Since 1964, 29 US surgeon general’s reports on smoking and health have concluded that tobacco use is the single most avoidable cause of disease, disability, and death in the United States.1 Yet, the tobacco industry continues to market its deadly products to youth.2 Each day, approximately 4,000 Americans between the ages of 12 and 17 years initiate cigarette smoking, and an estimated 1,140 young people become daily cigarette smokers.3 The younger people begin smoking cigarettes, the more likely they are to become addicted to nicotine.4,5 Accordingly, Healthy People 2010 calls for reducing rates of tobacco use among youth and raising the average age at which tobacco use is initiated.6
Although smoking rates among youth fell between 2000 and 2003, recent surveys indicate that the rate of decline has stalled.1 In 2004, 13% of middle school boys and 11% of girls reported they were current smokers.7 Twenty percent of 9th graders reported they were current cigarette smokers in 2005, rising to 28% of all high-school seniors.8 The rate among 12th graders is highest among White students (32%), followed by Hispanic (25%) and African American (13%) students.8 Among White high-school students, more young women report current cigarette use than young men.8 In addition to cigarette use, 5% of middle school students and 13% of high-school students are current cigar smokers, and 4% of male middle school students and 10% male high-school students are current users of spit tobacco.3
Healthy People 2010 calls for reducing rates of cigarette use by students in grades 9 through 12 to 16%, cigar use to 8%, and spit tobacco use to 1%,6 but these targets may not be achieved.1 The Centers for Disease Control and Prevention (CDC) concluded that the recent lack of progress at reducing rates of tobacco use among youth suggests the need for greater use of proven antismoking strategies.1 The Institute of Medicine concurred and recommended strengthening traditional tobacco control measures that are currently known to be effective, including comprehensive state tobacco control programs, increased tobacco excise taxes, restrictions on indoor smoking in public places, limits on youth access to tobacco products, prevention education and smoking cessation interventions, and national and state youth-oriented media campaign campaigns.9
One of the factors associated with youth tobacco use is a perception that tobacco use is normative.4 Researchers have documented how school policies that permit staff members to smoke significantly influence students’ attitudes toward cigarette use and have a significant negative effect on high-school students’ smoking behavior.10 Interviews with students indicate that they are well aware of which teachers smoke, even if smoking is restricted to the staff room.11 Whether or not they intend to, adults who use tobacco inevitably influence students’ attitudes by suggesting that it is a responsible adult decision to use a tobacco product. Allowing smoking areas or the use of spit tobacco by anyone on campus creates an aura of official school acceptance.12,13
Accordingly, since 1993 the American Public Health Association (APHA) has urged that all school campuses be tobacco free,14 and Healthy People 2010 calls for 100% of US schools to be tobacco-free environments.15 According to CDC, a tobacco-free environment exists if the state, school district, or school has a policy prohibiting cigarette, cigar, and pipe smoking, as well as spit tobacco use, by students, faculty, staff, and visitors at all times in school buildings, on school grounds, in school buses or other vehicles used to transport students, and at off-campus, school-sponsored events.16,17 Studies have found that schools with consistently enforced no-tobacco-use policies are more likely to have lower rates of student smoking than comparable schools without such policies.10,18,19 According to CDC and the National Association of State Boards of Education, a tobacco-free school policy is the cornerstone of a comprehensive school-based tobacco-use prevention program that includes tobacco-use prevention education in K through 12 classrooms linked with anti-tobacco initiatives in the community, and cessation services for tobacco-using students and staff members who want to quit.12,16
To help ensure that children are not exposed to secondhand smoke at school, the US Congress passed the Pro-Children Act of 1994, now part of the No Child Left Behind Act.20 The law requires that smoking be prohibited in those portions of indoor facilities used for provision of routine or regular kindergarten, elementary, or secondary education or library services to children if the services are supported by federal funds. Federal education grant applicants must certify that they are complying with this law. However, the Pro-Children Act does not mandate completely tobacco-free school environments: it applies only to indoor facilities that are used by children (i.e., not including staff lounges or outdoor areas) and to tobacco products that are smoked.
States, districts, and schools are free to go beyond the provisions of the Pro-Children Act, and some have. A textual analysis of state laws, regulations, and policies as of June 2007 found that 5 states (Arizona, Delaware, Mississippi, Oregon, West Virginia) have mandates for tobacco-free schools that fully meet the CDC’s criteria and are binding on all schools in the state, whereas another 11 states (Arkansas, Colorado, Connecticut, Illinois, Massachusetts, Montana, New Jersey, New Mexico, New York, Rhode Island, Washington) have strong mandates that meet most but not all of CDC’s criteria.12,21 Of the remaining 34 states and the District of Columbia that do not mandate tobacco-free school campuses, at least 16 specifically allow designated smoking areas, and 11 allow smoking breaks for school staff members, whereas 2 states do not have a statewide policy at all. At the local level, a nationwide CDC survey in 2000 found that 46% of school districts and 45% of schools reported they have policies that meet CDC’s criteria for a tobacco-free environment.17
A tobacco-free school environment policy should also include a ban on the possession on school grounds of all tobacco promotional items such as T-shirts, hats, backpacks, jackets, lighters, camping gear, and electronics because these items are highly visible in the school setting and their ownership is strongly associated with smoking behavior.22,23 Children who own tobacco-company promotional items are up to 7 times more likely to smoke than children who do not own these items.24 Although students in K through 12 schools have constitutionally protected rights to free political speech, courts have generally upheld the authority of school administrators to establish policies that have a valid educational purpose including regulating clothing that detracts from the learning environment.25 Further aggressive marketing tactics in low-income countries are often aimed at children despite the WHO’s Framework Convention on Tobacco Control.26
Therefore, the American Public Health Association—
- Calls on the US Congress to strengthen the Pro-Children Act and similar legislation by incorporating CDC’s definition of a tobacco-free school and prohibiting tobacco promotional items at school.
- Calls on state legislatures and state boards of education to adopt tobacco-free school laws or policies that incorporate CDC’s definition of a tobacco-free school and that prohibit tobacco promotional items at school.
- Urges school districts and individual schools in those states without a strong tobacco-free school policy to adopt policies that incorporate CDC’s definition of a tobacco-free school and that prohibit tobacco promotional items at school.
- Calls on the US Federal Trade Commission and the US Surgeon General to support efforts to monitor the framework convention to track tobacco advertising and marketing abroad, especially the specific targeting of children in tobacco advertising abroad.27
- Supports the provision of tobacco cessation interventions for employees of school districts and individual schools provided by the school districts and local schools.
- Calls on school boards to implement and state legislatures to support a sequential, age-appropriate educational program integrated within the K through 12 health education curriculum aimed at influencing students’ knowledge, attitudes, skills, and behaviors.
This updates APHA policy number 9302, which can be archived.
- Centers for Disease Control and Prevention. At-a-glance. Targeting tobacco use: the nation’s leading cause of death, 2007. Available at: www.cdc.gov/nccdphp/publications/aag/osh.htm. Accessed March 14, 2007.
- American Lung Association. State of tobacco control: 2006. Washington, DC: American Lung Association; 2007. Available at: http://lungaction.org/reports/tobacco-control06.html. Accessed December 8, 2007.
- Substance Abuse and Mental Health Services Administration. Results from the 2005 National Survey on Drug Use and Health: National Findings. Rockville, MD: Office of Applied Studies; 2006. NSDUH Series H-30, DHHS Publication No. SMA 06-4194. Available at: www.drugabusestatistics.samhsa.gov/nsduh/2k5nsduh/2k5results.pdf. Accessed December 8, 2007.
- US Department of Health and Human Services. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention; 1994. Available at: www.cdc.gov/tobacco/sgr/sgr_1994/index.htm. Accessed December 8, 2007.
- US Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2004. Available at: www.cdc.gov/tobacco/sgr/sgr_2004. Accessed December 8, 2007.
- Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: US Department of Health and Human Services; 2000. Available at: http://www.health.gov/healthypeople. See Chapter 27, Tobacco Use, available at: http://www.healthypeople.gov/Document/HTML/Volume2/27Tobacco.htm. Accessed December 8, 2007.
- Bloch AB, Mowery PD, Caraballo RS, Malarcher AM, Pechacek T, Husten CG. Tobacco use, access and exposure to tobacco in media among middle and high school students—United States, 2004. MMWR Morb Mortal Wkly Rep. 2005;54:297–301. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5412a1.htm. Accessed December 9, 2007.
- Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance—United States, 2005. MMWR Surveill Summ. 2006;55(SS05):1–108. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5505a1.htm. Accessed December 9, 2007.
- Committee on Reducing Tobacco Use: Strategies, Barriers, and Consequences. In: RJ Bonnie, K Stratton, RB Wallace, eds. Ending the Tobacco Problem: A Blueprint for the Nation, Washington, DC: National Academies Press; 2007. Available at: http://www.nap.edu/catalog/11795.html. Accessed December 9, 2007.
- Kumar R, O’Malley PM, Johnston LD. School tobacco control policies related to students’ smoking and attitudes towards smoking: national survey results, 1999–2000. Health Educ Behav. 2005;32:780–794.
- Bewley BR, Johnson MRD, Banks MH. Teachers’ smoking. Journal Epidemiol Community Health. 1979;33:219–222.
- Bogden, JF. Policies to prevent tobacco use. In: National Association of State Boards of Education. Fit, Healthy, and Ready to Learn: A School Health Policy Guide. 2nd ed. Alexandria, VA: National Association of State Boards of Education; 2007. Available at http://www.nasbe.org/HealthySchools/fithealthy.html. Accessed December 9, 2007.
- Center for Substance Abuse Prevention. Reducing Tobacco Use Among Youth: Community-Based Approaches: A Guideline for Program Practitioners. Rockville, MD: Prevention Enhancement Protocols System, Center for Substance Abuse Prevention, U.S. Department of Health and Human Services, Publication Number (SMA) 97-3146;1997. Available at: http://ncadi.samhsa.gov/govpubs/PHD745/toc.aspx. Accessed December 9, 2007.
- American Public Health Association. APHA Policy Statement 93-02. Tobacco-Free Schools. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=86. Accessed December 8, 2007.
- Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: US Department of Health and Human Services; 2000. Available at: http://web.health.gov/healthypeople/document/. See Chapter 7: Educational and Community-Based Programs, available at: http://www.healthypeople.gov/Document/HTML/Volume1/07Ed.htm. Accessed December 9, 2007.
- Centers for Disease Control and Prevention. Guidelines for school health programs to prevent tobacco use and addiction. MMWR Morb Mortal Wkly Rep. 1994.43(RR-2);1–18. Available at: http://www.cdc.gov/HealthyYouth/tobacco/guidelines/index.htm. Accessed December 9, 2007.
- Center for Disease Control and Prevention. School Health Policies and Programs Study (SHPPS) 2000: a summary report. J Sch Health. 2001; 71:249–350. See Center for Disease Control and Prevention. SHPPS 2000 fact sheet: tobacco-use prevention. Available at http://www.cdc.gov/HealthyYouth/shpps/2000/factsheets/index.htm. Accessed March 14, 2007.
- Peck D, Acott C, Richard P, Hill S, Schuster C. The Colorado Tobacco-Free Schools and Communities Project. J Sch Health. 1993;65:214–217.
- Wakefield MA, Chaloupka FJ, Kaufman NJ, et al. Effect of restrictions on smoking at home, at school, and in public places on teenage smoking: cross sectional study. BMJ. 2000;321:333–337.
- Pro-Children Act of 1994. Public Law 103-227. 20 USC 6081–6084.
- National Association of State Boards of Education. State school health policy database. Available at: http://www.nasbe.org/HealthySchools/States/State_Policy.asp. Online query accessed June 14, 2007.
- Sargent JD, Dalton M, Beach M, Bernhardt A, Pullin D, Stevens M. Cigarette promotional items in public schools. Arch Pediatr Adolesc Med. 1997;12:1189–1196. Abstract available at: http://archpedi.ama-assn.org/cgi/content/abstract/151/12/1189. Accessed December 9, 2007.
- Sargent JD, Dalton M, Beach M. Exposure to cigarette promotions and smoking uptake in adolescents: evidence of a dose-response relation. Tob Control. 2000;9:163–168.
- Frieden TR, Blademan DE. The dirty dozen: 12 myths that undermine tobacco control. Am J Public Health. 2005; 95:1500–1505.
- Hudson DL, Overview: K-12 public school student expression. Nashville, TN: First Amendment Center. Available at: http://www.firstamendmentcenter.org/Speech/studentexpression/overview.aspx. Accessed: June 16, 2007.
- WHO Framework Convention on Tobacco Control (WHO FCTC). Available at: www.who.int/tobacco/framework/en/. Accessed December 9, 2007.
- Dagbreveli E. Are low income countries targets of the tobacco industry? Int J Tuberc Lung Dis. 1999;3(2);113–118.
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