Undergraduate Research Journal for the Human Sciences

Keywords : smoking cessation programs, alternative schools, drug education, juvenile delinquents, tobacco use, smoking, substance use

Abstract

Alternative education students report more tobacco use than their counterparts in regular education programs, possibly due to a lack of programming specifically targeted to tobacco education and cessation for alternative school students. The researchers modified the Tobacco-Free Missouri Tobacco Cessation Program (a six-week long, highly interactive, small-group based program) to emphasize the key elements of successful alternative education programs (social skills training, concern for students, small learning groups, and active-learning strategies). The program was implemented in a rural, Northeast Missouri alternative education high school as a voluntary, ‘pull-out’ program for smokers during a mid-morning class time.

After examination, the enhanced program did not seem to affect participants’ first and most frequent tobacco use, perceived difficulty of being in smoke-free environments, the number of tobacco products used/day, and their intention to quit. During a later follow-up reactive evaluation interview, a few participants conveyed that they did quit using tobacco products since the conclusion of the program. Although this pilot project demonstrated mixed results for attitude or behavior change, further research is needed to identify types of interventions that would be most effective with the at-risk, alternative school population.

Introduction

Cigarette use, a risk behavior associated with the leading causes of death in our country, is still prevalent among U.S. adolescents. Historically, high school students’ current and lifetime cigarette use seemed to increase in the 1990s, decrease during the start of the new millennium, and then stabilize during the recent past. In order to meet our nation’s health objectives to decrease youth smoking prevalence, youth cigarette use trends need to decline again (Centers for Disease Control and Prevention [CDC], 2006). Results from the 2005 national Youth Risk Behavior Survey (YRBS) indicated that 54.3% of high school students ever tried cigarettes, and 23% reported current cigarette use. Of those who reported current cigarette use, almost 11% smoke more than 10 cigarettes per day, and over half (54.6%) had tried to quit smoking during the past year. Nationally, lifetime cigarette use and smoking over 10 cigarettes each day was reported to be higher among males than females, but females were more likely to report having tried to quit smoking over the past year (Eaton et al., 2006).

The CDC recommended implementation of comprehensive tobacco-control programs to reduce tobacco use among American youth (CDC, 2006). In addition to tobacco prevention education for non-smokers, another important part of a comprehensive program is tobacco cessation for those youth who do smoke or use smokeless tobacco. School-based curricula, media interventions, teen smoking cessation programs, and school-based clinic programs seemed to be effective (Adelman, Duggan, Hauptman, & Joffe, 2001; Boyle, Stilwell, Vidlak, & Huneke, 1999; Dino et al., 2001; Sussman, Dent, & Lichtman, 2001) as youth tobacco cessation interventions. When a comprehensive review of interventions was conducted, teen smoking cessation programs were viewed as promising strategies to be examined further (Lantz et al., 2000).

Although teen smoking cessation programs are recommended, specific interventions for rural youth are not well addressed. Even in relatively successful cessation interventions, rural adolescents’ quit rates were lower than rates found for non-rural adolescents (Horn, Dino, Kalsekar, & Fernandes, 2004). In general, smoking prevalence is higher in rural areas than in urban areas with a greater gap for adolescents. Rural areas typically lack tobacco prevention and cessation resources and activities in comparison to their urban counterparts (Stevens, Colwell, & Huchinson, 2003). Rural youth are about twice as likely as urban or suburban youth to engage in risk behaviors like frequent smoking, reinforcing the need for prevention and cessation programs focused on the specific needs of this sub-population (Atav, 2002).

Alternative high schools provide a non-traditional setting (e.g., self-contained classrooms, low teacher-student ratios, more support services, curricular flexibility) for students experiencing difficulties in regular high schools to more easily learn to move towards independence. Alternative education students typically have academic, family, and/or behavioral problems that require transfer or referral to an alternative campus not only for traditional coursework but also for work-study and counseling programs (Weist, Wong, Cervantes, Craik, & Kreil, 2001). Tobacco use rates seem much higher in those “at-risk” students attending alternative high schools because of school failure, drop-out or expulsion risk, behavioral and family problems, or delinquency. Nationally, almost 91% of high school students attending alternative schools reported ever trying cigarette smoking. In a Maryland study, alternative school students reported more tobacco use, more recent smoking initiation, and were reportedly more likely to reside in a household with a smoker than their regular school peers (Maryland Department of Health and Mental Hygiene, 2002).

Tobacco education and cessation programs are just as important for this population since alternative school students are at higher risk for many unhealthy behaviors and report more tobacco use. Although many model or successful programs address adolescent smoking cessation in regular school students (SAMSHA, n.d.), there is a lack of programming specifically targeted to tobacco education and

smoking cessation for alternative school students; especially for those in rural areas. Cessation programs for at-risk youth should include behavior-change strategies as well as motivation to quit techniques (Sussman, Dent, Severson, Burton, & Flay, 1998). In addition, successful alternative education programs have common features and key elements that provide students with a sense of community that can foster improved academic and social skills (Saunders & Saunders, 2002). Key features of research-based, model alternative schools include social skills education (Tobin & Sprague, 1999), instructor’s genuine concern for students (Saunders & Saunders, 2002), as well as small learning groups, and inventive instructional techniques (Husted & Cavalluzzo, 2001).

The purpose of this pilot project was to test an adapted tobacco education and cessation intervention based on the key elements of successful alternative schools on the tobacco use frequency of rural, alternative education students.

Methods

After IRB approval, as well as student, parental, and teacher consent, all 10 current tobacco users (seven boys and three girls; all White, ranging from 15-17 years of age) in a class of 17 (58.8%) high school-aged students who attended an alternative education school participated in the smoking cessation program during fall 2005.

A brief, written pre-post survey was used. The six-question, multiple choice survey addressed the following: time of day of participants’ first and most frequent tobacco use, their perceived difficulty of being in smoke-free environments and in quitting tobacco use, and the number of tobacco products used/day (Appendix). The survey was written at approximately the sixth grade reading level (University of Memphis, Institute of Education Sciences, n.d.). The survey was coded for analysis using a weighted

scale of a most desirable to a least desirable response: 1- least desirable behavior, 2- most desirable behavior, and 3- no response. For example, for item 5 (shown in the appendix) it would be more desirable to smoke later in the day because the urge to smoke would not be present upon waking. The Chronbach’s alpha (α) value for the six –item survey was .133. The low alpha value would suggest that each question within the survey was measuring a unique behavior or attitude for tobacco use, a highly multi-faceted behavior. The survey was pre-tested with a group of eight health education majors (to proofread and suggest format changes) and then with a group of five students from the previous alternative high school class (who were similar in demographics and academic ability as the current sample) and subsequently revised.

In addition, a responsive evaluation interview guide was used to identify concerns and issues about the tobacco education and cessation program affecting the participants as stakeholders. A responsive evaluation widens the focus of an evaluation beyond the traditional behavioral objectives to include such qualitative data as the political climate, personal values, and standards. Responsive evaluation attempts to more deeply and extensively describe the issues and values of the stakeholders being studied in order for the team of evaluators, in conjunction with the stakeholders, to make future programming recommendations (Gall, Gall, & Borg, 2003).

The guide was piloted with a group of eight health education majors (to improve the guide and interview procedure) and revised accordingly. Open-ended discussion questions focused on participants’ concerns (perceptions of what was “cool” in the program and what program segments were effective and persuasive), issues (sharing experiences/progress, tobacco use triggers, and coping with life stress), as well as their values (motivation, encouragement, social support, and health beliefs). An evaluation team conducted the interview two months post-program since state assessments and end-of-the-marking period testing had started, and school would then be out for winter vacation. Responsive evaluation, using subjective interviews and interactions/negotiations with stakeholders, is an informal process that is conducted as-needed by the audiences (Gall, Gall, & Borg, 2003).

The Tobacco-Free Missouri Coalition’s Tobacco Cessation Program (Tobacco Free Missouri Health Care Committee, 2000), a six-week long, highly interactive, small-group based program; was used as the intervention, but the program was enhanced to emphasize the key elements of successful alternative education programs (social skills training, concern for students, small learning groups, and active-learning strategies). Social skill training was emphasized through discussion of real-life scenarios focusing on positive interactions with others and healthy coping skills. The instructors, local college-aged health education majors in 4-5 person teams, instructed the program in place of the usual classroom teacher; interacting more like mentors than teachers. The classes were taught for one hour each week for six weeks. Instruction was conducted in small groups, and the mentors used inventive, active-learning instructional strategies with the participants.

Mentors asked all of the alternative education students if they smoked, and if so they were invited to participate in the program. All agreed. Participation by the smokers was voluntary with no incentive to become involved given by either the classroom teacher or the mentors. The program was conducted as a “pull-out” during the mid-morning (10:30-11:20am) class, and all participants attended all of the sessions. The program followed the Transtheoretical Model, a model used to promote intentional change, as participants made decisions about whether to quit smoking based on their readiness and motivation. Through the series of instructional sessions (each with different cognitive, affective, and skill objectives), participants were challenged to try the new behavior (Prochaska & DiClemente, 1984).

In Session 1, participants were congratulated on their decision to attend the sessions, session expectations were discussed, and active participation in all of the games, activities, and discussion groups was highly encouraged. Participants shared their experiences with tobacco, both first and second hand, and shared stories with the group about the people in their lives who smoke, namely friends and family. Participants were asked why they chose to smoke, were presented with national statistics about smoking, and then asked for their reactions. The mentors encouraged the participants using real-world examples and role-modeled positive interactions for them. The written pre-survey was distributed to monitor their aggregate progress and to note any changes by the end of the program.

In Session 2, the focus was on positive affirmations, the health effects of tobacco use, second hand smoke, their individualized plans for quitting, and obtaining their “quit-buddy” for social support. A video called “Don’t Smoke Around Me” initiated discussion of their reluctance to quit, and group brainstorming was conducted about the benefits of quitting. The mentors worked with participants in one-to-one or small groups on their individualized quit plans and used positive posters, affirmations, and continued encouragement to motivate the participants.

In Session 3, held during the week of the Great American Smoke-Out, the goal was to encourage participants to start cutting back on tobacco use. “Commit to Quit” contracts were signed, and participants role-played fun, creative ways to throw away their tobacco products. During this session, demonstration activities included pictures of lungs and other body parts that have been negatively affected by smoking as well as pictures of a “hairy” tongue demonstrating the negative effects of smokeless tobacco use. Triggers and avoidance of triggers to tobacco use were discussed.

In Session 4, a video called “I Can’t Breathe: A Smoker’s Story,” initiated evaluation of real-life values, attitudes, and coping techniques. Participants updated the group on their progress, positive self-talk was practiced, affirmations were continued, and helpful ideas were brainstormed, e.g., doing away with ashtrays and lighters.

In Session 5, the focus was on processing successes and struggles of the participants with increased support and encouragement from the mentors. A guided relaxation technique demonstration and group stress management activity were conducted because many participants shared that their main reason for smoking was usually because of stress. Coping strategies, relapse prevention, healthy snacking and exercising, and rewarding success in healthy ways were also reviewed.

In Session 6, group and individual progress were shared and success was celebrated. Each participant also shared something new that they learned from the program. This was followed by the post-survey, congratulations, and final tips and motivation for participants to quit smoking and not start again.

In the Follow-up Session, two months later, the evaluation team conducted the responsive evaluation interview with the participants.

A paired samples t-test was used to analyze the written pre-post survey. A paired samples t-test is used when describing change in the scores of a single group on the same variables or exposed to two measures over time, as in a pretest-posttest design (Thorne & Giesen, 2003).

The evaluation team analyzed the qualitative, descriptive information from the responsive evaluation interview results to ensure a comprehensive picture of the overall program. Concerns and issues described were used to make recommendations, in partnership with the participants, for future programming (Gall, Gall, & Borg, 2003).

Results

There were no significant differences in pre- to post-program time of day of participants’ first tobacco use, their perceived difficulty of being in smoke-free environments, the number of tobacco products used/day, and difficulty in quitting tobacco use. However, when asked if they smoked more frequently during the morning than during the rest of the day; participants were significantly (p<.001) more likely to smoke more frequently during the rest of the day (Table 1).

Table 1
Pre-test/Post-test Comparison of Smoking Behaviors and Attitudes among Alternative Education Youth (n = 10)

Participants’ Concerns. Many participants shared that they had close family members or friends who also used tobacco products and reported they were enticed into using tobacco to “fit in” with that friend or family member. When asked if they felt smoking was a “cool” thing to do, the majority answered yes. Many of the participants divulged that they were looking for approval by others, and that was what brought them to Alternative School in the first place. Some participants felt that it was the mentors’ job to show them that smoking will not win them support, but disapproval, in today’s society.

Participant (Stakeholder)/Evaluation Team Recommendations. It was recommended that the program could be improved by having a guest speaker who has fought cancer come in and share their story instead of just showing videos.

Participants’ issues. Overall, from the participants’ perspective, the program was a definite success. At least two participants shared with the evaluation team that they had quit smoking since the end of the program and one of them gave up smokeless tobacco use. The participants needed and desired to learn appropriate techniques and skills to quit tobacco successfully. One participant was thankful for the sessions and proudly displayed her nicotine patch as she was still charting her progress. Many of the participants informed the team that they had previously attempted to quit, they needed to know that failure was normal, and they had support from many people while they try to quit tobacco. Most disclosed that they had not really changed their behavior, but that the mentors started to make an impact on their attitude towards smoking. The smokeless tobacco user had also revealed that he had been motivated to quit after seeing the video on the baseball player who had half of his jaw removed.

Participant (Stakeholder)/Evaluation Team Recommendations. All of the information and knowledge they have been given concerning the repercussions of smoking will not help unless they have the tools to actually quit. More time on skills practice was recommended for future programming.

Participants’ values. In the beginning of the program, almost all participants reported being very resistant to the idea of changing their behavior to create a better lifestyle for themselves. Many participants shared that they “may as well enjoy themselves while they still have a chance” because they are bound to be unhealthy when they grow old, regardless of whether or not they used tobacco products. They were aware of the physical consequences of tobacco use but were apathetic to them. Many perceived that the physical barriers would inevitably lead to their lack of success in quitting. Social support in the areas of positive interactions and encouragement from their peers was valued. Two participants highly valued the buddy system and continued to use it in conjunction with monetary rewards to stay motivated to try to quit. One participant truly believed he could quit and would continue to try. Most participants shared that they observed a positive change in their values and behaviors towards using tobacco products.

Participant (Stakeholder)/Evaluation Team Recommendations. The buddy system was believed to be a positive motivator for most of them, and it was recommended that this strategy be incorporated into all future programming.

Discussion

Tobacco cessation programs for adolescents and youth-centered tobacco education have been identified as promising strategies in comprehensive tobacco control (Lantz et al., 2000). A six-week, tobacco education and cessation program was enhanced to include key elements of successful alternative schools in order to decrease the tobacco use frequency in a class of rural, alternative education students. The key elements included social skills training that emphasized positive interactions and coping skills, a team of mentors who showed concern for the participants, and delivery of instruction through active learning strategies. The enhanced program did not seem to affect participants’ first and most frequent tobacco use, their perceived difficulty of being in smoke-free environments, the number of tobacco products used/day, and their intention to quit.

Participants, however, were significantly more likely to smoke during the afternoon or evenings than during the morning hours. More cigarettes may have been smoked or more tobacco used by participants during after-school hours with their peers, as social and peer pressure influence smoking. Because youth are more at risk for smoking if their peers smoke (Leatherdale, McDonald, Cameron, & Brown, 2005; Nofzinger & Hye-Ryeon, 2006), this may have been how some in the alternative education peer group defined their social group. When developing future interventions, it may be useful to use peer influence in the form of peer supporters or mentors to encourage their social group not to smoke or assist them with quitting the habit (Audrey, Cordall, Moore, Cohen, & Campbell, 2004; Audrey, Holliday, & Campbell, 2006).

During later follow-up to a reactive evaluation interview, a few participants conveyed that they did quit using tobacco products since the conclusion of the program. Research-based alternative education strategies described as best practice include a low teacher-student ratio, positive behavior management, and social skills instruction (Tobin & Sprague, 1999). This enhanced program provided a team of mentors as instructors to improve the teacher-student ratio, encouragement and affirmation behavioral management, and activities to improve social skills and coping. Participants in this program shared during the reactive evaluation that they were engaging in tobacco use because of their perception that it will make them “cool” despite the health risks. The alternative education strategies used in this program attempted to build a support system for participants to make positive changes in their values and beliefs. Management of behavior and peer networks; as well as addressing image and appearance, especially for girls, seems to increase cessation rates (Turner & Mermelstein, 2004).

To counter participants’ positive perceptions of tobacco use; activities and group discussion emphasized tobacco use as an “un-cool” thing to do, a monetary burden on society, and an extremely unattractive quality to the opposite gender. When this message was communicated by a team of caring mentors that linked it to real-life social situations in a fun, interactive fashion, the participants seemed to value and appreciate the benefits of the tobacco-free lifestyle. When cessation programs focused on increasing motivation and emphasizing peer pressure to quit, adolescents were more likely to quit smoking (Turner & Mermelstein, 2004).

Standard lecture and fact presentation seemed to have little impact on participant attitude or behavior, but active learning projects conducted in small groups and focused on skills were perceived by the participants as informative. Participants did report that their attitudes and beliefs had positively changed as a result of working together, using a buddy system, and practicing real-life skills; and they recommended these strategies be emphasized in future programming of this type.

Limitations

Although participants reported almost no changes in attitudes and behaviors from pre- to post-program in the written surveys, they reported more positive effects of the program in the later reactive evaluations. Possibly, the participants were not ready to make a behavior change during or immediately following the program; but may have moved to an action stage after further contemplation of risks and benefits (Prochaska & DiClemente, 1984). Another explanation of this discrepancy and limitation of the program evaluation may be because of the response effect—specifically in the predispositions of the respondent, the interviewer, and the interview procedures (Gall, Gall, & Borg, 2003). Participants may have wanted to please the evaluation team as they may have related well to the college-aged mentors and evaluators. Even though interviewer training and practice was conducted and the guide was piloted, the evaluation team may have been uncomfortable in the alternative education setting and not explained the questions appropriately.

In order to minimize these effects, reactive evaluation team members were comprised of both males and females of the same ethnicity as the participants, were similar in age to the participants, and were dressed similarly to them. Also, the team conducted a group interview to better observe group interactions and group behaviors, accommodated participants’ class schedule, as well as used a structured interview guide to lessen interviewer bias (Neutens & Rubinson, 1997). In addition to self-report types of evaluation, future tobacco education and cessation programs with this population should include measurements of saliva cotinine, a principle metabolite of nicotine, to validate responses.

Using a short, six-week intervention with a team of mentors may have introduced testing effect and implementation effect. The one group, pre-test-post-test design also limited the study. Because of lack of randomization and a lack of numbers of participants in the class for a control group, these results would be considered preliminary findings (Cottrell & McKenzie, 2005). In addition, the survey was very brief and used only one question to measure each tobacco-related attitude or behavior as demonstrated by the low alpha value. A brief survey was used as the alternative school students historically demonstrated various attention difficulties when taking longer tests or surveys. In the future, a more comprehensive survey should be developed to measure the tobacco-related attitudes and behaviors with multiple questions for each attitude and behavior.

Future Recommendations

Tobacco use among alternative education students is still high; therefore, effective programs to encourage these students to quit are needed. Although this pilot project demonstrated mixed results for attitude or behavior change, further research is needed to identify types of interventions that would be most effective with the at-risk, alternative school population. Also, given the small sample size, further research is needed to determine if the results can be generalized to other alternative education schools in other parts of the country and in non-rural settings.

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A Tobacco Education and Cessation Program Following the Key Elements of Successful Alternative Schools: A Pilot Study