Extinguishing Adolescent Nicotine Addiction:

An Adolescent Nicotine Addiction Prevention Program Based on the Social Cognitive

Theory

Ethan Taylor

PUBH 6007

12-07-2014

Significance:

Background:

In America, the top four causes of death are heart attack, cancer, chronic lower

respiratory disease, and stroke in descending order (Center for Disease Control and Prevention,

2014a). Smoking can contribute to all four of these causes of death. The Center for Disease

Control and Prevention (CDC) credits direct and second-hand smoking with approximately 20

percent of annual United States’ deaths (2014b). Additionally, smokers have an overall mortality

rate three times higher than non-smokers and have a life expectancy ten years shorter (Center for

Disease Control and Prevention, 2014b).

For men, smokers see an increase of death because of coronary heart disease by four

times, bronchitis and emphysema by 17 times and trachea, lung and bronchus cancer by 23

times. Women smokers see an increase in death by bronchitis, emphysema and trachea, lung and

bronchus cancer 12 times higher than their nonsmoking counterparts (Center for Disease Control

and Prevention, 2014b). These statistics only evaluate deaths, not birth defects, percentage of

lung cancer cases attributed to smoking, and the monetary strain placed on the United States

healthcare system, among other consequences. Despite these alarming statistics, 46.6 million or

20.6 percent of American adults were identified as smokers in 2009 (American Lung

Association, 2014a).

Of these 46.6 million, 70 percent state wanting to quit smoking, but only seven percent at

most will succeed without aid from anyone else (American Cancer Society, 2014). This means

that 13.98 million do not want to stop smoking and 32.62 million smokers want to quit.

However, of these 32.62 million individuals, 30.34 million will have addictions so severe that

they are incapable of quitting without strong outside support. The United States Census Bureau

estimated that there were 316.1 million Americans in 2013 (2014a). By using the 2013 census

data and the number of smokers from 2009 who have unsuccessfully attempted to stop smoking,

it can be approximated that 9.6 percent of the American population has a tobacco addiction.

In an addiction study, researchers evaluated the success rate of people with various

addictions who wanted to quit with the help of behavioral therapy. In this study, 40.0 percent of

opium and cocaine users were able to quit, 18.0 percent of alcohol users could quit, but only

eight percent of cigarette smokers were able to stop (American Cancer Society, 2014), which

gives an alarming perspective on the strength of nicotine addiction.

While these adult related statistics are cause for concern, even more so are the statistics

revolving around adolescent cigarette smoking. As of 2012, 6.7 percent of middle school

students and 23.3 percent of high school students were smoking (Center for Disease Control and

Prevention, 2014c). These numbers only threaten to grow as each day 3,200 individuals under

18 years of age will smoke their first cigarette and 2,100 daily youth smokers will go from

occasional to daily smokers (Center of Disease Control and Prevention, 2014d). Of current adult

smokers, nine out of ten began smoking before they turned 18 years of age (Center of Disease

Control and Prevention, 2014c). Because smokers who have smoked 100 cigarettes before their

18th birthday report being unable to quit despite attempting to do so (American Lung

Association, 2010), 5.6 million of America’s youth are predicted to die prematurely from

diseases consequential from smoking (Center for Disease Control and Prevention, 2014c).

Attributing to this growing problem are the factors of education and socioeconomic

status. Of current adult smokers, 27.9 percent live below the poverty level (Center for Disease

Control and Prevention, 2014d). Aiding to the poverty level and paralleling the rates of smoking

in these populations is education. A quarter of people without a high school degree smoke,

nearly 42 percent of people possessing a General Equivalency Diploma (GED) smoke and

approximately 23 percent of people with a high school degree currently smoke (Center for

Disease Control and Prevention, 2014e).

Target Population and Ecologic Context:

Through careful examination of these factors, it was discovered that states with a high

prevalence of smoking, such as Mississippi, Alabama, Arkansas and Kentucky (American Lung

Association, 2014b), also had high rates of child poverty (Wright, Chau, & Aratani, 2010). These

states also possess low high school graduation rates (National Center for Education Statistics,

2010). A combination of high smoking prevalence, low educational and socioeconomic status,

coupled with childhood poverty and adolescent age form the target population.

Mississippi struggles with all of the prior mentioned factors affecting the target

population. High school smoking prevalence in Mississippi is 18.0 percent and a remarkable

48.0 percent of students have at least tried cigarettes (U.S. Department of Health and Human

Services, 2013). To couple smoking prevalence, Mississippi is tied for 49th, with California, in

high school graduation rates with 80.7 percent of the population possessing a high school

diploma (National Center for Education Statistics, 2010). Additionally, Mississippi ranks 47th in

Bachelor’s degree rates, as only 19.4 percent of the population possess a degree (United States

Census Bureau, 2008). Compounding these factors is the incredibly high rate of childhood

poverty. Mississippi, along with Washington D.C, hold the highest rates of childhood poverty as

over 25.0 percent of children in these areas live at or below the poverty line (Wright, Chau, &

Aratani, 2010). This staggering amount could impact educational levels, as students have to quit

school to work for the family or do not know how to receive money for college.

The intervention, to be called Extinguishing Adolescent Nicotine Dependency, will focus

on adolescents from the seventh grade through high school in 30 selected school districts in

southern Mississippi. This starting age was chosen due to the unknown variable of when students

drop out of high school and when the middle school population begins smoking. By starting at

this age, it is thought that the prevalence of smoking among middle school students will

decrease, eventually leading to a decrease in the prevalence of smoking in the high school

population and ultimately a decrease in adult smoking prevalence as these students age.

In order to approach the proper target population, specific, measurable, achievable,

relevant and time specific (SMART) objectives will be use to target adolescents in middle school

and high school. The Social Cognitive Theory, created by Albert Bandura, links social

interactions with people and the environment to learning and reinforcing behaviors (Boston

University School of Public Health, 2013). Due to the components of Bandura’s theory and the

strong social associations of smoking, the six stages of the Social Cognitive Theory will be used.

These factors are: self-efficacy, behavioral capability, expectations, expectancies, self-control

and emotional coping (Vyas, n.d.[a]). Through the usage of this theory and the development of

SMART objectives, the battle against adolescent cigarette smoking can begin to see

improvements.

Turning again to Mississippi and using calculations similar to those used to calculate

adult nicotine addiction, Mississippi’s adolescent nicotine addiction level was calculated.

Mississippi has 755,555 individuals under 18 years of age (United States Census Bureau,

2014b). Of those 755,555, 18 percent or 136,000 are smokers. Of those who smoke, 58 percent

or 78,880 have tried to quit smoking and failed. This data shows at least 78,880 or 10.4 percent

of Mississippi’s population under 18 years of age is addicted to nicotine (U.S. Department of

Health and Human Services, 2013). This percentage could be higher because students who have

not tried to quit are not included in the calculations and therefore could have a nicotine addiction.

The overall success of Extinguishing Adolescent Nicotine Dependency will be shown in longer,

healthier lives for southern Mississippi’s youth with the prevention of nicotine addiction being

the primary objective.

Health Objective:

The health objective of Extinguishing Adolescent Nicotine Dependency is to see a

decrease of nicotine addiction in southern Mississippi adolescents from approximately 10.4

percent to nine percent by year six of program implementation (Appendix A). This will be

achieved by targeting children in the seventh grade through high school with behavioral and

educational objectives based on the Social Cognitive Theory in attempt to prevent smoking and

nicotine addiction before it begins. By year six of Extinguishing Adolescent Nicotine

Dependency implementation, the students who first went through the complete program will be

finishing high school and the program can begin receiving the best data with regards to program

success. Nicotine addiction rates will be measured via anonymous survey. The survey will ask if

an individual smokes, how often they smoke, if they used to smoke and if they tried to quit

smoking without success. The method of an anonymous survey was chosen because it allows

students to answer truthfully without fear of repercussions and is therefore likely to see more

truthful results.

Behavioral Objectives:

Extinguishing Adolescent Nicotine Dependency has the goal of seeing the prevalence of

smoking in the southern Mississippi adolescent population decrease from 18.0 percent of the

population to 16.5 percent of the population by year three of program implementation, as

smoking is easier to prevent than it is to quit (Appendix A). This objective could be monitored

by an anonymous survey given in the last week of school. An anonymous survey was chosen for

the same reason it was chosen for the health objective. Ultimately, the program has the large goal

of seeing the prevalence of smoking in the adult southern Mississippi population decrease from

27.0 percent to 25.0 percent by year seven of intervention implementation, as the first set of

middle school students who completed the whole program will be becoming adults at about this

time (Appendix A).

In addition to a decrease in smoking prevalence among varied populations, Extinguishing

Adolescent Nicotine Dependency has behavioral objectives with regards to education. Because a

large portion of smokers have not completed high school and an even larger portion have not

completed college, the intervention aims to see an increase in high school graduation rates from

80.7 percent in those 30 high schools in the southern portion of the state to 82.5 percent by year

seven of program implementation (Appendix A). This is because the first students to complete

the whole program will be graduating around this time. High school graduation rates will be

measured by taking the amount of seniors graduated divided by the number of seniors expected

to have been in the graduating class.

To accomplish this, students will have to complete the mandatory health course, which

will spend a month teaching the adverse effects of smoking, in the seventh grade to progress in

their education. The goal is to have 90 percent of the students in the seventh grade of

participating schools to be completing this course by year three of program implementation

(Appendix A). This will be measured by examining how many people passed the course and how

many students are in the complete graduating class. Once in high school, students will have to

take a similar course as a graduation requirement. This course will be suggested to be taken

during the sophomore year of high school. The program wishes to see 85 percent of the high

school population in participating schools be completing this course by year three of program

implementation (Appendix A). This percentage is higher than the graduation rate goal because,

even though students may complete and pass the health course, they might not do the same for

the other courses required for graduation by the school. This objective will be measured in the

same way as the similar middle school objective.

Furthermore, Extinguishing Adolescent Nicotine Dependency wants to see an increase in

Bachelor degree possession rates from 19.4 percent to 20.5 percent by year ten of program

implementation (Appendix A). This time frame is centered on the first middle school population

that will be of college graduation age around this time. College graduation rates will be

determined by looking at what number of graduating high school seniors are going to college and

what number of them actually graduate college divided by the number of seniors who graduated

in the high school graduating class. This will allow the intervention to discover if a higher

percentage of high school graduating seniors go on to graduate college when compared to years

prior to intervention implementation.

Innovation:

Of the programs evaluated, both focused on the adolescent population in regards to

smoking, like the program to be implemented. Fichtenberg and Glantz found in their study

evaluating the access of cigarettes to minors that preventing adolescents from purchasing

cigarettes does not reduce the prevalence of smoking, as they will find other ways to access

cigarettes (2002). Conner et. al. produced a program similar to the one to be implemented

(2013). Their program, located in the United Kingdom, recognized the importance of starting a

program prior to children starting to smoke (Conner et. al., 2013). Seeing that 40.0 percent of

adult smokers started smoking prior to turning 16 years of age and that smoking prevalence rises

by 14.5 percent between the ages of 11 and 15 years (based on United Kingdom statistics), the

program began on year seven of school (Conner et. al., 2013). Their program involved four

classes of at least 30 students in each chosen school (Conner et. al., 2013). The classes occurred

every six months for four years (Conner et. al., 2013). The program showed a decrease in

adolescent smoking prevalence from 14 percent to four percent in relation to trial size (Conner

et. al., 2013). While this program is similar, it is far from the same, but does give support to the

intervention being implemented.

Extinguishing Adolescent Nicotine Dependency requires all students to complete a

yearlong health course at the strategic seventh grade year as a requirement to enter the eighth

grade and another health course to be completed as a graduation requirement in high school.

Each course will consist of a month long curriculum teaching the mal-effects of smoking in

conjunction with the Social Cognitive Theory. While this course can be taken at any time during

high school, counsellors will be instructed to promote the course to be taken during the

sophomore year. Instead of having intervention courses four times a year for four years, as the

Conner et. al. study did, Extinguishing Adolescent Nicotine Dependency will have required

assemblies four times a year lasting an hour and will require the attendance of all students from

the seventh grade to high school seniors. Although these assemblies are required, it is understood

that the assemblies will not see full attendance due to students missing school or leaving school

early. These assemblies will speak on future education and the effects of smoking. The goal of

this program is to reduce nicotine addiction by, among other things, stopping cigarette use before

it begins, which is a reason behind starting intervention during middle school.

Extinguishing Adolescent Nicotine Dependency will see the desired results because it

focuses on the primary behavioral factor, through the Social Cognitive Theory, along with the

secondary educational and socioeconomic factors. The assemblies, featuring current smokers

explaining their struggles with nicotine and cigarettes, will give the students real life experiences

from which to learn, an application of observational learning. Sometimes it is hard for the

magnitude of a situation to be fully understood through lecture or study, but seeing the struggle

first hand will help everything come together.

Extinguishing Adolescent Nicotine Dependency also looks to mend the secondary factors

contributing to smoking such as low educational and socioeconomic statuses through the

assemblies. The college graduates who speak during the various rallies about the importance of

college will help students realize the reason why college graduation is beneficial to their futures

and careers and, by offering tutoring three times a week, students will have the available

educational help they need in order to receive the grades necessary to be accepted into college.

College graduation allows for a higher salary ceiling. College graduates from the age of 25-34

make a median of $46,900 and high school graduates in the same age range make a median of

$30,000 (National Center for Education Statistics, 2014). While increasing socioeconomic status

might not be directly related to smoking, increasing this area will allow students to move outside

of environments that foster smoking behaviors and encourage others to adopt the habit. The

absence of smoking will also progress socioeconomic status as the money spent on cigarettes can

be saved or spent on better investments.

Studies, as cited, have examined decreasing the availability of cigarettes to minors and

the success of educational courses teaching the adverse effects of cigarette smoking on the

prevalence of adolescent smoking. Neither study had a means for students to listen to and

question a person who partakes in smoking. Neither program offered a means to encourage the

importance of a college education or a means to get into college either. Offering courses to

educate students of the adverse effects of smoking is not a new concept. Extinguishing

Adolescent Nicotine Dependency separates itself from other programs by how it couples

classroom materials and interactions with the personal struggles of smokers, along with college

graduate success stories and ways to be accepted into college, thus completely addressing all of

the factors playing a role in adolescent smoking prevalence. Focusing on these factors will be the

edge within this intervention to give ultimate success.

Methods:

The theory used to design the project is the Social Cognitive Theory and five of its six

components will be used. The five components being used are self-efficacy, behavioral

capability, expectations, expectancies, and self-control, excluding emotional coping. Self-

efficacy, being the confidence one has about a behavior, will be obtained in the seventh grade

and sophomore year health courses. These new courses will speak of the adverse effects of

smoking, as the more an individual is educated on a topic, the more their confidence will

increase and they will be able to make sound decisions based on learned facts involving the

behavior. Behavioral capability will be approached in the same way, as it focuses on the

knowledge used, in this case, to not perform a behavior (Vyas, n.d.).

Students will not only be taught facts and responses, but will go through role playing

exercises to better prepare them to handle to the ever-changing landscape of peer pressure. Role

playing fits with the observable learning factor of the Social Cognitive Theory, which is obtained

by observing, sharing and hearing others (Vyas, n.d.). Role playing exercises also aid in

behavioral capability because students can learn about and practice saying “no” to smoking peer

pressure. Students will be armed with the knowledge to say “no” to cigarettes and be able to give

reasonable explanations as to why they respond in that way, if questioned.

The expectations are based on what one learns based on experiences and it is hoped that,

through experiencing the assemblies, students will further learn the adverse effects of smoking.

The hope is that by seeing the struggles of others, and perhaps family members, students will be

able to more easily use their knowledge and experiences to say “no” to smoking. Through these

educational experiences, students will come to expect being smoke-free and will eventually have

the self-control to monitor their own behaviors to avoid smoking, including a smoking

environment (Vyas, n.d.).

Additionally, students will learn to expect poor outcomes from smoking, which will help

them maintain a smoke free lifestyle. Extinguishing Adolescent Nicotine Dependency focuses on

preventing smoking in youth populations and will not deal with the emotional coping stage of the

Social Cognitive Theory. This is because the program is created to prevent the start of the

behavior and the emotional coping stage looks to provide support while changing the behavior

(Vyas, n.d.).

Many of the theory components are accomplished in the classroom. Students will be

armed with the knowledge of the chemical components of cigarettes and the effects of smoking

on the bodies of themselves and the people around them. This will give the students self-

efficacy, as they can be confident in their knowledge of the behavior. Students will be taught to

use this knowledge to understand why they should not engage in the behavior. This knowledge

will lead them to be able to feel comfortable saying “no” to smoking cigarettes. Expectancies

will come from a combination of courses and assemblies.

By learning about how smoking affects the body and hearing first-hand accounts of how

smoking has negatively affected the lives of others, students will learn to expect the negative side

effects of smoking. This process will decrease the ‘it won’t happen to me’ thought process.

These assemblies will alternate between presentations given by smokers and people speaking on

the importance of college and how a college education has positively impacted their lives, which

is yet another application of observational learning. By students learning of the importance of

college, more students will exercise their college options and will be supported through the

tutoring program, should they choose to use the program available to them. This will counteract

the socioeconomic and educational secondary factors involved in smoking, as more students will

expect to attend college and have a higher career and salary ceiling.

These events, leading to outcomes and ultimately the impact, are not without respective

inputs. Health teachers, computers, books, writing utensils and paper are all necessities for the

health course. Teachers will teach the book through use of computers. Students will need writing

utensils and paper to take notes and complete their assignments. Ink, computers and paper are

necessary to disperse flyers through the halls highlighting the health courses and the upcoming

assembly speakers. Assembly speakers are inputs needed to hold the assemblies as are tutors for

the tutoring service. Class, assembly and tutoring time are included in the inputs, along with

counselors and counselor time (Appendix A).

Limitations/Discussion:

What gives the Social Cognitive Theory its best strength also delivers its weakness. It has

many components that make it easily applicable to many situations and interventions. An

example would be multifactorial situations, such as smoking, which involve education and

socioeconomic status in addition to the behavior. While a strength, this same trait can make it

easy to get lost and bogged down in all of the components contained in the theory. It is important

to focus only on the components that will make a particular program the most successful when

using this theory.

While there are other models and theories that can be used in smoking interventions, the

one that would work the best with this program, outside of the Social Cognitive Theory, would

be the Health Belief Model. This model, too, has six components: perceived severity, perceived

susceptibility, perceived benefits, perceived barriers, self-efficacy and cues to action (Vyas, n.d.

[b]). These perceptions can be developed through the courses and assemblies offered through

Extinguishing Adolescent Nicotine Deficiency. Just like the Social Cognitive Theory, the Health

Belief Model can be used to develop a preventative or cessation smoking intervention.

Interventions take a large amount of planning and, even with all of the planning, holes

can still appear. There are potentially a couple short comings within this suggested intervention.

The first being all interventions revolve around the students in an educational environment.

Extinguishing Adolescent Nicotine Dependency focuses on the adolescent’s knowledge, but only

the role playing exercises focus on the peer pressure that will be experienced outside of school in

cohort groups and family settings. The program does not extend into the student’s family setting

in attempt to change the smoking habits of authoritative family members and coaches who have

a high influence on the student population. It is the hope of the program that the students will be

able to resist temptation and peer-pressure by venturing through the intervention and first five

stages of the Social Cognitive Theory by applying their teachings and role playing exercises to

real life practices.

The second limitation of Extinguishing Adolescent Nicotine Dependency is the isolated

focus on the first five stages of the Social Cognitive Theory, not the final emotional coping

stage. This is because the intervention is designed to prevent nicotine addiction by averting

students from smoking through the application of the first five Social Cognitive Theory Stages

involving coursework and assembly attendance. The program does not offer support for current

smokers, as it is hoped the intervention starts at an age young enough that students have not

started smoking. Should Extinguishing Adolescent Nicotine Dependency become a success as

expected, an intervention specifically focused on the emotional coping stage could be developed.

It is recognized that the intervention put in place will not be 100 percent effective, but by having

a positive effect on the students involved in the intervention there will be a decreased need for an

adolescent emotional coping intervention.

Extinguishing Adolescent Nicotine Dependency has many positives to counteract the two

limitations. It is a complete intervention that examines not only the primary factor of youth

smoking, but the secondary factors as well. This intervention does not blindly set up protocols,

but is based upon the proven effective Social Cognitive Theory. In addition, this intervention is

set up similarly to a successful United Kingdom youth smoking intervention program.

Extinguishing Adolescent Nicotine Dependency expands on the United Kingdom program

through extended course work at two critical times in development, seventh grade and the

suggested sophomore year of high school. By extending these courses and adding assemblies,

students are better armed with information to combat the pressures they will face to smoke

cigarettes.

Extinguishing Adolescent Nicotine Dependency is set to be tested in only 30 school

districts in southern Mississippi, but is designed to be applicable throughout the whole state and

neighboring states once proven effective. Alabama, Arkansas and Kentucky, similar to

Mississippi, rank in the bottom five in percentage of the population with a high school degree

(National Center for Education Statistics, 2010), percentage of the population with a bachelor’s

degree (United States Census Bureau, 2008) and have child poverty rates of 20-24 percent

(Wright, Chau, Aratani, 2010). These factors only add to the high smoking prevalence shared by

each state (American Lung Association, 2014). Since all of the mentioned states share the same

variables, Extinguishing Adolescent Nicotine Dependency will be able to seamlessly transition to

surrounding southern states.

Based on the Social Cognitive Theory, Extinguishing Adolescent Nicotine Dependency is

geared to reduce adolescent nicotine addiction by addressing the factors circling it. The

intervention is applicable not only to southern Mississippi, but has the potential to spread

throughout the southern United States. This mediation has the ability to decrease adolescent

nicotine addiction, lengthen life expectancy and lead to a decrease in heart and lung disease. The

success of Extinguishing Adolescent Nicotine Addiction will ensure a healthier youth and a

healthier future for America.

Works Cited:

American Cancer Society. (2014, February 13). Is Smoking Really Addictive. Retrieved from http://www . cancer . org/cancer/cancercauses/tobaccocancer/questionsaboutsmokingtobaccoandhealth/ questions-about-smoking-tobacco-and-health-is-tobacco-addictive

American Lung Association. (2010, February). Children and Teens - American Lung Association. Retrieved from http://www . lung . org/stop-smoking/about-smoking/facts-figures/children-teens-and- tobacco . html

American Lung Association. (2014a). General Smoking Facts. Retrieved from http://www . lung . org/stop-smoking/about-smoking/facts-figures/general-smoking-facts . html

American Lung Association. (2014b). Contributing Factors - American Lung Association. Retrieved from http://www . lung . org/lung-disease/disparities-reports/cutting-tobaccos-rural- roots/2013/contributing-factors . html

Boston University School of Public Health. (2013, January 22). The Social Cognitive Theory. Retrieved from http://sphweb . bumc . bu . edu/otlt/MPH-Modules/SB/SB721-Models/SB721- Models5 . html

Center for Disease Control and Prevention. (2014a, July 14). FastStats - Leading Causes of Death. Retrieved from http://www . cdc . gov/nchs/fastats/leading-causes-of-death . htm

Center for Disease Control and Prevention. (2014b, February 6). CDC - Fact Sheet - Tobacco-Related Mortality - Smoking & Tobacco Use. Retrieved from http://www . cdc . gov/tobacco/data_statistics/fact_sheets/health_effects/ tobacco_related_mortality/

Center for Disease Control and Prevention. (2014c, February 14). CDC - Fact Sheet - Youth and Tobacco Use - Smoking & Tobacco Use. Retrieved from http://www . cdc . gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/

Center for Disease Control and Prevention. (2014d, April 24). CDC - Fact Sheet - Fast Facts - Smoking & Tobacco Use. Retrieved from http://www . cdc . gov/tobacco/data_statistics/fact_sheets/fast_facts/

Center for Disease Control and Prevention. (2014e, February 14). Adult Cigarette Smoking in the United States - Smoking & Tobacco Use. Retrieved from http://www . cdc . gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/

Conner, M., Grogan, S., Lawton, R., Armitage, C., West, R., Siddiqi, K., Gannon, B., Torgerson, C., Flett, K., Simms-Ellis, R. (2013). Study Protocol: A cluster Randomised Controlled Trial of Implementation Intentions to Reduce Smoking Initiation in Adolescents. BMC Public Health, 54(13). Retrieved November 10, 2014, from http://eds . a . ebscohost . com . proxygw . wrlc . org/eds/detail/detail?vid=2&sid=aeefe53d-e868-4a89- aa25-ce6c2226a863@sessionmgr4001&hid=4108&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ==#db=rzh&AN=2012082401

Fichtenberg, C., & Glantz, S. (2002). Youth Access Interventions Do Not Affect Youth Smoking. Pediatrics, 109(6), 1088-1092. Retrieved November 10, 2014, from http://eds . a . ebscohost . com . proxygw . wrlc . org/eds/detail/detail?sid=aeefe53d-e868-4a89-aa25- ce6c2226a863@sessionmgr4001&vid=0&hid=4108&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ==#db=rzh&AN=2002113162

National Center for Education Statistics. (2010). Percentage of persons age 25 and over with high school completion or higher and a bachelor's or higher degree, by race/ethnicity and state: 2008-10. Retrieved from http://nces . ed . gov/programs/digest/d12/tables/dt12_015 . asp

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Appendix A (Logic Model):

Input Activities Outputs Outcomes ImpactTutors

Health Teachers

Assembly Speakers

Fliers

Ink to make fliers

Computers for teaching and production of fliers

Classroom time

Textbooks

Writing Utensils

Paper

Class Time

Assembly Time

Tutoring Time

Tutoring three days a week

School assemblies four times a year

Health class five days a week

Completing coursework

Role playing exercises

Seventh grade students attend one health class every day of school during their seventh grade year.

High school students attend on health class every day of school during one of their years in high school.

School assemblies at least four times a year both at the middle school and high school with speakers encouraging students to pursue college and explaining how college has helped them or current smokers

90% of seventh graders in the participating schools complete a health course teaching the adverse effects of smoking as a requirement to moving into the 8th grade by year three of program implementation.

85% of high school students in the participating schools complete a health course teaching the adverse effects of smoking as a graduation requirement by year three of program implementation.

Decrease adolescent smoking in southern Mississippi from 18.0% to 16.5% within three years of program implementation.

Decrease adult smoking prevalence in southern Mississippi from 27.0% to below

Decrease nicotine addiction in southern Mississippi adolescents from greater than 10.4 percent to nine percent by year three of program implementation.

Counselors

Counselling Time

explaining their struggles with the nicotine and the adverse effects it has on their life.

Offer a tutor three times a week for students interested in improving their studies.

25.0% by year seven of program implementation.

Increase high school graduation rates from 80.7% to 82.5% by year seven of program implementation.

Increase rate of those with a Bachelor’s degree or more from 19.4% to 20.5% by year ten of program implementation.