2014 Georgia youth tobacco-free : school policy report

2014 Georgia Youth Tobacco-Free
School Policy Report
Georgia Tobacco Use Prevention Program dph.ga.gov/tobacco

Acknowledgements
Georgia Department of Public Health Brenda Fitzgerald, MD Commissioner, State Health Officer
Health Protection J. Patrick O'Neal, MD Director
Epidemiology Program Cherie L. Drenzek, DVM, MS State Epidemiologist
Chronic Disease, Healthy Behaviors and Injury Epidemiology Section Rana Bayakly, MPH Chief Epidemiologist
Chronic Disease Prevention Section Jean O'Connor, JD, DrPH Chronic Disease Prevention Director
Tobacco Use Prevention Program Kenneth Ray, MPH Deputy Director
For more information on tobacco surveillance in Georgia, please contact:
Alina Chung, MPH Tobacco Epidemiologist Chronic Disease, Healthy Behaviors and Injury Epidemiology Section Division of Health Protection Georgia Department of Public Health 2 Peachtree Street NW, 14th Floor Atlanta, GA 30303-3142 (404) 657-2588 http://dph.georgia.gov/georgia-tobacco-use-surveillance
Suggested citation: Velasquez-Portocarrero, C., Chung, A., Vajani, M., Bayakly, R. 2014 Georgia Youth Tobacco-Free School Policy Report. Georgia Department of Public Health, Health Protection, Epidemiology, Chronic Disease, Healthy Behaviors and Injury Epidemiology Section, August 2015
This publication is supported by the Cooperative Agreement 2U58DP002005-09 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the CDC.

Introduction
Smoking on school grounds has detrimental effects on students at school, including encouraging students to smoke. Furthermore, smoking during youth is particularly harmful due to cumulative exposure to toxins present in cigarettes and tobacco products, increasing the risk for diseases such as cancer, cardiovascular diseases, respiratory diseases and perinatal conditions later in adulthood.1
Almost all smokers have their first cigarette by age 26 and about 90 percent of smokers began smoking before 18 years of age1. In 2013, approximately 4 percent (14,000) of middle school (MS) and 13 percent (53,000) of high school (HS) students in Georgia smoked cigarettes, which is the lowest percentage since 2003 (Figure 1). Smoking prevalence generally increased with increasing grade, ranging from 2 percent among 6th graders to 15 percent among 12th graders (Figure 2).
Established in 2000, the Georgia Tobacco Use Prevention Program (GTUPP) is designed to meet the overall goal of reducing the health and economic burden associated with tobacco use. One of the goals of the GTUPP is to prevent tobacco initiation among youth. Tobacco-free school policies help to prevent smoking initiation among youth and stop youth smokers from becoming established adult smokers. The model "100% Tobacco-Free School Policy" includes no tobacco use or possession2,3:
On school property, in school vehicles or at school functions off school property By all students, staff, parents and visitors At all times, 24 hours a day seven days a week Youth involvement in tobacco-free trainings, advocacy, and coalition building at school are important steps to establish 100 percent tobacco-free school policies.
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Studies have found that 100 percent tobacco-free school policies contribute to reducing tobacco use among youth1. Farkas et al. also found that smoking bans in workplaces are related to lower adolescent smoking4. Smoking prevalence is lower among youth attending 100 percent tobacco-free schools due to lack of visibility of others smoking on school grounds, including parents and teachers, which has been associated with social acceptability5, reduced opportunity to smoke6, reduced negative role-models 7, 8 and changing social norms8, 6. Along with 100 percent tobacco-free school policies, enforcement must be in place in order to see lower student smoking rates1,7. As a result, the Georgia Tobacco Free Schools Project (GTFSP) was initiated in 2005 to reduce youth tobacco use and exposure to secondhand smoke. In addition to school policy, other influences in youths' environment also affect smoking behavior1. Social influences at school and at home are vastly important for youth, especially in their early years when smoking initiation begins. Parents and family networks also influence youth smoking behavior. It has been shown that lower smoking behavior is associated with parental communication around smoking9,10.
Georgia does not have statewide legislation mandating100 percent tobacco-free policies in public K-12 schools. Therefore, each school district must pass the 100 percent tobacco-free policy individually. As of 2014, 101 (56 percent) of the Georgia's 181 school districts successfully passed 100 percent tobacco-free policies (Figures 3 and 4). This is a significant increase from 2005, when only one Georgia school district had a 100 percent tobacco-free policy. In 2013, the Georgia Tobacco Use Prevention Program (GTUPP) added questions to the national Youth Tobacco Survey to assess the implementation of the 100 percent tobacco-free school policy in Georgia.
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Methodology/Sample
The Youth Tobacco Survey (YTS) was administered to public middle school and high school students in Georgia in 2013. A total of 41 middle schools and 50 high schools participated in the survey. (See Appendix A for additional details on methodology and sample size).
Tobacco Use on School Property
In 2013, approximately 13 percent (46,000) of Georgia middle school students and 33 percent (72,000) of high school students smoked a tobacco product on school property or knew someone else who smoked on school property. Smoking on school property was significantly higher among non-Hispanic (NH) White students (41 percent; 85,000) than NH Black (26 percent; 45,000) high school students (Figure 5).
Prevalence of smoking on school property was significantly higher among 8th graders (17 percent; 21,000) than 6th graders (9 percent; 11,000), but not when compared to 7th graders (11 percent; 14,000).
Prevalence of smoking on school property did not significantly differ among high school students, but it was highest among 11th graders (Table 1, Figure 6).
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Students who knew of someone, including themselves, who smoked cigarettes or used smokeless tobacco on school property In 2013, approximately 12 percent (43,000) of middle school students and 35 percent (160,000) of high school students in Georgia used smokeless tobacco product on school property.
NH White (46 percent; 95,000) high school students were significantly more likely than NH Black (25 percent; 43,000) and Hispanic (28 percent; 13,000) high school students to know someone who used smokeless tobacco on school property (Figure 7).
Among middle school students in Georgia, smokeless tobacco use on school property was significantly higher among 8th graders (18 percent; 22,000) than 6th graders (7 percent; 8,000) in 2013. However, using smokeless tobacco on school property did not differ significantly among high school students by grade (Table 2, Figure 8).
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Student Knowledge of Existing 100 Percent Tobacco-Free School Policies
Only 26 percent (98,000) of high school students and 21 percent (64,000) of middle school students in Georgia knew whether their school was a 100 percent tobacco-free school (Figure 9).
Among middle school (MS) students, the same percentage of male (21 percent; 32,000) and female students (21 percent; 32,000) stated that they knew their school was a 100 percent tobacco-free policy school.
Approximately 27 percent (52,000) of male high school (HS) students and 25 percent (46,000) of female HS students stated that they knew their school was a 100 percent tobacco-free policy school.
More than half of high school (59 percent; 222,000) and middle school students (63 percent; 191,000) were not sure whether their school had a 100 percent tobacco-free school policy.
Georgia high school students (43 percent; 158,000) were more likely than middle school students (37 percent; 110,000) to know they attended a school with a tobacco policy prohibiting tobacco use in all school locations including school grounds, in school buildings, on school buses or other school vehicles and at off-campus school-sponsored events.
Among Georgia middle school students, 29 percent (83,000) thought their schools' tobacco policy prohibited tobacco use during both school and non-school hours, while 43 percent (156,000) thought it prohibited tobacco use during school hours only and 2 percent (8,000) during non-school hours only.
Among Georgia high school students, 35 percent (125,000) thought their schools' tobacco policy prohibited tobacco use during both school and non-school hours, while 47 percent (214,000) thought it prohibited tobacco use during school hours only and 3 percent (14,000) during non-school hours only.
Youth Involvement in Tobacco-Free Advocacy, Training and CoalitionBuilding
Involvement in organized activities to keep young people from using tobacco
Students who are involved in tobacco-use prevention activities in their communities can help reduce the burden of the tobacco epidemic by preventing youth from initiating tobacco11.
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In 2013, Georgia middle school students (17 percent; 63,000) were more likely than high school students (13 percent; 60,000) to be involved in organized activities to keep youth from using tobacco.
In 2013, Georgia middle school smokers (24 percent; 2,700) were more likely than high school smokers (15 percent; 8,000) to be involved in organized activities to keep youth from using tobacco.
Students involved in organized activities to keep students of similar age from using tobacco products did not differ significantly among youth by grade (Table 3, Figure 10).
Youth as Part of a Tobacco-Free Coalition
Middle school students who were taught why not to use tobacco at school (29 percent; 62,000) were significantly more likely to participate in Tobacco-Free Coalitions on Youth Groups than middle school students who were not taught why not to use tobacco at school (20 percent; 30,000) (Figure 11).
High school students who were taught why not to use tobacco at school (27 percent; 47,000) were significantly more likely to participate in a Tobacco-Free Coalitions on Youth Groups than high school students who were not taught why not to use tobacco at school (16 percent; 44,000) (Figure 12).
Tobacco-Free Schools Youth Summit
More Georgia middle school students who were taught not to use tobacco at school (18 percent; 38,000) attended a Tobacco-Free Schools' Youth Summit than those who were not taught not to use tobacco at school during the current school year (14 percent; 22,000).
More Georgia high school students who were taught not to use tobacco at school (14 percent; 25,000) attended a Tobacco-Free Schools' Youth Summit than those who were not taught not to use tobacco at school during the current school year (10 percent; 27,000).
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Youth who presented or advocated to any school board or city council members for tobacco-free causes
Georgia middle school students who were taught why not to use tobacco at school during the current school year (14 percent; 30,000) were more likely to present or advocate to a school board or city council members than those who were not taught why not to use tobacco at school (9 percent; 14,000).
The prevalence of high school students who presented or advocated to a school board or city council member was higher among those who were taught why not to use tobacco at school during the current school year (11 percent; 20,000) than those students who were not taught why not to use tobacco at school (8 percent; 21,000).
Youth as Part of a Tobacco-Free Coalition/Youth Group
Georgia middle School students who were part of a tobacco-free coalition/youth group were significantly more likely to be aware (16 percent; 15,000) of someone who smoked than those MS students who were not part of the tobacco-free coalition/youth group (11 percent; 30,000) (Figure 13).
Georgia middle school students who were part of a tobacco-free coalition/youth group were more likely to be aware (15 percent; 14,000) of someone who used smokeless tobacco than those MS students who were not part of a tobacco-free coalition/youth group (11 percent; 29,000).
Georgia high school students who were part of a tobacco-free coalition/youth group were more likely to be aware (38 percent; 35,000 for smoking and 39 percent; 35,000 for smokeless tobacco) of someone who smoked or used smokeless tobacco than those HS students who were not part of a tobacco-free coalition/youth group (32 percent; 115,000 for smoking and 34 percent; 124,000 for smokeless tobacco).
Tobacco-Free Schools' Youth Summit
Georgia middle school students who attended a Tobacco-Free Schools' Youth Summit were significantly more likely to be aware of students who use tobacco products (21 percent; 12,000 for smoking and 20 percent; 12,000 for smokeless tobacco) on school property than students who did not attend a Tobacco-Free Schools' Youth Summit (10 percent; 23,000 for smoking and 9 percent; 21,000 for smokeless tobacco) (Figure 14).
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Georgia high school students who attended a Tobacco-Free Schools Youth Summit were more likely to be aware of students who use tobacco products (42 percent; 22,000 for smoking and 39 percent; 20,000 for smokeless tobacco) on school property than students who did not attend a Tobacco-Free Schools Youth Summit (32 percent; 108,000 for smoking and 35 percent; 117,000 for smokeless tobacco).
Youth who presented or advocated to any school board or city council members for tobacco-free causes
Georgia middle school students who advocated to a school board or city council for tobacco-free causes were significantly more likely to be aware (30 percent; 13,000 for smoking and 22 percent; 9,000 for smokeless tobacco) of other students who use tobacco products on school property than students who did not advocate to a school board or city council (10 percent; 32,000 for smoking and 10 percent; 33,000 for smokeless tobacco) (Figure 15).
Georgia high school students who advocated to a school board or city council for tobacco-free causes were significantly more likely to be aware (49 percent; 20,000 for smoking and 42 percent, 17,000 for smokeless tobacco) of other students who use tobacco products on school property than students who did not advocate at a school board or city council meeting (32 percent; 130,000 for smoking and 35 percent; 142,000 for smokeless tobacco) (Figure 16).
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References:
1. U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012.
2. Centers for Disease Control and Prevention, MMWR. "Guidelines for School Health Programs to Prevent Tobacco Use and Addiction". Vol 43(RR-2); 1-18. February 25, 1994 http://www.cdc.gov/mmwr/preview/mmwrhtml/00026213.htm
3. "A Model 100% Tobacco- Free School Policy For School Districts In Georgia", March 2011. http://www.gachd.org/healthy-living/100_tobacco-free_schools.php on Coastal Health District Website.
4. Farkas AJ, Gilpin EA, White MM, Pierce JP. Association between household and workplace smoking restrictions and adolescent smoking. JAMA: the Journal of the American Medical Association 2000;284(6):71722.
5. Alesci NL, Forster JL, Blaine T. Smoking visibility, perceived acceptability, and frequency in various locations among youth and adults. Preventive Medicine 2003;36(3):27281.
6. Levy, D. T., Friend, K., and Polishchuk, E. Effect of clean indoor air laws on smokers: the clean air module of the SimSmoke computer simulation model. Tobacco Control 2001: 345-351.
7. Wakefield, M. & Chaloupka, F. J. (2000) Effectiveness of comprehensive tobacco control programs in reducing teenage smoking in the USA. Tobacco Control, 9, 177186.
8. Wakefield and Forster. Growing evidence for new benefit of clean indoor air laws: reduced adolescent smoking. Tobacco control 2005, 14:292-293.
9. Chassin L, Presson CC, Rose J, Sherman SJ, Davis M, Gonzalez JL. Parenting style and smoking-specific parenting practices as predictors of adolescent smoking onset. Journal of Pediatric Psychology 2005; 30(4):333 44.
10. Huver RM, Engels RC, de Vries H. Are anti-smoking parenting practices related to adolescent smoking cognitions and behavior? Health Education Research 2006; 21(1):6677
11. Starr G, Rogers T, Schooley M, Porter S, Wiesen E, Jamison N. Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs. Atlanta, GA: Centers for Disease Control and Prevention; 2005.
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Appendix A:
Methodology
Data in this report came from the 2013 Georgia Youth Tobacco Survey (YTS), with the exception of basic smoking prevalence among youth. Smoking prevalence was calculated from the 2003-2013 Youth Risk Behavior Surveillance System (YRBSS). The Tobacco Use Survey has been conducted to gather information on use of tobacco, related behaviors and attitudes, and secondhand smoke exposure among public middle school (grades 6-8) and high school (grades 9-12) students statewide since 2001. The questionnaire included 97 questions and a core set of tobacco-related questions developed by Centers for Disease Control and Prevention. The topics covered in the questionnaire were: tobacco use, exposure to secondhand smoke, smoking cessation, school curriculum, minors' ability to purchase or obtain tobacco products, knowledge and attitudes about tobacco, familiarity with pro-tobacco and anti-tobacco media and message and asthma.
Sampling Procedure
A two-stage cluster sample design was used to produce a representative sample of middle school students and high school students. In the first stage sampling frame, all public middle schools in Georgia containing grades 6, 7, and 8 and public high schools containing any of grades 9, 10, and 11 were included in the sampling frame. Then 50 public middle schools and 50 public high schools were selected randomly with a probability proportional to enrollment size. The second sampling stage consisted of systematic equal probability sampling a random selection. All second period classes in the selected schools were included in the sampling frame.
Response Rates
Forty-one of 49 sampled middle schools in Georgia participated in the survey (83.67 percent school response rate) in 2013. Of the 2,241 sampled students in the middle schools, 2,100 completed usable questionnaires (93.70 percent student response rate). The overall response rate for the middle school survey was 78.40 percent (83.67 percent * 93.70 percent = 78.40 percent).
Thirty-five of the 50 sampled high schools participated in the survey (70.00 percent school response rate). Of the 1,983 sampled students in the high schools, 1,776 completed usable questionnaires (89.56 percent student response rate). The overall response rate for the high school survey was 62.69 percent (70.00 percent * 89.56 percent = 62.69 percent). Georgia's response rates for both samples met the CDC requirement of an overall response rate of 60 percent.
Weighting
For both the middle school and high school data, a weight variable was calculated for each questionnaire to reflect the likelihood of sampling each student and to reduce bias by compensating for differing patterns of non-response. The weight use for estimation is given by:
W = W1 * W2 * f1 * f2 *f3 *f4
W1 = the inverse of the probability of selecting the school
W2 = the inverse of the probability of selecting the classroom within the school
f1 = a school-level non-response adjustment factor calculated by school size category (small, medium, large).
f2= a class adjustment factor calculated by school
f3 = a student-level non-response adjustment factor calculated by class
f4 = a post stratification adjustment factor calculated by gender, race and grade
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