Effectiveness of School-Based Programs as a Component of a Statewide Tobacco Control Initiative — Oregon, 1999-2000

Morbidity and Mortality Weekly Report, August 10, 2001

With funds available from revenue generated by a voter-initiated ballot measure to increase the state cigarette excise tax [1], the Oregon Health Division (OHD) created the Tobacco Prevention and Education Program (TPEP) in 1997. Coalitions in all Oregon counties, a countermarketing campaign, a statewide tobacco cessation quitters' helpline, and competitive grants to community groups, tribal associations, and school districts are supported by TPEP [2]; 12% of TPEP's $8.5 million annual funding was used to implement CDC's Guidelines for School Health Programs to Prevent Tobacco Use and Addiction [3] in 23 school districts or consortia of districts. Data from annual school-based surveys conducted to monitor adolescent risk behavior indicated that from 1999 to 2000, 30-day smoking prevalence among eighth grade students declined more in funded schools than in a comparison group of nonfunded schools. The declines were significantly greater among schools with high and medium levels of implementation. These results suggest that comprehensive school-based programs can be an effective component of statewide antitobacco efforts.

Data on smoking behavior among students were collected by OHD from either the Oregon Public School Drug Use Survey (OPSDUS) questionnaire or the Youth Risk Behavior Survey (YRBS) questionnaire. In 1999, 49 (53%) of 93 funded schools and 61 (25%) of 246 nonfunded schools used the YRBS questionnaire. In 2000, 58 funded schools and 47 nonfunded schools used either the OPSDUS or YRBS questionnaires. All analyses were based on data from 38 funded schools and 14 nonfunded schools that participated in both 1999 and 2000. Eighth graders were selected for analysis because TPEP's most intensive interventions targeted middle schools, which meant that eighth graders in 2000, who were seventh graders in 1999, had been exposed to the program for 2 years. Smoking prevalence for 1999 and 2000 was measured in both funded and nonfunded schools, and multivariate logistic regression was used to compare the 2000 difference in prevalence between the two groups of schools. Prevalence in 2000 in schools with high, medium, or low pr ogram implementation scores also was compared with 2000 prevalence in nonfunded schools. Among the 52 schools, 1942 (55%) of 3519 eighth graders surveyed attended funded schools in 1999. In 2000, 4089 (74%) of 5556 eighth graders surveyed attended funded schools. Funded schools were required to conduct an eighth grade student census; nonfunded schools participated on a voluntary basis. The number of participating students varied as a result of differences in sampling protocol between the two surveys.

Without knowledge of the school survey results, each funded school district was categorized on cumulative implementation (progress before and during funding) of six areas identified in CDC guidelines [3]: tobacco-free school policies, family involvement, community involvement, tobacco prevention curriculum instruction, teacher/staff training, and student tobacco use cessation support. Tobacco-free school policies were assessed by summing the number of elements completed out of 19(3). Family involvement and student tobacco use cessation support were assessed by summing the total completed out of five criteria in each of two components (3). Community involvement was measured by whether the district sent a representative to community tobacco coalition meetings; teacher/staff training was assessed by whether the district had provided training during the survey period; and tobacco prevention curriculum instruction was assessed by the implementation of a CDC-identified curriculum. The quartile score for the first three areas (scored one to four) was added to the dichotomous measures of the latter three areas ("yes" was scored zero and "no" was scored one) for a final score that ranged from three (best score) to 15 (worst score). Based on natural cut-off points in the distribution of scores, the schools then were classified as low (nine-15), medium (six-eight), or high (three-five) on the six areas. Of the 38 participating funded schools, 14 were in low-ranked districts, 15 were ranked medium, and nine were ranked high on implementation criteria.

Both the YRBS and OPSDUS self-report questionnaires were administered anonymously to all students in the participating eighth grade classrooms. The YRBS question used to determine smoking status was "During the past 30 days, on how many days did you smoke cigarettes?" The OPSOUS question was "How frequently have you smoked cigarettes during the past 30 days?" Students who indicated that they had smoked on [greater than or equal to]1 days were classified as smokers on each survey.

In 1999, no statistical differences were observed in student or school characteristics, including eighth grade smoking prevalence, in funded versus nonfunded schools. The 30-day smoking prevalence decreased from 16.6% in 1999 to 13.0% in 2000 (p=0.002) in funded schools and from 17.0% in 1999 to 15.7% in 2000 (p=0.47) in nonfunded schools. Stratified by implementation level in 1999 and 2000, changes in prevalence among eighth grade students were larger in schools in districts with high (from 14.2% to 8.2%) or medium (from 17.8% to 13.9%) ratings; changes in smoking prevalence in schools in districts with low ratings (from 17.1% to 15.6%) were almost equal to those in nonfunded schools (from 17.0% to 15.7%) (Figure 1).