1. BACKGROUND
   1. General:

      Historically, tobacco prevention programs for youth have been school-based. Schools appear to be obvious places to deliver youth-focused interventions, as they are the physical settings where most youth can be reached. Despite the fact that tobacco education is part of the core curriculum content standards for schools, New Jersey has not seen a reduction in youth tobacco use. These curricula may not have achieved the desired impact partly because there have not been comprehensive, community- focused activities to support tobacco prevention outside of the school setting. Therefore, consideration should be given to expanding youth prevention programs beyond the school setting to include program delivery in other settings. An opportunity now exists to develop a sound, research-based approach that supported school-based instruction and complements it with effective community-based programming and support. Such programs need time, commitment, and planned evaluation.

      This section will outline some of the strengths and limitations of school-based programs and those delivered in other settings.

      School Programs

      Several studies have shown that school-based tobacco prevention programs which identify the social influences that promote tobacco use among youth and which teach skills to resist such influences can significantly reduce or delay adolescent smoking.39 Research indicates that these programs must be delivered with sufficient intensity and duration, often including booster sessions, in order to reduce or delay adolescent smoking.40 Studies have also demonstrated that school-based program effectiveness is enhanced by community wide partnerships involving parents and community organizations. These partnerships can affect school policies and restrictions on youth access.41,42 Since impressions about tobacco use are formed at an early age and many youth begin using tobacco before high school, interventions must be provided in elementary school and continued through middle and high school. 43,44

      School-based programs can be a vehicle for accomplishing four of the five goals of New Jersey's comprehensive tobacco control program as follows:

      Goal 1:	To decrease acceptability of tobacco use
      	Increase awareness of negative effects of smoking in community and personal settings
      	Increase the number of schools with smoke-free campuses and smoke-free school sponsored events
      	Increase the number of youth and school based programs that are designed to prevent tobacco use
      Goal 2:	To decrease youth initiation of tobacco
      	Increase the number of youth and school based programs that are designed to prevent tobacco usage which enhance or complement the mandated tobacco core curriculum
      Goal 4:	To decrease exposure to ETS
      	Increase awareness of the harmful effects of smoking in community and personal settings
      	Increase the number of schools with smoke-free campuses and smoke-free school sponsored events
      Goal 5:	To reduce disparities related to tobacco use and its effects among different population groups
      	Increase knowledge of minority populations that they are the targets of tobacco marketing
      	Ensure that youth/school-based tobacco control programs are appropriate for all populations including minorities and groups at highest risk

      Existing school programs also have limitations in addition to uneven program effectiveness including:

      • focus on program delivery in public schools only;
        
      • home rule preventing the Department of Education from instituting specific curricula;
        
      • difficulty in reaching out-of-school youth;
        
      • use of stand-alone curricula (limited effectiveness);
        
      • few, if any, linkages with community programs;
        
      • little focus on ETS as a program component; and,
        
      • few, if any, linkages to nicotine treatment (cessation) programs.

      Community Programs

      Delivering tobacco prevention programs for youth in community- based settings offers several advantages. Many community-based programs have strong track records in recruiting and serving out- of-school youth who are typically at higher risk than the in- school population for tobacco use. For example, drug-treatment agencies work with youth who are much more likely to use tobacco than the overall population. Community organizations tend to work with youth in smaller groups and have the flexibility to deliver prevention programs with sufficient intensity and duration that schools may not have. These organizations are also more likely to have linkages with other community wide efforts to change social norms, decrease youth initiation, reduce exposure to ETS, increase access to cessation programs, and reduce population disparities. In short, community-based programs serving youth can be a vehicle for addressing all five goals of a comprehensive tobacco control program as follows:

      Goal 1:	To decrease acceptability of tobacco use
      	Increase awareness of negative effects of smoking in community and personal settings
      	Increase the number of youth and school based programs that are designed to prevent tobacco use
      Goal 2:	To decrease youth initiation of tobacco
      	Increase the number of publicly funded community activities aimed at decreasing tobacco use among youth through age 24
      	Increase compliance of local vendors with State and Federal laws prohibiting sale of tobacco products to minors
      	Increase overall number of merchants who do not carry tobacco or tobacco related products
      	Increase the number of youth and school-based programs that are designed to prevent tobacco use which enhance or complement the mandated tobacco core curriculum
      Goal 3:	To increase the number of users who initiate treatment
      	Increase awareness of the availability of nicotine programs
      	Increase the number of individuals accessing nicotine treatment programs
      Goal 4:	To reduce exposure to ETS
      	Increase awareness of the harmful effects of smoking in community and personal settings
      	Increase the number of schools with smoke-free campuses and smoke-free school sponsored events
      Goal 5:	To reduce disparities related to tobacco use and its effects among different population groups
      	Increase knowledge of minority populations that they are the targets of tobacco marketing
      	Ensure that youth/school-based tobacco control programs are appropriate for all populations including minorities and groups at highest risk

      Community programs also have limitations including:

      • community organizations do not have access to the same number of youth as schools do;
        
      • community organizations cannot institute a school-wide curriculum; and,
        
      • level of agency competence is varied: not all community organizations are capable of delivering effective prevention programs incorporating research-based practices.

   2. Current Programs in New Jersey:

      New Jersey currently has the following school-based and community- based tobacco prevention programs:

      • Under the core curriculum standards, schools are required to have a curriculum in each grade which teaches the nature of tobacco and its physiological, psychological, sociological and legal effects on the individual, family, and society.

      • DHSS is in its third year of funding middle school peer leadership programs. By December 1999, 111 middle schools will be participating. During the school year the peer leaders are guided by adult mentors. The peer leaders teach their peers or younger students about the health effects of tobacco and industry manipulation. By the end of 1999, more than 890 students will have been trained as peer leaders and will be responsible for teaching over 20,000 students. Rutgers University is providing both a process evaluation and an outcome evaluation of this program, and the preliminary results are positive.

      • DHSS funds approximately 50 community-based organizations through the prevention set-aside of the PTSA block grant to deliver prevention services primarily to high risk youth and their families. Services are focused on changing knowledge and attitudes and ultimately reducing youth experimentation and use of all substances - alcohol, tobacco, and other drugs. Programs are required to have an outcome evaluation component. However, most data collected relates to decreasing initiation of all substances, and is non- specific for tobacco.

   3. Best Practices and Other States

      This section outlines best practices and other states' approaches to this program component:

      • CDC recommends two curricula which have been evaluated: "Implementation of Life Skills Training" and "Project Towards No Tobacco Use (TNT)." Although some states have had problems with implementing the curricula, when the protocols are followed exactly, they have been shown to have sustained impact on youth smoking rates.45,46

      • There are two basic approaches to providing tobacco education in school settings: stand-alone curriculum and curriculum infusion. While both are useful means of instruction, curriculum infusion is a means of incorporating lessons about tobacco into the various core educational subject areas and may warrant further study.

      • In California and Massachusetts funding goes directly to their state departments of education. The evaluation of California's Tobacco Control Program showed that students reported that health classes did not affect their attitudes toward smoking.47

      • Florida has elected to utilize curriculum infusion for grades K through 12. For example, The Berenstain Bear Scouts and the Sinister Smoke Ring from Scholastic Publishing is a reader appropriate for young elementary school students. Tobacco mathematics word problems are used for middle school students. These new curricula are currently being evaluated.

2. PROPOSED APPROACH

   This section outlines the proposed approach to implementing this program component in a school or community setting, including selecting the target population, establishing basic principles, and creating opportunities for public/private partnerships.

   1. Target Population:

      School-based and/or community-based programs will be expected to target youth, ages 5-18, both those who attend school and those who do not.

   2. Basic Principles:

      As the program begins to develop, it is important to incorporate the following basic principles:

      1. Youth, both smokers and non-smokers, should play a key role in developing and implementing programs to reach all youth, including minority youth.

      2. Age appropriate programs should be available for the entire age range of school-aged youth, 5-18 years.

      3. Program materials used should be culturally appropriate.

      4. Peer leadership is an effective-program delivery model when used in adjunct with teacher-led instruction.48,49

      5. Youth activities should be linked to activities/programs developed by communities.

   3. Opportunities for Public/Private Partnership:

      As indicated earlier, the effectiveness of tobacco prevention programs for youth is enhanced by linkages to community-wide programs involving parents and community organizations. It would be very appropriate for youth activities to be coordinated with/linked to programs developed by community partnerships.

This document may only be reproduced in its entirety. No portion of this document may be reproduced without the permission of the New Jersey Department of Health and Senior Services. © 1999 New Jersey Department of Health and Senior Services.

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