchase laws and targeted
  enforcement of use and possession laws near
  schools
• smoke-free community policy (Siegel, 2008)

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Resources

• Guidelines for School Health Programs to Prevent
  Tobacco Use and Addiction by CDC
• http//www.cdc.gov/mmwr/preview/mmwrhtml/00026213.
  htm
• Fit, Healthy, and Ready to Learn A School Health
  Policy Guide (under revision) by National
  Association of State Boards of Education see
  also 101 Packet
• http//www.nsba.org/MainMenu/SchoolHealth/101Packe
  ts/TobaccoUsePrevention101.aspx
• How Schools can help Student Stay Tobacco-free by
  The Campaign for Tobacco-Free Kids
• http//www.tobaccofreekids.org/research/factsheets
  /pdf/0153.pdf

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For questions please contact

• Kathy Begley 859/323-8539
• kathy.begley_at_uky.edu
• Carol Riker 859/323-6615 riker_at_email.uky.edu
• Ellen Hahn 859/257-2358
• ejhahn00_at_email.uky.edu
• http//www.mc.uky.edu/tobaccopolicy