October 2005

Grant Results

SUMMARY

From 1999 to 2004, staff at North Carolina's Department of Health and Human Services, Raleigh, N.C., advanced its tobacco use prevention and control mission by establishing three youth-led tobacco use prevention centers across the state.

The centers provided a platform for project staff to foster youth-led tobacco use prevention planning and advocacy and to provide leadership development to participating youth.

Key Results

  • Project youth advocated for and achieved 100 percent tobacco-free schools in two of the three targeted counties of the project — Durham and Buncombe counties. New Hanover County already had tobacco-free schools.
  • Project youth worked to reduce noncompliance with state law prohibiting the sale of tobacco to minors by securing pledges from vendors of tobacco and increasing the number of smoke-free establishments frequented by youth.
  • Project staff conducted four multi-day leadership training events during 2001–2003, as well as local training events.
  • Staff conducted two radio campaigns highlighting tobacco-free schools and a tobacco-control initiative in movie theaters. These complemented a separately funded statewide tobacco-control campaign featuring six radio messages on the subject by Governor Hunt and teenagers from his "Youth Advisory Team."
  • A total of 142 television, radio and print items reported on the project, focusing on youth involvement in tobacco prevention and control.

Funding
The Robert Wood Johnson Foundation (RWJF) provided a grant of $1,993,698 in support of this project between October 1999 and July 2004.

 See Grant Detail & Contact Information
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THE PROBLEM

In 1997, according to North Carolina's Youth Risk Behavior Survey (conducted as part of a national survey by the Centers for Disease Prevention and Prevention [CDC]), smoking among North Carolina's adolescents had increased by approximately 45 percent in the previous six years — by 40.8 percent for public high school students and by 48.6 percent for middle-school youth.

More than a quarter of North Carolina middle school students reported themselves as current smokers in 1997, and 42.9 percent of white and 24.5 percent of African-American high school students smoked, as compared to 39.7 percent of white and 22.7 percent of African-American students nationally.

Public health science overwhelmingly confirms that preventing young people from starting to use tobacco is the key to reducing death and disease caused by tobacco use. A 1996 Institute of Medicine Report (Growing Up Tobacco Free) noted that a comprehensive approach that involves youth in changing social norms connected with tobacco use has the greatest potential to prevent tobacco use by youth.

According to statistics issued by the state's Department of Health and Human Services in 1999, smoking was responsible for more than 12,000 deaths in North Carolina annually.

In 1991, 17 states began participating in the American Stop Smoking Intervention Study (ASSIST), a campaign to reduce tobacco use, funded by the National Cancer Institute and the American Cancer Society until 1998. The CDC continued to provide funds to states after 1998. North Carolina administered its Project ASSIST through its state's Division of Public Health in the Department of Health and Human Services.

By 1999, it had established a working infrastructure of partner organizations, public and private-sector leaders, trained volunteers and school and community leaders in tobacco policy, and was employing media advocacy to "raise the volume" regarding tobacco use by teens in the state. That year, then Governor James B. Hunt, Jr. called for a statewide "Teen Tobacco Prevention Summit" to bring together representatives of 350 schools to design effective teen strategies to prevent and control tobacco use.

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RWJF STRATEGY

RWJF has been involved with projects concerning tobacco control and prevention directed at youth since the beginning of its funding in the tobacco field. The Tobacco Policy Research and Evaluation Program (see Grant Results) funded a number of projects focused on youth, for example:

  • Advertising/Promotion Influence on Adolescent Perceptions of Smoking (see Grant Results on ID# 022935)
  • Tobacco Prices, Restrictions, and Use Among Youth (see Grant Results on ID# 022932)
  • Study of Ways to Reduce Tobacco Sales to Minors (see Grant Results on ID# 024784)
  • Does Active Enforcement of Tobacco Sales Laws Reduce Adolescents' Smoking? (see Grant Results on ID# 022928)
  • Research on Initiation of Teenage Smoking (see Grant Results on ID# 024413)

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THE PROJECT

From November 1999 through July 2004, staff within North Carolina's Department of Health and Human Services, acting through the state's Project ASSIST, established three youth-led tobacco use prevention centers in the state, through which they ran a youth-led tobacco use prevention planning and advocacy campaign (called the Question Why [?Y] campaign), and provided leadership development opportunities to project youth.

Local health departments and nonprofit agencies supported the centers, which were located in regionally and culturally diverse locations in the state: Wilmington (supported by Wilmington Health Access for Teens, a private, nonprofit health care center), Durham (Durham Area Corps, a charitable nonprofit), and Asheville (the Buncombe County Health Services).

Youths at these regional centers worked with adult volunteers (often collaborating, too, with statewide or community stakeholders such as school or law enforcement staffs) to plan and carry out a varied program of tobacco use prevention, targeting the social environment of adolescents. Paid staff at each center included a full-time project coordinator and five or six trained teen advocates working at least three afternoons a week.

Project staff pursued five specific goals:

  • Collaborate and mobilize both statewide and locally to develop and carry out youth-led model policy advocacy programs.
  • Develop strategic planning and training to enable the youth-led programs to work to change policies and social norms related to youth access to tobacco, exposure to environmental tobacco smoke, and tobacco-free schools.
  • Strengthen tobacco use prevention activities by promoting a tobacco-free norm through retreats, counter-advertising campaigns, advocacy activities, mini-grants, incentive programs, presentations and alternative activity programs (e.g., Smoke-free Soccer).
  • Utilize the media as an incentive for youth involvement in tobacco use prevention, and as a tool to disseminate and change public opinion.
  • Plan and conduct process and outcome program evaluation activities.

Staff adapted this project's specific activities from the CDC's Best Practices for Comprehensive Tobacco Control Programs, an evidence-based guide to help states plan and establish effective tobacco-control programs to prevent and reduce tobacco use. Project evaluation consisted primarily of the use of a computerized activities tracking system, written youth evaluations following activities and information from several youth surveys and available databases in the state.

In October 2003, the project received $500,000 in additional funds from the North Carolina Health and Wellness Trust Fund (the state's fiduciary for monies from the Tobacco Master Settlement Agreement), to support infrastructure and activities at the three youth centers.

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RESULTS

Project staff reported the following results to RWJF:

  • Project youth advocated for and achieved 100 percent tobacco-free schools in two of the three targeted counties of the project — Durham and Buncombe counties. New Hanover County already had tobacco-free schools. Other related accomplishments included the following:
    • In communities beyond the three targeted counties, youth advocacy helped support policy change efforts resulting in 100 percent tobacco-free schools in nine school districts and in three other schools. An additional school district strengthened its tobacco policy during the grant period (becoming tobacco-free except for a designated smoking area at outdoor athletic events), five schools improved their enforcement policies, and two adopted tobacco quitting programs as alternatives to suspension policies. Also in neighboring communities, project youth claimed new support for a tobacco-free school policy from 63 school board members or influential community leaders.
    • During the project, 28 youth-led "tobacco-free" teams, trained by project staff and youth, engaged 29,000 people through 41 schoolwide promotions to change school norms of tobacco use.
  • Project youth worked to reduce noncompliance with state law prohibiting the sale of tobacco to minors by securing pledges from vendors of tobacco and increasing the number of smoke-free establishments frequented by youth.
    • Five youth-led campaigns secured pledges not to sell tobacco to minors from 149 merchants.
    • Youth established working partnerships with three county or state environmental inspectors to bolster enforcement of a no-sale-to-minors policy.
    • Project youth convinced three major youth recreation centers to adopt stronger tobacco policies and five restaurants or public places to conduct a smoke-free trial period.
    • Project youth and adult staff sponsored smoke-free-air activities (e.g., smoke-free minor league baseball games), with a total of 3,000 youths and 2,300 adults in attendance.
  • Project staff conducted four multi-day leadership training events during 2001–2003, as well as local training events. The multi-day "summits," sponsored by the different regional youth centers, educated youth in empowerment and advocacy skills and engaged them in daylong advocacy work in the host community. Approximately 400 youths and 300 adults attended the sponsored summits, held in Wilmington, Ashville, Greenville and Charlotte. Project staff conducted more localized training events or interventions in the following categories:
    • Youth leadership. Through 16 training interventions, 336 youths went into communities to advocate for reduction in tobacco use, for tobacco-free schools or against secondhand smoke. Six of the trainings reached out to low-income communities and three to African-American communities. Four training groups of youth also conducted peer education and outreach activities reaching 1,875 individuals, mostly youths.
    • Smoke-free environments. Fourteen training events (including the four major youth "summits") educated 1,170 youths and adults in advocacy for smoke-free environments. Three of these events focused on low-income or rural counties, and one addressed an African-American community.
    • Tobacco-free schools. Through 23 training events, 787 youths or adults learned techniques for changing school policy or institutionalizing a youth cessation project. The training also addressed media advocacy concerning tobacco-free schools and taught youth to speak to school boards.
    • Schoolwide promotions. Two training events in how to develop schoolwide campaigns involved 53 youths and adults. Staff trained youth for one campaign that focused on spit tobacco and one on infusing tobacco education into the curriculum. Both resulting campaigns included an all-school assembly focused on media literacy (i.e., thinking critically about media as persuasion) regarding tobacco, with 27 follow-up school and youth group activities. These follow-up activities involved 8,906 participants.
    • Other tobacco-free activities. Eighty-seven training events focused on peer education in media literacy, merchant education, being media spokespersons, media advocacy, adult leader training and training for youth and adult leaders in the leadership development and critical thinking skills necessary to foster youth empowerment. These events involved 2,557 participants. Fourteen of these events trained individuals in the African-American community; two trained people in the American Indian community; two trained people in the Hispanic community; and nine trained low-income or rural populations.
  • Staff conducted two radio campaigns highlighting tobacco-free schools and a tobacco-control initiative in movie theaters. These complemented a separately funded statewide tobacco-control campaign featuring six radio messages on the subject by Governor Hunt and teenagers from his "Youth Advisory Team."
    • The project's statewide campaign, "Our Schools, Our Rules," began with a contest to select the best student-produced tobacco use prevention radio advertisement. Ten youth-oriented radio stations in seven media markets (Asheville, Charlotte, Greensboro, Jacksonville, Raleigh, Whiteville and Wilmington) ran the winning 60-second spot during June and July of 2002. The radio spot appeared an average of 20 times per week on each station during this period. Participating radio stations contributed approximately $56,800 of the campaign's $73,800 airtime budget. Staff of a project media consultant (the Raleigh, N.C.-based office of Porter Novelli International) supplemented this exposure with a press release, a "backgrounder" and a tobacco fact sheet.
    • Staff conducted a youth-led radio campaign in the state's eastern region, entitled "Check Yourself Before You Wreck Yourself."
    • Project staff arranged to show pre-movie slides to movie audiences about the danger of secondhand smoke in restaurants. Project youth created one slide and staff purchased the other from the CDC. In December 2002, the slides ran for four weeks in a 15-screen multiplex yielding 1,575 audience exposures apiece.
  • A total of 142 television, radio and print items reported on the project, focusing on youth involvement in tobacco prevention and control. According to the project director, the coverage was directly attributable to project activities. Coverage included 54 television items, 20 on radio and 68 print articles (with project youth collaborating in the writing of 58 of the print articles). Most media featured youth as leaders, spokespeople or activists in the tobacco prevention and control movement. Notably, the Durham County newspaper published a four-part series of articles written by youth with adult guidance. The paper, with a total readership of about 11,000, circulated the series free to middle and high schools in Durham, Orange, Vance, Warren and Chatham counties.

Communications

Staff helped write and then distributed approximately 1,000 copies of the 60-page manual Question Why Guide to Youth Empowerment for Tobacco Control, designed to aid replication of the project's methods. Distribution occurred primarily at conferences and through the CDC, and to youth leaders in 90 counties in North Carolina (in many cases accompanied by either formal training or one-on-one meetings). Staff also distributed a collection of six case studies, QY Community Change Chronicles, describing accomplishment of youth-led advocacy work for tobacco-free schools and clean indoor air. Both publications are available online; the case studies document is also available on a Web site funded by North Carolina's Department of Health and Human Services. Staff also distributed brochures and project information and material to local health departments in the state.

As mentioned under Results, articles or stories about the project appeared in media throughout the state. Staff made a presentation and held a poster session about the project at the National Tobacco OR Health Conference in San Francisco in November 2002. They also made a presentation and administered a tobacco use survey to 312 youths at a March 2004 gathering, "The Leadership Institute," in Research Triangle Park, N.C., co-sponsored by North Carolina's Tobacco Prevention and Control Branch and its Health and Wellness Trust Fund.

The project's Web site describes the project, lists contact and events information, provides facts, data and policies on tobacco use in North Carolina, as well as the full text of the project's youth empowerment model, Question Why Guide to Youth Empowerment for Tobacco Control. See the Bibliography for further details.

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LESSONS LEARNED

  1. Make sure those adults involved in "youth empowerment" fully understand the concept. Throughout the project, staff worked with agencies and adults who due to this lack of understanding did not feel comfortable in allowing project youth to be true leaders. To counter this, staff continually offered training to educate participating adults in three specific components of youth empowerment: fostering youths' critical awareness of the problem, their leadership skills development and how to seek out and act on opportunities to effect change. (Project Director)
  2. To achieve low turnover, adult leaders must be dedicated to working with youth, and the youth must be committed to working on the advocacy issue at hand. This project experienced extremely low turnover of adult leaders and youth working on tobacco use prevention. This may have been due to the adults' commitment and the thorough interview process for the youth staff. The continuity of the adult leaders was a big factor in keeping the same youths involved. (Project Director)
  3. When working with project youth, begin by researching or creating a definition of youth empowerment. Staff found that this "preliminary" work structured, clarified and placed needed limits on project adults as well as on youth. (Project Director)
  4. Adult staff should gear their youth empowerment training to the development level of each youth. Training is different, for example, for middle school, high school and college youth. (Project Director)
  5. Assure that youth from different cultures and backgrounds are included in every step of the project. The principle of planning with a target group rather than planning for a target group is vital for reaching diverse youth. In their trainings and activities, project staff found that diversity among their youth participants helped facilitate much greater perspective in designing, implementing and evaluating projects or training sessions. (Project Director)
  6. Anticipate that involved agencies will resist treating teens as stipend-funded employees. Agencies tended to lack reliable mechanisms to get project youth leaders the normal employee prerequisites — parking passes, e-mail addresses, phone numbers and paychecks. (Project Director)
  7. Transportation of teen "teams" will fall to adults. Project staff should anticipate that it will be necessary to rent a vehicle on occasion and to use adults' personal vehicles, potentially incurring added liability. (Project Director)
  8. A youth center's sponsoring agency must allow flex time. This project entailed a lot of evening and weekend work for its adult leaders, instead of regular 8:00 to 5:00 hours. Agencies also must allow adult leaders to take time off during the workweek to avoid burnout. (Project Director)
  9. In a "tobacco state," be prepared to confront barriers to youth involvement in tobacco-control activities. Social and legal norms give special status to tobacco and its use in North Carolina. This cultural sway, usually felt less strongly by teens than by the adults they sought to influence, was entrenched and sometimes demoralizing. (Project Director)
  10. Youth leaders need training in dealing with adults who can be unsupportive of youth involvement. For the most part the media, government officials and business owners responded very well to youth, but there were rare occasions in the project when youth were confronted with a hostile or dismissive attitude because of their age. (Project Director)
  11. Some youth leaders will inevitably want to select issues to focus on that are not in line with overall project objectives. Staff must address this issue of "straying" enthusiasm on the part of youth leaders by emphasizing project goals early in the project. (Project Director)
  12. Do not underestimate the value of teaching media literacy (i.e., thinking critically about the uses of media for persuasion) as a means to recruit and inspire youth. Staff felt that teaching media literacy allowed them to recruit youth and to engage them in the development of their skills in situations where other approaches would have failed. It also allowed staff significant opportunities for a presence in schools. Staff members believe, in general, that the potential of such teaching for skills development, media production and youth recruitment into projects involving new or contrary ideas, is often underutilized. (Project Director)
  13. Make all youth training or advocacy activities relevant to policy objectives, and allow time for youth to understand the key steps of policy advocacy. Early on in the project, participating youths were frustrated when they presented ideas for policy change strategies that adults could not support due to parameters and/or restrictions established by RWJF or the grantee. Project staff learned that youth needed to be well grounded in the actual objectives for the project, especially the policy-oriented objectives. Once they understood the issues fully, youth could be more fully engaged in planning for youth advocacy, and they felt empowered to work on policies — especially tobacco-free school policies. (Project Director)
  14. Do not be afraid to let youth try and fail. They will learn lessons that can be applied to their next interventions. There was a significant failure rate for youth attempting to persuade restaurant and small business owners to enforce stricter tobacco-control standards, but this frequently resulted in a gain in the youth's realism and determination, not a loss of morale. (Project Director)
  15. Create ongoing youth recruitment to replace those who "graduate out" of the program. Without ongoing recruitment, the number of youths involved in even the most successful programs in schools inevitably decreased, staff found. (Project Director)
  16. Find ways to welcome trained high school graduates into the greater tobacco-control advocacy community. Those college students who received leadership training and worked to reduce tobacco use during their high school years are a particularly valuable resource for the greater community. Funding them for tobacco-control work, however, remains an unmet need. (Project Director)

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AFTER THE GRANT

The project's three youth centers continue to operate through local county heath departments or nonprofit organizations in partnership with North Carolina Health and Human Services' Tobacco Prevention and Control Branch.

Following the grant period, Question Why opened a fourth center in the Charlotte, N.C., area in 2004, operated by the Durham Area Corp. The North Carolina Health and Wellness Trust Fund (since 2002 the state's fiduciary for monies from the Tobacco Master Settlement Agreement) supports adult staff at each center, which now focus on providing training and technical assistance to other trust fund grantee organizations throughout the state engaged in teen tobacco use prevention.

According to the project director in February 2005, 30 to 40 of these community grantees use the project model.

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GRANT DETAILS & CONTACT INFORMATION

Project

Statewide Youth-led Program to Prevent Tobacco Use by Young People

Grantee

State of North Carolina Department of Health and Human Services (Raleigh,  NC)

  • Amount: $ 1,993,698
    Dates: October 1999 to July 2004
    ID#:  033461

Contact

Jim D. Martin, M.S.
(919) 733-1343
jim.martin@ncmail.net

Web Site

http://www.questionwhy.org

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Reports

Question Why Guide to Youth Empowerment for Tobacco Control. Raleigh, N.C.: State of North Carolina Department of Health and Human Services, 2002. Also appears at www.questionwhy.org and http://stepupnc.com.

?Y Community Change Chronicles. Raleigh, N.C.: State of North Carolina Department of Health and Human Services, 2003.

Survey Instruments

"School Key Informant Survey," State of North Carolina Department of Health and Human Services, fielded in 2004.

World Wide Web Sites

www.questionwhy.org. Provides current information about project "QY" ("Question Why"), contact information, a calendar of events, event announcements, facts, data and policies concerning tobacco use in North Carolina, and the full text of the project model, "Question Why Guide to Youth Empowerment for Tobacco Control." Site is primarily for use by North Carolina youth, 2003.

Presentations and Testimony

Delmonte P. Jefferson, Bronwyn G. Glenn and Douglas R. Paletta, "Advocacy vs. Activism: Youth Empowerment in North Carolina," at the National Tobacco OR Health Conference, November 21–23, 2002, San Francisco.

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Report prepared by: James Wood
Reviewed by: Robert Crum
Reviewed by: Molly McKaughan
Program Officer: Karen K. Gerlach