School personnel can play a vital role in early tobacco prevention and intervention.1 Each day in the U.S., about 1,600 youth smoke their first cigarette and nearly 200 youth start smoking every day.2
Prevalence of Youth Smoking in the United States:
Nearly 90% of adult smokers began smoking before the age of 18. 2,3
Youth begin smoking in Middle School (6th-8th grade). The CDC tracked statistics in 2022 which measured tobacco use in the past month: 1% of 6th through 8th graders had smoked cigarettes, 3.3% had smoked e-cigarettes, 1% had smoked hookah, and 1% had used smokeless tobacco.2 When interviewing High Schoolers about the past 30 days: 2% had smoked cigarettes, 14.4% smoked e-cigarettes, 1.5% smoked hookah, and 1.6% used smokeless tobacco.2 In 2022, about 4.5% of middle school students and about 16.5% of high school students reported current use of a tobacco product.2
The use of e-cigarettes has become the most popular form of nicotine among High School students. Flavorings in tobacco products can make them more appealing to youth with 85.5% of high school students and 81.5% of middle school students who reported smoking in the last 30 days reporting use of a flavored e-cigarette.2
Tobacco use among youth is related to a number of social factors:2
- Peer pressure
- Peer approval
- Social-economic status
- Normalization of tobacco use in the environment, such as family tobacco use
- Lack of parent involvement
- Use of tobacco in the media
- Accessibility to tobacco products
Tobacco use is also complicated by other sources including2
- Genetic factors
- Prenatal exposure
- Co-occurring behavioral health issues,
- Mental health
- Low-academic achievement
- Perception of benefits (expectations to lose weight or reduce stress)
Why both prevention and cessation programs?
To successfully address smoking cessation in a school, both prevention and cessation services should be offered. Prevention programs can help many students from starting tobacco products. Cessation programs can be implemented to help them quit 4. For students and school personnel who have begun using tobacco products
How can school personnel assist in preventing tobacco use among students?
a) Enforce School Policy
- Prohibit all tobacco use (including smokeless tobacco and vapes) on the school premises. 5,6
- Prohibit all tobacco use at school-sponsored events (i.e. football games). 5,
- Reject school funding provided by tobacco companies. 5
b) Implement Smoking Prevention Curriculum 5,6,7
- Provide tailored smoking prevention curriculum from K-12.
- Programming should be reviewed and reinforced through Middle and High school years.
- Students should be taught 1) short-term and long-term health consequences, 2) social consequences, 3) peer pressure, 4) resistance and refusal skills, and 5) dangers of tobacco advertising.
- Students should be taught social norms of tobacco: (i.e. most students do not actually use tobacco products).
- Students need to understand why young people choose to smoke and how to find healthier alternatives.
- Students should be taught communication strategies, goal-setting, and other life skills to prevent start.
- Assess quality assurance and program outcomes regularly.
c) Involve Parents and the Community 8,9
- Involve parents in smoking prevention program by sending information and assignments home,
- Involve students in interactive prevention activities, such as Kick Butts Day in which students create a community project to end pro-tobacco beliefs.
- Invite coaches to discourage tobacco use, especially smokeless tobacco with athletes.
- Kick Butts Day is a national day that empowers adolescents to stand up to Big Tobacco companies. See the site for more information on how to plan and register your own Kick Butts Day.
How can school personnel intervene with student smokers
a) Implement a smoking cessation intervention 5,6,7
- Consider teaming-up with local health departments or hospital staff and co-teach cessation programs
- Provide tools for self-help and options for peer support
- Include immediate consequences of tobacco use, refusal skills, avoidance, and how to deal with stress
- Focus on achievable goals and reward students for reaching intervals along the way
- Assess outcomes of the program regularly
b) Provide outside services 5,6,7
- Promote and advertise the MD Quitline services for students: http://www.smokingstopshere.com/
- Advertise resources in the local community, including clinics and community centers
- Create a referral system to local resources and follow-up after each made referral
- Offer students options to quitting tobacco use: individual or family counseling, possible pharmacological
- Assess barriers-- Strategies should be discussed to overcome problems.
c) Community Involvement 5,7
- Create an Anti-Tobacco Committee that includes law enforcement officials, religious leaders, and other prominent figures to reinforce smoking cessation for youth in a variety of settings.
- Educate parents on dangers of smoking, and if applicable, offer them cessation services as well
- Invite outside resource centers to help with training school personnel responsible for cessation services.
Overall, what makes for successful prevention and intervention programs?
A School's Guide to Comprehensive Tobacco Control5 outlines the following domains for successful tobacco
prevention and intervention in schools. Note that the 7 domains should not be thought of as steps but as areas that should be addressed simultaneously:
5. Family Involvement
6. Tobacco Cessation Efforts
Examples of successful smoking prevention/ intervention programs in schools:
See SAMHSA's National Registry of Evidence-Based Programs and Practices for scientifically established behavioral health interventions and resources. There are several prevention strategies deemed effective by SAMSHA and NREPP. Below we summarize five effective smoking prevention programs. Check out this link for more information about the following programs:
Curriculum-Based Support Group (CBSG) 10
CBSG is a secondary preventative intervention for girls and boys aged 4-17 in school or community settings
- The program is designed for students who are at increased risk for substance use, delinquency, and violence.
- Students meet in small peer groups where confidentiality is assured.
- The themes of the program include a) coping skills for family situations, b) resistance and negotiation skills against alcohol, drugs, and peer pressure, c) goal setting, d) peer respect, and e) making healthy decisions.
- The program has been found to be successful for reducing antisocial and rebellious behavior, increasing anti-drug beliefs, and increasing coping skills.
- Two levels are available: Kid's Connection (ages: 4-12) and Youth Connection (ages: 10-17)
Life Skills Training (LST) 11
- A preventative program for grades 3-10
- Program focuses on reducing alcohol, drug, tobacco, and violence risk
- Curriculum aims to teach a) resistance and refusal skills, b) self-esteem and confidence, c) coping with stress, and d) avoiding short-term consequence
- 3 categories: Elementary School (grades 3-6), Middle School (grades 6-9), High School (grades 9-10)
- Noted by Wiehe et al. (2005)12 as the only intervention that maintained significant long-term benefits.
- Probably due to multiple levels of student interaction and participation in the program
Project Alert 13
- A completely online and free preventative program for Grades 7 and 8
- Goals include: a) non-drug use, b) developed refusal skills, and c) creation of new attitudes
- Curriculum consists of 14 lessons (only lessons 2, 10, 11 specifically target smoking)
- Objectives include a) refusal skills, b) short-term consequences of smoking, and c) why it is difficult to quit.
- An 8-session prevention and cessation program for grades 7-12; includes individual and group interventions.
- Students are taught a) refusal skills, b) communication skills, c) decision making skills, d) stress and anger management, e) dealing with peer pressure, and f) problem-solving skills.
Project TNT (Towards No Tobacco Use)15
- A prevention and cessation program, comprised of 12 lessons, for 5th-9th Graders
- Innovative program where students are encouraged to interact with materials (games, videos, role-play, etc.)
- Teaches students a) dangers of tobacco in advertising and the media, b) how to refuse peer pressure, and c) identify short-term consequences
Stanford University Tobacco Prevention Tool Kit16
A theory-based and evidence-informed educational resource created by educators and researchers aimed at preventing middle and high school students’ use of tobacco and nicotine products. Educators are encouraged to pick and choose which lessons will be most useful for their students and adapt activities to suit their needs. You will find that the PowerPoints, worksheets, and activities can all be altered as desired. The goals of the toolkit include:
- For students to understand basic information about tobacco products, including e-cigarettes/vape pens, and the harm they cause
- For students to gain awareness of strategies manufacturers of tobacco, including e-cigarettes/vape pens, employ to increase use among adolescents through deceptive and creative marketing strategies
- For students to gain skills to refuse experimentation and use of tobacco
- For school teachers and administrators to be able to develop and set new school policies
To access these resources visit the Stanford University Tobacco Prevention Tool Kit's website
In short, providing successful smoking cessation programs requires addressing both prevention and intervention.
The previous real-world programming examples have illustrated three key strategies for successful intervention:
- tailoring programs for various age groups,
- making the programs interactive and fun for students,
- teaching life-skills which can be implemented in various situations.
Centers for Disease Control and Prevention. (2022). Trends in Tobacco Use Among Youth. Retrieved February 27, 2023 from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/trends-in-tobacco-use-among-youth.html.
Centers for Disease Control and Prevention. (2022). Youth and tobacco use: Data. Retrieved February 27, 2023 from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm
U.S Department of Health and Human Services. (2016). Trends in adolescent tobacco use. Retrieved November 14, 2016 from http://www.hhs.gov/ash/oah/adolescent-health-topics/substance-abuse/tobacco/trends.html(link is external)
Campaign for Tobacco Free Kids. (2016). The path to addiction starts at very young ages. Retrieved October 31, 2016 from https://www.tobaccofreekids.org/research/factsheets/pdf/0127.pdf(link is external)
The Utah Department of Health Tobacco Prevention and Control Program. A school’s guide to comprehensive tobacco control. Retrieved February 27, 2023 from https://tobaccofreeutah.org/community/#resources
Campaign for Tobacco Free Kids (2016). How schools can help students stay tobacco-free. Retrieved November 7, 2016 from https://www.tobaccofreekids.org/research/factsheets/pdf/0153.pdf(link is external)
Centers for Disease Control and Prevention. (1994). Guidelines for school health programs to prevent tobacco use and addiction. Retrieved November 7, 2016. from http://www.cdc.gov/mmwr/preview/mmwrhtml/00026213.htm(link is external)
Campaign for Tobacco Free Kids (2016). Kick butts day. Retrieved November 7, 2016 from http://www.kickbuttsday.org/(link is external)
Maine Center for Disease Control and Prevention. (2016). Tobacco-Free Athletes. Retrieved February 27, 2023 from https://preventionforme.org/youth-young-adult/
Rainbow Days. (2016). CBSG Program. Retrieved November 21, 2016 from http://rainbowdays.org/our-services/cbsg-program-2/(link is external)
Life Skills Training. (2016). Life Skills Training Overview. Retrieved November 21, 2016 from http://www.lifeskillstraining.com/(link is external)
Wiehe, S. E., Garrison, M. M., Christakis, D. A., Ebel, B. E., & Rivara, F. P. (2005). A systematic review of school-based smoking prevention trials with long-term follow-up. The Journal of Adolescent Health: Official Publication Of The Society For Adolescent Medicine, 36(3), 162-169.
Project Alert. (2016). Program Overview. Retrieved November 21, 2016 from https://www.projectalert.com/(link is external)
Student Assistance Services Cooperation. (2011). Project Success. Retrieved November 21, 2016 from http://www.sascorp.org/success.html(link is external)
University of Southern California Institute for Prevention Research. (2016). Program Approach. Retrieved November 21, 2016 from http://tnt.usc.edu/program_approach.php(link is external)
Stanford University Tobacco Prevention Tool Kit (2023). Retrieved March 6, 2023 from https://med.stanford.edu/tobaccopreventiontoolkit.html