Tobacco prevention education for middle school and high school educators

Abstract

Objectives:

In an attempt to reduce tobacco use among adolescents in the USA, some health educators have created school-based tobacco education programmes. However, none currently exist for middle and high school educators. The current study sought to determine if middle and high school educators’ knowledge about combustible cigarettes and electronic cigarettes (e-cigarettes) improved following an educational session about youth tobacco use.

Design:

Pre-/post-assessment was employed to measure change in knowledge.

Setting:

Educators (N = 41) from a rural, southern middle and high school were invited to take part in the study during an educational workshop held during an in-service training event.

Method:

In addition to seven knowledge questions, participants also provided demographic information and details of current and previous use of cigarettes and e-cigarettes. Chi-square analyses examined changes in responses to individual items, and total pre-/post-knowledge score change was compared using a dependent t-test. Independent t-tests examined differences between knowledge change and participants’ personal and behavioural characteristics.

Results:

Participants’ overall knowledge improved from pre- to the post-test (p < .05); however, there was no relationship between pre-/post-test responses for individual items. In addition, there were no differences between participants’ knowledge change when compared by age, sex, grades taught and past use of cigarettes or e-cigarettes.

Discussion:

Increasing middle school and high school educators’ knowledge about tobacco products, particularly novel devices, is important due to the increasing rates of use among youth. More research is needed to determine how educators’ knowledge can help decrease tobacco initiation and use among school-aged children.

Keywords

Cigarettes electronic cigarettes prevention teachers tobacco education

Introduction

Tobacco use among middle and high school students in the USA increased from 5.6% and 19.6% in 2017 to 12.5% and 31.2% in 2019, respectively (Cullen et al., 2019; Wang et al., 2018). With no significant change in combustible cigarette use among middle (2.1% in 2017 to 2.3% in 2019) and high school (7.6% in 2017 to 5.8% in 2019) students, this increase has largely been attributed to electronic cigarette (e-cigarette) use, which was reported by 10.5% of middle school and 27.5% of high school students in 2019 (Cullen et al., 2019). Since 2014, e-cigarettes have become the most commonly reported tobacco product used by youth, and the increase in use since 2017 is largely attributed to the most popular e-cigarette brand, JUUL, which accounted for 76% of the e-cigarette market in 2018 (Cullen et al., 2018; Marynak et al., 2019; Vallone et al., 2019).

Such increase in youth e-cigarette use has been identified as a public health concern (U.S. Department of Health and Human Services, 2016) due to findings that suggest nicotine can adversely affect brain development (particularly the cerebral cortex) (England et al., 2015). In addition, e-cigarette use among youth may increase young people’s risk of nicotine addiction, susceptibility to using other tobacco products (e.g. combustible cigarettes) (Soneji et al., 2018), and risk of respiratory illnesses, including e-cigarette or vaping product use-associated lung injury (EVALI) (Taylor et al., 2019). An outbreak of EVALI was recently announced by the US Centers for Disease Control and Prevention (CDC) to be responsible for 2807 hospitalisations (15% were less than 18 years of age) and 68 deaths from 29 different states in the USA (CDC, 2020). The CDC currently suspects EVALI to be attributed to exposure to Vitamin E acetate, an agent found in tetrahydrocannabinol (THC) containing products to thicken the consistency of the liquid (Taylor et al., 2019).

In an effort to reduce tobacco use among youth and young adults, the US Congress recently passed a federal policy raising the minimal legal sales age (MLSA) of tobacco products to 21 years (Maloney, 2019), and in January 2020, the US Food and Drug Administration (FDA) announced it was prohibiting the sale of flavoured pod-mod devices (except tobacco and menthol flavour). If enforced properly, MLSA policies are believed to reduce tobacco initiation and long-term use (Friedman et al., 2019); however, the FDA’s flavour restriction has recently been criticised by many for the gaps it created by not including refillable or sealed disposable e-cigarette products (Gee, 2020; Hemmerich et al., 2020; Rodu, 2020). Such tobacco regulatory gaps demonstrate the importance of health promotion specialists using multiple strategies to reduce tobacco use among youth.

Beyond policy-level approaches, alternative strategies to tobacco prevention have included school-based education delivered to students (Brinker et al., 2019; Little et al., 2015; Nagler and Lobo, 2019; St Germain et al., 2017) and mass public health campaigns, such as The Real Cost (Brubach, 2019). Given research suggests young people believe e-cigarettes to be less harmful and less addictive than combustible cigarettes, a belief found to influence ever and past 30-day use of e-cigarettes (Dobbs et al., 2016), schools have been encouraged to include more education about these emerging products within their tobacco prevention education (Anand et al., 2015). However, such recommendations do not identify who should be delivering this education and how it should be delivered. While most educational programmes have been developed to be delivered directly to youth (Brinker et al., 2019; Little et al., 2015), no literature was found about tobacco prevention education created for middle school and high school educators. In Jamaica, student–teacher relationships were found to be a strong predictor of students’ decision to use combustible cigarettes (Oshi et al., 2018), and in Spain, children who saw a teacher smoke were more likely to try cigarettes than those with parents’ who smoked, identifying teachers as an important opinion leader for adolescents (Escario and Wilkinson, 2018). This may suggest that young people’s decision to use tobacco products (including e-cigarettes) could be influenced by multiple social ecological influences, including the behaviour of educators.

The social ecological model acknowledges people live within social environments that can influence behavioural decision-making. Such ecological systems are believed to influence behaviours and thus health outcomes (Golden and Earp, 2012). A framework of multilevel influences, first created by Urie Bronfenbrenner (1977), later identified five distinct social sources of behavioural influence: intrapersonal, interpersonal, organisational/institutional, community, and policy (McLeroy et al., 1988). While most studies about e-cigarettes have examined the influence of intrapersonal factors such as peers’ attitudes towards e-cigarettes (Cho et al., 2019), interpersonal factors (e.g. family) (Fite et al., 2018), or public policy (Friedman et al., 2019), few studies have explored behavioural strategies at the organisational- or community-levels of the social ecological model. School educators and administrators may have a key opportunity to influence middle and high school students’ health behaviours at an interpersonal and organisational-level.

The purpose of this study therefore was to examine potential changes in knowledge among middle school and high school teachers who taught at a public school in a rural community and attended a tobacco prevention workshop. To do this, an educational lesson about combustible cigarettes and e-cigarettes was provided to a pilot sample of teachers to measure their knowledge about youth tobacco use within the state with data being collected both before and after the session.

Methods

Intervention

Prior to the start of the 2019 school year, P.D.D. was invited by the assistant superintendent of a rural, southern US school district to speak to middle and high school educators about tobacco, emphasising information about emerging products (e.g. e-cigarettes). The school district enrolled approximately 1000 students within one middle school and one high school, with most students reported to be non-Hispanic white. Two informal phone conversations were held with the administrator to assess prior knowledge and experiences that warranted the request. Based on these conversations, it was determined that perceptions of how many middle and high school students were using combustible cigarettes and e-cigarettes, and the health outcomes known and suspected to be attributed to e-cigarette use were relevant topics for the intervention. Guided by the Precede-Proceed model (Green and Kreuter, 2005) as a planning framework, knowledge about these particular topics was believed to be influenced by educators’ background factors, such as age, sex and prior/current use of cigarettes and e-cigarettes, predictors of adult e-cigarette use (Pericot-Valverde et al., 2017). As seen in Figure 1, educators’ knowledge about cigarettes and e-cigarettes was believed to be a contributing factor to student knowledge, which was then believed to influence student behaviour.

Figure 1.

Potential influential factors of middle and high school students’ use of tobacco products.

During the 90-min educational lesson P.D.D. provided information about cigarette and e-cigarette use among middle and high school students in the state where data were collected and discussed health outcomes known (e.g. heart disease) and suspected (e.g. cancers and respiratory diseases) to be caused by e-cigarette use.

Participants and protocol

Administrators, teachers and staff members (n = 41) were invited to take part in a one-group, pre-test/post-test study (Shaughnessy et al., 2000) that assessed changes in their knowledge about youth cigarette and e-cigarette use during a 2-day in-service training event held August 2019. Participants were recruited during a general assembly announcement, where those interested in learning about Preventing Youth from Using The 21st century Cigarette were invited to attend a break-out session. Of those who attended the session, participants were asked if they would voluntarily take part in a study that asked them to complete a questionnaire about cigarettes and e-cigarettes before and after the educational session. All participants were provided an informed consent document and allowed time to read the document before they decided if they wanted to complete the paper/pencil survey. One assessment was collected before the educational presentation was delivered and a post assessment was collected immediately after the presentation. All procedures were approved by the University of Oklahoma Institutional Review Board.

Measures

Participants were asked questions that assessed their knowledge about cigarette and e-cigarette use among middle and high school students, as well as demographic questions and items that measured their past tobacco use during the pre-test assessment. Demographic questions included sex, race/ethnicity, age and grades taught.

Cigarette/e-cigarette use

Prior tobacco use measured past and current use of cigarettes and e-cigarettes. Participants were asked ‘Have you smoked a cigarette in your entire life, even one puff?’ and ‘Have you smoked at least 100 cigarettes in your entire life?’ Response options included dichotomous Yes/No responses. Participants were also asked to select if they now smoked cigarettes ‘every day, some days, or not at all’. Those who reported they had never smoked a cigarette in their lifetime were classified as never smokers. Those who answered they had smoked at least one puff but had not smoked 100 cigarettes in their lifetime were classified as experimenter smokers. Those who had smoked at least 100 cigarettes in their lifetime but reported ‘not at all’ to the item measuring if they now smoked cigarettes were classified as former smokers. Those who had smoked 100 cigarettes in their lifetime and selected they now smoked ‘every day’ or ‘some days’ were classified as current smokers. E-cigarette use was measured similarly to the items that measured combustible cigarettes, adapting the measure to read ‘electronic cigarettes’ and ‘used e-cigarettes’ rather than ‘cigarettes’ and ‘smoked’, respectively.

Knowledge questions

The same knowledge questions were asked during both the pre- and post-test to serve as a measure of the knowledge change following the educational intervention. Questions measuring knowledge about cigarette and e-cigarette use among middle and high school students included rates of ever-use and past 30 day use of cigarettes and e-cigarettes, what products people can vape in an e-cigarette device, what researchers know can be caused by e-cigarette use, and what researchers suspect can be caused by e-cigarette use. Rates of use included the percentages of youth tobacco use in the state where the assessment took place, using data from the 2017 Youth Behavioural Risk Surveillance (YRBS) (Kann et al., 2018).

Quantitative data analysis

Using IBM SPSS Statistics 24 (IBM Corporation, 2016), data were analysed by first reporting descriptive statistics about the participants who completed both the pre- and post-assessments. Associations between correctly/incorrectly answered items before and after the educational intervention were measured using 2 X 2 Pearson Chi-Square analyses. Fisher’s Exact test was employed to examine significance when 25% of the expected cell count was less than 5 due to its ability to examine relationships between small sample sizes while controlling for type I error. The total knowledge score was measured by calculating a sum of the seven knowledge items. Then, a paired-sample t-test was used to examine the difference between the mean value of the pre- and post-intervention test score. Finally, independent t-tests were conducted to examine if there were differences between change of knowledge and various participant characteristics (e.g. sex, age, smoker status). Change in knowledge was calculated by subtracting the pre-test sum score from the post-test sum score and used this change score as a continuous variable. Alpha was set at 0.05 for all analyses.

Observation

Immediately following data collection, P.D.D. took notes about the intervention implementation, participants’ questions/comments during the presentation and additional interactions that took place during the implementation phase of the study. After analysing all data, the author reflected on these notes to consider relevance of key messages and potential misconceptions among the participants.

Results

Among our sample (n = 41), 37 participants were between the ages of 30 and 65 years; only four were less than 30 years of age. Age categories were broken into those less than 40 years of age (n = 19) and those 40 years of age and older (n = 22) based on participants’ responses (M = 42.3, SD = 11.4). The majority were white (n = 37, 90.2%), 20 participants were female, and 40 were teachers (one participant identified as a school administrator). Participants taught students ranging from the 6th to 12th grade, and the majority instructed grades 9–12. All participants taught more than one grade-level. Overall, 43.9% (n = 18) of participants reported they had never tried a combustible cigarette, 39% (n = 16) had experimented with cigarettes but were not current users, and 12.2% (n = 5) were former smokers. None reported the current use of combustible cigarettes. Similarly, 87.8% (n = 36) of participants reported to have never used an e-cigarette, and 12.2% (n = 5) had experimented with some type of e-cigarette product but were not current users. No participants reported current use of e-cigarettes (Table 1).

Table 1.

Participant characteristics (N = 41).

Variable	N	%
Age (years)
20–29	4	9.8
30–39	15	36.6
40–49	10	24.4
50–65	12	29.3
Sex
Female	20	48.8
Male	20	48.8
Missing	1	2.4
Race/Ethnicity
White	37	90.2
American Indian or Alaskan Native	2	4.9
Hispanic	2	4.9
Position
School administrator	1	2.4
Teacher	40	97.6
Grades taught^a
6th	15	36.6
7th	17	41.5
8th	19	46.3
9th	26	63.4
10th	29	70.7
11th	26	63.4
12th	26	63.4
Cigarette use
Never user	18	43.9
Experimenter	16	39.0
Former user	5	12.2
Current	2	4.9
E-Cigarette use
Never user	36	87.8
Experimenter	5	12.2

Totals may not add up to 100% due to multiple item selection.

Knowledge assessment

When asked what health conditions could potentially be affected by e-cigarette use, 85.4% (n = 35) of the sample correctly answered the question during the pre-test. Among those, 31 answered the question correctly again during the post test, and 3 participants who answered the question incorrectly during the pre-test answered it correctly during the post-test, χ²(1, N = 41), = 5.38, p = .05. No other significant relationships were found between pre-/post-item responses for items asking about the percent of high school students who had ever used an e-cigarette, currently used e-cigarettes, had ever used regular cigarettes, currently used combustible cigarettes, what other substances someone could inhale from an e-cigarette and what health conditions were known to be affected by e-cigarette use. Although there were no significant differences between individual pre-/post-test item responses (see Table 2), the overall knowledge sum score significantly increased from pre-test assessment (M = 2.93, SD = 1.2) to post-test assessment, M = 3.46, SD = 1.3; t(40) = -2.15, p < .05.

Table 2.

Correct responses to pre/post knowledge about E-cigarette use.

Variables	PreN (%)	PostN (%)	p-value
1. What % of high school students (grades 9–12) have ever used an e-cigarette?	15 (36.6)	20 (48.8)	.84
2. What % of high school students (grades 9–12) used an e-cigarette in the last 30 days?	17 (42.5)	23 (57.5)	.43
3. What % of high school students (grades 9–12) have ever used a regular cigarette?	10 (26.3)	6 (15.8)	.16^a
4. What % of high school students (grades 9–12) used a regular cigarette in the last 30 days?	10 (24.4)	7 (17.1)	.33^a
5. Besides nicotine, what other substances can someone use an e-cigarette to inhale?	31 (75.6)	39 (95.1)	.43^a
6. What health conditions has recent research shown to be affected by e-cigarette use?	1 (2.4)	13 (31.7)	.32^a
7. What health conditions does recent research suggest COULD be affected by e-cigarette use?	35 (85.4)	34 (82.9)	.05^a
Total score (M, SD)	2.93 (1.21)	3.46 (1.29)	.04

SD: standard deviation.

N value indicates number of correct responses. Chi-square analysis was used to compare differences per individual items. Dependent (paired sample) t-test was used to measure total score.

Fisher’s exact was employed when 25% of the expected cell count was less than 5.

Differences in knowledge

While small improvements of knowledge scores were found to be higher among women than men, t(38) = 0.80, p = .436, those 20–39 years than those 40–65 years, t(39)= 1.14, p = .261, those who did not teach high school students than those who did t(9) = 0.68, p = .501, never smokers than those who had tried a combustible cigarette, t(39) = 0.32, p = .734, and e-cigarette experimenters than never users, t(39) = 1.62, p = .113, none of these differences were significant. See Table 3 for full data pertaining to changes in knowledge based on participant characteristics.

Table 3.

Differences between participant characteristics and change in knowledge.

	Change in knowledge	p-value
	M (SD)
Sex		.426
Males	0.40 (1.67)
Females	0.80 (1.47)
Age		.261
20–39	0.84 (1.64)
40–65	0.27 (1.55)
Taught high school students		.501
No	0.82 (1.25)
Yes	0.43 (1.72)
Smokers status		.734
Never	0.44 (1.62)
Experimenter	0.25 (1.69)
Vaper status		.113
Never user	0.39 (1.54)
Experimenter	1.60 (1.82)

SD: standard deviation.

Notes and reflections

Based on the researchers’ journal, informal conversations throughout the educational session revealed (1) misconceptions about the amount of young people who were using e-cigarettes, (2) uncertainty about the existence of e-cigarette products and (3) how best to approach regulatory actions for youth caught using tobacco products at school. Among those study participants who had heard about e-cigarettes, many had been told by middle and high school students that all students used them. Many were under the impression that all students in their high school had tried an e-cigarette at least once, and more than one participant stated that the rate of use among high school students was higher in their school district than the state-wide rate reported in the presentation. Albeit few, some participants stated that they had not heard about e-cigarettes at all, with the presentation being the first they had heard of these devices. Finally, many participants asked how they should regulate these products within their school. They discussed suspension measures taken for those involved in extracurricular activities; however, these were not believed to be effective and seemed unrealistic if all students within the activity engaged in e-cigarette use.

Discussion

This study examined middle and high school teachers’ knowledge about tobacco products before and after a tobacco prevention educational session that focused on combustible cigarettes and e-cigarettes. Despite the small sample size, findings provide valuable lessons for those developing and implementing tobacco prevention programmes created for middle and high school educators.

Besides the summed knowledge score, there were no significant differences between the pre-/post-scores for individual items; however, more participants in the sample answered items about combustible cigarettes correctly during the pre-test than the post-test. With items that asked about the percentage of middle school and high school students who use e-cigarettes, it is possible that educators may have overestimated use among their students, similar to findings that suggested young people overestimate their peers’ use of e-cigarettes and combustible cigarettes (Agaku et al., 2019). To our knowledge, our study is the first to find educators overestimating e-cigarette use among their students. Based on the researcher’s notes, we suspect students’ estimation of use among their peers may have strongly influenced participants’ perceptions.

Instead, school-based tobacco prevention education programmes are encouraged to explain the potential health effects that may be attributed to e-cigarette use to provide context about the potential harms of using these products, a factor found to influence youth e-cigarette ever and past 30-day use (Dobbs et al., 2016). Such programmes may explain that e-cigarette use has been found to increase cardiovascular-related diseases (Bhatta and Glantz, 2019) and increase risks for lung disease (Clapp and Jaspers, 2017) and cancer (Lee et al., 2018). Moreover, those delivering a tobacco prevention programmes to educators and/or students are encouraged to use evidence-based educational resources, such as the Stanford Tobacco Prevention Toolkit (Stanford Medicine, 2020), a resource not used for the present study. In prior studies, medical students have delivered tobacco prevention educational classes to middle and high school students (Brinker et al., 2019), but this may not be feasible for rural communities, especially those that are medically underserved. Feasible options for rural schools may include mobile or text messaging-based tobacco education and prevention programmes for students, parents and/or educators, as used for other health behaviours in rural youth populations (Brown et al., 2019).

Just as individual behaviours are influenced by higher-levels of the social ecological model, it should also be recognised that lower-levels factors, such as individual, interpersonal, organisational and community, may also influence higher levels of the social system (e.g. policy adoption) (Glover-Kudon et al., 2019). For tobacco prevention in youth populations, particularly those attending middle and high school, increasing the knowledge of those who have interpersonal relationships with students or who influence organisational processes or campus policies may be the initial strategies needed to reduce youth e-cigarette use. Our findings suggest that middle school and high school teachers’ knowledge increased following an educational workshop. However, more research is warranted to understand how middle school and high school educators can help to support campus, community-wide and state-level policies and programmes that seek to reduce tobacco use among youth (Figure 2).

Figure 2.

Social ecological approach to reduce youth e-cigarette use.

Limitations

This study was subject to limitations. Due to the research design, no causal claims can be made. The small sample size may have attributed to the lack of significant findings. With a larger sample, it may have been possible to identify significant differences between characteristics such as smoker status and change in knowledge scores. Also, due to the lack of availability of an institution of similar size and educator demographic make-up, we were unable to recruit an institution to serve as a control group.

Conclusion

Teachers and administrators at middle and high schools are in an important position to influence adolescents’ decision to try tobacco products. Increasing educators’ knowledge about the harms of tobacco use including the use of e-cigarettes may help schools promote an organisational-wide message. Health educators working with schools may find it helpful to use recently developed evidence-based programmes, such as the Stanford Tobacco Prevention Toolkit, to inform teachers and students about emerging tobacco products. By increasing knowledge about novel tobacco products, the harms associated with the use of all forms of tobacco, and strategies to reduce use among youth, school-based tobacco prevention programmes may help reduce initiation and use among youth.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Page D Dobbs

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, et al. (2018) Tobacco product use among middle and high school students–United States, 2011–2017. Morbidity and Mortality Weekly Report 67(22): 629–633.