Healthy Tobacco-Free Schools CDC s Division of Adolescent and School Health DASH

2. DASH’s Mission To promote the health and well being of children and adolescents so they become healthy and well-functioning adults. As you see here, our mission is to prevent the most serious health risk behaviors among, children, adolescents and young adults. Accomplishment of this mission is predicated on 4 national strategies As you see here, our mission is to prevent the most serious health risk behaviors among, children, adolescents and young adults. Accomplishment of this mission is predicated on 4 national strategies

3. Key Health Issues for Young People Intentional and unintentional injuries Alcohol/drug use Sexual risk behaviors Tobacco use Physical inactivity Poor eating habits Asthma Mental health Based on this epidemiological analysis, CDC has identified these 6 key risk behaviors as the behaviors that adolescent health programs must address to have the greatest impact on the health of adolescents in the present and in the future. Based on this epidemiological analysis, CDC has identified these 6 key risk behaviors as the behaviors that adolescent health programs must address to have the greatest impact on the health of adolescents in the present and in the future.

4. Coordinated School Health Programs CDC has advocated a multi-component school health model because it integrates the efforts of the various health-related activities of the school setting that have an impact on student health and learning. The Coordinated School Health Program model advocated by CDC has eight components as seen in We have often referred to a well functioning model as a “Coordinated School Health Program.” Yet, the more we have been working with others to improve school health, the more we recognize that a simple 8 component model does not fully describe a coordinated school health program. That our definition of CSHP, using only these components and their common purpose, is inadequate. CDC has advocated a multi-component school health model because it integrates the efforts of the various health-related activities of the school setting that have an impact on student health and learning. The Coordinated School Health Program model advocated by CDC has eight components as seen in We have often referred to a well functioning model as a “Coordinated School Health Program.” Yet, the more we have been working with others to improve school health, the more we recognize that a simple 8 component model does not fully describe a coordinated school health program. That our definition of CSHP, using only these components and their common purpose, is inadequate.

5. CDC/DASH-Funded Coordinated School Health Programs

7. CDC/DASH has developed school health guidelines for the major risk behaviors of young people. The “Guidelines for School Health Programs to Prevent Tobacco Use and Addiction” were published in 1994, and are being updated and revised, as many of you know. CDC staff anticipated that they would be ready for field review by this meeting, however, that has not happened – but the draft guidelines should be ready by the end of the calendar year. Therefore, today I am giving you the best and closest to some of the guidelines strategies possible at this time. Expert panels and field review may or may not change some of these concepts contained in the presentation. CDC/DASH has developed school health guidelines for the major risk behaviors of young people. The “Guidelines for School Health Programs to Prevent Tobacco Use and Addiction” were published in 1994, and are being updated and revised, as many of you know. CDC staff anticipated that they would be ready for field review by this meeting, however, that has not happened – but the draft guidelines should be ready by the end of the calendar year. Therefore, today I am giving you the best and closest to some of the guidelines strategies possible at this time. Expert panels and field review may or may not change some of these concepts contained in the presentation.

8. Guidelines Review Process Literature search Convene DASH workgroup Code articles (approx. 500) Copies stored in hard copy and Ref. Mgr. Draft list of strategies Convene experts/partner panel Draft for CDC internal review/partner review CDC clearance process The guidelines review process is similar for all topic areas (revisions of the physical activity/nutrition guidelines are underway also, with others to come). (Read list from slide.)The guidelines review process is similar for all topic areas (revisions of the physical activity/nutrition guidelines are underway also, with others to come). (Read list from slide.)

9. 1994 Guidelines for School Health Programs to Prevent Tobacco Use and Addiction 1. Policy 2. Instruction 3. Curriculum 4. Training 5. Family Involvement 6.Tobacco-Use Cessation 7. Evaluation The 1994 tobacco-use prevention guidelines have stood the test of time, so to speak, and therefore much of what is currently in the present guidelines will be retained – and updated with new references. Current recommendations cover school policy, instruction and curriculum, teacher training, family involvement, tobacco-use cessation programs, and evaluation of the school-based tobacco programs.The 1994 tobacco-use prevention guidelines have stood the test of time, so to speak, and therefore much of what is currently in the present guidelines will be retained – and updated with new references. Current recommendations cover school policy, instruction and curriculum, teacher training, family involvement, tobacco-use cessation programs, and evaluation of the school-based tobacco programs.

10. 2010 Guidelines Revisions Health Services: school health nurses, health care providers, counselors; cessation programs Community + School Efforts Parental Involvement School Staff Involvement After School/Advocacy Programs Tobacco Awareness Events Media/Advertising Effects of Secondhand Smoke After synthesis of the research, CDC not only will be expanding some sections, but will be adding a few new ones. Two major additions are: (1) an expanded role for the school nurse and other school-based health care providers; and (2) recommendations for connecting school and community efforts in tobacco prevention (as a result of the community Guide Recommendations, which I will mention later in this presentation). Parent and staff involvement will be expanded, and guidance on the judicious implementation of advocacy and tobacco awareness activities. Media and advertising will be covered, as they relate to the school environment, and the new research on the harmful effects of exposure to secondhand smoke will be a critical addition. After synthesis of the research, CDC not only will be expanding some sections, but will be adding a few new ones. Two major additions are: (1) an expanded role for the school nurse and other school-based health care providers; and (2) recommendations for connecting school and community efforts in tobacco prevention (as a result of the community Guide Recommendations, which I will mention later in this presentation). Parent and staff involvement will be expanded, and guidance on the judicious implementation of advocacy and tobacco awareness activities. Media and advertising will be covered, as they relate to the school environment, and the new research on the harmful effects of exposure to secondhand smoke will be a critical addition.

11. Comprehensive School Tobacco-Free Environment Creation of a strong tobacco-free policy Communication of the policy Enforcement of the policy Prohibiting advertising and promotion Tobacco-use cessation advice and referral Tobacco-use prevention instruction The current guidelines recommend a comprehensive and written policy that includes: A rationale for the policy. (This remains the same.) The creation of a totally tobacco-free environment both on school property and at all schools events, for all students, staff and visitors. (This section is enhanced.) - Procedures for communicating the policy to students, school staff, parents and the community. ( More examples will be included in this revision, such as adequate signage identifying the buildings, grounds, and events as “ tobacco-free”, announcements at school functions, letter to parents, etc.) - Provisions for enforcing the policy. (This will be enhanced to recommend more positive methods of working with students who violate the policy.) - A section that either mandates or recommends providing instruction for all students on avoiding tobacco use. (This remains the same.) - A prohibition on tobacco advertising in school buildings, at school functions, and in school publications. (This section will have additions to it.) - Provision for students and staff to have access to tobacco-use cessation programs will still be important to include in a comprehensive policy. ( Some cautions will be added to this section in the guideline recommendations -which I will cover later, in that section of this presentation.) The current guidelines recommend a comprehensive and written policy that includes: A rationale for the policy. (This remains the same.) The creation of a totally tobacco-free environment both on school property and at all schools events, for all students, staff and visitors. (This section is enhanced.) - Procedures for communicating the policy to students, school staff, parents and the community. ( More examples will be included in this revision, such as adequate signage identifying the buildings, grounds, and events as “ tobacco-free”, announcements at school functions, letter to parents, etc.) - Provisions for enforcing the policy. (This will be enhanced to recommend more positive methods of working with students who violate the policy.) - A section that either mandates or recommends providing instruction for all students on avoiding tobacco use. (This remains the same.) - A prohibition on tobacco advertising in school buildings, at school functions, and in school publications. (This section will have additions to it.) - Provision for students and staff to have access to tobacco-use cessation programs will still be important to include in a comprehensive policy. ( Some cautions will be added to this section in the guideline recommendations -which I will cover later, in that section of this presentation.)

12. Tobacco-Free Environment Emphasis on total tobacco-free environment at all times (24/7) New research on secondhand smoke’s lingering effects in buildings Secondhand smoke and asthma Influence of role modeling by teachers, staff, visitors, and parents More emphasis will be placed on having a tobacco-free environment at all times. This is especially critical in the light of a preponderance of research now published about the lingering effects of tobacco smoke in vents and other places indoors. Tobacco-free school environments help protect children from second-hand smoke, model the behavior that encourages a healthy lifestyle, decrease the access to and the opportunity to experiment with tobacco, and prepare young people for the real world where most workplaces are now smoke-free. More emphasis will be placed on having a tobacco-free environment at all times. This is especially critical in the light of a preponderance of research now published about the lingering effects of tobacco smoke in vents and other places indoors. Tobacco-free school environments help protect children from second-hand smoke, model the behavior that encourages a healthy lifestyle, decrease the access to and the opportunity to experiment with tobacco, and prepare young people for the real world where most workplaces are now smoke-free.

13. Exposure to Secondhand Smoke 2006 Surgeon General’s Report: There is no “risk-free” level of exposure to secondhand smoke. Only eliminating smoking in indoor spaces fully protects non-smokers from exposure to secondhand smoke. Separating smokers from non-smokers, cleaning the air, and ventilating buildings cannot eliminate exposure. A key addition to the new guidelines will be the research and implications from the U S. Surgeon General’s recent comprehensive report on the dangers of exposure to secondhand smoke. Implications for schools are: There is no “risk-free” exposure to secondhand smoke, thereby making it crucial that students, staff, and visitors are protected from its harmful effects at all times during their school experience. Elimination of smoke only while students are in the school building is no longer adequate, since the SGR says that smoke lingers in ducts and air vents, and eliminating smoking at all times is the only complete protection.A key addition to the new guidelines will be the research and implications from the U S. Surgeon General’s recent comprehensive report on the dangers of exposure to secondhand smoke. Implications for schools are: There is no “risk-free” exposure to secondhand smoke, thereby making it crucial that students, staff, and visitors are protected from its harmful effects at all times during their school experience. Elimination of smoke only while students are in the school building is no longer adequate, since the SGR says that smoke lingers in ducts and air vents, and eliminating smoking at all times is the only complete protection.

14. Exposure to Secondhand SmokeSGR, 2006, continued Secondhand smoke exposure causes disease and premature death in children and adults who do not smoke. Children exposed to secondhand smoke are at increased risk for SIDS, acute respiratory infections, ear problems, and more severe asthma. - Secondhand smoke exposure causes disease and premature death in children and adults who do not smoke. - Children exposed to secondhand smoke are at increased risk for SIDS, acute respiratory infections, ear problems, and more severe asthma. - Secondhand smoke exposure causes disease and premature death in children and adults who do not smoke. - Children exposed to secondhand smoke are at increased risk for SIDS, acute respiratory infections, ear problems, and more severe asthma.

15. Guidelines also cover… Effects on students from : - Attitudes of teachers and parents toward school tobacco-free policies - Harmful effects of minimal exposure to secondhand smoke - Secondhand smoke and impaired cognition - Schools and students raising tobacco crops Additional research will be covered on how students are affected by Attitudes of teachers and parents toward tobacco-free policies Minimal exposure to secondhand smoke Secondhand smoke and impaired cognition Growing tobacco at home or as part of school-related agriculture projects.Additional research will be covered on how students are affected by Attitudes of teachers and parents toward tobacco-free policies Minimal exposure to secondhand smoke Secondhand smoke and impaired cognition Growing tobacco at home or as part of school-related agriculture projects.

16. Tobacco-Free Policy:  Cornerstone Prohibit all tobacco use on all school property, in school vehicles, at school- sponsored events (on and off school property) for students, staff, and visitors 24/7. While there are a number of components that make up a good policy for tobacco use at school, the most important and most often discussed is the tobacco-free environment -- or the tobacco-free school policy. Just like you can tell a lot about a person by walking into his or her home, you can tell a lot about what is valued and supported at school by looking around. Do cigarette buts litter the school grounds? Are teachers smoking in the presence of students? Are students smoking on the grounds? What about in the building? Do teachers “sneak” off to smoke? Do parents regularly smoke and chew at the school football games? Children are always observing teachers, parents and peers at school, and tobacco use may be learned or encouraged in this process. A completely tobacco-free environment sends a strong message. According to SHPPS, the areas that need the most work are in enforcing tobacco-free policies among staff and visitors, and especially at off-site school events. While there are a number of components that make up a good policy for tobacco use at school, the most important and most often discussed is the tobacco-free environment -- or the tobacco-free school policy. Just like you can tell a lot about a person by walking into his or her home, you can tell a lot about what is valued and supported at school by looking around. Do cigarette buts litter the school grounds? Are teachers smoking in the presence of students? Are students smoking on the grounds? What about in the building? Do teachers “sneak” off to smoke? Do parents regularly smoke and chew at the school football games? Children are always observing teachers, parents and peers at school, and tobacco use may be learned or encouraged in this process. A completely tobacco-free environment sends a strong message. According to SHPPS, the areas that need the most work are in enforcing tobacco-free policies among staff and visitors, and especially at off-site school events.

17. School, District, and State Tobacco-Use Prevention Policies Schools: 64% Districts: 55% States: 38% Policies are least likely to address smokeless tobacco use and tobacco use among visitors While most states, districts, and schools had adopted policies prohibiting some tobacco use in some locations, in 2006, only 38% of states, 55% of districts, and 64% of schools had adopted policies that 1) prohibited cigarette smoking and smokeless tobacco use among students, faculty and staff, and school visitors in school buildings; outside on school grounds; on school buses or other vehicles used to transport students; and at off-campus, school-sponsored events; and 2) prohibited cigar or pipe smoking by students, faculty and staff, and school visitors.While most states, districts, and schools had adopted policies prohibiting some tobacco use in some locations, in 2006, only 38% of states, 55% of districts, and 64% of schools had adopted policies that 1) prohibited cigarette smoking and smokeless tobacco use among students, faculty and staff, and school visitors in school buildings; outside on school grounds; on school buses or other vehicles used to transport students; and at off-campus, school-sponsored events; and 2) prohibited cigar or pipe smoking by students, faculty and staff, and school visitors.

18. School Policies Prohibiting Tobacco Advertisements

19. Communication and Enforcement of the Policy Clear communication to students, staff, visitors, contractors, and the community Remedial* sanctions work best for students. *Remedial = counseling, alternatives to suspension programs instead of suspension or expulsion, cessation programs, etc. More research is now available for the importance of providing remedial sanctions for violations of school tobacco-free policies – things such as counseling, alternatives to suspension classes, and cessation programs.More research is now available for the importance of providing remedial sanctions for violations of school tobacco-free policies – things such as counseling, alternatives to suspension classes, and cessation programs.

20.  Recommendations for School-based Tobacco-Use Prevention Education Community Guide to Preventive Services, 2004 The Task Force recommends use of school-based interventions when combined or coordinated with mass media campaigns and community education activities based on strong evidence of effectiveness in reducing tobacco use by students. There is insufficient evidence to determine the effectiveness of school-based education (classroom programs) and other activities when implemented without additional community activities. The Task Force on the Community Guide to Preventive Services recommends the use of school-based interventions when combined or coordinated with mass media campaigns and community education activities based on strong evidence on effectiveness in reducing tobacco use by students. Classroom programs/curricula, alone, have shown insufficient evidence of effectiveness. There are some curricula that have shown strong effects, alone, but not enough for a strong recommendation. Of note, CDC has always recommended that schools and communities work together for maximum effectiveness of school programs.The Task Force on the Community Guide to Preventive Services recommends the use of school-based interventions when combined or coordinated with mass media campaigns and community education activities based on strong evidence on effectiveness in reducing tobacco use by students. Classroom programs/curricula, alone, have shown insufficient evidence of effectiveness. There are some curricula that have shown strong effects, alone, but not enough for a strong recommendation. Of note, CDC has always recommended that schools and communities work together for maximum effectiveness of school programs.

21. Tobacco-Use Prevention Education Classroom programs should be delivered in conjunction with community and media messages. Instruction should be K-12 and include: Short- and long-term health consequences Social influences Peer norms Refusal skills Life and decision-making skills Emphasis during middle and high school Successful programs address multiple psychosocial factors related to tobacco use. (This remains the same, with some current references added). These concepts and skills include: - Short term consequences, such as decreased stamina, shortness of breath, foul breath, stained teeth, ostracism by non-smoking peers. - Long term consequences, such as disease (cancer, heart disease, stroke), nicotine addiction. - Social norms, to decrease the social acceptability of tobacco use, highlighting the existing anti-tobacco norms in society and that most adolescents do not use tobacco. - Adolescents’ reasons for using tobacco that discuss the reasons tobacco users give, such as peer acceptance, appearance of maturity, coping with stress. Positive alternatives to accomplish these goals should be included. - Social influences, such as marketing, tobacco industry promotion, use of tobacco in the media. - Behavior skills in orders to resist social and peer influences - General personal and social skills, such as assertiveness, communication, goal-setting, and problem-solving. **An important addition to the current guidelines will be the new recommendations from the Community Guide that say these programs are stronger when delivered in conjunction with media and community efforts. Successful programs address multiple psychosocial factors related to tobacco use. (This remains the same, with some current references added). These concepts and skills include: - Short term consequences, such as decreased stamina, shortness of breath, foul breath, stained teeth, ostracism by non-smoking peers. - Long term consequences, such as disease (cancer, heart disease, stroke), nicotine addiction. - Social norms, to decrease the social acceptability of tobacco use, highlighting the existing anti-tobacco norms in society and that most adolescents do not use tobacco. - Adolescents’ reasons for using tobacco that discuss the reasons tobacco users give, such as peer acceptance, appearance of maturity, coping with stress. Positive alternatives to accomplish these goals should be included. - Social influences, such as marketing, tobacco industry promotion, use of tobacco in the media. - Behavior skills in orders to resist social and peer influences - General personal and social skills, such as assertiveness, communication, goal-setting, and problem-solving. **An important addition to the current guidelines will be the new recommendations from the Community Guide that say these programs are stronger when delivered in conjunction with media and community efforts.

22. Guidance, tools, and resources for a clear, complete, and consistent analysis of health education curricula Based on CDC School Health Guidelines and National Health Education Standards Identifies common characteristics of effective health education curricula Higher expectations for and greater rigor in curriculum development and selection Improved health education HECAT contains …. It is based on the CDC School Health Guidelines and the National Health Education Standards. In fact, the Guidelines form the foundation for all our tools. They are the method by which we synthesize the literature to identify effective strategies. Guidelines include both strategies identified through rigorously evaluated intervention studies as well as those identified by the preponderance of not-as-rigorous research AND best practices identified by the field. HECAT contains …. It is based on the CDC School Health Guidelines and the National Health Education Standards. In fact, the Guidelines form the foundation for all our tools. They are the method by which we synthesize the literature to identify effective strategies. Guidelines include both strategies identified through rigorously evaluated intervention studies as well as those identified by the preponderance of not-as-rigorous research AND best practices identified by the field.

23. Tobacco-Use Cessation for Students and Staff Schools should identify students and staff who need assistance Schools should give “brief advice” on quitting to students and staff Schools should refer students and staff to outside providers Schools should refer to the CDC guidance document if adopting an evaluated program or if developing its own program Recommendations for tobacco-use cessation remain the same to: - Identify students and staff who need assistance - Give “brief advice” on quitting to students and staff - Refer students and staff to outside providers. * However, CDC has new guidance if a school decides to conduct a tobacco-cessation program for students. Recommendations for tobacco-use cessation remain the same to: - Identify students and staff who need assistance - Give “brief advice” on quitting to students and staff - Refer students and staff to outside providers. * However, CDC has new guidance if a school decides to conduct a tobacco-cessation program for students.

24. CDC’s Guidance Tool “Youth Tobacco Cessation: A Guide to Making Informed Decisions” (2004) Contributors: Youth Tobacco Cessation Collaborative American Legacy Foundation National Cancer Institute Canadian Tobacco Control Research Initiative This document, available on the CDC/ Office on Smoking and Health Website, combines all the research to date on youth tobacco-use cessation and provides what we know and do not know at this point about how to assist young people in quitting. This document, available on the CDC/ Office on Smoking and Health Website, combines all the research to date on youth tobacco-use cessation and provides what we know and do not know at this point about how to assist young people in quitting.

25. Parent Involvement Program planning Reinforcing messages Role modeling Garner community support for tobacco-free policies and programs Encourage smoke-free homes and cars Involving parents in school-work assignments, program planning and reinforcing tobacco prevention messages remains critical. Not much was in the former guidelines about the importance of parents as role models and the potential influence parents can have in supporting community tobacco-free policies and programs – and these will be included.Involving parents in school-work assignments, program planning and reinforcing tobacco prevention messages remains critical. Not much was in the former guidelines about the importance of parents as role models and the potential influence parents can have in supporting community tobacco-free policies and programs – and these will be included.

26. School + Community Model This is a diagram that shows the School + Community Model, and how the classroom education piece, is just one small part of concentric circles that building upon education, and support a tobacco-free environment. This concept will be promoted in the new guidelines. This is a diagram that shows the School + Community Model, and how the classroom education piece, is just one small part of concentric circles that building upon education, and support a tobacco-free environment. This concept will be promoted in the new guidelines.

27. Enables schools to identify strengths and weaknesses of health policies and programs Enables schools to develop an action plan for improving student health Engages teachers, parents, students, and the community in promoting health enhancing behaviors and better health

28. School Health Index Topics Physical activity Healthy eating Tobacco use prevention Unintentional injuries and violence prevention (safety) Asthma The latest edition of the SHI, which was the 4th edition, was released in August of 2005 and covers these 5 health topic areas: physical education and physical activity, healthy eating, tobacco use prevention, unintentional injuries and violence prevention, and most recently asthma. Additional health topic areas will be added in future editions. The latest edition of the SHI, which was the 4th edition, was released in August of 2005 and covers these 5 health topic areas: physical education and physical activity, healthy eating, tobacco use prevention, unintentional injuries and violence prevention, and most recently asthma. Additional health topic areas will be added in future editions.

29. Dissemination and Diffusion: “D-Train” A national cadre of master trainers for DASH tools, including the SHI and the HECAT

30. National Association of State Boards of Education DASH helped the National Association of State Boards of Education develop Fit Healthy and Ready To Learn, which was also released earlier this year. This document is a policy guide that features model policies on physical activity, nutrition, and tobacco-use prevention that can be used at the school, district, or state board level. This document is available through the NASBE website: www.nasbe.org.DASH helped the National Association of State Boards of Education develop Fit Healthy and Ready To Learn, which was also released earlier this year. This document is a policy guide that features model policies on physical activity, nutrition, and tobacco-use prevention that can be used at the school, district, or state board level. This document is available through the NASBE website: www.nasbe.org.

31. Resources www.cdc.gov/healthyyouth (CDC/DASH) www.nsba.org/schoolhealth (National School Boards Association) www.nasbe.org (National Association of State Boards of Education) Linda Crossett: LCrossett@cdc.gov