Dissemination of CATCH My Breath, a middle school E-Cigarette prevention program

Abstract

Objectives:

In 2016, the US Surgeon General issued a Call to Action to address adolescent e-cigarette use and school-based prevention interventions are an effective component of comprehensive tobacco control. This study describes the development and dissemination of CATCH My Breath, an e-cigarette prevention program for middle and high school students.

Methods:

Starting in 2014, a university and nonprofit collaboration designed, formatively evaluated, pilot tested, and disseminated the CATCH My Breath Program (CMB). The team used Social Cognitive Theory to develop the program and Diffusion of Innovations Theory to disseminate the program. Dissemination strategies were applied beginning in 2016. This paper describes the application of both theories and the resulting reach of CMB.

Results:

Since dissemination began, CMB has been rapidly adopted, following the typical diffusion normal curve. As of June 2020, approximately 4,000 schools in the United States have adopted the program, 70,000 teachers have taught the program, and 1,400,000 students have been exposed to program materials.

Conclusion:

The application of Social Cognitive Theory and Diffusion of Innovation Theory resulted in effective prevention results and rapid, widespread adoption of the CMB. This level of adoption and implementation represents 25% of the school marketplace. CMB should be considered as the school component of the recommended combustible and e-cigarette prevention and control toolkit, alongside mass media, marketing restrictions, retail access, taxation, flavor ban, and FDA premarket approval. Other public health interventions seeking rapid adoption should consider applying principles of Diffusion of Innovation as a guide for development and dissemination.

1. Introduction

E-cigarettes are the most commonly used tobacco product among adolescents in the US (Wang et al., 2019). From 2014 to 2019, the number of adolescent e-cigarette users more than doubled, from 2.5 million to 5.4 million (Arrazola et al., 2015; Wang et al., 2019). Adolescent e-cigarette use is linked to nicotine dependence (Case et al., 2018) and combustible tobacco initiation (Odani, Armour, King, & Agaku, 2020). Citing prevalence and corresponding health implications, the US Surgeon General and the National Academy of Sciences issued calls to action for adolescent e-cigarette prevention interventions.

In 2014, university researchers began developing the “CATCH My Breath” (CMB) e-cigarette prevention program to address rising adolescent e-cigarette use. As most e-cigarette initiation occurs by the age of 14 (i.e., first year of high school) (Sharapova et al., 2020) and is typically preceded by susceptibility to use during middle school (Barrington-Trimis et al., 2019), the CMB e-cigarette prevention program was specifically developed for middle school students (6th–8th grade). CMB was informed by best practices from prior tobacco prevention interventions (Thomas, McLellan, & Perera, 2013, 2015) and educates youth on health consequences of tobacco use, addresses environmental risk factors (e.g., advertising), and develops refusal skills.

Pilot evaluation found CMB reduced e-cigarette initiation among middle school students from 6th to 7th grade by 46% (Kelder et al., 2020). The program also significantly improved combustible tobacco incidence, and intermediate variables related to e-cigarette use (e.g., knowledge; outcome expectations) (Kelder et al., 2020). Our aim is to describe the development and dissemination of the CMB e-cigarette prevention program, including use of the guiding principles of Diffusion of Innovation Theory.

2. Development of CATCH My Breath (CMB)

The research team created CMB in collaboration with an experienced partner in school health education, the CATCH Global Foundation (CGF), a 501(c)3 designed to dissemination school health programs. Guided by the “Whole School, Whole Community and Whole Child” ecological framework (Lewallen, Hunt, Potts-Datema, Zaza, & Giles, 2015), CGF provides curriculum, training/technical assistance, evaluation, and other resources to build school and community capacity for creating healthy environments for children. CGF delivers health education programming to approximately 15,000 educational sites, globally, reaching 3 million Pre-K—12th grade students annually. This university and nonprofit collaboration designed CMB for both effectiveness and reach to bring the program to scale.

The CMB program builds on decades of tobacco prevention research (Thomas et al., 2013, 2015) and uses framework aimed at creating an eco-system of supports within school, home, and community settings for child health promotion. The CMB program fosters normative expectations, social competence, and resistance skills, essential elements of prevention programs. Experienced curriculum writers, middle school teachers, and leaders in the tobacco control practice field were included to gain insight from key partners ‘within systems’ (Hawe, 2015; May, Johnson, & Finch, 2016). CMB was designed to fit into class schedules as a stand-alone program or a component of tobacco prevention programming.

Fig. 1 provides the logic model for CMB program. With a foundation in Social Cognitive Theory, CMB builds from the concept of reciprocal determinism by intentionally targeting:

• Behaviors and performance objectives including initiation, current use, refusal skills, and promotion of anti-vaping message;

• Intrapersonal factors for e-cigarette use including knowledge, outcome expectations, self-efficacy, perceived susceptibility/severity, social support;

• Environmental factors and performance objectives including parent support to prevent e-cigarette use, enhancing school context for e-cigarette prevention, school policies, and anti-vaping support.

Fig. 1.

CATCH My breath logic model.

The primary components in support of these behavioral and environmental targets include: (a) classroom lessons for 6th⁻8th grade students; (b) PE lessons incorporating ‘physically active learning’ about e-cigarette prevention; (c) classroom activity breaks providing physically active learning for e-cigarette prevention can be incorporated across middle school classes; (d) parent education for parenting best practices (e.g., monitoring child’s free time) and reinforcing prevention messages at home; (e) media with rotating posters and announcements with anti-vaping messages at school; and (f) teacher training to deliver the CMB curriculum and serve as role models of student social support.

2.1. Effectiveness of CATCH My Breath

A quasi-experimental pretest–posttest study of 12-middle schools found positive CMB effects: from 6th grade baseline to 16-month follow-up, e-cigarette initiation, knowledge, and 30-day tobacco use were positively (and significantly) impacted by CMB relative to comparison schools (Kelder et al., 2020). To our knowledge, CMB is the first e-cigarette prevention program to be developed and evaluated for middle school students in the US. Details can be found elsewhere (Kelder et al., 2020).

2.2. CMB dissemination and sustainability

The CMB team was concerned of reports that health innovations, on average, take 17 years from demonstrated impact to widespread adoption (Morris, Wooding, & Grant, 2011). Although pharmaceutical and clinical practice innovations are not directly comparable to school health education, and research to marketplace varies widely, the CATCH team decided the growing e-cigarette epidemic, and possible lifetime of nicotine addiction, warranted a rapid response. The problem-identification-to-solution lag time is largely due to the top-to-bottom response in solving health problems: 1) Identify prevalence and consequences of the problem; 2) Determine multi-level risk factors for the problem; 3) Develop and evaluate interventions; 4) Secure funding for experimental evaluation of interventions; 5) Conduct experimental effectiveness trials of interventions; 6) Replicate findings under varying conditions and target audiences; 7) Secure funding for dissemination of interventions; 8) Disseminate warranted interventions; and 9) Evaluate effectiveness of intervention adoption, implementation, and dissemination. This linear process can be slow and inefficient because success of any workstream (items 1–9) depends on proof points from the preceding workstreams.

Linear development and dissemination can be ineffective if the intervention is based on rapidly evolving problems and circumstances. E-cigarettes are a rapidly evolving segment of the tobacco environment with new and evolving products (Pearson, Reed, & Villanti, 2020), new methods of direct marketing tactics and mediums used to recruit new users, and responses by regulatory agencies (Berman & Yang, 2016; Patel et al., 2020). The CMB team addressed this challenge by compressing the 9-step process from a multi-year timeline to a semi-annual cycle by limiting decision-making heuristics to only one DOI adoption group at a time (Innovators to Laggards).

Rapid Response to the E-cigarette Epidemic.

The study team selected Diffusion of Innovation Theory (DOI) as the framework to accelerate the dissemination of CMB (E. Rogers, 2003). DOI posits a two-step process (Fig. 2). First, organizations (e.g., schools) become interested in, and implement, new curriculum/programs/polices a series of stages (Fig. 2). Second, program promoting organizations (e.g., CGF) use strategies that appeal to individuals according to their interest and willingness to adopt new ideas (Fig. 3) (E. Rogers, 2003; E. M. Rogers, 2004). It is important to note different funders also belong to different categories on this adoption spectrum. Early-stage ‘Innovative Funders’ (e.g., private foundation opportunity funds) will support projects with few proof points, but usually provide smaller amounts of funding; ‘Early Majority-stage Funders’ (e.g., NIH) require more demonstrated progress, but make larger financial commitments.

Fig. 2.

The diffusion of innovation process.

Fig. 3.

CATCH my breath diffusion curve.

2.2.1. Stages of CMB diffusion of innovation (Fig. 2)

In the knowledge stage, stakeholders become aware of the innovation through social networks, media coverage, publications, and partnerships. Once aware, they explore characteristics of the innovation (e.g., relative advantage, compatibility) and if favorable, enter the trial or implementation stage. If the trial is successful, they adopt and institutionalize the innovation by incorporating into, budgeting, policy and long-term plans.

Messaging to inform school decision makers were guided by key DOI constructs known to accelerate adoption: (1) Relative Advantage; (2) Compatibility; (3) Complexity; (4) Trialability; and (5) Observability. These constructs were applied to make the value of the program more recognizable for state education and health authorities, local education agencies, principals and teachers.

Relative Advantage is an understanding of how new innovation compares to current practices; this is typically operationalized in terms of effectiveness or cost. Whereas the field of youth tobacco prevention is mature, CMB was developed to fill a unique and rapidly growing concern where no e-cigarette prevention programs had previously existed. Although first developed for middle school, in response to school demand CMB program developers continually improved the program based on user feedback and created flexible, age-appropriate program materials for 5th, 6th, 7/8th and 9–12th grades.

2.2.2. Compatibility

The CMB program is compatible with established national health standards for prevention education, which are required in most states in the US for program adoption. Further, while CMB focuses on e-cigarettes, it also covers essential information and tobacco prevention activities. It offers classroom lessons, supporting physical education and classroom activities, in-person and online parent education, social media outreach, and school posters.

2.2.3. Complexity

The CMB program was intentionally designed with input from teachers and school administrations so schools could intuitively implement and disseminate the program. All CMB materials are 100% accessible through a digital platform which utilizes google slides to provide lessons in a format teachers already use (slide presentations). The digital platform has a teacher feedback mechanism to provide real-time updates in response to the changing e-cigarette landscape (e.g., new products, risk factors, epidemiology).

Trialability. The CMB program is situated within the CGF non-profit with a mission to disseminate school health programs at low, or no, cost to schools. Trialability is enhanced because potential adopters can easily browse the online program and pilot test before larger-scale adoption, without incurring cost. Trialability is further aided by free teacher webinar and online training. Although free is a key feature, without outside financial support, we estimate the program delivery breakeven cost (not new program development or evaluation) at 10 cents per pupil.

2.2.4. Observability

Parents, school visitors, and local media can easily observe children learning and becoming informed about the dangers of combustible cigarettes, e-cigarettes and addiction. CMB in action can easily and frequently be observed through parent involvement strategies, presentations of program activities (e.g., social media campaign classroom assignments), morning announcement’s, or watching CMB PE activities. It’s important for the social layers of the school community to observe CMB so an informed decision on adoption can be made. In most instances, implementation of CMB is positively viewed as timely and forward thinking by school leadership, parents, and local community members.

2.2.5. CMB adoption categories (Fig. 3)

Once U.S. surveillance systems reported the rise of youth e-cigarette use, the research team concluded in 2014 the epidemiological evidence suggested: 1) although not all the harmful consequences were fully elucidated, youth addiction to e-cigarette delivered nicotine was sufficient to justify implementation of prevention activities; and 2) the well-established combustible youth tobacco control literature was sufficient to provide the basis for program development.

The development and deployment of CATCH My Breath was structured as a rapid response to an emerging public health epidemic and proceeded quickly because, instead of addressing workstreams in a top-to-bottom sequence (1–9 above), we developed workplans and workstreams using the DOI left-to-right user adoption categories; it is critical to understand that adoption categories are self-selected. Typically, identification of innovators and early adopters through several simultaneous strategies. In larger districts, it’s common to use ‘snowball sampling’ where program staff call district health personnel and ask “Who in your district is most important regarding tobacco or substance use prevention?” The same question is asked of those recommended, until a common group of names are repeated a meeting is scheduled – these are innovators or early adopters. This method can also be applied at the state level by calling the state tobacco control officer or state public health and education officers. Another method is to contact topic related national health associations and organizations such as the CDC and office of Smoking and Health, FDA, American Heart Association, or American Lung Association. Finally, a professional online presence directed at innovators and early adopters highlighting the key DOI constructs known to accelerate adoption is critical: Relative Advantage, Compatibility, Complexity, Trialability; and Observability. This can be accomplished through Webinars and professional conferences or by using social media strategies such as Facebook, LinkedIn or Twitter.

Innovators are eager to try and develop new ideas and willing to take the risk to first try the innovation. Typically, innovators have stature across social systems and the ability to understand and apply complex technical knowledge in varied and new situations. The CMB team identified Innovators concerned about rising e-cigarette prevalence and invested personnel effort to individually communicate with them. The goal was to gain a commitment to adopt and trial CMB by communicating the features and benefits (innovation characteristics) of the program while establishing the credibility of the university and CGF partnership. Once a satisfactory pilot implementation was achieved, CGF requested an endorsement by the Innovator, followed by public relations to spread the word and diffuse CMB from Innovators to Early Adopters.

Early Adopters are already aware of the need for change, often seek advice from innovators, and embrace results-oriented change opportunities. They often hold a managerial position within their school or district and a leadership position in professional organizations. Early Adopters are respected opinion leaders and have a reputation for successfully operationalizing new ideas. CGF acted as a ‘change agent’ by actively communicating Innovator recommendations, survey feedback, and the market need which the CMB program filled. These messages were targeted to tobacco control and health education professionals’ early adopters who were reached through booths and presentations at professional conferences, webinars, a dedicated website, and social media. Finally, during this phase CGF began nationwide mass communications to set the stage for reaching members of the Early Majority.

Early Majority members are respected by their peers, frequently interact with them, and are comfortable adopting new ideas within their organization. Data-driven verification in a scientific peer-reviewed form is required for the Early Majority authorities to endorse and approve adoption of a school health program. The CMB pilot evaluation (Kelder et al., 2020) demonstrating feasibility and initial effectiveness was a crucial milestone in reaching this group.

Credible publication(s) are a prerequisite for funding agencies to provide resources to offset the costs of the program, an essential activity facilitated by the CGF. CGF designed strategies to appeal to this population by communicating success stories and evidence of the innovation’s effectiveness. Many leaders of large organizations are in the Early Majority adoption category, so during this communication stage CGF focused on using proof points of success to approach large school districts about using CMB within their schools. As of the end of the 2019–2020 school year, CMB was approved for use in 5 of the 7 largest districts nationwide, who collectively educate 1.4 million 5th–12th grade students.

Individuals in the Late Majority group are skeptical of change and adopt an innovation only after it has been established as the norm by early adopters and early majorities. They are cautious and reluctant to adopt new ideas until there is significant social pressure within the school district, or by local professional organizations. Strategies to appeal to this population include distributing normative success stories by early adopters and early majorities users and were praised by students, parents, and the school community. Incentives and local news coverage can motivate those in the late majority, as can colleagues who demonstrate the features and benefits of CMB first-hand.

Laggards are the last to adopt an innovation, and many times never do. They carry little opinion leadership and are localities to the point of being isolated compared to more open adopter categories. Resistance to changes makes these individuals expensive to convince and often are not targeted as a priority because of the poor expense to adoption ratio. Nevertheless, adoption may be achieved with laggards through strong pressure from local organizations (e.g., PTA; school health advisory councils). State and federal policy initiatives may move Laggards to adoption with state educational code requirements, seed funding, monitoring and enforcement, reprimands.

CGF applied DOI to develop a rapid response strategy to the youth vaping epidemic which led to reaching over 4,000 schools, 70,000 teachers trained, and 1,400,000 youth during 4 years, including 1,000,000 youth during the 4th year. This figure represents approximately 25% of the addressable market, a growth curve far steeper than typical programs of this type. The principles which guided this success are:

1. Modifying existing program and organizational resources accelerates adoption. Fortunately, the field of youth combustible tobacco prevention is mature, several large organizations have longstanding tobacco recommendations (CDC, FDA, AHA, ALA), and most states require some form of tobacco prevention. In addition, the CATCH Global Foundation was able to take advantage of an internal national contact list for their diet and physical education CATCH programs.

2. Working sequentially by DOI adoption group (i.e., left-to-right in Fig. 3), instead of the sequential top-to-bottom workstream approach (steps 1–9).

3. During each adoption segment: secure funding, develop the program and evaluation materials minimally necessary to address the needs of that segment.

4. Focusing resources exclusively on the segment being addressed (e.g., starting with smaller school districts and developing proof of success before expanding).

5. Planning fundraising and budgeting by anticipating the DOI progression from Innovators to Early Majority by one adoption group per year.

3. Discussion

This study described the application of Diffusion of Innovation Theory to efficiently and effectively disseminate the CATCH My Breath e-cigarette prevention program to middle and high schools in the United States as a response to the ongoing e-cigarette epidemic (National Academies of Sciences & Medicine, 2018; Wang et al., 2019). Initial evaluation of CMB demonstrated program effectiveness in addressing e-cigarette and combustible initiation during middle school (Kelder et al., 2020). In applying DOI Theory, the research team effectively reached more than 1.4 million middle and high school students from 2016 to 2020; the cumulative curve followed a normal diffusion curve (based on implied market share) (Fig. 3). The approach and procedures described in this study were intended to reduce the recognized lag time from development-to- validation-to wide-spread dissemination in public health interventions (Morris et al., 2011).

In recognizing the potential public health ramifications of widespread e-cigarette use among adolescents, the university team and CGF set out to develop an intervention to reduce this behavior. Given the known, and speculated, harmful consequences of youth vaping, the typical program development- pilot test-RCT-disseminate process seemed too lengthy to rapidly respond and prevent vulnerable youth from nicotine addiction. To ensure the timely implementation and dissemination of CMB, the program was disseminated following the structured principles of Diffusion of Innovation Theory, thus addressing the “upstream” root behavioral causes of poor health.

The CDC recommends youth tobacco prevention programs be composed of local, state and national policies of tobacco prevention and control (Control & Prevention, 2014). CMB was the first elementary, middle school and high school e-cigarette prevention program nationally available. Others have joined the school prevention effort, but to our knowledge, CMB is the school option evaluated for student behavioral outcomes (Kelder et al., 2020). If CDC recommendations are to be sufficiently reached, the lessons learned from youth combustible prevention can be rapidly applied and shorten the time frame to flatten the curve and begin the decline of youth e-cigarette use.

Decades of tobacco prevention research offers many insights which inform rapid response interventions for newly developed products such as e-cigarettes. The research and dissemination teams used the accumulated tobacco knowledge and applied DOI messaging constructs known to accelerate adoption (Relative Advantage, Compatibility, Complexity, Trialability. and Observability) and directed messages to Innovators and Early Adopters. Indeed, it appears as if e-cigarette companies deployed a similar strategy with social media influencers for the rapid uptake among youth (Huang et al., 2019). These strategies may be helpful for COVID vaccination when the time comes.

Funding is needed for accelerated adoption, but funding at the right time is critical. State support for faculty effort, and small-scale internal seed money, covered the expenses for early development and formative evaluation of CMB. As Innovators and Early Adopters came on board, fundraising needed to keep pace. Moving from paper copies and shipping to an on-line program delivery platform became a priority, and CGF found institutional support for digital dissemination from a University of Texas cancer research and treatment center. CMB is currently offered to US schools free of change thanks to a gift from CVS Health and support from philanthropy. Greater staffing and outreach support were needed during the transition from Early Adopters to Early Majority and CVS Health played a pivotal role by providing resources, including funding a Discovery Education initiative in 2019.

Conclusive evidence will be required for continued dissemination as the field of e-cigarette prevention and control matures. Because of CMB pilot results and dissemination, funding for the CMB group randomized trial from NIH submissions began in 2019. The full trial results will be available in 2024, five years after the beginning of program development and seven years into the epidemic, highlighting the need for Innovation and Early Adopter funding agencies to support prevention efforts at the beginning of an epidemic. Support for early pilot funding for the elementary and high school versions has been secured but experimental evaluation studies are needed.

4. Conclusion

Interventions seeking rapid adoption should consider principles of DOI to guide program development and dissemination. Since 2016, middle schools using the CMB program have reported positive feedback without unanticipated negative outcomes and have directly requested elementary and high school versions of the program. The adaptive and new elements of CMB are primarily developed by the university team, and national program dissemination by CGF, in collaboration with CVS Health, Discovery Education, school districts, and community partners.