Abstract
Introduction
In 2019, 25.8% of Kansas high school youth reported using any form of tobacco product. Schools can prevent and reduce youth tobacco use by adopting comprehensive tobacco policies, which include all tobacco products, on school grounds and at school-sponsored, off-campus events, for all individuals at all times, and integrate cessation services for students who violate the tobacco policy. The purpose of this study was to determine the prevalence of comprehensive tobacco policies in unified school districts (USD) across Kansas to determine how many schools have adopted such policies.
Methods
All 286 USDs in Kansas were eligible to participate in this study including elementary, middle, and high schools. Participating schools were asked to upload their policies to a website developed by the Kansas Department of Health and Environment (KDHE). Frequencies and percentages were computed to identify the type of tobacco products prohibited, the locations where tobacco use is prohibited, who is prohibited from using tobacco, when tobacco is prohibited, and consequences of students’ violation of the tobacco policy.
Results
Several USD policies met some of these comprehensive recommendations; however, 97.9% (n = 280) did not. In other words, 2.1% of USD policies (n = 6) were comprehensive in Kansas. Most districts (98.3%, n = 281) presented policies prohibiting use of all forms of tobacco for students, but policies often offered more leniency for faculty/staff and visitors. Fewer districts presented policies prohibiting use of all tobacco products for staff/faculty (73.1%, n = 209) and visitors (45.8%, n = 131) of policies.
Conclusions
Nearly all USDs in Kansas have an opportunity to strengthen their tobacco policies. Relatively simple edits can be made to prohibit all tobacco products, prohibit use on school grounds and at school-sponsored, off-campus events, ensure these policies apply to everyone, at all times, and integrate cessation resources for students who violate the tobacco policy.
Keywords: tobacco, smoke-free policy, schools, Kansas
INTRODUCTION
Smoking is the leading cause of preventable death in the United States.1 This leads to a national expense of $170 billion in direct medical costs annually, which could be saved if the initiation of tobacco products among youth were prevented.2 In 2019, 16.2% of Kansas adults smoked combustible cigarettes. This exceeded the national median of 14.0%.3,4 In 2019, 25.8% of Kansas high school youth reported currently using any form of tobacco product, including combustible cigarettes, cigars, smokeless tobacco, and electronic cigarettes (e-cigarettes).5 In the U.S., 89.7% of smokers started using tobacco products before they were 18 years old.3
From 2011 through 2018, the use of combustible cigarettes decreased among youth in the U.S.3 However, youth usage of e-cigarettes has surged. The number of middle and high school students using e-cigarettes rose from 3.6 million in 2018 to 5.3 million in 2019, a difference of about 1.7 million.3 In 2019, 22.0% of high school students in Kansas reported using e-cigarettes within the last 30 days.5
An important strategy to prevent and reduce youth tobacco use is the adoption of comprehensive policies that prohibit any use of tobacco in schools.6–10 Comprehensive tobacco policies must prohibit all people (e.g., students, faculty/staff, and visitors) at all locations (e.g., inside, on school grounds, in vehicles, and at school-sponsored, off-campus events) from using all tobacco products (including e-cigarettes) at all times (e.g., during school hours and non-school hours) and include some form of tobacco intervention (e.g., cessation resources) for students violating the tobacco policy as the school’s disciplinary action.
School tobacco policies are most effective when they prohibit use of all tobacco products, for all people, at all locations, and at all times.4,6,11 Additionally, tobacco policies are most effective when schools uphold consistent consequences for students who violate tobacco policy.6,12,13 The Kansas Department of Health and Environment (KDHE) recommended that consequences for students’ violation of a tobacco policy have supportive disciplines, such as tobacco training or cessation program.4 Such an intervention can be more effective than suspension or detention in promoting more positive student outcomes, such as improved likelihood of tobacco cessation.12,14
It is unknown how many school districts in Kansas have adopted comprehensive tobacco policies. This information is needed to reduce youth tobacco use. Therefore, the purpose of this study was to determine the prevalence of comprehensive tobacco policies in USDs across Kansas.
METHODS
Participants
All USDs in Kansas were eligible to participate in this study. Each USD had a policy which encompasses policies for all public schools located in the USD, including elementary, middle, and high schools. Private schools in Kansas were not included in this study, this was the only exclusion. Participation was voluntary and schools were not provided an incentive to participate.
Instrument
A Microsoft® Excel document was created by KDHE that established the variables that were to be abstracted from the policies. Variables assessed included “Do the districts have a policy prohibiting tobacco use?”, “Are e-cigarettes included in the policy?”, “Types of tobacco prohibited for students, faculty/staff, and visitors?”, “Where is tobacco prohibited?”, “When is tobacco use prohibited?”, and “What is the student enforcement for the policy?”.
Procedures
This study was deemed to be “not human subjects” by the University of Kansas Medical Center’s Institutional Review Board. The Kansas Department of Education (KDE) requires every USD to have a structured policy book. This book includes topics such as student, faculty, and visitor policies. Although the structure of the policy books is standardized, the policies are not; each policy varies for each USD. KDE does not require USDs to have a tobacco policy for all three subgroups, and if a USD does not have one, the section title is included but the content is left blank. If a school district has a tobacco policy, these sections can include which tobacco products are disallowed, the locations that products are disallowed, and punitive measures for breaking policies.
To conduct this study, staff in the Kansas Department of Education (KSDE) e-mailed all 286 eligible schools on October 17, 2019, requesting that the superintendent of each USD submit their current tobacco policies for students, faculty/staff, and visitors. The e-mail included a link to a secure KDHE website. Participating schools were asked to submit their policies to the 2019 Kansas Comprehensive Tobacco-Free Schools Database. The website was designed for school personnel to upload their current tobacco policies. If the policy was not submitted by November 1, 2019, the school district was called by a Master of Public Health (MPH) student from the University of Kansas School of Medicine-Wichita. A maximum of three attempts were made to obtain school district participation.
Once all policies were submitted, the MPH student accessed the database to review the policies, then abstracted information and entered it into the Microsoft® Excel document developed by KDHE staff. Any tobacco policy that did not specify which products were prohibited were coded as “tobacco products not specified”.
The data abstracted from the submitted policies were assessed by the research team to determine: 1) if school districts have a tobacco policy; 2) the type of tobacco products (including e-cigarettes) included in the policy; 3) the individuals the policy applies to (e.g., students, faculty/ staff, and visitors); 4) the locations where tobacco is prohibited (e.g., in school buildings, on school grounds, in school vehicles, and school-sponsored, off-campus events); 5) when tobacco use is not permitted (e.g., during school hours, after school hours, at all times); and 6) what enforcement is included in the policy (e.g., cessation resources, tobacco education, suspension, detention, report to local law enforcement).
Analysis
Each policy was reviewed to identify which level (e.g., student, faculty/staff, and visitors) was most appropriate for each variable (e.g., prohibited tobacco products, locations, times the policy is enforced such as during school hours). Categories were pre-defined and associated with evidence-based tobacco policies. The primary outcomes for this study were the frequencies and percentages of the policies’ inclusion of which tobacco products were prohibited, where tobacco products were prohibited, and when tobacco products were prohibited for each separate level and consequences of students’ violation of tobacco policy.
RESULTS
All 286 USDs in Kansas were asked to participate, and all 286 participated in this study. Of the 105 counties represented, 34.3% (n = 36) were frontier [fewer than 6.0 persons per square mile (ppsm)], 32.4% (n = 34) were rural (6.0–19.9 ppsm), 18.1% (n = 19) were densely-settled rural (20.0–39.9 ppsm), 9.5% (n = 10) counties were semi-urban (40.0–149.9 ppsm), and the remaining 5.7% (n = 6) counties were urban (150.0 ppsm or more).15
Tobacco Products
The specific prohibited tobacco products were noted in 98.3% (n = 281) of student policies, 73.1% (n = 209) of faculty/staff policies, and 45.8% (n = 131) of visitor policies (Table 1). One (0.3%) student policy specified that only combustible cigarettes were prohibited.
Table 1.
Tobacco products prohibited in school district policies.
| Products Prohibited | Student Policy % (n) | Faculty Policy % (n) | Visitor Policy % (n) |
|---|---|---|---|
| Tobacco-free (all “tobacco” products are prohibited, including e-cigarettes) | 98.3% (281) | 73.1% (209) | 45.8% (131) |
| Smoke-free (only combustible products are prohibited) | 0.3% (1) | 0.0% (0) | 0.0% (0) |
| Tobacco products not specified (does not specify which tobacco products are prohibited) | 1.4% (4) | 26.9% (77) | 54.2% (155) |
Tobacco Prohibition by Location
Nearly all policies (98.3%, n = 281) prohibited some form of tobacco product (smoke free or tobacco free) in at least one of the following locations: school buildings, school grounds, school owned vehicles, or school sponsored events (Table 2). Nearly all (98.3%, n = 281) student policies prohibited some type of tobacco use in school buildings, on school grounds (e.g., parking lots), and in school vehicles. In 95.1% (n = 272) of student tobacco policies, some type of tobacco use was prohibited at school-sponsored, off-campus events (as a location).
Table 2.
Policy locations prohibiting some type of tobacco use.
| Location | Student Policy % (n) | Faculty Policy % (n) | Visitor Policy % (n) |
|---|---|---|---|
| In school buildings | 98.3% (281) | 71.3% (204) | 45.1% (129) |
| On school grounds (parking lots and playing fields) | 98.3% (281) | 66.8% (191) | 40.2% (115) |
| In school-owned vehicles | 98.3% (281) | 70.6% (202) | 40.6% (116) |
| School-sponsored, off-campus events | 95.1% (272) | 36.0% (103) | 9.8% (28) |
In 71.3% (n = 204) of the policies, faculty/staff were prohibited from using some type of tobacco product in school buildings. In 66.8% (n = 191) and 70.6% (n = 202) of the policies, faculty/staff were prohibited from using some type of tobacco product on school grounds and in school-owned vehicles, respectively. In 36.0% (n = 103) of the policies, faculty/staff were prohibited from using some type of tobacco product at school-sponsored, off-campus events.
In 45.1% (n = 129) of the policies, visitors were prohibited from using some type of tobacco product in school buildings. In 40.2% (n = 115) and 40.6% (n = 116) of policies, visitors were prohibited from using some type of tobacco product on school grounds and in school-owned vehicles, respectively. In 9.8% (n = 28) of the policies, visitors were prohibited from some type of tobacco product at school-sponsored, off-campus events.
Individuals Prohibited from Some Type of Tobacco Use
In 25.2% (n = 72) of the policies, only students (not faculty/staff or visitors) were prohibited from using some type of tobacco product (Table 3). In 14.7% (n = 42) of the policies, students and faculty/staff were prohibited from using some type of tobacco product; visitors were not addressed in these policies. In 9.8% (n = 28) of the policies, all possible individuals, including students, faculty/staff, and visitors, were prohibited from using some type of tobacco product.
Table 3.
Location and individuals prohibited from some type of tobacco use.
| Policy | Percent (n) |
|---|---|
| Tobacco-free for students only | 25.2% (72) |
| Tobacco-free for all (faculty/staff and visitors excluded from policy at school-sponsored, off-campus events) | 17.5% (50) |
| Tobacco-free for students and faculty/staff only | 14.7% (42) |
| Tobacco-free for all (no exceptions) | 9.8% (28) |
| Tobacco-free for all (visitors excluded from policy at school-sponsored, off-campus events) | 8.0% (23) |
| Other (e.g., varying locations and individuals included in policy) | 24.8% (71) |
Location and Individuals Prohibited from Some Type of Tobacco Use
In 24.8% (n = 71) of all policies, the locations where tobacco usage was disallowed varied for students, faculty/staff, and visitors. In 17.5% (n = 50) of the policies, tobacco prohibitions were applicable to everyone, although this excluded faculty/staff and visitors from school-sponsored, off-campus events. The remaining 8.0% (n = 23) of the policies were applicable to everyone; visitors were excluded from school-sponsored, off-campus events.
Consequences for Students’ Violation of a Tobacco Policy
The most common consequence for students’ violation of a tobacco policy was law enforcement notification (Table 4). More than one-third of policies (36.7%, n = 105) presented this as the only consequence of student violation. Suspension was the second most common consequence, with 32.2% (n = 92) of policies. An additional 23.8% (n = 68) of policies stated law enforcement notification, notification of parents, and participation in a tobacco intervention, such as cessation services. Only 3.5% (n = 10) of policies did not state consequences for students’ violation for the tobacco policy.
Table 4.
Consequences for students' violation of a tobacco policy.
| Consequences | Percent (n) |
|---|---|
| Law enforcement notification | 36.7% (105) |
| Suspension | 32.2% (92) |
| Parent notification, participation in tobacco intervention, and law enforcement notification | 23.8% (68) |
| Not stated | 3.5% (10) |
| Parent notification | 1.0% (3) |
| Suspension and law enforcement notification | 1.0% (3) |
| Parent and law enforcement notification | 0.7% (2) |
| Report to principal | 0.7% (2) |
| Detention | 0.3% (1) |
DISCUSSION
Tobacco policies in schools can be an effective strategy to reduce tobacco use among youth in the U.S. and in Kansas. Considering the increase of youth tobacco use, especially the use of electronic cigarettes,4 and because youth who use electronic cigarettes are four times more likely to use combustible cigarettes later in life,16 it is necessary to identify whether school districts offer the maximum protection for students.
Comprehensive tobacco policies must prohibit all people, at all locations, from using all tobacco products at all times and include some form of tobacco intervention as a consequence for students violating the tobacco policy as a form of discipline. It is essential to identify the number of Kansas USDs with comprehensive school tobacco policies to know how schools are helping to address the current issue with tobacco usage in youth. Although several policies met some of these recommendations, only 2.1% (n = 6) of the USD policies met comprehensive tobacco policy criteria.
The six USD policies that were comprehensive were in counties with varying population densities. Fifty percent (n = 3) of the policies were in a county classified as frontier; 33.3% (n = 2) were in a county classified as rural; and 16.7% (n = 1) of the policies were in a county classified as urban. None of the six counties shared borders with each another.
The results of this study suggested that school tobacco policies in Kansas vary largely from one USD to another. It is a positive first step that nearly all policies (98.3%) prohibit students’ use of all tobacco-related products. Nearly all policies prohibited some type of tobacco product in at least one location on campus. Nearly all student policies prohibited some type of tobacco use in school buildings, on school grounds, and in school vehicles. In 95.1% (n = 272) of student tobacco policies, school-sponsored, off-campus events prohibited some type of tobacco use.
The results show that many schools were not consistent in what locations were included in their tobacco policies. Only 9.8% (n = 28) of policies had all areas for all individuals on campus. Although 25.2% (n = 72) of policies covered all areas, these policies only applied to students. Visitors often were left out of locations altogether in policies. In 72.7% (n = 208) of policies, visitors were left out of some or all locations in the tobacco policies, with 45.2% (n = 94) of these policies specifically excluding visitors from school-sponsored, off-campus events.
A weakness in most Kansas USD policies is that not all faculty/ staff are required to adhere to the tobacco policies. In Kansas, 25.2% of the policies (n = 72) prohibited only students from using some form of tobacco; faculty/staff and visitors were not prohibited from using tobacco in these policies. Prohibiting faculty/staff and visitors from tobacco use can improve attitudes toward comprehensive school tobacco policy implementation.17 Faculty/staff and visitors play a key part in being positive role models for youth, and inclusion of them in the policy is needed for effective implementation. Additionally, inclusion of all faculty/staff can make policies easier to enforce when everyone is prohibited from using tobacco products on school grounds or events. As no other studies similar to the current study have been published, it is unclear how the prevalence of comprehensive tobacco policies in unified school districts across Kansas compares to other states. The field of tobacco prevention and treatment would benefit from extending this research to other states.
Kansas school districts can strengthen their tobacco policies by incorporating interventions or training for students who violate school tobacco policies about the risks of tobacco usage into their disciplinary actions. Only 23.8% of policies included an interventional opportunity as a consequence for students who violate the tobacco policy. This type of disciplinary action can produce positive outcomes (i.e., decreased use in the future), as it seeks to support youth using tobacco products to help them quit rather than solely punishing them. This allows students to learn more about the dangers of tobacco use and helps them in the long-term by teaching the risks and providing tools to quit.17
In Kansas, there was a lack of comprehensive tobacco policies adopted in the school districts throughout the state. School districts should be doing more to address tobacco use in youth. To protect Kansas youth adequately, school districts have an important opportunity to update their policies to prohibit tobacco products more comprehensively.
Limitations
This study includes all Kansas USDs, and generalizability beyond Kansas is limited. A limitation of this study was that it is unknown how well schools uphold their policies. Although policies may be comprehensive, if they are not followed or enforced properly, they are not as effective. Also, even though policies may include positive student intervention, the specific intervention being used was not included in the policies. It is important that an evidence-based curriculum be used as the educational component for the best results.
CONCLUSIONS
This study suggested that nearly all school districts in Kansas have an opportunity to revise and strengthen their policies to reduce youth tobacco use, including e-cigarettes. Necessary edits to these policies include prohibiting everyone from using any tobacco product on school property and at all school-sponsored, off-campus events, and more supportive violation consequences, such as a cessation intervention for students. By updating these policies, schools may have a substantial impact on preventing early tobacco usage among Kansas students.
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