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Chapter 12 Promoting Communitywide Tobacco Control Activities by Involving Schools Deborah Bowen, Lesa T. Dalton, Rosemary Walker, Susan Crystal, and Mario A. Orlandi INTRODUCTION Tobacco use among youth is a critical public health problem. National surveys from high school classes from 1975 to 1990 indicate that smoking rates among adolescents had not declined in comparison with adult smoking rates (Johnston et al., 1991). Recently, rates of lifetime use, use in the past 30 days, and half-pack daily use have not declined from 1991 and 1992 to 1993 among 8th, 10th, and 12th graders (National Institute on Drug Abuse, 1994). Trends in smoking prevalence among high school seniors of both sexes are presented in Figure 1. These data indicate clearly that cigarette use rates among adolescents have changed little over the past decade and also suggest that smoking could be on the increase among those in this age group. Similar findings have been reported by others, including reports in a series of nationally representative estimates of smoking among U.S. youth ages 12 to 18 conducted by the U.S. Public Health Service since 1968 (U.S. Department of Health and Human Services, 1994). The trend for teens is directly opposite that for adults, whose smoking rates have declined steadily among both men and women since the mid-1970’s (Shopland, 1995). The data presented in Figure 1 represent an older, in-school population and do not include those youth who dropped out of school before their senior high school year and who have higher smoking rates than those who stay in school. Thus, the magnitude of the youth smoking problem is likely to be higher than the figures for high school students suggest. The lack of progress in reducing youth tobacco use on a national level has led researchers and community health experts to search for opportunities to influence youth smoking behavior. The Community Intervention Trial for Smoking Cessation (COMMIT) has provided several of these opportunities. This chapter describes COMMIT intervention activities to reduce youth tobacco use that were connected with schools. It describes the rationale for including youth and schools in COMMIT and the intervention and evaluation strategies related to schools. It also includes the field experiences in implementing the school-based youth tobacco use interventions and discusses some of the lessons learned about working with schools in the hope that the knowledge of those experiences might help others working with school-based public health tobacco programs. Rationale for As discussed in Chapter 2, the main goal of COMMIT is cessation Including Youth among adults who are heavy smokers, with the primary in COMMIT intervention targets being adult smokers who smoke more than 25 cigarettes per day. The initial reaction of investigators to including youth as a focus within COMMIT was that it was inappropriate. Youth are not likely to be found in the target group (i.e., heavy smokers) of COMMIT. Many members of the steering committee thought that including a focus on youth would detract from the focus on adults and on heavy smokers. Some further thought that all available resources should be spent on heavy smokers and that there were not enough funds for targeting youth. Over time, the scientific groups realized that COMMIT would enhanced the likelihood of change in the communities by including youth, so a youth intervention and evaluation component was added.  The decision to broaden the intervention and evaluation targets to include youth was based on several arguments. First, it was hoped that youth could serve as a conduit to reach heavy smokers. Anecdotal evidence from school-based smoking prevention programs indicates that many parents are pressured to quit by their children. There is a consistently positive relationship between parent and youth smoking, indicating that influencing youth smokers may help reach adult smokers. It was hoped that targeting youth would prove an additional source of both pressure on and encouragement for heavy smokers to quit. Second, and equally important, it was hoped that communitywide intervention targeting adults, especially heavy smokers, would increase awareness of smoking as a public health problem among young people and those who deal with them in their daily activities. Such awareness could reduce youth smoking as well. If adults are actively involved in trying to quit smoking, they might present smoking in a negative light to their children and other youth. This could result in fewer adolescents starting to smoke. In a larger perspective, youth as well as adults should be aware of several components of the COMMIT intervention, including communitywide media intervention, advertising bans, and interventions in public places. These communitywide interventions theoretically should change community norms about smoking and make it more difficult for youth to begin using tobacco. Rationale for Recommending School-Based Interventions Schools are an excellent channel for reaching youth and have received much research attention. There is an extensive body of knowledge about the most efficacious school-based smoking prevention curriculum to implement at the junior high school level in COMMIT (Flay et al., 1983). School-based curriculum programs have been evaluated in previous vigorous research programs and are widely available. There is evidence that these programs have consistent short-term effects (Best et al., 1988) and therefore should form part of a comprehensive communitywide effort to reduce smoking. Many schools across the country have mandates to include or mention smoking as part of general health education or drug abuse prevention, although this varies by region and locale. However, few schools provide focused attention and curriculum time to tobacco control without guidance and support from experts, and it is in this expert role that COMMIT staff members could collaborate with schools to implement appropriate curricula. School policy regarding tobacco, and subsequent policy enforcement, is another area of school-based intervention, with support for efficacy in preventing onset. Policy alters health behavior when the policy is clearly and simply stated, when it is fairly and consistently enforced, and when the means for following it are available to all whom it affects (Sabatier and Mazmanian, 1979). Most COMMIT schools had a policy limiting smoking in some fashion (Bowen et al., in press). Many schools had a smoking area or allowed smoking outside the school building. However, few schools disseminated the policy clearly, enforced it consistently, or provided full resources for students to follow it. The limited data on the effects of policy on smoking rates indicate that school policy, when clearly stated and enforced in a positive manner rather than a punitive one, is related to lower levels of youth smoking (Penz et al., 1989). Youth are essentially a captive audience at school for several hours per day. To affect youth smoking it is essential that the school be used as a channel for providing clear, strong messages against smoking and other tobacco use. Policies involving no smoking on school grounds or at school events could be one strong message, provided it is enforced and supported. Other ways to provide messages at school include the policies that govern teachers’ smoking behavior. Community activities that involve youth in the planning or the activities are appropriate for increasing the visibility of smoking as a social problem. COMMIT interventions attempted to include all these strategies in their arsenal. INTERVENTION ACTIVITIES AND PROCESS OBJECTIVES FOR SCHOOLS The goals for this channel were to (1) increase the percentage of public schools that are tobacco-free, (2) increase the percentage of heavy smokers in the community who perceive social pressure from their children to quit smoking, and (3) decrease the prevalence of smoking among youth. To achieve those objectives, several mandated activities (see Table 1) were developed. The interventions were based on the previously cited literature on school-based intervention where available (e.g., Glynn, 1989 [see below]). Where other information was not available, interventions were based on examples of tobacco-related youth activities that, in the experience of the intervention teams, had been successful in involving youth. The major strategies are described below. Curriculum Initiatives Each site was given several resources to encourage schools to initiate tobacco use prevention curricula in schools or to improve on existing efforts. These included an article by Thomas Glynn, then program director for smoking research at the National Cancer Institute, called “Essential Elements of School-Based Smoking Prevention Programs” (Glynn, 1989), which discussed strategies within existing programs that seem most critical for successful smoking prevention packages, including prices, descriptions, and ordering information. The field staff members at each site were encouraged to use these and other available materials. School Policy Policy changes of all types were a major focus of COMMIT, in keeping with the community and public health nature of the intervention focus. Influencing school policies on smoking was thought to be different from influencing State or community law about smoking because of the process by which organizations such as schools make decisions about their internal rules and functioning. However, some COMMIT communities sought to make changes in school policy at the State level (e.g., Oregon). Although knowing that clear, enforced school smoking policies could prevent tobacco use, COMMIT staff members used care in coming from outside the school system to alter policy. To promote policies, many communities used a manual created by the National School Board Association on creating and implementing school policies. This well-written manual includes a description of types of nonsmoking policies, methods of deciding on and implementing the policies, examples of policies that have been implemented and all the supporting legal and other documents used in the implementation process, and a list of school districts nationally that were willing to provide technical assistance. Again, COMMIT field staff members were encouraged to use these documents to assist schools in forming strong, restrictive tobacco use policies.  School-Based Activities That Targe Youth Other activities involving schools were not clearly defined in a protocol and were left up to the field staff and schools to negotiate. These included using schools to publicize community events involving youth and recruiting youth from schools to help with covert tobacco-buying adventures (see Chapter 13). The accessibility of youth through schools enabled many community-based activities to involve youth more fully. School Activities That Target Adults Youth were used as a conduit to reach the adults in their lives, both passively and actively. The school student is a conduit for information to smokers or potential smokers at home. Young people can be organized into groups to seek out and recruit adults into antismoking activities. These adults can be relatives, other community members, or even members of the press, who can send a powerful message about smoking’s harm. COMMIT interventionists were encouraged to consider using youth to “hook” adults whenever they could. IMPLEMENTING SCHOOL-BASED INTERVENTIONS In many of the 11 COMMIT intervention sites, community Boards included representation from the education sector, such as district personnel (e.g., superintendents, assistant superintendents), health educators specializing in drug abuse prevention, teachers, and Community parent-teacher association (PTA) members. Although sites with Board school gatekeepers (i.e., those who could “open doors” to Membership individuals) on their Boards expected to have fairly easy access to the school system, that was not necessarily the case. Some sites were hampered by uncooperative key contacts whose individual personalities or smoking status created difficulties in working with the schools. At sites with school decisionmakers in a COMMIT leadership role, there was occasional conflict between the task force and the Board over youth or school activities, thus reducing some of the task force’s autonomy. In one site this occurred so frequently that the uncooperative COMMIT member was bypassed whenever possible by directly approaching the targeted schools or teachers to plan activities. Boards were generally enthusiastic about youth activities and, in particular, activities with an educational focus. However, there was criticism from Boards about the protocol’s minimal focus on youth tobacco use prevention education. Project staff members often struggled to explain the reasoning behind the protocol’s relatively minimal focus on youth activities and to involve schools in cessation activities. Activities like the American Heart Association’s (AHA) Save a Sweet Heart (SASH) campaign were embellished to increase their educational focus; for example, in some sites teachers were given educational materials for classroom use. Task Force Youth and school activities fell under the jurisdiction of the public education task force; however, a few sites divided the public education task force into a media task force and a youth task force, thereby creating five task forces to carry out COMMIT activities in those communitites. Many communities formed formal subcommittees within the public education task force to carry out youth- or school-based activities and planned activities under their general task force agendas; other sites established ad hoc subcommittees. Many sites had some school personnel representation on task forces or subcommittees, although these individuals were not necessarily decisionmakers. Even individuals holding high-level positions within the school system often acted more as liaisons to COMMIT than as representatives of the schools. In sites where there was no school representation on the task force, planning for activities that were either promoted or conducted through the schools was complicated; task forces had to negotiate several tiers of decisionmakers to obtain approval for implementation. Some sites established separate task forces comprising youth. These task forces then took on the responsibility of ensuring that mandated and other activities within schools were implemented. Volunteers Teachers, guidance and peer assistance counselors, school nurses, PTA members, students, and others played key roles in implementing school-based youth activities. Volunteerism was essential for implementing policy initiatives, “magnet events,” and promotional activities within the schools. Without the dedication and enthusiasm of these volunteers, task forces would have had little support for implementing or promoting activities for youth within the complex structure of most sites’ school systems. Volunteers from the schools were also essential when youth attempted to recruit adults into programs, as was done in New York in Yonkers’ second “Quit and Win” contest and other campaigns. In addition, volunteers played a key role in promoting school-based youth activities. For instance, in Brantford, Ontario, Canada, teachers were supportive of a poster campaign based on the themes “How to get your friends to quit smoking.” They incorporated the campaign into a classroom activity and made nominations for a poster contest. Many students in grades 1 through 8 entered the contest, and the 18 winners of free tickets to the Toronto Blue Jays baseball game on “World No Tobacco Day” arrived in chauffeured limousines. In Yonkers, teachers were instrumental in the implementation of two annual “No Proof, No Puffs” campaigns within the schools. These campaigns focused on activities to encourage stores to ask for age identification before selling tobacco products to adolescents. Teachers who are also COMMIT volunteers worked with staff and students to incorporate smoking prevention and cessation education into classroom activities. The first year, after writing to local area merchants, students went with their teachers from store to store to deliver their letters and other information regarding legislation on youth access to tobacco. The second year, teachers helped students write letters to merchants about youth access and to magazine publishers asking them to stop accepting tobacco advertisements. There were other classroom activities on the issues of smoking, and teachers developed a “Smoke-Free for a Week Partnership” campaign in which students encouraged the adults of their choice to quit smoking for a week. In all these examples, volunteer support provided the mechanism for educating youth and helped to foster good will for tobacco control efforts throughout the community because of the publicity these activities received. Other types of volunteer support included stuffing envelopes, staffing booths, distributing survival kits, disseminating materials, and promoting activities. Sometimes gatekeepers provided access for volunteer support by appointing staff members within the schools to assist with a given activity or by identifying personnel interested in smoking control activities. Gatekeepers also helped COMMIT by directing staff or task forces through appropriate channels for implementing smoking control activities within the schools. At other times, staff members and task forces enlisted volunteers through personal and professional contacts. PATTERNS OF SCHOOL-BASED INTERVENTIONS The types of activities implemented by COMMIT interventionists that focus on schools are summarized in Table 2. This list of activities was obtained from quarterly reports submitted by each study center (Corbett et al., 1990-91). This table does not represent Intervention all activities for each community but only the most salient for the Activities data collection staff. The four categories (activities For Youth, To Influence Youth, Involving Youth, and Through Youth) represent the four common methods of targeting youth, each with different purposes, potential efficacy, and commitment of staff and other resources.  The first category of activities, For Youth, included those types of activities that were relatively easy to do and included information provided to students in the context of an existing meeting, class, or structure. Many schools produced displays about smoking and quitting. Curricula were offered as part of health or physical education classes. Although COMMIT sites were mandated to provide state-of-the-art educational materials to schools, there was little opportunity for task forces and staff members to work one on one with educators to expand this activity beyond the mandated material dissemination process. Most sites were able merely to supply their school district with curriculum materials. However, some States like Iowa and Massachusetts held teacher training workshops, or as in Brantford, staff members were given the opportunity to schedule a workshop. Many times these curricula were integrated with a drug abuse prevention program, such as Drug Awareness Resistance Education (DARE) or SASH. For example, in Yonkers field staff members worked with the AHA and the Yonkers Pulse Healthy Heart Project to disseminate educational packets promoting SASH to more than 12,000 students’ homes. The packets contained interactive materials for parents to use in talking about smoking with their children, AHA SASH pledge cards to quit smoking for a specified time, activity sheets, and COMMIT smoker registration cards in English or Spanish. Students were asked to encourage their smoking parents to return the registration cards by mail. In addition, part of the intervention was to have parents and students work on the activities together at home, and students were expected to bring completed sheets back to school for class discussion. Unfortunately, few smoker registration cards were returned through the mail, and few activity sheets were returned through the schools. However, COMMIT staff members were able to work onsite with SASH youth volunteers and student assistance counselors at information booths in the schools on SASH days. Staff members performed expired carbon monoxide testing on adult smokers; distributed self-help brochures, cessation guides, and survival kits; and registered some faculty and school personnel in the Smokers’ Network. As a result of these efforts, the issue of smoking is permanently integrated into a community organization in the form of sessions, movies, and ongoing discussions. Events that occurred during or after school hours, such as assemblies and club meetings, were used as vehicles for getting word about smoking to youth. Speakers at classes and gatherings were included to emphasize a motivating aspect of quitting smoking. Social activities, such as adopt-a-younger-student days and career days, were used to include an antismoking message. Special antismoking activities, such as puppet shows, rallies, and theater presentations, were used to increase awareness about smoking in an enjoyable and entertaining manner. The second category of activities, To Influence Youth, was conducted on the social and environmental structures that can promote or reduce smoking in the youth environment. Contact with teachers was used as a consistent way to indirectly influence youth. Teachers attended special COMMIT-led training sessions as an in-service requirement and received advice from COMMIT staff on the choice of curricula and other teaching devices. Other school personnel and youth-oriented staff members were exposed to COMMIT messages via staff discussion, training, and encouragement. Counselors at schools received special training in helping students quit smoking. PTAs and school boards received presentations and encouragement from COMMIT staff. Officials from schools were encouraged to take a public stand on the problem of tobacco use. Coaches at schools and in the community were urged to treat tobacco use as a health problem. Several local restrictions on access, including sales to minors, were organized first through schools and school personnel. Enforcement of existing school policies with positive supportive approaches and penalties was encouraged. These broadbrush intervention strategies probably helped to reach students who would not have been reached by the more traditional curriculum-based interventions. The third category of activities, Involving Youth, involved youth as players in the planning or execution of the activity. Several different types of art projects and drama projects were developed, written, staged, or played by youth as part of class or school projects. Contests were held to get the messages of COMMIT out to youth, including contests in art, kite making, floats, athletics, essays, rap music, and photographs. In addition, youth in several communities attempted to counter the tobacco companies by creating counteradvertising. These activities often were sponsored by COMMIT staff, but young people were asked to plan and create the activities and often became involved in the final products. Finally, for the fourth category of activities, Through Youth, young people served as a conduit to other youth groups and to adult heavy smokers. Individual COMMIT sites used this option in different ways. For example, some sites distributed cessation flyers and materials for youth to take home to give to family and community members. Some sites organized youth to speak to other young people, often to groups of younger or disadvantaged youth. Some sites had youth recruit and enroll adult smokers in the COMMIT Smokers’ Network. Students wrote to local officials, tobacco companies, and their school personnel. Most sites found youth willing to participate actively in helping others to stop smoking. Successes and Failures Across Communities In general, communities wanted to do more in prevention than the protocol provided for; in fact, in many communities task force members were more interested in prevention than cessation and had difficulty understanding why the project did not have a stronger prevention focus. Communities thought that youth are important as a channel to reach adult smokers. Youth also provided a channel to the media when they were involved in newsworthy activities. Most sites found schools to be fairly difficult to work with compared with other groups in the community. Field directors believed that a comprehensive approach was needed to involve schools, which COMMIT did not have a clear mission to provide. The amount of effort for COMMIT staff members to get schools involved varied from site to site, ranging from one site reporting that it took little effort to three sites reporting that it took a great deal of effort. The tendency of schools to leave tasks to the COMMIT staff was not as great as that of some other groups, but this also varied greatly from site to site. The extent to which schools used COMMIT information was high, with nearly half the sites reporting they used it a lot. Schools collaborated willingly with COMMIT at most sites. Often, they showed some ownership of COMMIT activities or the project as a whole. Several sites found that schools showed innovation in implementing or institutionalizing COMMIT activities. There was considerable variation in the extent to which schools showed leadership or creativity in designing activities. There was also considerable variation in the provision of resources; several sites reported that schools provided many resources and in-kind donations, especially for poster contests and flyers, whereas other sites reported that few resources were provided. Two communities had smokers on the school board who opposed smoke-free school policies. In one community, this barrier was not overcome. In the other, a COMMIT letter to the editor in a local newspaper initiated a public dialog that resulted in the policy’s being implemented successfully. When no-smoking policies were implemented, schools in some communities became more amenable to COMMIT activities. For instance, in Brantford the school board enlisted COMMIT’s assistance in handling the logistics of implementing its new smoke-free buildings policy. Oregon held a successful school and law enforcement summit following the passage of an antismoking ordinance. Some communities felt constrained in their approach to schools, either because there were limited entry points to schools—they required a formal approach through appropriate administrative channels—or because other groups already were involved in selecting and providing school smoking curricula. An Example of a Successful Your Activity Brantford held a poster contest with the theme “How to get your friends to quit smoking” in early 1991. There were 18 prizes— tickets to a Toronto Blue Jays baseball game on World No Tobacco Day—with the winners to be driven to the game by limousine. Two prizes were allocated for each grade (1 through 8), and two prizes were to be allocated by a random draw from early entrants. On the advice of a task force member, prizes were awarded randomly as opposed to through a judging process. Task force members obtained the necessary school board approval, with the assistance of two COMMIT Board members (an elementary school principal and a superintendent) who were familiar with the system. A letter was sent to each school principal, and if the principal agreed to participate, classroom packages were sent to each teacher in the school through the board’s mail system. Each child was given a flyer and an entry form to take home, both describing the contest and containing educational information on smoking. A parent’s signature was required to allow the poster to be displayed publicly and to indicate that the child was permitted to accept the prize if he or she won. Several classroom teachers supported the contest enthusiastically, and there were several instances where a whole class submitted an entry as well as the anticipated individual entries. In addition to creating a focus on smoking cessation in the schools, the contest also provided some publicity opportunities. There was press coverage of the winners heading to the baseball game, and a selection of the posters was subsequently displayed in the community at the public library and at a health fair mall display. Youth Activities With Some School Involvement Across Ontario in winter 1992, a petition for a smoke-free planet was circulating and collecting names, with the objective of being able to measure the length of the petition in miles. (and Mixed Success) The activity was sponsored by the Council for a Tobacco-Free in Brantford, Ontario (CTFO), which at that time functioned primarily Ontario, Canada as a coalition of the various agencies involved in smoking reduction and focused on events for National Non-Smoking Week and, to a lesser extent, World No Tobacco Day. COMMIT was one of the partner organizations in the CTFO. The petition was launched during National Non-Smoking Week and was to be presented to a government official in a ceremony to take place in Brantford on World No Tobacco Day. In almost all involved communities, the petition was circulated through the schools. Brantford public health nurses, who had contact with the schools, led the effort. However, a resident from the nearby tobacco-growing area objected to the antitobacco information that accompanied the petition, and as a result, the Brant County Board of Education recommended that each principal decide whether to allow the petition to circulate in his or her school. Some allowed it, and some did not. The final petition was two and a half times as long the Canadian National tower (the world’s tallest freestanding building) in Toronto. In another example, the worksite task force held a video contest. The theme was smoking cessation, and one objective was to obtain some short videos that could be used in conjunction with presentations. One place targeted for contest entries was the schools. Getting appropriate administrative approvals proceeded smoothly, but because of either an administrative problem or lack of interest, the contest registration and information materials did not get distributed in the schools for several weeks. When COMMIT staff members noticed this, they succeeded in arranging distribution, and there were several excellent entries from students. Audiovisual staff and teachers at the schools were supportive of the students who prepared entries. Examples of Some Successful School Policy Initiatives COMMIT sites achieved success in promoting changes in school smoking policies. For instance, in Cedar Rapids/Marion, IA, the public education task force formed a smoke-free schools subcommittee in September 1989 to change the school district’s smoking policy. Although the standing policy prohibited youth from smoking on school grounds, it allowed teachers and employees to smoke in designated areas. The proposed change was complete ban in all district buildings and vehicles, but no restriction on smoking outside the buildings. The smoke-free schools subcommittee wrote letters and disseminated policy information to the PTA presidents and school board members. They also obtained 300 signatures from individuals supporting smoke-free schools and presented their proposal to the school board. In response to the proposal, the school board scheduled two public hearings. At the first hearing, which was not well attended, there was no opposition to the proposal. The only two people to address the school board were members of the subcommittee. The second hearing received greater publicity and attracted more than 20 individuals. Opposition to the proposed policy changes was evident from the statements of several teachers and other school employees. A counterpetition with 281 signatures opposing the change was submitted to the school board. Despite opposition, almost 6 months after the initial presentation to the school board, the smoke-free schools proposal was approved on a 4-to-2 vote. The new policy was instituted at the beginning of the next calendar year, and cessation classes were offered to help smokers quit. Another successful school policy initiative occurred in Yonkers. In response to the New York State Clean Indoor Air Act, the Yonkers school district decided to institute a restrictive smoking policy. After the school board approved the policy, administrators worked with legal counsel to develop a written policy and distributed a lay version to all employees. Friendly reminders were disseminated to all district personnel over the 3-month planning phase informing them of the number of days until the implementation of the new policy. Concern over employee welfare prompted the formation of a wellness committee that COMMIT joined. Although the district wanted to set an example for students and the community, it also hoped to minimize tensions among school district employees. COMMIT worked with district personnel and the Yonkers Pulse Healthy Heart Program to provide materials for the district’s approximately 950 smokers at the initiation of the new policy. Heart-healthy snacks, bottled water, and cessation referral information as well as self-help materials were given to each of the 37 schools to help support smokers during the first week of the policy’s implementation. Volunteers were recruited to prepare materials, and school nurses assisted by staffing tables and counseling smokers. These supportive efforts helped to minimize employee hostility over the new policy and maintained a feeling of good will between the district and its employees. It also helped to promote smoking as a public health issue and educated nonsmokers about the difficulties smokers face in quitting. Using Youth and Schools as a Channel Although some youth channel activities were conducted within school systems, others were only promoted there. The Yonkers second annual quit-smoking campaign, called “A Thousand Good Reasons,” used youth as a draw or hook to motivate adults to quit. The event matched an adult smoker with “an adopted child” in a 6-week campaign resulting in a grand prize of a $1,000 savings bond for the youth’s education and a $250 supermarket gift certificate for the adult smoker. This effort sought to entice community participation by children, ages 5 to 18, encouraging adult smokers to quit. Promotion of this event occurred throughout the community in a variety of sectors, including the public schools. COMMIT was able to enlist the support of the school district through the district’s public relations director, principals, and teachers. The public relations director contacted all elementary school principals, requesting their support in the dissemination of information promoting the contest. Through the schools, COMMIT was able to reach the parents of 12,000 students by having the students distribute flyers. In addition, through the district’s central office, registration forms were sent to 1,360 teachers, administrators, and maintenance personnel. Posters were hung in each school, and the assistant superintendent was interviewed on the local cable television station to promote the campaign. One teacher who registered allowed her quitting progress to be followed throughout the 6-week period by the community’s major daily newspaper and the cable station. Yonkers’ COMMIT field staff members also helped to organize two annual “No Proof, No Puffs” campaigns. The first-year elementary students went to local merchants to distribute information regarding the New York State law prohibiting the sale of tobacco products to minors, statistics on youth smoking, and display signs promoting the law. COMMIT staff members arranged for publicity, helped prepare materials, and provided a luncheon for students and teachers. Teachers enhanced this activity by planning a week’s worth of lessons on smoking issues and helped students develop a song about preventing youth smoking that was performed for the entire school. Likewise, field interventionists played a significant part in the implementation of the second annual No Proof, No Puffs campaign. Field staff members worked with teachers to develop and plan activities as well as to coordinate the intervention. Staff members provided resource materials, collated “survival kits” for the Smoke-Free Partnership participants, gave T-shirts to student participants, arranged publicity, and even served pizza to students, teachers, and parents at the culminating celebration. In the above examples, the schools were an effective vehicle for promoting smoking control activities. However, there were other instances throughout the trial where local districts hampered COMMIT’s efforts to promote change, ignoring the fact that adults are critical role models for children. For example, in Vallejo, CA, the local school board sought to obtain a $700,000 grant for the school district from RJR Nabisco Foundation. A vocal group of COMMIT volunteers organized to block the school board’s efforts to obtain the grant because of the “tainted” funding source. The COMMIT volunteers chose to frame the issue as a problem of insufficient school funding and an increase in the tobacco companies’ handouts for youth projects, rather than reflect negatively on the school board’s actions. The volunteers met, formulated plans, and presented resolutions to the school board and other community groups. Fortunately, the school district was not awarded the grant, although its attempts forced COMMIT volunteers into action to enlighten the school board about the hypocrisy of accepting money from the tobacco industry. Another example of a school district hampering COMMIT efforts occured in Brantford, as discussed above. The Council for a Tobacco-Free Ontario sponsored a petition for a smoke-free planet to coincide with World No Tobacco Day and National Non-Smoking Week; its goal was to measure petition length in miles. Almost all Ontario communities circulated the petition through the schools, but the Brantford school district would not permit the petition to be circulated even though the community was one of COMMIT’s intervention sites. In other cases, individuals presented barriers to change. For example, although administrators in Utica, NY, were supportive of implementing a smoke-free school district, they were not ready to fight the school board and local unions, which had smoking members. This resistance became even more frustrating to COMMIT when another school district outside the intervention community asked for help in initiating a smoke-free policy. LESSONS LEARNED Several lessons were learned from implementing COMMIT FROM COMMIT school-related activities, although these lessons were not SCHOOL-BASED completely understood until the end of the intervention ACTIVITIES project. For example, distributing materials to schools is relatively easy, but getting schools to use the materials and institute projects is more difficult. Often, materials would sit forgotten on a shelf until a COMMIT volunteer found them and reminded someone to use them. School personnel have many issues and activities to deal with, and a smoking prevention curriculum was sometimes not high enough on the list of priorities to move forward. Most COMMIT sites would have liked more direct input into planning school-based intervention activities, but the role of COMMIT field staff members was often restricted by the school administration. Field staff members found the dissemination process for curriculum and school policy information frustrating because they were allowed only minimal contact with individual school decisionmakers and had little information about how (if at all) COMMIT materials were used in most cases. Another difficulty was a difference in the definition of the role of the school in children’s lives. Some school administrators and teachers (and parents) saw themselves as the purveyors of knowledge and not as the conveyance for the solutions to social problems. Smoking, by COMMIT’s definition a social problem, sometimes did not fit under what was perceived as the school’s mandate. The COMMIT interventionists thought that they needed more time to work with school personnel to help them see themselves as health promotion agents and as well as educators. This translated into a need for more followup on delivery of curriculum and policy recommen-dations regarding smoking. Some COMMIT interventionists found that encouraging the enforcement and implementation of school policy is more difficult than setting policy. Enforcement of policy often requires resources and constant monitoring, sometimes beyond the strained limits of schools today. At times the enforcement of policies limiting smoking in schools put teachers and staff in awkward positions (i.e., the role of the cop or “bad guy” rather than the students’ friend). The issue of enforcing smoking or tobacco policy when other seemingly more important policies go unenforced is a difficult choice for officials who are overworked and whose schools are understaffed. The COMMIT teams believed that there was much more to be done to enforce current policies in schools. Most COMMIT field staff members found that youth could function well within the structure of COMMIT. The caution for the field staff was not to underestimate the effectiveness of teenagers, because they can be incredibly competent. In many sites, youth identified activities, planned the strategies, and participated fully in community organizing. Youth need “hands-on” projects with lots of activities for them to do. Youth of all ages participated in COMMIT, from elementary school children to college artists who designed some of the projects, logos, and other materials. Involving youth in as many activities as possible was encouraged and can be increased in an intervention like COMMIT. Youth smoking is a highly visible issue in a community and draws attention from many groups and constituencies. Prevention is a high-profile media issue. Print and broadcast media writers and photographers will use information from youth in addition to expert or community testimony. Schools can help community organizers by providing good access to media for students. Youth can be coached to respond well to the limelight and can testify before local and State governing bodies with effectiveness. Young antismoking advocates can be effective for prevention and cessation. Adults can be pressured by their children or by any children to quit smoking, and older children can influence younger children not to start smoking. In addition, prevention is a more compelling concept for volunteers than cessation. Many people want to help keep children from smoking, whereas some feel uncomfortable pushing adults to quit. Community Boards felt that organizing a community for prevention could help to encourage adults to quit as a side benefit. In some cases, community interest in youth antismoking efforts threatened to overshadow adult cessation activities. It took a great deal of planning and encouragement for interventionists to redirect the focus and energy on youth smoking to a broader one of tobacco control in the community. REFERENCES
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