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 Provost’s Distinguished Service Professor

2. Youth Tobacco Statistics, 2003 (KY) CDC Data Highlights 2006 http://www.cdc.gov

3. Costs of Not Intervening • Kentucky’s 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). • Kentucky’s 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)

6. 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 Lexington’s 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

8. 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

9. 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

10. 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.

11. 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

12. 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!

13. 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

14. 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

15. 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

16. 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

17. Conduct the Phone Interview • Get complete information…ask clarifying questions if needed • Don’t offer the “I don’t 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

18. 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”

19. 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

20. 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!

21. Located On the Websitehttp://www.mc.uky.edu/tobaccopolicy/ • 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

22. Located On the Website (cont.)http://www.mc.uky.edu/tobaccopolicy/ • 2009 School Tobacco Policy Protocol • Follow up sheet • Letter to schools

23. Preparing for the Interview Go to our website: http://www.mc.uky.edu/tobaccopolicy/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

24. School List

25. 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.

26. 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, you’ll only have disposition sheets to send to UK.

27. 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 Guide—one 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)

28. 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.

29. 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.”

30. Completing the PDF Forms (cont.) • If you make a mistake—place 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@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.)

31. 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@uky.edu if you are having difficulty FAXing the forms or have questions.

32. 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 contacts…indicate which schools are interested in more information. • Do not keep copies of the interview forms; send to UK.

33. 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

34. 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

35. 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

36. 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)

37. 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).

38. 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; don’t be last!

39. 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

40. 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 short–term effects on smoking behavior. • Sussman (TNT) found effects into high school, as did Botvin (Life Skills Training)

41. 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.

42. 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

43. 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).

45. 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).

47. 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.

48. 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.”

49. 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)

50. 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/101Packets/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