CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 14 • Number 3 • Fall 2001

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School Programs to Prevent Tobacco Use

Although tobacco use has long been the leading preventable cause of death in the United States, most young people start this deadly habit not fully understanding the addictiveness of tobacco or the seriousness of the health consequences. Elementary and secondary students account for one-fifth of the U.S. population, or 53 million Americans. According to Lloyd J. Kolbe, PhD, Director of CDC's Division of Adolescent and School Health (DASH), schools offer an excellent opportunity to reach this large population of young people with important health messages before they have adopted unhealthy behaviors. Well-designed, well-implemented school programs to prevent tobacco use and addiction have proven effective. The benefits of school programs to prevent tobacco use among young people include the following: 

• Help prevent long-term health problems and premature death: Cigarette smoking causes heart disease, stroke, chronic lung disease, and several different forms of cancer. If smoking rates remain the same, an estimated 5 million Americans younger than age 18 today will die prematurely of smoking-related illnesses. 
• Promote optimal health and decrease school days missed because of respiratory illnesses: Cigarette smoking increases coughs, shortness of breath, and respiratory illness; decreases physical fitness; and adversely affects blood cholesterol levels. 
• Dramatically decrease the likelihood that a young person will be a regular tobacco user as an adult: The younger people are when they start using tobacco, the more likely they are to become strongly addicted to nicotine. About 80% of all people who ever smoked daily first tried a cigarette before they were 18.

CDC currently funds 20 states for coordinated school health programs that include components to prevent tobacco use. More states are expected to be added in the future. In addition, CDC works closely with a variety of national nongovernmental organizations, including voluntary agencies and professional associations, to develop products and services that can help schools implement effective tobacco-use prevention programs.

 
CDC's Guidelines for School Health Programs to Prevent Tobacco Use and Addiction 
The CDC Guidelines for School Health Programs to Prevent Tobacco Use and Addiction, published in 1994, is the foundation for CDC's efforts to support tobacco prevention programs in schools. Developed by CDC staff in collaboration with experts from other federal agencies, state agencies, universities, voluntary organizations, and professional associations, the guidelines include specific recommendations to help states, districts, and schools adopt programs and policies that have been found to be most effective in preventing tobacco use among young people. According to Linda Crossett, RDH, CDC health scientist, the guidelines are intended to affect the whole school environment, not just the classroom program. "The aim is to develop a supportive environment that promotes a tobacco-free norm," she said. 

CDC, in collaboration with its partners, has developed and distributed several tools to help states use the guidelines. The tools include the following: 

• School Health Index—A self-assessment and planning tool designed to help schools identify the strengths and weaknesses of their physical activity, nutrition, and tobacco policies and programs and develop an action plan for improving student health. The index also provides an effective means for involving teachers, parents, students, and the community in improving school services. 

• Fit, Healthy, and Ready to Learn: A School Health Policy Guide—This policy guide, developed with CDC support by the National Association of State Boards of Education, features sample policy language on physical activity, nutrition, and tobacco-use prevention, as well as data to support the policies and practical suggestions for putting them into action. More information is available through the Web site of the National Association of State Boards of Education (www.NASBE.org*).

A Framework for Action 
Research has shown that effective school programs are not conducted in isolation; they are but one critical part of comprehensive tobacco control programs that include other components such as community programs to reduce tobacco use, enforcement of minors' access laws, cessation programs, and countermarketing campaigns. A Framework for Action: Helping Schools Prevent Tobacco Use and Addiction was developed by DASH and CDC's Office on Smoking and Health (OSH) in response to requests for assistance from state and local education and health agencies. Based on CDC's Guidelines for School Health Programs to Prevent Tobacco Use and Addiction, the document presents strategies and resources to help schools and communities jointly prevent tobacco use among young people. According to Ms. Crossett, the framework is not meant to be prescriptive. "Each state should determine its own priorities and resources to develop school policies and programs," she said. "However, the framework provides a starting point for ensuring that schools and communities are working together to prevent tobacco use among young people." 

To accomplish the strategies outlined in the framework, DASH and OSH project officers have conducted training sessions that brought together staff of health and education agencies from 30 states to plan tobacco prevention programs for schools. 

Programs That Work 
In response to requests from schools for examples of effective prevention programs, CDC developed the Programs That Work project. Programs That Work identifies and disseminates programs that have been shown to be effective in reducing health risk behaviors, including tobacco use, among young people. Programs That Work is also a means of providing educators with information and training on effective programs. 

Selecting Programs That Work 
To identify prevention programs that meet the criteria for Programs That Work, CDC staff review electronic databases, published literature, meta-analyses, and other reports. Two external panels of experts, one comprising evaluation experts and the other program experts, review the programs and the evaluation studies. If both panels recommend that a program be adopted, CDC designates the program as a Program That Works. Thus far, the review panels have chosen the following two middle school tobacco prevention curricula as Programs That Work: 

• Project Towards No Tobacco Use (Project TNT)— Targeted at seventh graders, Project TNT teaches students about the course of tobacco addiction and disease, the consequences of using tobacco, and the prevalence of tobacco use among their peers. The curriculum also focuses on helping young people develop effective coping skills, build self-esteem, understand how the media and advertisers influence teens to use tobacco products, and learn strategies for advocating no tobacco use. Students who participated in Project TNT were 25%–30% less likely to start using tobacco than students in the control group. In addition, Project TNT participants who already used tobacco reduced cigarette smoking by approximately 60% and eliminated smokeless tobacco use. 

• Life Skills Training—Designed for students in grades 6 through 9, Life Skills Training helps students identify myths and misconceptions about tobacco, alcohol, and marijuana use; understand the physiological effects of smoking; and evaluate advertising techniques designed to manipulate consumer behavior. Because it is built on the theory that social influences to smoke, drink, or use drugs interact with individual vulnerability, this program also focuses on helping students cope with anxiety, communicate more effectively, improve their self-esteem, and develop successful relationships. Students who completed at least 60% of the 3-year Life Skills Training program were much less likely than other students to use tobacco, alcohol, and marijuana. 

Disseminating Programs That Work 
To assist in establishing these programs at the local level, CDC works with the developers to prepare the programs for dissemination and provides technical assistance to state and local education and health agencies who choose to use the programs. Included in this technical assistance are national workshops to train those who will train teachers. More information about Programs That Work is available on the DASH Web site (www.cdc.gov/nccdphp/dash).

 
Surveillance Is Key 
CDC's DASH monitors school pro-grams that prevent tobacco use through two surveillance systems: the School Health Policies and Programs Study (SHPPS) and the School Health Education Profiles. 

SHPPS is a national survey periodically conducted to assess school health policies and programs—including those addressing tobacco use—at the state, district, school, and classroom levels. The largest and most comprehensive assessment of school health programs ever undertaken, SHPPS was originally conducted in 1994. It was most recently conducted last year. Between 1994 and 2000, the percentage of school districts requiring schools to teach tobacco-use prevention rose from 83% to 92%. During the same period, the percentage of schools nationwide with a tobacco-free environment rose from 36% to 64%. A tobacco-free environment prohibits all forms of tobacco use by students, school staff, and school visitors on school property, in school vehicles, and at school-sponsored functions away from school property. 

The School Health Education Profiles are school-based surveys conducted biennially by state and local education and health agencies in representative samples of middle/junior and senior high schools. School principals and lead health education teachers complete self-administered questionnaires that assess health education policies and programs.

Prevention Evaluation Research Registry for Youth (PERRY)
Research synthesis activities in DASH include the establishment of PERRY, a database that contains a comprehensive set of citations and abstracts of intervention research for each of six adolescent risk behaviors: tobacco use, physical inactivity, poor nutrition, risky sexual behavior, violence and unintentional injury, and alcohol and other drug use. It includes both prevention evaluation research and nonevaluation background studies identified and abstracted from published and fugitive literature sources. In the near future, studies will be searchable via the Internet, providing a service to research and program planners worldwide. 

School programs to prevent tobacco use provide education during the years when the risk of becoming addicted to tobacco is greatest. Through these programs, schools can provide a tobacco-free environment that establishes being tobacco-free as the norm and offers opportunities for positive role modeling. For more information, visit www.cdc.gov/nccdphp/dash.

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