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Community-based participatory research to decrease smoking prevalence in a high-risk young adult population: an evaluation of the students against nicotine and tobacco addiction (SANTA) project.

Students Against Nicotine and Tobacco Addiction is a community-based participatory research project that engages local medical and mental health providers in partnership with students, teachers, and administrators at the Minnesota-based Job Corps. This intervention contains multiple and synchronous elements designed to allay the stress that students attribute to smoking, including physical activities, nonphysical activities, purposeful modifications to the campus's environment and rules/policies, and on-site smoking cessation education and peer support. The intent of the present investigation was to evaluate (a) the types of stress most predictive of smoking behavior and/or nicotine dependence, (b) which activities students are participating in, and (c) which activities are most predictive of behavior change (or readiness to change). Quantitative data were collected through 5 campus-wide surveys. Response rates for each survey exceeded 85%. Stressors most commonly cited included struggles to find a job, financial problems, family conflict, lack of privacy or freedom, missing family or being homesick, dealing with Job Corps rules, and other-unspecified. The most popular activities in which students took part were physically active ones. However, activities most predictive of beneficent change were nonphysical. Approximately one third of respondents were nicotine dependent at baseline. Nearly half intended to quit within 1 month and 74% intended to quit within 6 months. Interventions perceived as most helpful toward reducing smoking were nonphysical in nature. Future efforts with this and comparable populations should engage youth in advancing such activities within a broader range of activity choices, alongside conventional education and support.

Keywords: youth smoking, tobacco use, tobacco dependence, smoking cessation, community-based participatory research

Supplemental materials: http://dx.doi.org/10.1037/fsh0000003.supp

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Community-based participatory research (CBPR) emphasizes close collaboration among researchers and community members to generate knowledge and solve local problems. Research carried out in this manner is not conducted "on" people; it is conducted "with" them. Community participants take active roles in the entire research process--from conceptualizing problems and formulating solutions, designing and implementing interventions, identifying benchmarks of success and analyzing outcome data, and feeding results back into the maintenance and/or revisions of care initiatives and intervention designs (Agency for Healthcare Research and Quality, 2004; Berge, Mendenhall, & Doherty, 2009; Hancock, 2012; Minkler & Wallerstein, 2011).

CBPR methods have been successfully applied in smoking cessation studies with communities identified as "high risk." For example, Daley et al. (2010) developed a program engaging American Indians through All Nations Breath of Life, which has been initiated and pilot-tested across both urban and reservation communities. Tsark (2001) likewise addressed the need for culturally relevant approaches with Native Hawaiians. Power, Gillies, Madeley, and Abbot (1989) engaged young mothers in a small New Zealand community. In New York City, researchers are partnering with young adults in the Chinese American community (Shelley et al., 2008). The common thread running through these projects is the collaborative methodology used to develop interventions that are immediately relevant to the communities in which they are positioned, addressing unique challenges and tapping local wisdom and resources in context (Andrews, Newman, Heath, Williams, & Tingen, 2012; Ma, 2004). In the Students Against Nicotine and Tobacco Addiction (SANTA) Project, described below, the authors similarly worked with a young, ethnically diverse, and socioeconomically disadvantaged student community at the Minnesota-based Job Corps (Mendenhall, Whipple, Harper, & Haas, 2008; Mendenhall, Harper, Whipple, & Haas, 2011).

Hubert H. Humphrey Job Corps, St. Paul, Minnesota

Job Corps (JC) was established in 1981 under the direction and funding of the United States Department of Labor. Its mission is to provide high-quality education and training, combined with a safe living environment, for at-risk youth (ages 16-24 years). Job Corps' Minnesota-based center is situated on the edge of an urban, middle-class neighborhood. It houses 225-300 students at any given time, and most stay 6-12 months. Most come from low socioeconomic backgrounds and have struggled in conventional school environments. Many have also struggled with alcohol, drug use, and mental health problems such depression, anxiety, or attention-deficit/hyperactivity disorder. Enrollment data show that gender ratios tend to favor males (avg. 62%), and ethnicity is diverse (avg. 46% African American, 23% White, 7% American Indian or Alaskan Native, 7% Hispanic, 2% Asian or Pacific Islander, 15% other).

Internal research found that >40% students at JC smoked, with substantial increases in smoking after arriving on site (Haas, 2005). Although almost 70% of smokers wanted to quit (and most had tried to in the past), few reported having been successful. These findings were troubling to JC's administration for several reasons. Students were smoking at more than twice the rate of the general young adult population (National Institutes of Health, 2013; Villanti, McKay, Abrams, Holtgrave, & Bowie, 2010). Professionally led smoking cessation classes and support groups were readily available on campus, but they were poorly attended. A variety of nicotine-replacement therapies were offered through JC's Health and Wellness Department, but few students sought them out.

SANTA

Rising to meet this campus-wide challenge, a CBPR endeavor was initiated and launched involving health providers from the University of Minnesota and JC's students, administrators, teachers, counselors, and staff. The group met several times to discuss smoking and whether it represented a "pressure point" of concern in the JC community. Administrators shared worries about students' smoking and future employability. Teachers, counselors, and staff shared worries about students' smoking and their academic and trade-related performance. Students shared concerns about their own and friends' health, and about how smoking relates to stress (broadly defined) with a limited repertoire of options for managing stress.

United in their concerns, group members worked together to create and launch a variety of interventions designed to change the culture at JC (see Table 1). They did this through a combination of weekly meetings--which are still ongoing--oriented to different facets within SANTA's broader mission. For a detailed account of this project's construction and early development, see Mendenhall et al. (2008, 2011).

Call for Investigation

SANTA's complex constellation of activities and efforts mirrors the complex nature of the JC environment in which its students live. However, this blessing is also a curse, insofar as the initiative functions as a blunt tool. In the study described here, we set out to evaluate (a) the types of stress most predictive of smoking behavior and/or nicotine dependence, (b) which activities students are participating in, and (c) which activities are most predictive of behavior change (or readiness to change). Establishing a better understanding of how these intervention components, processes, and contextual pieces fit together will (a) advance local efforts to refine and further improve SANTA's effectiveness, and (b) inform future CBPR within similar high-risk populations and contexts (e.g., juvenile detention centers, prisons, high schools).

Method

Consistent with guiding principles of CBPR, our investigation encompassed an active partnership between professional researchers and JC students, staff, and administrators in the construction of survey measures, data collection, and data analysis and interpretation.

Participant Characteristics

All students enrolled at the Minnesota-based JC during the time that surveys were administered were eligible to participate. As outlined above, this residential population favors males, ages range from 16-24 years old, and participants are ethnically diverse.

Survey and Measures

Quantitative data were collected with a survey that targeted content outlined in Table 2. Also see Table 2 for references regarding select instrument components' reliability/validity and a description of data cleaning and management processes. See Appendix 1 in the online Supplemental Materials for a copy of the survey.

Data Collection

Surveys were administered during a single class period at five distinct time points. The process required between 20 and 30 min, depending on class size. Response rates for every survey exceeded 85%.

Statistical Analysis

Participant characteristics were tabulated to evaluate potential population shift over time from turnover at JC. Characteristics and responses were also tabulated across responses within an individual and used for estimating associations of candidate predictors (e.g., participation in activities) with outcomes. Odds ratios were estimated with generalized estimating equations (Diggle, Heagerty, Liang, & Zeger, 2002), adjusting for gender and ethnicity and accounting for correlation between multiple survey responses from the same participant. Robust variance estimation was used for confidence intervals and p values. Conservative power calculations in the original proposal suggested 88% power for odds ratios of 1.5 for tobacco use. All analyses were conducted in R Version 2.12.0.

Results

Descriptive results are presented in Appendix 2 in the online Supplemental Materials, wherein data for all survey items (e.g., readiness to change, types of stressors, participation in physical and nonphysical activities, perceptions of influence for respective SANTA interventions) are organized across all five survey time periods and categorized by group (e.g., all students, smokers, smokers who are nicotine dependent, nonsmokers). To assess trends, only the subset of respondents who submitted at least two surveys was included in the analysis; the demographic profile of this group mirrors the overall group of respondents (see Table 3). About 40% reported having used tobacco products. Of these, 30% can be described as dependent, having Fagerstrom scores of 4 or greater. Nearly half (48%) intended to quit within 1 month and 74% intended to quit within 6 months.

Student Stress

Stressors most commonly identified by students are outlined in Appendix 2 in the online Supplemental Materials. The effect of each stressor on repeated measures of prevalence and Fagerstrom score was modeled, accounting for the correlation among multiple measurements on the same subject and adjusting for gender and ethnicity (see Figure 1 A). For example, the odds of using tobacco products among those reporting elevated stress about freedom of using tobacco products was higher than the odds among those who did not report elevated stress about freedom of using tobacco, holding constant gender and ethnicity (p = .007). Stress related to JC rules approached significance for tobacco use (p = .078). Stressors evidencing elevated odds ratios for dependency included struggles with academics (p = .036) and relationships (p = .047). Stress related to dormitory life and conflict with peers approached significance (p = .06 and p = .055, respectively). Conversely, the odds of tobacco dependence among those reporting elevated stress about finances were lower than those who reported lower stress about finances (p = .048).

In assessing readiness to change, either on a I-month or 6-month time horizon, roommates were of particular note (see Figure 1B). The odds of being ready to change among those with elevated stress from roommates were lower than those without elevated stress with roommates. Odds ratios for those with elevated vocational stress versus not, on the other hand, suggest the opposite trend (p = .048).

SANTA Interventions

Perceptions of SANTA's interventions were evaluated similarly to how stressors were (outlined above). Students who viewed interventions as favorable influences on themselves and others in making eventual changes in behavior were more likely to use tobacco (see Figure 1A). Perceptions of SANTA activities, JC policies, environment, and social support were uniformly recognized as favorable influences (p = .001 for each). Those with a favorable view of the influence of JC policies were also more likely to be nicotine dependent (p = .014).

Roughly four in five respondents reported participating in at least one SANTA activity. The most popular were physical in nature (e.g., basketball, volleyball, dancing). The most popular nonphysical activities included arts/crafts, drama, and seminars. Participation in any activity per se did not appear to make students' immediate tobacco use or dependence less likely (see Figure 1A). Students participating in nonphysical activities, however, were more likely to report readiness to change across both 1-month (p = .001) and 6-month (p = .035) horizons (see Figure 1B).

Discussion

Stressors most commonly cited by students in JC included struggles to find a job, financial problems, family conflict, lack of privacy or freedom, missing family or being homesick, dealing with JC rules, and other-unspecified. The most popular activities in which students took part were physically active ones, but the activities most predictive of beneficent change were nonphysical. Taken collectively, these results suggest that the breadth and diversity of SANTA's interventions should be maintained, alongside increased energy and attention to specific activity types.

Maintaining a Broad Range of Activities and Efforts

Students engaged in smoking reported perceiving all of SANTA's efforts as potentially helpful. This response echoes the notion that "anything" oriented to smoking cessation is a good thing. And because considerably more students reported smoking behaviors (vs. dependence), the diversity of SANTA's interventions is well equipped to fit the different and respective personalities of individual students. This is further supported by empirical studies and professional literature. SANTA's work to combat stress and boredom through physical activities parallels others' understandings about how such social sequences can facilitate smoking cessation (e.g., Bullock, Mears, Woodcock, & Record, 2001; Doescher, Jackson, Jerant, & Hart, 2006; Everson, Taylor, & Ussher, 2009; Grable & Ternullo, 2003; Horn et al., 2013). Its efforts to change JC's physical environment to one that is not friendly toward smoking align with what many have called for in workplace and academic environments (e.g., Alekseeva, Alekseev, & Chukhrova, 2007; Chassin, Presson, Sherman, & McGrew, 1987; Nichols, Birnbaum, Birnel, & Botvin, 2006). SANTA's endeavors to change campus policies related to student and faculty/staff rules are consistent with literature advancing public health (e.g., Bloor, Meeson, & Crome, 2006; Reitsma & Manske, 2004; Schumann et al., 2006; Turner & Gordon, 2004; Uslan, Forster, & Chen, 2007). Its work to establish systems of peer support and mentoring align with education and support systems that have evidenced good results (e.g., Clark & Hegedus, 2002; Huang, 2005; Price, Yingling, Dake, & Telljohann, 2003).

Increasing Nonphysical Activities

Moving beyond the call to keep "doing it all," however, our findings suggest that nonphysical activities warrant more attention. This was surprising, insofar as SANTA's physical activities are the most well--and consistently--participated in. They are also the most visibly advertised and held up by JC administration as key to healthy living. But at both 1-month and 6month horizons, nonphysical activities were more likely paired with readiness to change.

As we shared and discussed these results with SANTA's members and other JC students, many disclosed how nonphysical activities are more facilitative for accessing social support from other students or trusted faculty/staff. For example, cocreating art is an easy way to talk with others who either share in one's struggles or can empower positive change. Drama sequences wherein students have written and directed on-campus plays about how to better handle roommate conflicts, engage in healthy lifestyles, set quit dates, and tap support systems have been cited as both interpersonally bonding and intrapersonally meaningful. Seminars discussing financial management, job search strategies, relationship communication and conflict resolution, and other topics consistent with what students identify as important to learn more about are often cast as immediately relevant and useful. These qualitative reflections are consistent with quantitative trends found in the current investigation, wherein support from peers was also paired with readiness to change (p = .041; see Figure 1A).

As SANTA responds to these findings, it will be important to engage the JC community in what this response will look like. All of the activities (physical and nonphysical) that the initiative has created and advanced have been led by students who communicated interest and passion to do so, and the constellation of activities over time has changed with student leaders' passions and campus-wide interest. For example, some activities (e.g., chess club, billiards) have come and gone and come back again in accord with who is currently enrolled on-site. Other activities are always present secondary to consistent student interest (e.g., basketball, arts/crafts). As SANTA increases its attention on nonphysical activities, it will be important that the activities it advances represent the wants and voices of those participating in them. It would be easy, for example, for us to create discussion groups, book clubs, or other nonphysical activities and then invite students to come, but this would be inconsistent with CBPR tenets of cocreating interventions. Instead, SANTA must engage in purposeful conversations and brainstorming with the JC community about what nonphysical activities students want to create, who is passionate about leading them, and how JC administration can further facilitate chosen activities' success.

Limitations

The revolving-door nature of JC students makes collecting any kind of longitudinal data (and tracking any kind of change over time) difficult. Because new students are always entering the site and current students are always graduating, every survey that we conducted included only a subset of participants who had taken the same survey previously. Relatedly, data were not 100% complete in terms of overall participation and completion of survey items. Missing data are a potential limitation in any study, decreasing precision and possibly biasing estimates. To the extent that the data are missing completely at random, the results are unbiased. The high response rate mitigates this to large degree. Changes in behavior or motivation also likely to evolve over more time than any of the series of surveys we administered could capture, and staying connected with graduates after they leave JC is administratively-- and financially--prohibitive. It could be that SANTA's efforts to influence students' smoking do not take full effect until after graduation (e.g., as students come to fully realize how difficult it is to secure work if potential employers know that they smoke). It could also be that SANTA's influence quickly wanes after graduation (i.e., out of sight, out of mind). Ultimately, we do not know.

Another limitation relates to the finding that almost half of our participants struggle with stressors that were not captured by the survey instrument. This is confusing because previous CBPR sequences had connected students' smoking to the relatively short list of "most common" stressors inquired about. Are there new stressors at JC now that were not prevalent even 1 year ago?

As current SANTA members and other JC students were asked in follow-up to reflect on what students may have meant when they checked "other-unspecified" as something causing stress, ideas and reflections were myriad. Some shared that they were stressed about rumors regarding the JC administration soon advancing even more restrictive nonsmoking rules in response to federal mandates. Others talked about a recent wave of bed bugs in JC dormitories. Still others were upset about all of the doomsday messages they have been hearing about the U.S. economy. This information is important to know and should be systemically sought in future CBPR efforts to understand what students are struggling with. Current efforts to respond to things that students have heretofore identified as worrisome (e.g., orienting them to JC's highly structured environment, offering support while being away from and missing family, assisting with job-hunting sequences) are still missing something that is clearly widespread.

Conclusions

SANTA's buffet of activities and efforts at JC serves to cast a broad net in smoking cessation for its students. Continuing to offer the range of things that it does will ensure that something "fits" for almost everyone in some way, whether it is deliberately supportive of something that is good (e.g., 1:1 coaching and support) or deliberately prohibitive of something that is bad (e.g., nametags that facilitate administrative punishment to minors if caught smoking). Within this larger frame, the initiative will be further advanced as it works to include more nonphysical activities as part of this buffet. So too will SANTA strengthen as it explores and responds to new and evolving foci of students' stress. Indeed, it is stress (broadly defined) that leads so many to smoke in the first place.

It is important to note that history is full of shining examples of "community projects" that faltered or dissolved altogether as soon as external funding ran out or their charismatic leaders) left. A key tenet of CBPR is that initiatives not follow this path, as extant community resources and energies are continuously tapped and project ownership is shared collectively (Doherty, Mendenhall, & Berge, 2010; Mendenhall & Doherty, 2005). SANTA's initial funding (secured by the first and second authors in partnership with JC administration) concluded several years ago, and the project has not lost momentum. As participants in the CBPR process (students, staff, administrators) have taken ownership of the initiative, professional leaders' leadership roles synchronously (and appropriately) decreased (Berge et al., 2009; Minkler & Wallerstein, 2011). As students work to replace themselves upon graduation, they nominate peers who they believe would be energetic and passionate contributors to the group's mission. To date, no independent student-based group or organization in the history of JC has lasted as long as the SANTA initiative already has.

In closing, SANTA's larger mission is to create a democratic model of health and human services that unleashes the capacity of ordinary people as producers of health and social change for themselves and their communities. Its members are a part of something more than a time-limited support group with restricted scope or simply another antismoking campaign that advances sentiments that the general public sees on TV and billboards every day. The initiative is instead a movement, changing and affecting the lives of people who its members may never meet and families they may never know through its collective energies, resources, and passion to work together to create something that no group within it (i.e., students, staff, administrators, professional researchers) could craft by itself.

References

Agency for Healthcare Research and Quality. (2004). Community-based participatory research: Assessing the evidence. Rockville, MD: Author.

Alekseeva, N., Alekseev, O., & Chukhrova, M. (2007). Some psychosocial aspects of smoking: 10-year experience in "Quit & Win" campaigns in Novosibirsk. Alaska Medicine, 49(2 Suppl.), 71-74.

Andrews, J., Newman, S.. Heath, J., Williams. L., & Tingen, M. (2012). Community-based participatory research and smoking cessation interventions: A review of the evidence. Nursing Clinics of North America, 47, 81-96. doi:10.1016/j.cnur.2011.10.013

Berge, J., Mendenhall, T., & Doherty, W. (2009). Using community-based participatory research (CBPR) to target health disparities in families. Family Relations, 58, 475-488. doi: 10.1111/j .1741-3729.2009.00567.x

Bloor, R., Meeson, L., & Crome, I. (2006). The effects of a non-smoking policy on nursing staff smoking behavior and attitudes in a psychiatric hospital. Journal of Psychiatric and Mental Health Nursing, 13, 188-196. doi: 10.1111/j. 1365-2850 .2006.00940.x

Bullock, L., Mears, J., Woodcock, C., & Record, R. (2001). Retrospective study of the association of stress and smoking during pregnancy in rural women. Addictive Behaviors, 26, 405-413. doi: 10.1016/S0306-4603(00)00118-0

Chassin, L., Presson, C., Sherman, S., & McGrew, J. (1987). The changing smoking environment for middle and high school students: 1980-1983. Journal of Behavioral Medicine, 10, 581-593. doi: 10.1007/BF00846656

Clark, J., & Hegedus, P. (2002). Community outreach: Providing a comprehensive approach to smoking cessation. Journal of Oncology Management, 11, 29-35.

Daley, C., Greiner, K., Nazir, N., Daley, S., Solomon, C., Braiuca, S., ... Choi, W. (2010). All Nations Breath of Life: Using community-based participatory research to address health disparities in cigarette smoking among American Indians. Ethnicity & Disease, 20, 334-338.

Diggle, P., Heagerty, P., Liang, K., & Zeger, S. (2002). Analysis of longitudinal data. New York, NY: Oxford University Press.

Doescher, M., Jackson, E., Jerant, A., & Hart, G. (2006). Prevalence and trends in smoking: A natural rural study. Journal of Oncology Management, 22, 112-118.

Doherty, W., Mendenhall, T., & Berge, J. (2010). The Families & Democracy and Citizen Health Care Project. Journal of Marital and Family Therapy, 36, 389-402. doi.T0.ll 11/j. 1752-0606.2009 .00142.x

Everson, E., Taylor, A., & Ussher, M. (2009). Determinants of physical activity promotion by smoking cessation advisors as an aid for quitting: Support for the transtheoretical model. Patient Education and Counseling, 78, 53-56. doi: 10.1016/j.pec .2009.05.004

Fagerstrom, K., & Schneider, N. (1989). Measuring nicotine dependence: A review of the Fagerstrom Tolerance Questionnaire. Journal of Behavioral Medicine, 12, 159-182. doi:10.1007/ BF00846549

Forsberg, L., Halldin, J., & Wennberg, P. (2003). Psychometric properties and factor structure of the Readiness to Change Questionnaire. Alcohol and Alcoholism, 38, 276-280. doi: 10.1093/alcalc/ agg067

Grable, J., & Ternullo, S. (2003). Smoking cessation from office to bedside: An evidence-based, practical approach. Postgraduate Medicine, 114, 45-48.

Haas, S. (2005). Smoking prevalence at Job Corps: An internal survey of students enrolled at the St. Paul, MN Site. Unpublished document.

Haddock, C., Lando, H., Klesges, R., Talcott, G., & Renaud, E. (1999). A study of the psychometric and predictive properties of the Fagerstrom Test for Nicotine Dependence in a population of young smokers. Nicotine & Tobacco Research, l, 59-66. doi: 10.1080/14622299050011161

Hancock, P. (2012). Participatory practice: Community-based action for transformative change by Margaret Ledwith and Jane Springett. Journal of Policy Practice, 11, 210-213. doi:10.1080/ 15588742.2012.687708

Heatherton, T., Kozlowski, L., Frecker, R., & Fagerstrom, K. (1991). The Fagerstrom Test for Nicotine Dependence: A revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addiction, 86, 1119-1127. doi: 10.1111/j. 1360-0443 .1991.tb01879.x

Horn, K., Branstetter, S., Zhang, J., Jarret, T., Tompkins, N., Anesetti-Rothemel, A., ... Dino, G. (2013). Understanding physical activity as a function of teen smoking cessation. Journal of Adolescent Health. Retrieved from https://www.clinicalkey .com/#!/ContentPlayerCtrl/doPlayContent/1-s2.0-S1054139X13000748

Huang, C. (2005). Evaluating the program of a smoking cessation support group for adult smokers: A longitudinal study. Journal of Nursing Research, 13, 197-205. doi: 10.1097/01.JNR.0000387541 .83630.71

Knight, K., Holcom, M., & Simpson. D. D. (1994). TCU psychosocial functioning and motivation scales: Manual on psychometric properties. Fort Worth, TX: Texas Christian University, Institute of Behavioral Research.

Ma, G. (2004). ATECAR: An Asian American community-based participatory research model on tobacco and cancer control. Health Promotion and Practice, 5, 382-394. doi: 10.1177/ 1524839903260146

Mendenhall, T., & Doherty, W. J. (2005). Action research methods in family therapy. In F. Piercy & D. Sprenkle (Eds.), Research methods in family therapy (2nd ed., pp. 100-118). New York, NY: Guilford Press.

Mendenhall, T., Harper, P., Whipple, H., & Haas, S. (2011). The SANTA Project (Students Against Nicotine and Tobacco Addiction): Using community-based participatory research to reduce smoking in a high-risk young adult population. Action Research, 9, 199-213. doi: 10.1177/ 1476750310388051

Mendenhall, T., Whipple, H., Harper, P., & Haas, S. (2008). Students Against Nicotine and Tobacco Addiction (S.A.N.T.A.): Community-based participatory research in a high-risk young adult population. Families, Systems, & Health, 26, 225-231. doi: 10.1037/1091-7527.26.2.225

Minkler, M., & Wallerstein, N. (Eds.). (2011). Community-based participatory research for health: From process to outcomes. San Francisco, CA: Jossey-Bass.

National Institutes of Health. (2013). Smoking and youth. Retrieved from http://www.nlm.nih.gov/ medlineplus/smokingandyouth.html

Nichols, T., Birnbaum, A., Birnel, S., & Botvin, G. (2006). Perceived smoking environment and smoking initiation among multi-ethnic urban girls. Journal of Adolescent Health, 38, 369-375. doi: 10.1016/j.jadohealth.2005.04.016

Power, F., Gillies, P., Madeley, R., & Abbot, M. (1989). Research in an antenatal clinic: The experience of the Nottingham Mothers' Stop Smoking Project. Midwifery, 5, 106-112. doi: 10.1016/ S0266-6138(89)80024-5

Price, J., Yingling, F., Dake, J., & Telljohann, S. (2003). Adolescent smoking cessation services of school-based health centers. Health Education & Behavior, 30, 196-208. doi: 10.1177/ 1090198102251032

Prochaska, J., & DiClemente, C. (1992). Stages of change in the modification of problem behaviors. Progressive Behavior Modification, 28, 183-218.

Radzius, A., Moolchan, E., Henningfield, J., Heishman. S., & Gallo, J. (2001). A factor analysis of the Fagerstrom Tolerance Questionnaire. Addictive Behaviors, 26, 303-310. doi:10.1016/S03064603(00)00114-3

Reitsma, A., & Manske, S. (2004). Smoking in Ontario schools: Does policy make a difference? Canadian Journal of Public Health, 95, 214-218.

Schumann, A., John, U., Thyrian, J., Ulbricht, S., Hapke, U., & Meyer, C. (2006). Attitudes towards smoking policies and tobacco control measures in relation to smoking status and smoking behavior. European Journal of Public Health, 16, 513-519. doi: 10.1093/eurpub/ck1048 Shelley, D., Fahs, M., Yemeni, R., Das, D., Nguyen, N., Hung, D., ... Cummings, K. (2008). Effectiveness of tobacco control among Chinese Americans: A comparative analysis of policy approaches versus community-based programs. Preventive Medicine, 47, 530-536. doi:10.1016/j.ypmed.2008 .07.009

Tsark, J. (2001). A participatory research approach to address data needs in tobacco use among Native Hawaiians. Asian American/Pacific Islander Journal of Health, 9, 40-48.

Turner, K., & Gordon, J. (2004). Butt in, butt out: Pupils' views on the extent to which staff could and should enforce smoking restrictions. Health Education Research, 19, 40-50. doi:10.1093/her/ cyg005

Uslan, K., Forster, J., & Chen, V. (2007). Smoking policies in small worksites in Minnesota. American Journal of Health Promotion, 21, 416-421. doi: 10.4278/0890-1171 -21.5.416

Villanti, A., McKay, H., Abrams, D., Holtgrave, D., & Bowie, J. (2010). Smoking-cessation interventions for U.S. young adults: A systematic review. American Journal of Preventive Medicine, 39, 564-574. doi: 10.1016/j.amepre.2010.08.009

Wellman, R., DiFranza, J., Pbert, L., Fletcher, K., Flint, A., Young, M., & Druker, S. (2006). A comparison of the psychometric properties of the Hooked on Nicotine Checklist and the modified Fagerstrom Tolerance Questionnaire. Addictive Behaviors, 31, 486-495. doi:10.1016/j.addbeh .2005.05.031

DOI: 10.1037/fsh0000003

Received March 21, 2013

Revision received August 12, 2013

Accepted August 16, 2013

Tai J. Mendenhall, Ph.D., Peter G. Harper, M.D., Lisa Henn, M.S., and Kyle D. Rudser, Ph.D. University of Minnesota

Bill P. Schoeller, L.A.D.C., B.S. Hubert H. Humphrey Job Corps Center, St. Paul, Minnesota

This article was published Online First September 30, 2013.

Tai J. Mendenhall, Ph.D., Department of Family Social Science, University of Minnesota; Peter G. Harper, M.D., Department of Family Medicine and Community Health, University of Minnesota; Lisa Henn, M.S., and Kyle D. Rudser, Ph.D.. Clinical and Translational Science Institute, University of Minnesota; Bill P. Schoeller, L.A.D.C., B.S., Hubert H. Humphrey Job Corps Center, St. Paul, Minnesota.

Tai J. Mendenhall and Peter G. Harper received funding for this research through ClearWay Minnesota Research Program Grant RC 2006-0043.

Correspondence concerning this article should be addressed to Tai J. Mendenhall, Ph.D., University of Minnesota, Department of Family Social Science, 290 McNeal Hall, 1985 Buford Avenue, Saint Paul, MN 55108. E-mail: mend0009@umn.edu

Table 1
Students Against Nicotine and Tobacco Addiction (SANTA) Interventions

Reducing stress and boredom
  Physical activities (e.g., basketball, volleyball)
  Nonphysical activities (e.g., arts/crafts, drama)
Changing the physical environment
  Smoking area (e.g., designated location, under-age identification
   cards)
  Media (e.g., antismoking posters, campus newsletter)
Changing policy
  Clothing and uniforms (e.g., SANTA T-shirts)
  Teacher/staff smoking (e.g., away from students)
  Rewards (e.g., privileges for cleaning campus grounds of cigarette
    butts)
  Punishments (e.g., consequences for breaking rules related to
   smoking)
Smoking cessation education/support
  Support groups (e.g., student-led education and coaching)
  Stress management (e.g., seminars targeting common student
   stressors)

Table 2
Study Measures

Measure                                  Description

Sources of stress      Respondents were asked to rate a variety of
                         stressors in their current lives (e.g.,
                         difficulties with finances, family, peers,
                         roommates, academics, personal
                         relationships, JC restrictions and rules,
                         physical health) according to a 10-point
                         Likert scale. Raw data were then classified
                         into "low stress" ([less than or equal to]
                         3) or "high stress" ([greater than or equal
                         to] 4) categories.

Awareness of SANTA     Students' awareness of intervention domains
  interventions          was assessed through survey measures
                         identifying SANTA'S ongoing efforts across
                         on-campus activities to reduce stress and
                         boredom, JC policies, physical environment,
                         smoking cessation education, and support.
                         Responses were recorded on a 5-point Likert
                         scale (1 = not at all aware; 5 = extremely
                         aware).

Participation in       Students' participation in activities to
  SANTA                  reduce stress and boredom and in smoking
  interventions          cessation education and support were
                         assessed through survey measures tracking
                         involvement and frequency of participation.
                         Responses followed a checklist format,
                         alongside frequency counts measuring the
                         extent of participation in selected
                         activities.

Perceptions of         Students' perceptions of the intervention
  interventions'         domains' influence on smoking behaviors were
  influence              assessed through survey measures scaling
                         discerned impact of each domain on smoking
                         (or nonsmoking) behaviors. Responses were
                         recorded on a 5-point Likert scale (1 = not
                         at all aware; 5 = extremely aware).

Smoking behaviors      Smoking variables assessed included data
  and nicotine           across a broad range of dependence.
  dependence             contextual, and behavioral foci. To evaluate
                         participants' physical dependency to
                         smoking, we employed the Fagerstrom Test of
                         Nicotine Dependence (Fagerstrom & Schneider,
                         1989: Heatherton, Kozlowski, Frecker, &
                         Fagerstrom, 1991; Radzius, Moolchan,
                         Henningfield, Heishman, & Gallo, 2001). This
                         measure has confirmed high reliability and
                         validity (Haddock, Lando, Klesges, Talcott,
                         & Renaud, 1999; Wellman et al., 2006). Items
                         (e.g., "How soon after you wake up do you
                         smoke your first cigarette?" "How many
                         cigarettes a day do you smoke?") were summed
                         to yield an overall score between 0 and 10.

Readiness to change    Stages of change were measured based on the
                         three-item measure by Prochaska and
                         DiClemente (1992). This instrument has
                         confirmed high reliability and validity
                         (Forsberg, Halldin, & Wennberg, 2003;
                         Knight, Holcom, & Simpson, 1994). Smokers
                         were classified into the precontemplation
                         stage if they did not intend to quit in the
                         next 6 months, contemplation stage if they
                         intended to quit in the next 6 months, and
                         the preparation stage if they intended to
                         quit in the next 30 days. The latter is a
                         modification of the original Prochaska and
                         DiClemente framework, which includes
                         attempts at quitting in the past 12 months
                         in the "preparation' stage criteria.

Data cleaning and      Data irregularities were corrected before
  management             analyses were conducted. This effort
                         included resolving conflicting responses
                         (e.g., indication that the respondent
                         participated in volleyball, but on zero
                         occasions, or indication that the respondent
                         is not a user of tobacco, but enumerated
                         specific tobacco use), standardizing of
                         spellings, removing duplicate observations,
                         removing nonconforming data (e.g.,
                         nonnumeric data in numeric fields),
                         assigning responses outside of a question's
                         range to a within-range extreme, and filling
                         in information from obvious cross-
                         tabulation data (e.g., missing date of
                         survey inferred from survey number, or vice
                         versa). Free-form responses were reviewed
                         and classified to augment tabulations from
                         yes/no questions.

Note. JC = Job Corps; SANTA = Students Against Nicotine and Tobacco
Addiction.

Table 3
Demographic Attributes of Job Corps Survey Respondents With Multiple
Survey Responses

                                          Survey date

                           Survey 1:       Survey 2:       Survey 3:
                           4/30/2009       7/15/2009      11/10/2009
                            (N = 89)       (N = 122)       (N = 131)
       Variable              n (%)           n (%)           n (%)

Male                       48 (53.93)      62 (50.82)      73 (55.73)
Female                     41 (46.07)      59 (48.36)      58 (44.27)
Gender--Missing             0 (0.00)        1 (0.82)        0 (0.00)
African                     8 (8.99)       12 (9.84)       13 (9.92)
African American           43 (48.31)      60 (49.18)      59 (45.04)
American Indian/            5 (5.62)        5 (4.10)        4 (3.05)
  Alaska Native
Asian American              2 (2.25)        3 (2.46)        3 (2.29)
Euro-American/White        20 (22.47)      20 (16.39)      24 (18.32)
Hawaiian/Pacific            0 (0.00)        1 (0.82)        1 (0.76)
  Islander
Hispanic/Mexican            2 (2.25)        4 (3.28)        5 (3.82)
  American
Other                       9 (10.11)      17 (13.93)      21 (16.03)
Ethnicity--Missing          0 (0.00)        0 (0.00)        1 (0.76)
Used tobacco--Yes          47 (52.81)      54 (44.26)      47 (35.88)
Used tobacco--No           42 (47.19)      68 (55.74)      84 (64.12)
Age                     19.87 (2.14)    20.16 (2.34)    20.21 (2.06)
Age--Missing                0 (0.00)        0 (0.00)        0 (0.00)
Fagerstrom               2.47 (2.22)     2.77 (1.99)     2.39 (1.71)
Fagerstrom--Missing         4 (8.51)       11 (20.37)       3 (6.38)
Dependence yes/no--No      27 (57.45)      24 (44.44)      31 (65.96)
Dependence yes/no--Yes     16 (34.04)      19 (35.19)      13 (27.66)
Dependence yes/no--         4 (8.51)       11 (20.37)       3 (6.38)
  Missing

                                   Survey date

                           Survey 4:       Survey 5:
                           2/1/2010        6/21/2010
                           (At= 115)        (N = 38)
       Variable              n (%)           n (%)

Male                       65 (56.52)      19 (50.00)
Female                     50 (43.48)      19 (50.00)
Gender--Missing             0 (0.00)        0 (0.00)
African                    14 (12.17)       4 (10.53)
African American           46 (40.00)      15 (39.47)
American Indian/            5 (4.35)        0 (0.00)
  Alaska Native
Asian American              3 (2.61)        1 (2.63)
Euro-American/White        22 (19.13)       7 (18.42)
Hawaiian/Pacific            0 (0.00)        1 (2.63)
  Islander
Hispanic/Mexican            5 (4.35)        3 (7.89)
  American
Other                      18 (15.65)       7 (18.42)
Ethnicity--Missing          2 (1.74)        0 (0.00)
Used tobacco--Yes          38 (33.04)      11 (28.95)
Used tobacco--No           77 (66.96)      27 (71.05)
Age                     20.71 (2.13)    20.82 (2.00)
Age--Missing                0 (0.00)        0 (0.00)
Fagerstrom               2.43 (1.67)     0.57 (0.98)
Fagerstrom--Missing         3 (7.89)        4 (36.36)
Dependence yes/no--No      25 (65.79)       7 (63.64)
Dependence yes/no--Yes     10 (26.32)       0 (0.00)
Dependence yes/no--         3 (7.89)        4 (36.36)
  Missing

                                           Survey repetition

                                    First response    Second response
                                   CN = 196) n (%)     (N = 196) n (%)

Male                                 106 (54.08)        104 (53.06)
Female                                89 (45.41)         92 (46.94)
Gender--Missing                        1 (0.51)           0 (0.00)
African                               21 (10.71)         15 (7.65)
African American                      90 (45.92)         88 (44.90)
American Indian/Alaska Native          8 (4.08)           7 (3.57)
Asian American                         5 (2.55)           6 (3.06)
Euro-American/White                   37 (18.88)         37 (18.88)
Hawaiian/Pacific Islander              1 (0.51)           1 (0.51)
Hispanic/Mexican American              6 (3.06)           6 (3.06)
Other                                 28 (14.29)         33 (16.84)
Used tobacco--Yes                     88 (44.90)         76 (38.78)
Used tobacco--No                     108 (55.10)        120 (61.22)
Age                                20.05 (2.16)       20.26 (2.11)
Fagerstrom                          2.39 (2.01)        2.50 (1.79)
Fagerstrom--Missing                   11 (12.50)         12 (15.79)
Dependence yes/no--No                 51 (57.95)         42 (55.26)
Dependence yes/no--Yes                26 (29.55)         22 (28.95)
Dependence yes/no--Missing            11 (12.50)         12 (15.79)

                                           Survey repetition

                                    Third response    Fourth response
                                    (N = 75) n (%)     (N = 23) n (%)

Male                                  42 (56.00)         12 (52.17)
Female                                33 (44.00)         11 (47.83)
Gender--Missing                        0 (0.00)           0 (0.00)
African                               10 (13.33)          5 (21.74)
African American                      35 (46.67)          8 (34.78)
American Indian/Alaska Native          3 (4.00)           1 (4.35)
Asian American                         1 (1.33)           0 (0.00)
Euro-American/White                   13 (17.33)          5 (21.74)
Hawaiian/Pacific Islander              0 (0.00)           0 (0.00)
Hispanic/Mexican American              4 (5.33)           2 (8.70)
Other                                  9 (12.00)          2 (8.70)
Used tobacco--Yes                     25 (33.33)          6 (26.09)
Used tobacco--No                      50 (66.67)         17 (73.91)
Age                                20.73 (2.21)       21.26 (2.36)
Fagerstrom                          2.61 (1.95)        2.50 (2.17)
Fagerstrom--Missing                    2 (8.00)           0 (0.00)
Dependence yes/no--No                 16 (64.00)          3 (50.00)
Dependence yes/no--Yes                 7 (28.00)          3 (50.00)
Dependence yes/no--Missing             2 (8.00)           0 (0.00)

                                   Survey repetition

                                    Fifth response
                                     (N = 5) n (%)

Male                                  3 (60.00)
Female                    -            2 (40.00)
Gender--Missing                       0 (0.00)
African                               0 (0.00)
African American                      2 (40.00)
American Indian/Alaska Native         0 (0.00)
Asian American                        0 (0.00)
Euro-American/White                   1 (20.00)
Hawaiian/Pacific Islander             1 (20.00)
Hispanic/Mexican American             1 (20.00)
Other                                 0 (0.00)
Used tobacco--Yes                     2 (40.00)
Used tobacco--No                      3 (60.00)
Age                               21.20 (1.92)
Fagerstrom                         0.00 (0.00)
Fagerstrom--Missing                   0 (0.00)
Dependence yes/no--No                 2 (100.00)
Dependence yes/no--Yes                0 (0.00)
Dependence yes/no--Missing            0 (0.00)
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Author:Mendenhall, Tai J.; Harper, Peter G.; Henn, Lisa; Rudser, Kyle D.; Schoeller, Bill P.
Publication:Families, Systems & Health
Article Type:Report
Geographic Code:1USA
Date:Mar 1, 2014
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