The Prevention of Nicotine Use in the State of Arkansas That Has Geographic Tobacco Use Disparities: The Perceived Prevention Needs and Realities of School Professionals

Abstract

The current study used a convergent mixed-methods design and identified Arkansas school professionals’ perceptions about 1) their schools’ tobacco use prevention needs and 2) the implementation of tobacco prevention programming at their schools. Differences in perceptions based on school-related factors and personal tobacco use history were examined. Surveys were collected from teachers, administrators, and school staff from K-12 schools in Arkansas (QUANT; N=325) and in-depth interviews were conducted with a separate sample of school administrators (QUAL; N=20). Logistic regressions identified the associations between dependent variables, school-related factors (school type, school position, years of education work experience, and school rurality), and school professionals’ tobacco use histories. The tobacco prevention components perceived as most important were parent education, school tobacco-free policies, and up-to-date teacher training. Yet, parent education and up-to-date teacher training were perceived as being poorly integrated into schools. Quantitative and qualitative findings emphasized the importance of integrating parents into tobacco prevention. There were differences in school professionals’ perceptions about important tobacco prevention components based on school level, personal tobacco use history, and work experience. There were also differences in perceptions about how well tobacco prevention was integrated into schools between teachers vs. administrators and related to school rurality, school level, and work experience. School professionals in Arkansas, a state with tobacco disparities, identified that: 1) student tobacco use is a top health priority; 2) key strategies include parent education, tobacco-free policies, and teacher training; and 3) barriers exist, particularly in implementing parent education and teacher training.

Introduction

Arkansas is a part of Tobacco Nation, one of 12 states with disproportionate tobacco use and tobacco-caused diseases relative to the national average [1, 2]. In 2023, current nicotine and tobacco use (i.e., current use of cigarettes, cigars, smokeless tobacco, or vapes) was higher among Arkansas high-school students (24.9%) relative to national averages (17.9%) [3]. Additional state-level data indicates similar or higher rates of nicotine and tobacco use (henceforth referred to as tobacco use) across 6^th, 8^th, 10^th, and 12^th graders in Arkansas relative to national averages [4]. Numerous factors contribute to Arkansans’ greater tobacco burden, including but not limited to rurality (41% of Arkansas residents live in rural areas), poverty (21–22% of Arkansas children live in poverty), and suboptimal state tobacco control support [5–9]. Insufficient tobacco control resources impede tobacco use prevention (henceforth referred to as tobacco prevention) programming. For example, 35% of Arkansas students reported that they were never taught about the dangers of tobacco use in classes during their current school year (ranging from 30% of 6–8^th graders to 46% of 12^th graders), and 22% reported tobacco was discussed rarely [4]. School-based tobacco prevention is critical for reducing tobacco use among Arkansas youth [10–13].

Yet, additional research is needed to improve the effectiveness of school-based tobacco prevention programs, especially for students experiencing geographic tobacco disparities [5, 12], and to elucidate how to best implement them within schools with varied resources [14]. Numerous barriers could preclude implementation of school-based tobacco prevention programs including insufficient resources, lack of access to evidence-based programs, or school professionals’ attitudes, perceptions, or behaviors related to tobacco use. For example, although 67% of middle- and high-school teachers and administrators have heard of JUUL, only 47% could identify them in photographs, and awareness was greater among high-school versus middle-school staff [15]. A qualitative study with school staff in Nebraska identified that: 1) staff felt that school-based vaping prevention was important, but few schools had comprehensive nicotine prevention and cessation programs, 2) key barriers to tobacco prevention program implementation were time, knowledge, and coordinated efforts, and 3) parental engagement in tobacco prevention was critical [16]. These findings are informative, but key differences between Arkansas and Nebraska exist that limit generalization to Arkansas. For example, Nebraska is not in Tobacco Nation [1], only 28% of residents live in rural areas (compared to 44% in Arkansas) [17], the childhood poverty rate (11%) is lower than Arkansas’ at 21% % [9], and Nebraska has somewhat better state-level tobacco control than Arkansas [18].

The current study addresses critical gaps in the literature by focusing on school professionals in Arkansas (administrators; teachers; staff) across diverse school settings and using a convergent mixed-methods design to identify their perceptions about 1) their schools’ tobacco prevention needs and 2) the realities surrounding the implementation of tobacco prevention at their schools. We also examined if school-related factors (school type; position at the school and length of time working in education; school rurality) or school professionals’ personal tobacco use history related to perceptions about tobacco prevention needs and reality.

Methods

Surveys were collected from a convenience sample of teachers, administrators, and school staff from K-12 schools in Arkansas (QUANT; N=325) and in-depth interviews about school tobacco control policies were conducted with a separate sample of school administrators (superintendents, principals, and counselors; QUAL; N=20). Our convergent mixed-methods study design allowed us to determine how survey respondents’ (teachers, school staff, and administrators) and administrators’ perceptions of school tobacco prevention aligned or diverged. The quantitative and qualitative methodologies were given equal priority, were not based on sequence, and allowed us to confirm or distinguish findings from the different methodologies [19, 20].

In April 2024, school personnel were invited to complete a 10-minute survey about school tobacco prevention and control via targeted emails sent to staff in K-12 schools in Arkansas. Staff were recruited directly via emails identified from publicly available websites and by asking school administrators to share with staff in their school. The first 250 survey participants received $10. Interview participants were recruited from May to June 2024 via email using contact information collected via publicly available websites. In the recruitment email, participants were informed that the interview would take up to 60 minutes, and that the first 20 participants would receive $100 for their time. All participants provided informed consent prior to completing the survey or interview. Procedures were approved by the institutional review board.

Quantitative Measures

Demographic variables included age, gender, race, ethnicity, type of school at which they taught (elementary, middle school, junior high, high school, other), position (teacher, administrator, mental or healthcare professional, instructional aide, security, office staff, other), number of years worked in education, and rurality of school (based on 2023 USDA continuum [21]). See Table 1 for a full list of demographic variables and response options. School professionals were asked if they had ever used cigarettes, smokeless tobacco, or electronic cigarettes (e-cigarettes)/vapes in their lifetime. Response options were yes/no. Tobacco prevention survey items for the current study (dependent variables) came from the California Educator Tobacco Survey [22, 23].

Table 1.

Demographic information for teacher survey (N = 325) and school leader interviews (N = 20)

	Survey (N = 325)	Interviews (N = 20)
	n (%)/ M (SD)	n (%)/ M (SD)
Respondent Demographics
Age	43.36 (11.50)	44.95 (6.32)
Gender
Female	234 (72.7%)	5 (25%)
Male	87 (27.0%)	15 (75%)
Transgender	1 (0.3%)
Other __________
Race
White	291 (90.1%)	18 (90%)
Black/ African American	22 (6.8%)	2 (10%)
American Indian/ Alaska Native	2 (0.6%)	0 (0%)
Asian	1 (0.3%)	0 (0%)
Other	7 (2.2%)	0 (0%)
Ethnicity
Non-Hispanic/ non-Latino(a/x)/ non-Spanish	313 (96.9%)	19 (95%)
Hispanic/ Latino(a/x)/ Spanish	10 (3.1%)	1 (5%)
School-Related Factors
School type
Elementary school	8 (2.5%)	0 (0%)
Middle school	69 (21.2%)	0 (0%)
Junior high school	26 (8.0%)	3 (15%)
High school	207 (63.7%)	15 (75%)
Other (oversee more than one school)	15 (4.6%)	2 (10%)
Respondent school position
Teacher	240 (73.8%)
School administrator	30 (9.2%)
Vice Principal		1 (5%)
Principal		16 (80%)
Superintendent		2 (10%)
School Counselor		1 (5%)
School mental or healthcare professional	11 (3.4%)
Instructional aide/ security/ office staff/ other	44 (13.5%)
Respondent years of work experience in education
Less than 1 year	15 (4.6%)
1–5 years	62 (19.1%)
6–10 years	70 (21.6%)	2 (10%)
11–15 years	52 (16.0%)	2 (10%)
More than 15 years	125 (38.6)	16 (80%)
Highest Education Completed
Master’s degree		9 (45%)
Ed.S.		7 (35%)
Doctorial degree (PhD, EdD)		4 (20%)
Rurality of school based on USDA continuum a
Metro	133 (44.8%)
Non-metro (rural)	164 (55.2%)
Respondent Tobacco Use History
Lifetime history of smoking cigarettes
No	155 (47.7%)
Yes	170 (52.3%)
Lifetime history of using smokeless tobacco
No	261 (80.3%)
Yes	64 (19.7%)
Lifetime history of using electronic cigarettes/ vapes
No	257 (79.1%)
Yes	68 (20.9%)

Notes:

^aUSDA RUCC CODES 2023.

School Tobacco Prevention Needs.

Several questions asked about participants’ perceptions about their school tobacco prevention needs. School professionals were asked, “What do you think are your school’s current top 3 health priorities?” Options to select included mental health, bullying and school safety, nicotine/tobacco use, sexual health, etc. (see Table 2 for the full list of response options). Participants were also asked, “What do you believe are important components of an effective tobacco prevention program?” Response options included tobacco-free policies, at-risk youth development, parent education, etc. (see Table 2 for the full list of options). Each option was represented as a yes/no variable.

Table 2.

Survey respondents preceptions about school tobacco programming needs and implementation (N=325).

School Tobacco Prevention Needs
N=325	No n (%)	Yes n (%)	-	-	-
Perceptions about school’s top 3 health priorities
Mental health	108 (33.2%)	217 (66.8%)
Bullying and school safety	141 (43.4%)	184 (56.6%)
Social media and screen time	179 (55.1%)	146 (44.9%)
Cannabis use (including cannabis vaping)	240 (73.8%)	85 (26.2%)
Nicotine/ tobacco use (including vaping)	164 (50.5%)	161 (49.5%)
Alcohol and other drug use	273 (84.0%)	52 (16.0%)
Physical activity	278 (85.5)	47 (14.5%)
Healthy eating	305 (93.8%)	20 (6.2%)
Sexual health	297 (91.4%)	28 (8.6%)
Obesity/ overweight/ healthy weight	312 (96.0%)	13 (4.0%)
Perceptions about the important components for effective tobacco prevention programs a
Tobacco-free policies	81 (24.9%)	244 (75.1%)
At-risk youth development	157 (48.3%)	168 (51.7%)
Parent education	96 (29.5%)	229 (70.5%)
Research-based curriculum	206 (63.4%)	119 (36.6%)
School/ district cessation services	216 (66.5%)	109 (33.5%)
Up-to-date teacher training	151 (46.5%)	174 (53.5%)
Prevention integrated in academics	224 (68.9%)	101 (31.1%)
School tobacco specialists	245 (75.4%)	80 (24.6%)
School Tobacco Prevention Reality
	No n (%)	Yes n (%)	-	-	-
Tobacco use prevention included in school curriculum	57 (33.9%)	111 (66.1%)
During the last 12 months, did your school offer any of these tobacco prevention activities?
Red Ribbon Week	89 (27.4%)	236 (72.6%)
Student-led or initiated events targeting tobacco use	289 (88.9%)	36 (11.1%)
Alternative to suspension programs (e.g., YVAPE)	307 (94.5%)	18 (5.5%)
Guest presentations on tobacco use	234 (72.0%)	91 (28.0%)
Parental education on tobacco use	311 (95.7%)	14 (4.3%)
Groups to help students quit smoking or vaping	318 (97.8%)	7 (2.2%)
Health fairs	314 (96.6%)	11 (3.4%)
Out-of-school clubs to prevent tobacco use	321 (98.8%)	4 (1.2%)
Great American Smoke Out	320 (98.5%)	5 (1.5%)
Referral to Arkansas Quit Line	321 (98.8%)	4 (1.2%)
Kick Butts Day	323 (99.4%)	2 (0.6%)
	Poor	Fair	Well	Very well	Excellent
How well does your school do the following?
Keep teachers updated on vape products	142 (45.5%)	80 (25.6%)	53 (17.0%)	25 (8.0%)	12 (3.8%)
Keep teachers updated on other tobacco products	146 (46.8%)	84 (26.9%)	55 (17.6%)	15 (4.8%)	12 (3.8%)
Provide peer-to-peer tobacco prevention education	180 (57.9%)	82 (26.4%)	35 (11.3%)	8 (2.6%)	6 (1.9%)
Equip students with techniques to refuse tobacco	142 (45.7%)	111 (35.7%)	39 (12.5%)	11 (3.5%)	8 (2.6%)
Include parents in tobacco prevention activities	180 (57.9%)	77 (24.8%)	36 (11.6%)	11 (3.5%)	7 (2.3%)
How would you rate your school’s integration of effective tobacco prevention program components?
Tobacco-free policies	39 (13.0%)	60 (20.1%)	69 (23.1%)	70 (23.4%)	61 (20.4%)
At-risk youth development	93 (31.7%)	103 (35.2%)	72 (24.6%)	15 (5.1%)	10 (3.4%)
Parent education	136 (46.1%)	97 (32.9%)	43 (14.6%)	12 (4.1%)	7 (2.4%)
Research-based curriculum	124 (42.3%)	83 (28.3%)	55 (18.8%)	20 (6.8%)	11 (3.8%)
School/ district cessation services	148 (50.5%)	78 (26.6%)	42 (14.3%)	19 (6.5%)	6 (2.0%)
Up-to-date teacher training	146 (49.2%)	78 (26.3%)	52 (17.5%)	13 (4.4%)	8 (2.7%)
Prevention integrated in academics	144 (49.1%)	88 (30.0%)	42 (14.3%)	12 (4.1%)	7 (2.4%)
School tobacco specialists	192 (66.0%)	54 (18.6%)	31 (10.7%)	7 (2.4%)	7 (2.4%)

Notes: Valid percents reported.

^aParticipants were asked to select (all that applied).

School Tobacco Prevention Reality.

Several questions asked about participants’ perceptions about tobacco prevention efforts at their schools. School professionals were asked if tobacco prevention was included somewhere in their school curriculum; response options were “yes”, “no”, and “I don’t know” (no participant endorsed “I don’t know”). School professionals were asked, “In the past 12 months, did your school participate in/offer any of the following tobacco prevention activities?” Table 2 details all options that were assessed; participants could select more than one option. Each option was represented as a yes/no variable. Participants were also asked how well their school did each of the following (each option is a separate item): keep teachers updated on vaping products, keep teachers updated on other tobacco products, provide students peer-to-peer tobacco prevention education, equip students with techniques (language) to refuse tobacco, and include parents in tobacco prevention activities. The response options for each item used a 5-point Likert scale, ranging from poor (1) to excellent (5). Lastly, participants rated their school’s integration of eight effective tobacco prevention program components (using the same program components assessed in the tobacco prevention needs section; listed in Table 2); participants rated their school’s integration from poor (1) to excellent (5).

Quantitative Data Analysis

Descriptive statistics were used to identify means, frequencies, and percentages. Logistic regressions identified the associations between dependent variables and school-related factors (school type, school position, years of education work experience, and school rurality) and school professionals’ tobacco use (lifetime history of cigarette, smokeless tobacco, or e-cigarette use). Separate models were executed for each dependent variable related to school tobacco prevention needs (top school priorities, perceptions about effective tobacco prevention components) and school reality (how well school integrates effective tobacco prevention components, how well school does tobacco prevention, and if school has tobacco prevention included in their curriculum). We did not examine correlates of which prevention activities schools offered in the past year due to variable distributions.

Only 168 participants (51.7%) answered the question asking if tobacco prevention was included in the curriculum; the reason for missing data is unknown. To understand missingness correlates, we created a missing data indicator for this variable and explored the associations between all the variables listed in Table 1 and having a tobacco prevention curriculum and its associated missing data indicator. Only school position was related to both having a tobacco prevention curriculum and missingness on this variable. Teachers and instructional aides/ security/ office staff/ other were more likely than administrators to have missing data on this question (p=.004). Teachers were less likely than administrators to report that their school had tobacco prevention in their curriculum (p=.012). School position was included in the adjusted model examining this dependent variable (along with school type and rurality); however, results should be interpreted with caution.

SPSS version 29 was used [24]. For logistic regressions, 95% confidence intervals (CI) and adjusted odds ratios (AOR) were reported. A p-value was set a priori at <.05. Across models, there were some unstable estimates, likely due to quasi-separation; we retained the problem variable instead of removing or collapsing it since the other estimates remained valid [25].

Administrator Interview

Interview participants provided consent, completed a demographic questionnaire, and then took part in a semi-structured, one-on-one Zoom interview that lasted between 35–60 minutes. The author (PDD) who conducted the interviews had formal training and experience with qualitative interviewing. Participants were asked to provide open-ended responses to questions about school-based tobacco control and prevention policies and programming. First, lead questions were asked to help participants feel comfortable, and included items such as, “Can you please describe tobacco product use, including e-cigarettes and vaping products, on your campus?” Next, questions regarding factors that could influence policy and program implementation were asked, including: “Who are the stakeholders you need to get on board with your tobacco-free policy?” and “How aware are teachers and staff of students’ tobacco use or nicotine addiction at your school?”

Qualitative Data Analysis

Audio recordings of the interviews were transcribed by Zoom’s transcription feature. Next, VK checked all transcriptions for accuracy. Then, using a grounded theory approach, PDD and KL read all 20 transcripts twice to familiarize themselves with the data and to generate an initial codebook [26]. Next, the authors read the transcripts two more times, defining codes, and then identified themes. The authors reviewed the transcripts a final time to identify representative quotes for identified patterns in the data.

Mixed-Methods Analysis

For this convergent mixed-methods design, we collected both quantitative and qualitative data to merge the data and compare responses [20]. The point of conversation was at data analysis. By integrating the survey findings and the identified themes from the interviews, we were able to compare if school professionals’ perceptions of needs and the reality of tobacco prevention in their schools aligned with perceptions of school leaders who participated in the interviews. Findings were reported using a joint display to portray the data integration [20].

Results

Survey respondents were mostly female (73%), White (90%) and non-Hispanic (97%), mainly worked in high schools (64%), and mostly teachers (74%). Over 55% worked in rural schools. Regarding lifetime tobacco use, 52% had smoked cigarettes, 20% had used smokeless tobacco, and 21% had vaped (Table 1). Interview participants were mostly school administrators and mostly male (75%), White (90%) and non-Hispanic (95%), mostly worked in high schools (75%), and mostly principals (80%).

School Top Three Health Priorities

As shown in Table 2, survey participants identified their school’s top three health priorities as mental health (66.8%), bullying and school safety (56.6%), and tobacco use (including vaping; 49.5%). Participants working in middle schools were less likely than those working in high schools to endorse tobacco use as a top health priority for their school (AOR: 0.48, CI: 0.25–0.93, p=0.03). Participants with <1 year of work experience were more likely than those with >15 years of experience to endorse tobacco use as a top school health priority (AOR: 4.74, CI: 1.20–18.74, p=0.03). There were no other significant associations.

One of the themes that emerged from the interview data was the challenges school leaders perceived with vaping in their schools. Participants described vaping as a “one of the biggest things that [they] are now facing.” #11 Many described being overwhelmed and hopeless. Several schools invested in vape detectors; however, these devices often created more issues, such as false positives, or if 20 students were in the bathroom when it went off, they were faced with the challenge of searching all students. With vape detectors that sent email and text alerts to administrators, one school reported 191 alerts in a single day and claimed they stopped paying attention to the alerts. One participant described it as playing, “Whack-a-mole” #7. These participants felt like students were always one step ahead. See Table 3 for illustrative quotes of emergent themes.

Table 3.

Qualitative Themes from Interview with School Leaders (N = 20)

Theme	Description	Representative Quote
Challenges	School leaders described challenges of vaping in schools to include frustration from their teachers or school district to fix the problem and overwhelmed by the task. Many described students as one step ahead of them by concealing the devices and use. Many were overwhelmed or were hopeless in their attempt to address youth vaping in their schools.	I need parents involved. I need community members involved. I need especially those that know have seen the effects of those devices and so, I need more of those people involved. I really need a committee to stop it. They expect me to do it alone, and it’s such a daunting task with all the other things that we do in a day. #10 We have for the past few years had a major problem with kids vaping. That is definitely what we discipline the most is vaping. #13 My teachers are really frustrated. They want me to wave a magical wand and fix it, and I can’t. Some are not always so helpful in their criticism. They want me to literally strip search a kid, and I'm like, “Ain’t no way I'm looking in their bra, or their underwear, behind their belt buckle.” Their suggestion was to put myself in every bathroom between classes, and I'm like, “We literally have 15 bathrooms. That’s not even possible.” And then they're like, “Well, we'll take turns going in there.” I'm like, “You literally can’t go stand in a stall with a kid.” So, it’s just a frustration for everybody. #19
Reactive vs. Proactive Responses	Almost all participants explained that their current policies and procedures were reactive, including punitive measures when students were caught vaping, with few discussing proactive measures to prevent use or create healthy alternatives for students who wanted to quote.	Well, as far as the consequences the student gets a citation, especially if we find the vape. They also get disciplinary consequences in our school for 3 days and usually those are either out-of-school suspension or in-school suspension, depending on if it’s the first offense or second offense. #5 Right now it’s (school policies) all punitive. There's nothing there to deter them…. I just wish there was a way we could be more proactive instead of just, yeah, we catch you with it and slap you on the hand and send you on the way….we've got to find a way to be proactive whether that’s the first day of school, whether that’s once a month, where that’s getting more help from our parents…I mean it’s a good policy, but it’s not, it’s not deterring. #18
Education and Prevention	Many participants stated that they needed more education and prevention opportunities, but some were apathetic about the effectiveness of current strategies. Educational needs included those for students, parents, and teachers.	Students This year was one of the worst years that we've had. It was pretty bad. We're trying to do different things, different approaches, different consequences. Working more on, not just consequences, but also education, anything that we can do to prevent the use and start of it. A lot of the kids that I I had conversations with this year . . . [talk about] their struggles with being addicted and just how they had tried to quit so many times. . . It’s a major problem, and it’s not just here. #20 Parents We definitely need parents to be more involved. We've had incidents where kids are bringing their parents’ product. #2 Teachers I can’t think of any training that’s offered to them [teachers]. #2

Several school leaders mentioned teachers were frustrated and expected administrators to do more to end vaping in their school. These school leaders explain that teachers often made them feel personally and solely responsible to tackle the issue of substance use in their school. Teachers expected harsher punishments, like writing possession citations when students were first caught with a vaping device, and for administrators to search all student and all locations to find vaping devices in their school.

Nearly all participants explained that vaping issues included both nicotine and tetrahydrocannabinol (THC). One school leader reported that 60% of vaping-related incidents were for nicotine, while 40% were for THC. Students were often recommended for out-of-school suspension or expulsion for their first offense of vaping THC, and several schools used drug testing or drug dogs to determine if vaping devices contained THC. Schools in towns that bordered states with less strict laws regarding THC emphasized that they struggled with students bringing THC-containing vapes, with one school reporting that 30 middle-school students had been expelled for this the prior year.

School Tobacco Prevention Needs and Reality

Table 2 displays the components that survey participants believed were important for effective tobacco prevention programs as well as how well they believe their school integrated each of these components. The three tobacco prevention components endorsed most frequently as important were tobacco-free policies (75.1%), parent education (70.5%), and up-to-date teacher training (53.5%). Yet, as shown in Table 2, participants indicated that these components were not well integrated at their school. Thirty-three percent of participants reported poor or fair integration of tobacco-free policies in their schools, while 79% indicated the same for parent education and 75% for up-to-date teacher training.

These findings were confirmed during the interviews. Administrators described their policies as reactive instead of proactive. Most stated their policy complied with the Arkansas School Board Association model policy, but consequences varied by school. They also mentioned a need for more parental education but noted challenges getting the parents to attend these sessions, particularly among those who needed it most. For example, one participant said,

We may try to have a community parent meeting, but you know it’s like a lot of them, the parents you get, don’t need to be there. The parents you really want to talk to are not there. The only time we get to see them is once in an expulsion meeting. #11

Some stated they had tried to educate parents, but most schools indicated more (or any) education was needed for parents. Discussion about parent education had two foci. First, participants described some parents as naïve to vaping and did not know what vapes looked like or how to detect them. Participants also described the need for education for parents who vaped, describing that students were getting their vapes from parents. In this context, participants explained that parents did not believe vaping was harmful for their child and needed more awareness about the harms of adolescent use. For teacher training, some mentioned they had no training provided at all, and when they did provide training, it was exclusively to explain what vapes looked like to help teachers detect them.

Additional survey findings also highlight the reality of tobacco prevention among schools. About 66% of participants reported tobacco use was included in their school curriculum. The most prevalent past year activities related to tobacco prevention were Red Ribbon Week (72.6%), guest presentations on tobacco use (28.0%), and student-led or initiated events on tobacco use (11.1%). Though parent education on tobacco use was identified as an important component of effective tobacco prevention programs, only 4.3% of participants reported that their school had offered any parental education on tobacco use in the past year. Table 2 highlights additional areas for improvement, with survey participants rating the following areas as primarily poor or fair at their school: Keeping teachers up to date on vapes (71.2%) and other tobacco products (73.7%), providing peer-to-peer tobacco prevention education (84.2%), teaching students tobacco refusal skills (81.4%), and including parents in tobacco prevention activities (82.6%).

Interviews with school leaders confirmed that “Red Ribbon Week” or one-time speakers were often the only prevention effort completed. However, when we asked interview participants about ideas for future prevention, the only suggestion mentioned was to bring an outside speaker. Participants often explained that valuable internal sources such as their school counselors, security resource officer (SRO), or nurse were currently providing vaping education for their school. Many mentioned the need for better education for students and parents, explaining that current resources (e.g., pamphlets) were often not well received by the students, and thus, they felt these needed to be improved. As reported above, the need for parent education was noted in most administrator interviews, describing the need to engage with all parents, including those who used tobacco. See Table 3 for representative quotes.

Correlates of School Tobacco Prevention Needs

Perceptions about Important Components of Effective Tobacco Prevention Programs

Table 4 summarizes models examining correlates of perceptions about important components of tobacco prevention programs. Teachers were more likely than school administrators to endorse tobacco-free policies as an important component of effective tobacco prevention (AOR: 2.92, CI: 1.05–8.12). Participants who had smoked cigarettes were more likely than those who had not to endorse at-risk youth development as an important prevention component (AOR: 1.77, CI: 1.03–3.05); however, those who had vaped were less likely than those who hadn’t to endorse this as an important component (AOR: 0.38, CI: 0.20–0.75). Participants working at junior-high schools were more likely than those working in high schools to endorse up-to-date teacher training as an important component (AOR: 4.15, CI: 1.31–13.09). Participants who worked in elementary schools (vs. high schools; AOR: 6.22, CI: 1.14–33.99), had less work experience (vs. those with >15 years of experience; AOR: 3.46, CI: 1.004–11.93), and who had used smokeless tobacco (vs. those who had not; AOR: 2.17, CI: 1.05–4.47) were more likely to endorse school tobacco specialists as an important prevention component.

Table 4.

Multivariable logistic regressions predicting school professionals’ perceptions about the important components of effective tobacco prevention programs in Arkansas.

	Perceptions About Important Components of Effective Tobacco Prevention Programs
	Tobacco-free policies (Yes vs. No)	At-risk youth development (Yes vs. No)	Parent education (Yes vs. No)	Research-based curriculum (Yes vs. No)	School/ district cessation services (Yes vs. No)	Up-to-date teacher training (Yes vs. No)	Prevention integrated in academics (Yes vs. No)	School tobacco specialists (Yes vs. No)
	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)
School-Related Factors
School type
Elementary school	0.98 (0.17–5.81)	1.70 (0.34–8.49)	1.29 (0.22–7.44)	1.56 (0.32–7.68)	0.59 (0.10–3.41)	1.71 (0.34–8.58)	1.34 (0.24–7.61)	6.22 (1.14–33.99) *
Middle school	0.61 (0.31–1.20)	1.10 (0.58–2.09)	0.77 (0.39–1.52)	0.76 (0.39–1.48)	0.89 (0.46–1.75)	0.74 (0.40–1.40)	1.77 (0.91–3.44)	1.48 (0.71–3.12)
Junior high school	2.03 (0.56–7.39)	0.84 (0.33–2.12)	2.90 (0.80–10.52)	0.92 (0.36–2.37)	0.85 (0.32–2.28)	4.15 (1.31–13.09) *	0.81 (0.28–2.38)	1.50 (0.53–4.26)
Other	-a	0.81 (0.23–2.83)	4.02 (0.48–33.47)	1.44 (0.41–5.03)	2.08 (0.59–7.39)	1.62 (0.44–5.90)	0.88 (0.22–3.58)	0.75 (0.15–3.78)
High school	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
School position
Teacher	2.92 (1.05–8.12) *	1.90 (0.75–4.83)	1.99 (0.76–5.23)	1.64 (0.61–4.45)	1.22 (0.47–3.17)	2.30 (0.90–5.89)	2.83 (0.88–9.15)	2.02 (0.64–6.36)
School mental or healthcare professional	1.69 (0.30–9.57)	0.94 (0.19–4.64)	7.28 (0.72–73.80)	1.46 (0.29–7.34)	3.91 (0.79–19.52)	1.50 (0.31–7.17)	2.39 (0.39–14.56)	0.50 (0.04–5.75)
Instructional aide/ security/ office staff/ other	2.24 (0.64–7.79)	1.30 (0.43–3.94)	1.23 (0.39–3.90)	1.63 (0.51–5.24)	0.67 (0.21–2.16)	1.69 (0.56–5.15)	2.27 (0.59–8.70)	1.59 (0.41–6.10)
School administrator	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Years of work experience in education
Less than 1 year	0.83 (0.23–3.01)	1.46 (0.45–4.71)	0.95 (0.26–3.40)	1.22 (0.39–3.87)	0.75 (0.21–2.68)	0.72 (0.23–2.25)	0.96 (0.29–3.18)	3.46 (1.004–11.93) *
1–5 years	1.00 (0.43–2.30)	1.71 (0.83–3.52)	0.92 (0.42–2.03)	1.01 (0.49–2.05)	1.05 (0.50–2.21)	0.60 (0.29–1.21)	0.96 (0.46–2.00)	2.00 (0.89–4.52)
6–10 years	0.90 (0.41–1.95)	1.43 (0.73–2.78)	1.14 (0.53–2.46)	0.76 (0.38–1.51)	1.16 (0.58–2.31)	0.91 (0.46–1.78)	0.77 (0.38–1.55)	1.59 (0.73–3.45)
11–15 years	0.82 (0.36–1.85)	0.81 (0.40–1.65)	0.49 (0.23–1.05)	0.70 (0.34–1.48)	1.24 (0.60–2.56)	0.60 (0.30–1.23)	0.57 (0.38–1.55)	1.26 (0.55–2.90)
More than 15 years	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
School rurality
Non-metro (rural)	1.48 (0.79–2.74)	1.00 (0.59–1.70)	1.31 (0.72–2.36)	0.93 (0.54–1.60)	1.11 (0.64–1.92)	0.78 (0.46–1.33)	1.39 (0.79–2.47)	1.56 (0.83–2.92)
Metro	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Tobacco Use History
Lifetime history of smoking cigarettes
Yes	1.21 (0.65–2.27)	1.77 (1.03–3.05) *	0.90 (0.49–1.63)	1.62 (0.94–2.800	0.84 (0.48–1.47)	1.03 (0.60–1.77)	0.93 (0.53)	0.89 (0.48–1.66)
No	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Lifetime history of using smokeless tobacco
Yes	1.70 (0.73–3.95)	1.20 (0.62–2.32)	0.81 (0.40–1.65)	0.99 (0.51–1.90)	1.75 (0.90–3.41)	1.00 (0.52–1.92)	1.01 (0.50–2.04)	2.17 (1.05–4.47) *
No	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Lifetime history of using e-cigarettes/ vapes
Yes	1.08 (0.49–2.38)	0.38 (0.20–0.75) **	0.70 (0.34–1.44)	0.97 (0.50–1.89)	0.90 (0.45–1.82)	1.17 (0.60–2.27)	1.26 (0.63–2.52)	0.67 (0.31–1.47)
No	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref

Notes:

^*p < .05,

^**p < .01,

^***p < .001. The analytic sample size across analyses was 297 across analyses (i.e., 91% of the total sample).

^aUnstable estimate.

Correlates of School Tobacco Prevention Reality

Perceptions about School Integration of Components of Effective Tobacco Prevention Programs

Survey participants rated how well their school integrated components of effective tobacco prevention programs. For adjusted models, outcome responses were categorized into poor/ fair (referent) and well/ very well/ excellent. The results are presented in Table 5.

Table 5.

Multivariable logistic regressions predicting school professionals’ perceptions about how well their school integrates components of effective tobacco prevention programs in Arkansas.

	Perceptions About How Well School Integrates the Important Components of Effective Tobacco Prevention Programs
	Tobacco-free policies (Well/ Very Well/ Excellent vs. Poor/ Fair)	At-risk youth development (Well/ Very Well/ Excellent vs. Poor/ Fair)	Parent education (Well/ Very Well/ Excellent vs. Poor/ Fair)	Research-based curriculum (Well/ Very Well/ Excellent vs. Poor/ Fair)	School/ district cessation services (Well/ Very Well/ Excellent vs. Poor/ Fair)	Up-to-date teacher training (Well/ Very Well/ Excellent vs. Poor/ Fair)	Prevention integrated in academics (Well/ Very Well/ Excellent vs. Poor/ Fair)	School tobacco specialists (Well/ Very Well/ Excellent vs. Poor/ Fair)
	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)
School-Related Factors
School type
Elementary school	0.13 (0.01–1.22)	- a	- a	- a	- a	- a	- a	- a
Middle school	1.51 (0.71–3.21)	0.99 (0.47–2.10)	1.15 (0.46–2.84)	0.88 (0.41–1.90)	1.24 (0.53–2.94)	0.96 (0.42–2.20)	0.94 (0.39–2.24)	2.77 (1.07–7.15) *
Junior high school	12.98 (1.65–102.48) *	1.99 (0.73–5.46)	5.14 (1.69–15.61) **	1.76 (0.62–4.98)	1.32 (0.41–4.18)	1.91 (0.67–5.43)	1.53 (0.47–5.00)	1.49 (0.36–6.17)
Other	2.27 (0.45–11.53)	3.71 (1.01–13.68) *	1.39 (0.27–7.28)	0.88 (0.21–3.63)	0.92 (0.18–4.80)	1.31 (0.31–5.47)	1.61 (0.37–7.02)	3.85 (0.83–17.91)
High school	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
School position
Teacher	0.22 (0.06–0.96) *	0.30 (0.10–0.88) *	0.91 (0.24–3.48)	0.91 (0.30–2.74)	0.35 (0.11–1.08)	0.57 (0.18–1.73)	0.38 (0.12–1.21)	0.84 (0.19–3.71)
School mental or healthcare professional	- a	0.17 (0.02–1.54)	1.12 (0.09–13.22)	1.72 (0.24–12.36)	0.49 (0.05–4.49)	1.32 (0.18–9.72)	0.17 (0.01–2.81)	- a
Instructional aide/ security/ office staff/ other	0.41 (0.09–1.98)	0.29 (0.08–1.03)	0.61 (0.12–3.06)	0.68 (0.18–2.54)	0.28 (0.07–1.14)	0.54 (0.14–2.05)	0.50 (0.13–1.96)	0.87 (0.16–4.82)
School administrator	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Years of work experience in education
Less than 1 year	- a	18.26 (2.62–92.01) ***	46.13 (8.06–264.01) ***	6.13 (1.63–23.13) **	23.86 (5.45–104.37) ***	14.61 (3.50–60.99) ***	13.45 (3.42–52.85) ***	26.05 (5.75–118.04) ***
1–5 years	1.46 (0.66–3.20)	1.16 (0.51–2.65)	1.14 (0.40–3.23)	0.68 (0.28–1.64)	1.35 (0.49–3.71)	0.98 (0.39–2.46)	0.91 (0.32–2.57)	1.53 (0.47–4.96)
6–10 years	1.04 (0.50–2.16)	1.63 (0.76–3.48)	1.96 (0.77–4.96)	1.42 (0.67–3.02)	2.14 (0.89–5.19)	1.25 (0.54–2.90)	1.63 (0.67–3.93)	2.21 (0.77–6.33)
11–15 years	1.51 (0.64–3.55)	1.09 (0.47–2.53)	1.15 (0.40–3.26)	0.96 (0.41–2.23)	2.25 (0.89–5.68)	1.72 (0.73–4.09)	1.18 (0.44–3.12)	2.44 (0.84–7.11)
More than 15 years	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
School rurality
Non-metro (rural)	1.15 (0.62–2.16)	0.49 (0.26–0.92) *	0.40 (0.18–0.86) *	0.54 (0.29–1.02)	0.71 (0.35–1.46)	0.66 (0.34–1.29)	0.49 (0.24–1.003)	0.56 (0.24–1.32)
Metro	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Tobacco Use History
Lifetime history of smoking cigarettes
Yes	1.06 (0.57–1.95)	0.97 (0.52–1.81)	0.67 (0.30–1.48)	0.80 (0.42–1.51)	0.99 (0.48–2.04)	0.84 (0.43–1.66)	0.64 (0.30–1.37)	0.85 (0.36–2.00)
No	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Lifetime history of using smokeless tobacco
Yes	1.40 (0.65–3.02)	1.21 (0.56–2.64)	3.16 (1.24–8.04) *	2.56 (1.20–5.45) *	2.28 (0.99–5.24)	2.11 (0.96–4.64)	2.64 (1.13–6.19) *	2.98 (1.10–8.12) *
No	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Lifetime history of using e-cigarettes/ vapes
Yes	0.52 (0.24–1.12)	0.77 (0.35–1.70)	0.87 (0.33–2.27)	0.74 (0.33–1.67)	0.65 (0.26–1.63)	1.18 (0.51–2.69)	0.93 (0.37–2.34)	0.72 (0.25–2.09)
No	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref

Notes:

^*p < .05,

^**p < .01,

^***p < .001.

^aUnstable estimate. The analytic sample sizes across analyses ranged from 268 (82.5% of total sample) to 274 (84.3% of the total sample).

Participants working at junior-high schools were more likely than those working at high schools to report that their school integrated tobacco-free policies well (AOR: 12.98, CI: 1.65–102.48) relative to poor or fair. Teachers were less likely than school administrators to positively rate their school’s integration of tobacco-free policies (AOR: 0.22, CI: 0.06–0.96).

Participants who worked in other types of schools (vs. high schools; AOR: 3.71, CI: 1.01–13.68) and had less than one year of work experience (vs. >15 years of experience; AOR: 18.26, CI: 2.62–92.01) were more likely to rate their school’s integration of at-risk youth development positively. Alternatively, teachers (vs. school administrators; AOR: 0.30, CI: 0.10–0.88) and those working at rural schools (vs. metro schools; AOR: 0.49, CI: 0.26–0.92) were less likely to rate their school’s integration of at-risk youth development positively.

Participants who worked in junior-high schools (vs. high schools; AOR: 5.14, CI: 1.69–15.61), had less than one year of work experience (vs. >15 years of experience; AOR: 46.13, CI: 8.06–264.01), and who had used smokeless tobacco (vs. not used; AOR: 3.16, CI: 1.24–8.04) were more likely to positively rate their school’s integration of parent education. Participants working in rural schools were less likely to perceive favorable integration of parent education at their schools (vs. metro schools; AOR: 0.40, CI: 0.18–0.86).

Participants who had used smokeless tobacco (AOR: 2.56, CI: 1.20–5.45; AOR: 2.64, CI: 1.13–6.19; AOR: 2.98, CI: 1.10–8.12) and had worked in education less than one year (AOR: 6.13, CI: 1.63–23.13; AOR: 13.45, CI: 3.42–52.85; AOR: 26.05, CI: 5.75–118.04) were more likely to rate their school’s integration of research-based tobacco prevention curriculum, prevention into academics, and school tobacco specialists positively, respectively. There was a nonsignificant association between school rurality and perceptions about prevention’s integration into academics (AOR: 0.49, CI: 0.24–1.003; p=.051). Participants working in middle schools were more likely than those working in high schools to perceive that school tobacco specialists were integrated into their schools well (AOR: 2.77, CI: 1.07–7.15).

Participants with <1 year of experience were more likely than those with more than 15 years of experience to perceive that their school integrated cessation services well (AOR: 23.86, CI: 5.45–104.37) and provided up-to-date teacher training well (AOR: 14.61, CI: 3.50–60.99).

Several school leaders mentioned their policy described a cessation option, but in reality, they did not have the resources to offer this. For those that did offer a cessation program, it was part of their punitive response to catching a student with an e-cigarette. No interview participant mentioned providing cessation resources for help-seeking students. Several participants talked about students struggling with addiction. Only one interview participant described a second chance program that the school offered for students who violated their substance use policies.

We’ve got a second chance program, which is a diversion program to which we attach instead of going straight to expulsion for having THC or alcohol. We form a committee that includes our, our director of Mental Health services, assistant superintendent, principal, a counselor, and we put the kids through six months of being on probation. Counseling is a part of it. Check ins, drug tests, that kind of thing. #3

Perceptions about School’s Tobacco Prevention Efforts

Table 6 presents correlates of perceptions about school prevention efforts. Across analyses, participants with less than one year of work experience were more likely than those with more than 15 years of experience to perceive that their school engaged in the various tobacco prevention efforts well. Teachers were less likely than school administrators to perceive that their schools were doing well in keeping teachers updated on vaping (AOR: 0.17, CI: 0.06–0.49), providing peer-to-peer tobacco prevention education (AOR: 0.28, CI: 0.08–0.91), and equipping students with techniques to refuse tobacco (AOR: 0.27, CI: 0.08–0.84). Instructional aides/ security/ office staff/ and other school professionals were also less likely than school administrators to perceive their school was doing well at keeping teachers updated on vaping (AOR: 0.17, CI: 0.05–0.60). Finally, participants working at junior-high schools were more likely than those working at high schools to perceive that their schools were doing well at including parents in tobacco prevention activities (AOR: 3.45, CI: 1.19–10.04).

Table 6.

Multivariable logistic regressions predicting school professionals’ perceptions about their school’s tobacco prevention efforts in Arkansas.

	How Well Does Your School Do the Following?
	Keep Teachers Updated on Vape Products (Well/ Very Well/ Excellent vs. Poor/ Fair)	Keep Teachers Updated on Other Tobacco Products (Well/ Very Well/ Excellent vs. Poor/ Fair)	Provide Peer-to-Peer Tobacco Prevention Education (Well/ Very Well/ Excellent vs. Poor/ Fair)	Equip Students with Techniques to Refuse Tobacco (Well/ Very Well/ Excellent vs. Poor/ Fair)	Include Parents in Tobacco Prevention Activities (Well/ Very Well/ Excellent vs. Poor/ Fair)
	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)
School-Related Factors
School type
Elementary school	- a	- a	- a	- a	- a
Middle school	0.86 (0.41–1.80)	0.76 (0.35–1.63)	2.10 (0.86–5.14)	1.58 (0.70–3.61)	1.09 (0.45–2.63)
Junior high school	1.96 (0.71–5.44)	1.89 (0.68–5.29)	2.94 (0.89–9.74)	2.09 (0.66–6.61)	3.45 (1.19–10.04) *
Other	1.51 (0.39–5.82)	1.59 (0.43–5.91)	1.64 (0.30–8.96)	1.31 (0.25–6.90)	1.31 (0.25–6.81)
High school	Ref	Ref	Ref	Ref	Ref
School position
Teacher	0.17 (0.06–0.49) **	0.38 (0.14–1.06)	0.28 (0.08–0.91) *	0.27 (0.08–0.84) *	0.66 (0.19–2.23)
School mental or healthcare professional	0.30 (0.05–1.84)	0.71 (0.12–4.30)	1.24 (0.18–8.81)	0.91 (0.13–6.15)	0.90 (0.11–7.46)
Instructional aide/ security/ office staff/ other	0.17 (0.05–0.60) **	0.36 (0.10–1.25)	0.33 (0.07–1.46)	0.32 (0.08–1.29)	0.60 (0.13–2.65)
School administrator	Ref	Ref	Ref	Ref	Ref
Years of work experience in education
Less than 1 year	3.61 (1.10–11.83) *	3.29 (1.01–10.70) *	10.14 (2.71–37.95) ***	10.57 (2.96–37.69) ***	9.07 (2.60–31.58) ***
1–5 years	1.12 (0.49–2.60)	0.80 (0.34–1.91)	0.98 (0.30–3.24)	0.91 (0.30–2.76)	0.72 (0.24–2.16)
6–10 years	1.35 (-.61–2.94)	1.01 (0.46–2.21)	1.27 (0.44–3.74)	2.31 (0.93–5.72)	1.33 (0.53–3.34)
11–15 years	1.25 (0.54–2.90)	0.85 (0.36–2.01)	2.34 (0.89–6.18)	1.52 (0.57–4.07)	1.24 (0.47–3.26)
More than 15 years	Ref	Ref	Ref	Ref	Ref
School rurality
Non-metro (rural)	0.68 (0.37–1.26)	0.87 (0.48–1.62)	0.73 (0.33–1.61)	0.81 (0.39–1.66)	0.75 (0.36–1.56)
Metro	Ref	Ref	Ref	Ref	Ref
Tobacco Use History
Lifetime history of smoking cigarettes
Yes	0.79 (0.42–1.49)	0.68 (0.36–1.30)	0.94 (0.42–2.15)	0.92 (0.43–1.98)	1.11 (0.52–2.38)
No	Ref	Ref	Ref	Ref	Ref
Lifetime history of using smokeless tobacco
Yes	1.98 (0.94–4.15)	1.57 (0.74–3.34)	2.09 (0.81–5.39)	1.32 (0.54–3.23)	1.80 (0.76–4.23)
No	Ref	Ref	Ref	Ref	Ref
Lifetime history of using e-cigarettes/ vapes
Yes	0.89 (0.40–1.94)	0.98 (0.44–2.19)	0.52 (0.18–1.55)	1.02 (0.41–2.50)	0.91 (0.36–2.27)
No	Ref	Ref	Ref	Ref	Ref

Notes:

^*p < .05,

^**p < .01,

^***p < .001.

^aUnstable estimate. The analytic sample sizes across analyses ranged from 287 (88.3% of total sample) to 2286 (88.0% of the total sample).

In the interviews, participants often reflected on the years they had served in their leadership role and the shift in popularity for vaping devices. Several participants noted the impact that JUUL had caused on the vaping culture on their campus.

I’ve got a drawer… that’s got probably 400 vapes in there.

Before 2017 we almost got to a point where we never had any kind of tobacco discipline, and then JUUL come around. It completely went off the rails. #7

Almost all participants mentioned that they could be doing more, but many didn’t know exactly what to do. Figure 1 (a joint display) demonstrates the discrepancies between participants’ perceptions about what were important tobacco prevention components and how well these components were integrated in their schools, as well as representative quotes from administrators that provide more nuanced perspectives about these discrepancies. The largest discrepancy was for parent education.

Figure 1.

Joint Display: School professionals’ perceptions about the effective components of tobacco prevention programs and how well schools integrate them.

Tobacco Prevention included in School Curriculum

For this model, only school type, participant position at the school, and school rurality were examined as independent variables. The analytic sample for this outcome was 154 due to missing data. Teachers were less likely than school administrators to report that tobacco prevention was included in their curriculum (AOR: 0.10; CI: 0.01–0.81, p=.03). There were no other significant associations.

No interview participants mentioned that tobacco education was included in the school curriculum. They relied on one-day events, outside speakers, or school nurses or counselors. It was often perceived as an addition to their current curriculum, and there was only so much they could accomplish in a day. This challenge of feeling overwhelmed often was echoed as an issue that was not going to be improved overnight and needed a comprehensive approach.

Discussion

This convergent mixed-method study identified that student tobacco use was a top school health priority among school professionals in Arkansas (administrators, teachers, staff). The three tobacco prevention components Arkansas school professionals believed to be most important were parent education, school tobacco-free policies, and up-to-date teacher training. Notably, this differs from California school professionals’ endorsed priorities, which were school tobacco-free policies, research-based curriculum, and youth development opportunities [23]. This highlights unique needs of a state experiencing tobacco disparities.

Unfortunately, two of the top three prevention components perceived as most important to Arkansas school professionals (parent education and up-to-date teacher training) were perceived as not being well integrated into schools. Over 66% of survey respondents indicated that tobacco prevention was included in their school curriculum. Yet, most schools mainly relied on Red Ribbon Week, or other one-day events, to serve as their tobacco prevention programming. Interview data confirmed that schools were mainly using reactive rather than proactive approaches to address student tobacco use. Overall, school professionals and administrators endorsed the need for tobacco prevention programming at their schools, but numerous challenges were noted, including the rise of student vaping and the need for better educational resources and initiatives for school professionals, students, and parents. The importance of integrating parents into tobacco prevention efforts, and the critical need for resources to help schools to do so, was echoed across our quantitative and qualitative findings. For example, interview data identified that students were obtaining tobacco products from their parents. Future research should explore how to effectively engage and integrate parents into school-based tobacco prevention efforts and, more broadly, how to enhance the adoption and implementation of research-based school tobacco prevention programs in states experiencing tobacco disparities.

Overall, there were few differences in school professionals’ perceptions about the importance of tobacco prevention, though some differences did emerge. Participants who worked in middle schools were less likely those who worked in high schools to identify student tobacco use as a top priority; school professionals with less than 1 year of experience were more likely to endorse it as a top priority. Turning to the importance of specific prevention components, teachers perceived tobacco free policies as more important than administrators, and professionals in elementary and junior high more likely to perceive that additional supports for addressing student tobacco use were important (school tobacco specialists and teacher training, respectively). While other studies have examined how school staff feel their personal tobacco use affects their ability or authority to intervene in student tobacco use [27], our study is among the first to document how school professionals’ personal tobacco use history relates to their perceptions about tobacco prevention, identifying how personal use of different products is linked to varying perceptions about what is an important component to prevent student tobacco use. Understanding this could provide insights into how to improve tobacco prevention efforts. Future research could examine how school professionals’ tobacco use history may impact engagement in school tobacco prevention efforts.

We also identified differences in school professionals’ perceptions about how well tobacco prevention was integrated into their schools. Teachers were less likely than school administrators to report that their school curriculum included tobacco prevention and that their school was integrating and implementing various tobacco prevention components well. Interview data from school administrators illustrated how they felt about teachers’ beliefs that tobacco prevention was largely the responsibility of administration but also agreed that more needed to be done. We also identified that professionals working in high schools were less likely to endorse that their school was doing well at integrating various tobacco prevention components (e.g., parental education) compared to professionals working in junior-high schools (and sometimes middle schools/ other schools). Importantly, professionals working in rural schools were less likely than those working in non-rural schools to perceive that their school integrated at-risk development and parental education well. This dovetails with prior work that identified that rural schools were less likely than urban schools to be tobacco-free campuses and to provide cessation resources [28]. Differences by rurality could contribute to the disproportionate tobacco burden among rural communities [5, 8].

This study advances our understanding of barriers to implementing school tobacco prevention efforts in a state with geographic tobacco disparities; however, several limitations should be noted. Due to our sampling method, generalizability may be limited. The small cell sizes for some of the adjusted models may have limited our ability to detect effects and the precision of some of our estimates. This study identified perceptions about school tobacco prevention efforts in schools rather than the actual implementation, though our survey and interview data largely converged. Future work may benefit from exploring differences in documented tobacco prevention curriculum and strategy implementation.

In conclusion, school professionals in Arkansas, a state with significant tobacco burdens, identified that: 1) student tobacco use is a top health priority for their schools, 2) the most important strategies for their schools included parent education, school tobacco-free policies, and up-to-date teacher training, and 3) they faced numerous barriers to effectively implementing tobacco prevention in their schools, especially for implementing parent education and teacher training. There were differences in the perceived effective implementation of tobacco prevention by rurality, position (teachers vs. administrators), school level (high schools struggled more), and level of work experience. Future research should explore effective ways to engage parents in school-based tobacco prevention and use implementation science to improve the adoption of research-based programs, particularly in states with tobacco disparities.

Data Availability:

The data underlying this article will be shared on reasonable request to the corresponding author in order to protect the confidentiality of participants from a low-density population in a specific geographic region.