Prevention of Tobacco Use Among Teenagers Aged 13-18 Years

Table of Contents

Title Page 1

Table of Contents 2

Abstract  5

Evaluation of the Problem in Target Population 6

Population Health Impact 6

Youth Impact 7

Tobacco Industry Targeting Adolescents 7

Economic Impact 11

Future Implications 12

Unique Characteristics of The Adolescent Population That Interact with the Health Issue 12

Social Environment 13

Physiology 13

Self-efficacy 14

Factors that Need to be Taken into Account for an Intervention to be Successful 15

Socio-demographic Factors 15

Environmental Factors 16

Behavioral Factors 17

Successful Interventions/Programs that Address the Issue/Population 18

Price Inflation 18

Ban on Broadcast Advertisements 19

Restricted Access 19

Media Campaigns 20

School-based Programs 21

Other Approaches, Enhancements, System Changes to Address the Issue 24

Social Media 24

Change in Curriculum 25

Mirror Target Corporations 26

Involve the Community 26

Applicable Behavior Principles, Theories, and Models 27

Trans-theoretical Model of Behavioral Change 27

Theory of Planned Behavior 27

Health Belief Model 28

Social Cognitive Theory 28

Suggested Intervention Ideas/Objectives 29

Emulate Already-Successful Youth Programs 29

System Changes/Policies 30

Health System Changes: Chronic Care Model of Smoking 30

Program Development Objectives 31

References 32

Contributions 38

Abstract

Cigarette smoking is the leading cause of preventable death in the United States. It is an addiction responsible for almost half a million deaths each year, surpassing those caused from illegal drug use and motor vehicle accidents (CDC, 2016). There is an abundance of information supporting tobacco abstinence, but to effectively relay the message is to understand the complexities of the populations most at risk for initiation, as well as the Tobacco Industry’s motivations. This epidemic can be terminated by infiltrating adolescents aged 13—18, where most smoking initiation begins. It is now up to public health workers to take this knowledge apply it to already-successful prevention interventions, minding the behavior principles, theories, and models applicable to their target population.

Evaluation of the Problem in Target Population

Population Health Impact

Cigarette smoking in the United States has been identified as a leading cause of preventable death. Smoking kills more individuals than illegal drug use, alcohol use, motor vehicle injuries, firearm-related incidents and the Human Immunodeficiency Virus (HIV) combined (CDC, 2016). As a result, various organizations have worked together in planning initiatives, and implementing regulations and policies towards the diminution of deaths due to tobacco product use. Healthy People 2020, the US Food and Drug Administration, the Centers for Disease Control and Prevention, the Affordable Care Act, and the National Prevention Council have all made it their goal to participate in efforts to reduce and prevent tobacco product use among all individuals. Statistics provided by the Centers for Disease Control and Prevention (CDC) conclude that cigarette smoking kills more than 480,00 individuals each year (CDC, 2016) due to the effects of smoking on health outcomes. Cigarette smoking has been found to contribute to chronic medical conditions such as cardiovascular disease, stroke, lung diseases, and multiple forms of cancer. Consequently, “more than ten times as many U.S. citizens have died prematurely from cigarette smoking” (CDC, 2016). It also increases the risk for complications like the development of cataracts, tooth and gum disease, and affects the management of other medical conditions such as diabetes. Research has found cigarette smoking affects individuals throughout the lifecycle. Reduced fertility, increased risk of preterm delivery, stillbirth, low birth weights, and Sudden Infant Death Syndrome (SIDS) have all been associated with complications of cigarette smoking. Additional studies have found adolescence to be a critical point in the initiation of tobacco product use, thus, prevention efforts at this stage are essential to society’s well-being.

Youth Impact

“Each day in the United States, more than 3,200 youth aged 18 years or younger smoke their first cigarette and an additional 2,100 youth and young adults become daily cigarette smokers” (CDC, 2016). Strategies to diminish and prevent cigarette smoking have assisted in the decline of cigarette smoking rates among the U.S youth, however, the tobacco industry has found other ways to reach the adolescent population. Increased rates in the use of electronic cigarettes, hookahs, smokeless tobacco, cigars, pipes, and bidis have all been noted as early as 2011 (CDC, 2016). Use of multiple tobacco products is prevalent among the youth. “In 2015, about 3 of every 100 middle school students (3.3%) and 13 of every 100 high school students (13.0%) reported use of two or more tobacco products in the past 30 days” (CDC, 2016). Without effective interventions and preventative programs, at the current smoking rate among adolescents, 1 in 13 Americans 17 years or younger will die from a smoking-related illness (CDC, 2016). The tobacco industry understands the effect of nicotine dependence and utilizes it to their advantage. Adolescents who use multiple tobacco products are at increased risk of developing dependence and continued use of tobacco products into adulthood. As a result, tobacco industries have much to gain by targeting the youth.

Tobacco Industry Targeting Adolescents

The interest of the tobacco industry is to maintain its profit margin of billions of dollars in revenue, regardless of whom they target. They are adept at enticing adolescents to buy their products and making them nicotine addicts. The adolescent population represents a continuous customer base since most smokers initiate the habit as adolescents. Per the Campaign for Tobacco Free Kids (2016), major tobacco companies spend about $9.1 billion a year – approximately $25 million per day – promoting and selling their products in the market. Litigation documents against major tobacco companies have shown evidence that the tobacco industry specifically targets youth as young as 13 years of age (Tobacco Free Kids, 2016). The tobacco industry has studied smoking behavior extensively and strategically. They develop marketing programs towards adolescents by using themes that appeal to them such as creating the impression that smoking can make adolescents “cool” and therefore accepted among their peers. Kaplan and Weiler (1997) show that through advertising, the tobacco industry makes their products appealing by playing with “independence, healthfulness, adventure seeking and youthful activities,” enticing adolescents to believe that cigarettes and other tobacco products will give them the ideal image. Tobacco giants also have studied which brands are most preferred by adolescents. The top three brands per the CDC (2016) are 1) Marlboro, 2) Newport and 3) Camel.  Newport brand specifically targets females to make them think that by smoking Newport, they will be more appealing, attractive and thin.

Alternative tobacco products such as e-cigarettes are advertised in a manner that promotes the cultivation of tobacco product usage, suggesting that users start with a low nicotine dosage and work their way up in intensity. This makes e-cigarettes a gateway for a new generation of smokers, and a “route to conventional cigarette addiction” (World Health Organization as reported on Tobacco Tactics). Big Tobacco utilizes the abovementioned marketing strategies. They also make e-cigarettes more attractive by perpetuating the idea that electronic cigarettes are “healthier” with fewer carcinogens. There is a current void in scientific evidence as there is yet to be an independent longitudinal study on absorption, blood values, and level of carcinogen exposure. The World Health Organization issued a statement in 2013 stating that “the potential risks posed for the health of users remains undetermined, furthermore scientific testing indicates that the products vary widely in the amount of nicotine and other chemicals they deliver and there is no way for consumers to find out what is actually delivered by the product” (Tobacco Tactics). E-cigarette sales have significantly increased from “20,000,000 in 2008 to 2,875,000,000 in 2015” (Statistic Brain Research Institute). These high sales are driven by the popularity of e-cigarettes among adolescents due to the high saturation of e-cigarette products in the market. There are approximately “466 brands and 7,764 flavors, [coupled with] slick youth oriented big tobacco marketing designed to create the perception that e-cigarettes are not only safe, but cool” (Rimer, Boston University). Based on current projections, sales are expected to rise at a rate of “24.2% per year through 2018” (Wahba, 2014).

Another marketing strategy used to attract adolescents to smoking is through product packaging (Surgeon General Report, 2012). Enhancement of flavor and adjustment of nicotine content are a few examples of how tobacco companies can alter the strong taste of tobacco and make their products more appealing to novice smokers, such as adding fruit flavoring and altering the strength of their products (i.e., mild and smooth). Since many female adolescents believe that smoking can make them thinner, tobacco companies leverage this belief by making cigarettes that are slimmer in appearance (i.e., Virginia Slims) in order to further appeal to this demographic. Other marketing strategies used include: retail marketing, direct advertising such as window ads, and use of digital media (Surgeon General Report, 2012). Tobacco companies also affect adolescents’ perception of social norms through the use celebrities and actors to portray smoking in movies, magazines, and through the tobacco industries’ own YouTube channels. Studies have shown that advertising cigarettes, directly and indirectly, increase cigarette demands (Chaloupka & Werner, 1999). But advertising does not only come through use of celebrities and actors to influence use of tobacco products.

The tobacco industry uses aggressive field marketing tactics to target adolescents. Before the turn of the century, R.J. Reynolds, the United States’ second-largest tobacco company copped to using schools, movie theaters, amusement parks, arcades, and even baseball camps as chosen venues at which to distribute tobacco-related propaganda (Landman, Ling, & Glantz, 2002). In the early 80s, they had gone as far as infiltrating concerts, nightclubs, and the like to engage in “person-to-person interaction” with young adults in hopes of securing potential tobacco-using recruits (Backinger, Fagan, Matthews, & Grana, 2003). Even more head-turning are the countless tobacco industry-sponsored youth smoking prevention programs. In 2001 Philip Morris admitted, in previously-secret industry documents, to having been actively involved in over 130 youth smoking prevention programs not just in the United States but in more than 70 countries (Backinger, Fagan, Matthews, & Grana, 2003). Their goal was not to help prevent youth smoking initiation, but to evade the law, avoid criticism, establish political allies, all while simultaneously gathering research on minors for advertising purposes. The “anti-smoking” youth programs were very successful due to a few themes the tobacco industry made sure were constantly emphasized: smoking is an “adult choice,” smoking is like a “forbidden fruit,” and smoking is “an act of rebellion” (Landman, Ling, & Glantz, 2002). For adolescents looking to come into their own, eager to make their own decisions, smoking is “a statement, a naughty adventure, a milestone episode” (Landman, Ling, & Glantz, 2002). By targeting youth through aggressive field marketing, tobacco companies have acquired profitable results.

Economic Impact

Adolescent smoking has a significant economic impact. Per the CDC (2017), smoking costs more than $300 billion each year, $170 billion of which is spent on direct medical costs to cover the prevention, diagnosis, and treatment of smoking-related diseases. Indirect costs, such as loss of wages (or productivity loss related costs), amount to $156 billion dollars each year. Other costs, referred to as “indirect mortality costs,” are associated with premature deaths related to smoking. The tobacco industry is transnational and its interest is to maintain a high youth demand. They pursue this interest by strategically targeting adolescents. As of 2006, five cigarette companies accounted for more than 90% of sales in the U.S. (Chaloupka & Warner, 1999). These five major companies are mostly located in North Carolina and Virginia. The tobacco industry is made up of five sectors: tobacco cultivation, manufacturing, warehousing, wholesale, and retail trade. Statistics provided by the Campaign for Tobacco Free Kids (2016) show that although the acreage for tobacco farming has decreased in the last two decades (from 831,231 in 1992 to 342,932 in 2012), the sales of cigarettes have not proportionally decreased. The total annual revenue from cigarette sales in a 10-year lapse, from 2004 to 2014, showed a 32.5% decline (Campaign for Tobacco Free Kids, 2016). Taxed cigarette sales have declined, but as mentioned previously, other forms of tobacco have taken over the sales.

Future Implications

There are many impending health and social consequences of adolescent smoking. Long-term health consequences of adolescent smoking, according to the Report of Surgeon General (2012) include early damage to tissues. For example, the abdominal aorta can become hardened, making adolescent smokers more susceptible to heart disease at an earlier age. Furthermore, the lungs of teenagers that smoke never reach full adult size and capacity. This can directly contribute to loss of productivity and a shorter life expectancy. Additionally, tobacco contains nicotine, “one of the most addictive substances that exist” as Dale W. Vogt, Ph.D. stated via an interview (Apr 16, 2017). Statistics show that most smokers start in adolescence, a period in life when they are highly susceptible to temptations, leading to other substance addictions such as alcohol and marijuana. Adolescent smoking has also been linked to “health-compromising behaviors, including being involved in fights, carrying weapons, and engaging in high risk sexual behavior” (CDC, 1994). The impact of these behaviors span beyond the adolescent population and affect society as a whole.

Unique Characteristics of The Adolescent Population That Interact with the Health Issue

Adolescence is a stage in the life cycle of rapid physical, psychological (cognitive and emotional), and social development. Attitudes and habits formed at this stage can have a lasting effect on an individual’s health for the remainder of the lifecycle. Many behaviors such as tobacco use, that underlie the development of chronic diseases in adulthood, often start during adolescence. The overwhelming personal uncertainty associated with this transitional phase, from childhood to maturity, “[underscores] that adolescence and young adulthood represent a time of heightened vulnerability to tobacco use and the initiation of cigarette smoking” (National Center for Chronic Disease Prevention and Health Promotion. 2012). Adolescents have a heightened sensitivity to behavioral influences. There are three main categories of influence on behavior: individual (i.e., physiology, self-efficacy), community (i.e., physical and social environment), and organizational (i.e., policies, health systems) (Riekert, Okeene, & Pbert, 2013). “A person is affected by her or his culture, social and physical environments, and personal perceptions of those environments that influence subsequent tobacco use” (National Center for Chronic Disease Prevention and Health Promotion, 2012). A critical aspect of this development is how adolescents interact with their environments (family, peers, social values, community leaders, policies, etc.).

Social Environment

Social environment (network and support) is fundamental in the prevention of tobacco use among adolescents. “Risk factors for smoking initiation in youth include peer and family smoking, family conflict, and exposure to tobacco industry promotional campaigns” (Institute of Medicine, 2001). Tobacco use by close social networks (i.e., family and friends), coupled with influences from the social environment at large (i.e. advertising, smoking by idols in pop culture), formulates the “perceptions by adolescents that tobacco use is normative, that is, usual or acceptable behavior” (National Center for Chronic Disease Prevention and Health Promotion, 2012).

Physiology

In examining the unique characteristics of the adolescent population that make them susceptible to tobacco use, one must also consider the physiological aspects. This includes both cognitive and emotional growth. The cognitive pattern for adolescents tends to be egocentric. Research has shown that the frontal lobe of the brain is one of the last regions to mature, not reaching full maturity until well beyond adolescence. This lobe is particularly important for “executive functioning, [which includes] planning ahead, reasoning, considered decision-making and self-discipline” (Johnson, Blum, & Giedd, 2009). This may serve as an explanation for why adolescents and youths tend to take risks and are prone to making decisions motivated by emotions and experiences rather than logical reasoning. This phenomenon is also referred to as “hot cognition” (National Research Council, 2015).

Self-efficacy

Self-efficacy and decision-making skills are characteristics that also influence use of tobacco products among adolescents. The emotional state of adolescents is hallmarked by high sensitivity to criticism and a strong desire to be accepted by peers. The formulation of a means to positively utilize peer influence is highly important in the development of an efficacious intervention for which the target population is adolescents. It is crucial to intervene both at the individual and environmental level for measurable and sustainable impact. Groupthink is a phenomenon that is both a cause and a solution to tobacco use among teens. The effort would not directly be towards changing individual behavioral patterns but rather towards the redirection of social norms to that effect. Groupthink is unquestioned conformity due to a shift in social norms within one’s immediate ecosystem. This can be exploited positively by designing adolescent tobacco prevention interventions in a way that allows adolescents to engage with and receive feedback from role models who are their peers. There are a few key sources from which motivation is derived, which include: personal experience, verbal persuasion, and vicarious experiences. Teenagers often look to the actions and behaviors of others to determine their own, particularly the behaviors of those with whom they can relate. Observational learning can be utilized by providing credible role models with whom the target population can identify. This methodology is in line with that of the Social Cognitive Theory (Riekert, Ockene, & Pbert, 2013). A school-based approach for the aforementioned-intervention may prove fruitful, as the setting guarantees consistent access to students for a number of years. However, it should also be expanded to community organizations in order to not limit the effort to adolescents who are in school. Adolescents who do not attend school are more prone to risky/unhealthful behavior.

Factors that Need to be Taken into Account for an Intervention to be Successful

Socio-demographic Factors

Preventive steps to curb the initiation of adolescent smoking cannot be a one-size-fits-all effort. Psychosocial factors – the intermingling of social factors with individual thoughts and behaviors – should be accounted for when identifying an intervention’s target population. Take sociodemographic factors like age, gender, and ethnicity for starters. Nearly 90% of adult smokers report having tried a cigarette or picked up the habit before the age of 18 (Backinger, Fagan, Matthews, & Grana, 2003). This confirms the need to reach impressionable adolescents in an effort to nix the addiction before it begins. In western culture, females are more likely than males to smoke. This is a complex issue rooted in perceived body image and deceitful advertising around weight loss and control (Tyas & Pederson, 1998). Analysis of smoking rates, stratified by race/ethnicities, is also more complex than how one is classified on paper and has more to do with the level of acculturation into American mainstream society. Among non-Whites, the more assimilated into western culture, the higher the prevalence of smoking (Reiss, Lehnhardt, & Razum, 2015). Even factors that may seem irrelevant such as living arrangements should be taken into consideration: Do they have somewhere safe to call home? Do they bounce from one place to another? Is there overcrowding within the house? These inconsistencies in living arrangements can become a trigger for unhealthful behaviors during adolescence.

Environmental Factors

Environmental factors (physical environment and social network) are another layer of psychosocial elements that need to be taken into consideration. As one would expect, adolescents with parents and/or siblings who smoke often become smokers themselves, however the influence of a smoking sibling is surprisingly stronger than that of a smoking parent (Tyas & Pederson, 1998). Parental attachment is another important component. “A poor relationship between mother and child was associated with a higher prevalence of smoking for boys and girls; a poor father/child relationship significantly influenced smoking for girls” (Tyas & Pederson, 1998). Beyond the home, peer influence has a major impact on adolescent behaviors and choices. Adolescents tend to assume their friends and acquaintances smoke more than they actually do, creating an unnecessary desire to fit in. “Best friend tried smoking” was the most common reason kids started smoking in elementary school, while “closest five friends tried it” was the reported reason for adolescents in high school (Tyas & Pederson, 1998).

Behavioral Factors

In designing an adolescent tobacco prevention intervention, the overwhelming influence of correlated behavioral factors must be taken into account. Students with high academic aspirations and those who do well in school are less likely to engage in smoking than those lacking these characteristics. Alternatively, risk-taking and deviant behaviors are more prevalent in adolescent smokers than non-smokers. Antisocial behaviors (fighting, stealing, gang membership) are a common trend among adolescent smokers (as well as those who engage in underage drinking, illegal drug use, and academic failure) (Backinger, Fagan, Matthews, & Grana, 2003). Similarly to adults, adolescents who “adopt a healthy lifestyle with regard to one aspect of their lives tend to do so in others as well” (Tyas & Pederson, 1998). Intrapersonal variables create the need for tailored interventions. For example, everyone is exposed to and deals with motivational factors like stress. However, individual coping mechanisms are partially derived from personal characteristics. Religion can also be a confounding variable. Without creating guilt, understanding an adolescent’s perspective of their religious beliefs can provide a foundation for an intervention; a “your body is a temple”-type approach. Finally, psychological and biological disorders must also be considered. Researchers have found that adolescents with ADHD are ten times more likely to try smoking than their non-ADHD adolescent peers (Backinger, Fagan, Matthews, & Grana, 2003). The number of factors considered will undeniably vary from one intervention to another, and from one target population to another. However, flexibility to consider the varying psychosocial determinants of adolescent health behaviors tremendously increases the odds of a successful intervention.  

Successful Interventions/Programs that Address the Issue/Population

Price Inflation

“The importance of the social environment is supported by evidence for the efficacy of some anti-tobacco media campaigns, smoke free environment policies, and cigarette taxes” (Institute of Medicine. 2001). One of the current policies that promote the prevention of tobacco use among adolescents in the United States is the tax increase on tobacco products. Price inflation greatly influences the acquisition of tobacco products by teenagers as they generally have a limited budget. Many econometric studies have been conducted to determine the effects of high cigarette prices. According to Chaloupka and Pacula (1998), “permanent in inflation-adjusted increases in cigarette prices, will lead to significant reductions in smoking prevalence rates.” Economists use the term “price elasticity of demand” (Chaloupka & Werner, 1999) to describe the impact of a change in the price on consumption. As described by Chaloupka & Werner (1999), cigarette demands respond to price fluctuations. The price paid by the user includes time and other costs associated with using the product. When focusing on adolescents, the economic theory states that the “price elasticity of demand” is inversely proportionate for several reasons: 1) teens will smoke if they have more money or less if they have less resources, 2) adolescents are more susceptible to peer influence and will either smoke more or less depending upon the influence of their peers, and 3) they behave “myopically” meaning that adolescents do not perceive the future consequences of smoking (Chaloupka & Werner. 1999). Studies have concluded that increasing the price of tobacco products is effective in reducing smoking among adolescents. Adolescents and young adults are more susceptible to increases in tobacco prices (Chaloupka & Werner, 1999).

Ban on Broadcast Advertisements

A longstanding policy that marked the initiation of progress towards adolescent tobacco use prevention is the “ban on broadcast cigarette advertising [that] went into effect in 1971” (National Center for Chronic Disease Prevention and Health Promotion). Such policies are effective within the adolescent population as they are both profoundly exposed to and highly interested in media communications. However, the tobacco industry has found effective means of countering the effects of this policy on their profit margin by increasing funding for other means of advertising such as product placements. Another successful intervention is the Family Smoking Prevention and Tobacco Control Act of 2009. Hackberth (2012) shows that this act gave the FDA authority to regulate and restrict children’s exposure to tobacco products. Yet, tobacco companies have somewhat circumvented this policy by focusing on areas that the policy does not affect, such as “discounting of cigarettes, increased point-of-purchase advertising, and product placements in tobacco products” (Hackberth, 2012).

Restricted Access

Although the tobacco industry fights the implementation of public policies, some have been implemented with success. In 1992, Congress enacted the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act, which also includes the Synar Amendment [section 1926] (Hackbarth, 2012). This legislature is aimed at prohibiting adolescents, under the age of 18, from having access to tobacco products. If states fail to enforce this law, the federal government can decrease (up to 40%) the money granted to the state for substance abuse and treatment programs. There is variability among states regarding the stringency with which the aforementioned law is enforced, thus depending on geographic location, some youth have no difficulty buying tobacco products despite their age.

Media Campaigns

There are a variety of anti-tobacco media campaigns, including “Truth” and “The Real Cost.” The “Truth” campaign was initiated in 2000 as a national effort towards youth smoking prevention. Research shows that exposure to the “Truth” campaign is “associated with increased agreement with anti-smoking beliefs, decreased smoking intentions, and lower rates of smoking initiation” (Davis et al., 2009). On the other hand, “The Real Cost” campaign (a secondary effort launched in 2014 on multiple media platforms) was designed to appeal to the rebellious nature of adolescents. The campaign challenges the notion of many teenagers that smoking is an assertion of independence and rebellion. Instead, it equates tobacco addiction to “loss of control” and conformism. It also emphasizes the health consequences of tobacco products via dramatization. “Studies have found that ads graphically portraying the effects of living or suffering from the afflictions of tobacco use ranked high in getting youth to stop and think about tobacco use” (Davis et al., 2009). There are also a variety of state-based teen tobacco use prevention initiatives. One of the most efficacious is the “State Tobacco Education & Prevention Partnership (STEPP) at the Colorado Department of Public Health and Environment (CDPHE)” (Conrad, McCracken, & Phelan, 2009). STEPP also utilizes various media platforms (i.e., TV and internal forums) to engage teenagers and empower them to abstain from the use of tobacco products. The STEPP initiative successfully played a part in Colorado having one of the lowest teenage smoking rates in the nation by “building teen life skills in choice-making…[and] normalizing positive choice making behavior” (Conrad, McCracken, & Phelan, 2009).

School-based Programs

Numerous policies have been implemented in an effort to reduce the availability and prevent adolescent use of tobacco products. Research studies show that a multi-faceted approach guides the most successful and effective interventions. Among these approaches are school-based programs. Although there have been some positive results, the programs alone have not been as successful as anticipated. By combining macro and micro-level approaches (i.e., policy intervention, school-based education, and community aiding interventions), smoking prevention programs have resulted in more effective outcomes. “School-based anti-tobacco policies” that strictly prohibit smoking among students and staff on or anywhere around school grounds are also very effective by controlling “perceptions of prevalent tobacco use on school grounds [which] may promote social norms that encourage smoking uptake and persistence” (National Center for Chronic Disease Prevention and Health Promotion, 2012). There are also successful school-based programs that target specific demographics within the population of interest that were determined to be at high risk for tobacco use.

One study used the National Cancer Institute’s (NCI) systematic method of determining successful intervention programs to find which school-based smoking prevention programs were most successful (Sherman & Primack, 2009). The five programs selected for contributing to successful intervention rates include: 1) Project Towards No Tobacco Use (TNT), 2) Pathways to Health, 3) Native FACETS, 4) Kentucky Adolescent Tobacco Prevention Project (KATPP), and 5) Sembrando Salud (SS). The significance of these programs was characterized by their success rates, according to type of intervention offered and socio-demographic factors addressed. The programs were evaluated based on five characteristics: grade level, racial background, educational setting and format, and instructor qualifications. The majorities of the programs targeted 5th-8th graders, were in a school-based setting, and offered between 6-16 sessions. Only two programs provided “booster” classes for participants along with additional training for instructors. Key differences include: only one program was implemented in a community-based center, one program was 100% Native American, and another 100% Hispanic.

The noteworthy outcomes of these programs are as follows: Project TNT had a 26% reduction rate in initiation of cigarette use and 30% reduction in the initiation of smokeless tobacco products. However, teachings of refusal assertion skills were not effective. Pathways to Health used a pretest/post-test format to evaluate intent to smoke and found that nearly 92% of students who were provided with interventions remained non-users post-test compared with 82% of those in the control group (Sherman& Primack, 2009). Outcomes of the Native FACETS program indicated increased knowledge of the negative effects of tobacco products, awareness of tobacco advertising objectives and methods, and ability to resist peer pressure. The positive results were most notable among the group of individuals who also discussed dietary change rather than the tobacco-only group. The KATPP program demonstrated positive results one year after the additional “booster” sessions were given. Results of decreased smoking were evident in groups with interventions at 24-hour, 7-day, and 30-day smoking intervals (Sherman & Primack, 2009). The Sembrando Salud program accessed susceptibility to tobacco and alcohol use among the Hispanic population through improved communication between parents and children. Though 30-day smoking and drinking rates did not change significantly, levels remained low. Results indicated that the program was more effective in families with fewer siblings, generating further interest in research on larger families (Sherman & Primack, 2009). Each of these programs demonstrated some form of successful intervention and direction for further research.

Other successful programs that intervene at a school-based level are the ASSIST (A Stop Smoking in Schools Trial) and LifeSkills Training (LST) programs. ASSIST was a peer-led intervention program in the U.K. in which students were asked to select older students whom the student body respected or thought would make good leaders. The nominees were asked to serve as peer supporters to help students stop smoking. They were trained on different subjects (conflict resolution, empathy, communication skills, etc.) and met with students who needed support outside the classroom. The study, conducted on students aged 12-14 from six different schools, “suggested that the intervention was especially successful with students who were occasional, experimental, or ex-smokers” (Campbell et al., 2008). Additional results concluded the ASSIST training program “was effective in achievement of a sustained reduction in uptake of regular smoking in adolescents for 2 years after its delivery” (Campbell et al., 2008).

As important as macro and micro-level approaches are in the implementation of successful interventions, understanding of behavioral principles, theories, and models can help improve outcomes. LifeSkills Training (LST) is a low-cost program initiated among middle-school students, with follow-ups for approximately five to six years. The program “teaches students social and self-management skills, including skills in resisting peer and media pressure to smoke, drink, or use drugs; and informs students of the immediate consequences of substance abuse” (Coalition for Evidence Based Policy). The program produced results of approximately 20% reduction in smoking initiation. The only limitation of the program is that “effectiveness applies to rural or suburban public schools with a mostly white population. Evidence for urban, minority schools is promising but limited by lack of long-term follow-up” (Coalition for Evidence Based Policy).

Other Approaches, Community Enhancements or System Changes to Address the Issue           

Tobacco product use has a significant impact on youths, general social wellbeing, and the economy. As the leading preventable cause of death in the United States, tailored interventions that take into consideration the unique characteristics and psychosocial factors of the adolescent population can yield successful outcomes. Through use of different theories and models, interventions can be formulated in a way that can address perceptions, social structures, and developmental stages of adolescents. In conjunction with previously successful interventions, new approaches, community enhancements, and system changes can be developed to accommodate current trends in society. In a high-tech era, the use of computer-based systems can be one approach to implement educational preventative efforts. “For instance, Innovative Training Systems is developing a computer game designed to educate children about the harms from tobacco products” (Lantz et al., 2000).

Social Media

Mass media and social networks are of particular interest to adolescents. Not only are they heavily exposed to mass media, but tobacco companies are using their own marketing to reach the youth population. “In a study of two communities, the one that received a mass media intervention along with the educational program for four years had an almost 40% lower rate of smoking than the one receiving the educational program alone” (Lantz et al., 2000). Through a combination of effective programs, interventions can produce greater results. However, technology-based programs are not the only approaches to be considered.

Change in Curriculum

In addition to computer-based schemes, a simple enhancement in school curriculums could address some of the root causes for many at-risk youths. Incorporating stress-relieving practices into the school day could provide an escape for negative feelings that ultimately contribute to unhealthful behaviors. An elementary school in Baltimore experimented with this concept, where some of its students were homeless and/or regular witnesses to crimes. Rather than issuing detention slips after in-school altercations, the students were sent to a meditation room where they had a chance to reflect and calm down. One student articulated, “I did some deep breathing, had a little snack, and I got myself together. Then I apologized to my class” (Bloom, 2016). Yoga is another practice that is being incorporated into school curriculums. The advantages of yoga juxtaposed with the fallout from stress is known and accepted among (most) adults, but children get stressed as well. With the amount of homework, tests, and extracurricular activities they juggle, unresolved stress finds its outlet somewhere. Some may argue yoga is a religion, but it is not. It is a coping method that teaches individuals how to slow down and breathe. One instructor (and mother-of-three with an autistic son) highlights three benefits of incorporating yoga into a child’s life: 1) It teaches one how to breathe, which affects the ability to manage stress, 2) It allows children to move with control and confidence (versus feeling inadequate from performing poorly at X sport), and 3) It promotes the power of mindfulness (Santas, 2016).

Mirror Target Corporations

Following in the footsteps of big corporations like CVS is another approach a public initiative can encourage. CVS did not eradicate smoking, but 95 million fewer packs of cigarettes were bought in the year after they made the decision to stop selling them (O’Donnell, 2015) because smokers did not simply go elsewhere for their purchases. In 13 states where CVS pulled the tobacco plug, researchers found that the average smoker purchased fewer cigarettes at drug stores, gas stations, and convenience stores (O’Donnell, 2015). CVS’ rebranding eared them a reputation as “one of the most innovative and one of the most admired” businesses (Pasquarelli, 2016). It would be impactful to replicate the results of this success story in other nationally operated convenience stores and pharmacies.

Involve the Community

This above-mentioned effort can trickle down to corner stores and/or bodegas – community establishments not run on a national scale. Incentives (i.e. Incentive Motivation) can be offered in exchange for lowering cigarette sales. Get Healthy Philly is an example of a community-level approach where philosophy and policy are united to bring real change to the city in its fight against obesity. The public health initiative works with more than 900 local retailers to improve access to healthier foods, honoring those that have lowered negative sales while increasing positive ones. The same framework could be applied to corner stores and/or bodegas regarding the sale of tobacco products. Another local effort includes involving community leaders and role models to reach at-risk populations in a manner that some public health workers may be unable to. It is a form of Observational Learning that triggers a “lead by example” way of behaving (Bandura, 1990). Religious leaders, coaches, and barbers are examples of individuals who serve as mentors and role models with whom adolescents interact with beyond the home and school settings. 

Applicable Behavior Principles, Theories, and Models

Trans-theoretical Model of Behavioral Change

The stages in the use of tobacco products by adolescents are parallel to the stages identified in the Trans-theoretical Model of Behavioral Change, except they apply to negative behavior rather than the cultivation of healthful behavior. These stages include: pre-contemplation (no intention formulated), contemplation (intent to smoke), preparation (acquisition of tobacco products), action (experimental smoker), and maintenance (chronic smoker). In order to prevent the use of tobacco products among adolescents, it is crucial to focus on addressing the first three stages of progression: pre-contemplation, contemplation, and preparation. Tobacco prevention is vital as cessation is more of a daunting task due to nicotine addiction.

Theory of Planned Behavior

It is imperative for a prevention effort to foster an environment that promotes the pre-contemplation stage in which adolescents are yet to develop any intent of using tobacco products. Endorsement of this form of abstinence requires the promotion of deliberately thoughtful behavior, which is a construct of the Theory of Planned Behavior.  It focuses on the impact of attitude and perception of norms on behavior. It would include efforts towards minimizing adolescent exposure to certain cues to action such as advertising by the tobacco industry, breaking the perception that tobacco use is normative, and encouraging parental support.  

Health Belief Model

An intervention developed around the contemplation stage would be most effective if modeled against the constructs of the Health Belief Model, which include: perceived susceptibility, perceived severity, perceived benefit, perceived barriers, and self-efficacy. In this model, perceptions are the key motivators of behavior rather than reality. This is applicable to the target population because many adolescents are under the misconception that there are positives outcomes to tobacco use that marginalize the risks such as weight loss, “cool” social image, etc. This intervention would employ two main channels in achieving its objective: empowerment (health education), and fear appeal (dramatization of potential effects). The constructs of this approach dictate that the intervention: personalizes the risk associated with tobacco use for the target audience, portrays and specifies the seriousness of negative health outcomes, highlights benefits of abstaining from tobacco use, breaks perceived barriers by demonstrating that benefits outweigh costs, and actively improves self-efficacy to resist stimulus of tobacco use.

Social Cognitive Theory

An effort that focuses on the preparation stage is more policy driven, as it addresses the accessibility of tobacco products to adolescents. An efficacious effort that utilizes the Social Cognitive Theory “addresses the knowledge gap, attitudes (beliefs), and changes to environment to affect behavioral change” (Riekert, Ockene, & Pbert. 2013). This includes initiatives such as “anti-tobacco media campaigns, smoke free environment policies, and cigarette taxes” (Institute of Medicine, 2001). Effective engagement requires a comprehensive understanding of the target audience. Cultural competency in this instance refers to both demographic factors and “adolescent culture,” which is defined by their social environment and attitude towards perilous behavior. At this particular stage of the life cycle, adolescents are progressing from dependency to independence through the establishing of personal and social identities characterized by exploration and/or risk-taking. Understanding the aforementioned elements fosters a holistic comprehension of the target audience, aiding in the development and implementation of efficacious teenage tobacco prevention programs that “resonated universally with teens of all ages, ethnicities, genders, geographic locations and income levels” (Conrad, McCracken, & Phelan, 2009).

Suggested Intervention Ideas/Objectives

Emulate Already-Successful Youth Programs

Several factors influence tobacco use among the youth. As discussed, these include lower socioeconomic status, lower levels of academic achievement, lower self-esteem, peer influences, accessibility and price of tobacco products, and exposure to tobacco advertising (CDC, 2016). Intervention ideas should be designed to address these factors within identified at-risk populations and implement strategies accordingly to prevent tobacco use in adolescents. For example, with understanding of social media and peer influence on youths, a program that incorporates elements of the ASSIST program can be successful. Though the Sembrando Salud program did not reduce rates of smoking, enhanced understanding for the family, social and cultural dynamics can be used to achieve better outcomes for subsequent Hispanic populations. As previously learned, no one intervention is successful. A collaborative approach with other agencies, and system changes, can reinforce the measures taken to prevent tobacco use among adolescents.

System Changes/Policies       

From a legislative approach, youth access laws and the regulation of tobacco product distribution have been topics of discussion. Tobacco excise taxes and public smoking ordinances have been established, but adolescents still have access to tobacco products. Further suggestions to reinforce prevention strategies include working with law enforcement to aggressively issue monetary fines and impose sanctions on anyone who sells tobacco products to a minor, and to issue fines to minors themselves if found in the possession of tobacco products. Additional recommendations to reinforce prevention include implementing suspension of adolescents’ learner’s permits/driver’s licenses and requiring the completion of tobacco education programs in order to regain permit or driver’s license. Collaboration with law enforcement has great potential. However, due to the immensely negative impact adolescent tobacco use has on health outcomes, an intervention via the health care system can also provide supplemental reinforcement for the prevention of tobacco use.

Health System Changes: Chronic Care Model of Smoking

There is increasing interest in conceptualization of smoking as a disease that “requires long term treatment” (Batra et al., 2002). In the same manner that chronic diseases require a continuum of care, smoking should be approached the same way. This approach would facilitate the understanding of all the developmental phases of smoking: development, motivation, pre-cessation, cessation, adherence, relapse, and recovery (Mermelstein et al., 2016). Gaining an understanding of the aforementioned phases can provide the necessary theoretical framework for programs aiming to prevent the onset of the smoking addiction.

Program Development Objectives

The above-mentioned intervention suggestions towards the prevention of tobacco product use among adolescents are meant to be implemented collectively as a comprehensive approach with the following objectives: Enhancement of self-efficacy to resist the use of tobacco products, shifting of social norms and adolescent perception that tobacco use is normative, utilization of peer influence via the employment of role models with whom the target population can relate, and implementation of social policies that discourage use of tobacco products among the target population.

References

Backinger, C., Fagan, P., Matthews, E., & Grana, R. (2003). Adolescent and young adult tobacco prevention and cessation: Current status and future directions. Tobacco Control, 12(4). https://dx.doi.org/10.1136/tc.12.suppl_4.iv46

Bandura, A. (1990). What is social cognitive theory? Retrieved March 20, 2017 from https://www.med.upenn.edu/hbhe4/part3-ch8-key-constructs.shtml

Batra,V., Parkar, A. A., Weibel, S. & Leone, F.T. (2002, September). Tobacco smoking as a chronic disease: notes on prevention and treatment. Primary Care: clinics in office practice. 29(3), 629-648. doi: https://dx.doi.org/10.1016/S0095-4543(02)00016-7

Bloom, D. (2016, November 8). Instead of detention, these students get meditation. Retrieved March 30, 2017 from https://www.cnn.com/2016/11/04/health/meditation-in-schools-baltimore/

Campaign for Tobacco Free Kids (2015, October 13). The shrinking role of tobacco farming and tobacco product manufacturing in the United States economy. Retrieved from https://www.tobaccofreekids.org/research/factsheets/pdf/0344.pdf

Campaign for Tobacco Free Kids (2016, November 28). Tobacco company marketing to kids. Retrieved April 10, 2017 from https://www.tobaccofreekids.org/research/factsheets/pdf/0008.pdf

Campbell, R., Starkey, F., Holliday, J., Audrey, S., Bloor, M., et al. (2008). An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): A cluster randomized trial. The Lancet, 371, 1595-1602. doi: https://dx.doi.org/10.1016/S0140-6736(08)60692-3

Centers for Disease Control and Prevention (2016). Health effects of cigarette smoking. Retrieved from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm

Centers for Disease Control and Prevention (2016). Tobacco Industry Marketing. Retrieved from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/marketing/index.htm

Centers for Disease Control and Prevention (2016). Youth and tobacco use. Retrieved from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/

Centers for Disease Control and Prevention (2017). Economic trends in tobacco. Retrieved from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/economics/econ-facts/

Chaloupka, F.J. & Liccardo P. R. (n.d.). The impact of price on youth tobacco use. Retrieved April 10, 2017 from https://cancercontrol.cancer.gov/brp/tcrb/monographs/14/m14_12.pdf

Chaloupka, F., & Warner K. (2000). The economics of smoking. Handbook of Health Economics, 1(B), 1539-1627. doi: 10.3386/w7047

Coalition for Evidence Based Policy. Social programs that work: LifeSkills Training. Retrieved from: https://evidencebasedprograms.org/1366-2/lifeskills-training

Conrad, J, McCracken, J, and Phelan, K. (2009). ‘Own Your C’ – Colorado’s youth tobacco prevention and cessation campaign. Cases in Public Health Communication & Marketing, 3, 219- 241. Retrieved from: www.casesjournal.org/volume3

Davis, K.C., Farrelly, M.C., et al. (2009). The impact of national smoking prevention campaigns on tobacco-related beliefs, intentions to smoke and smoking initiation: Results from a longitudinal survey of youth in the United States. International Journal of Environmental Research and Public Health, 6, 722-740. doi:10.3390/ijerph6020722

Ekpu, V.U., & Brown, A.K. (2015). The economic impact of smoking and reducing smoking prevalence: Review of evidence. Tobacco Use Insights, 8, 1-35. doi: 10.4137/TUI.S15628

Institute of Medicine (US) Committee on Health and Behavior: Research, Practice, and Policy. (2001). Health and behavior: The interplay of biological, behavioral, and societal influences. National Academies Press. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK43750/

Johnson, S. B., Blum, R. W., & Giedd, J. N. (2009). Adolescent Maturity and the Brain: The Promise and Pitfalls of Neuroscience Research in Adolescent Health Policy. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 45(3), 216–221. https://doi.org/10.1016/j.jadohealth.2009.05.016

Kaplan, M.S & Weiler, R.E. (1997, February). Social patterns of smoking behavior: Trends and practice implications. Health & Social Work, 22(1) 47-52 retrieved from https://www.questia.com/library/journal/1G1-19209063/social-patterns-of-smoking-behavior-trends-and-practice

Landman, A., Ling, P., & Glantz, S. (2002). Tobacco industry youth smoking prevention programs: Protecting the industry and hurting tobacco control. American Journal of Public Health, 92(6)

Lantz, P. (2003). Smoking on the rise among young adults: Implications for research and policy. Tobacco Control, 12(1), i60–i70. https://doi.org/10.1136/tc.12.suppl_1.i60

Lantz, P.M., Jacobson, P.D., Warner, K.E., Wasserman, J., Pollack, H.A., Berson, J., & Ahlstrom, A. (2000). Investing in youth tobacco control: A review of smoking prevention and control strategies. Tobacco Control, 9(47), 47-63. Retrieved from: https://tobaccocontrol.bmj.com/content/9/1/47.short

Mermelstein, R. et al. (2016, March). Tobacco control research priorities for the next decade: Working group recommendations for 2016-2025. Retrieved from   https://cancercontrol.cancer.gov/pdf/nci-tobacco-control-research-priorities-rpt-feb-2016.pdf

National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health (2012). Preventing tobacco use among youth and young adults: A report of the Surgeon General. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK99236/

National Research Council (2015). 6 hot cognition: Defensive reactivity, emotional regulation, and performance under stress. Measuring Human Capabilities: An Agenda for Basic Research on the Assessment of Individual and Group Performance Potential for Military Accession. Washington, DC: The National Academies Press. doi: 10.17226/19017

National Institutes of Health (2010, October). Tobacco addiction fact sheet. Retrieved April 16, 2017 from https://report.nih.gov/NIHfactsheets/Pdfs/TobaccoAddictionb(NIDA).pdf

O’Donnell, J. (2015, September 3). A year later, CVS says stopping tobacco sales made a big difference. Retrieved March 30, 2017 from https://www.usatoday.com/story/news/2015/09/02/cvs-stopping-tobacco-sales/71606590/

Pasquarelli, A. (2016, October 20). How CVS won by not selling cigarettes. Retrieved March 30, 2017 from https://adage.com/article/special-report-ana-annual-meeting-2016/cvs-won-selling-cigarettes/306384/

Pierce, J.P., White, V.M., Emery, S.L. (2012). Strategic directions and emerging issues in tobacco control: What public health strategies are needed to reduce smoking initiation? BMJ Journal of Epidemiology and Community Health, 21(2), 258-264. doi:10.1136/tobaccocontrol-2011-050359

Reiss, K., Lehnhardt, J., & Razum, O. (2015, April 16). Factors associated with smoking in immigrants from non-western to western countries – what role does acculturation play? A systematic review. Tobacco Induced Diseases, 13(11). doi: 10.1186/s12971-015-

Riekert, K. A., Ockene, J. K., & Pbert, L. (2013). The handbook of health behavior change, (4th ed.). New York: Springer Publishing Company.

Robert Wood Foundation (2016, June 23). Signs of progress: Philadelphia, Pennsylvania. Retrieved March 23, 2017 from https://www.rwjf.org/en/library/articles-and-news/2013/07/philadelphia-- signs-of- progress.html

Saloojee, Y. & Dagli, E. (2000). Tobacco industry tactics for resisting public policy on health. Retrieved from https://www.who.int/bulletin/archives/78(7)902.pdf

Santas, D. (2016, May 10). Beyond ‘Namaste’: The benefits of yoga in schools. Retrieved March 30, 2017 from https://www.cnn.com/2016/05/10/health/yoga-in-schools/

Shadel, W. G., Shiffman, S., Niaura, R., Nichter, M., & Abrams, D. B. (2000). Current models of nicotine dependence: what is known and what is needed to advance understanding of tobacco etiology among youth. Drug and Alcohol Dependence, 59(1S9-S22)

Sherburne, S.H., Bach, N., & Baum, C. F. Impact of tobacco control policies on adolescent smoking. (2016). Journal of Public Health, 58(6), 679-685

Sherman, E.J., & Primack, B.A. (2009). What works to prevent adolescent smoking? A systematic review of the national cancer institute’s research-tested intervention programs. Journal of School Health, 79(9), 391-399. doi: 10.1111/j.1746-1561.2009.0046.x

Short, A. (2016, June 25). Alarming trends I’ve noticed teaching yoga to little kids. Retrieved March 30, 2017 from https://www.alternet.org/education/alarming-trends-ive-noticed-teaching-yoga-elementary-school-kids

Simons-Morton, B. & Farhat, T. (2010). Recent findings on peer group influences on adolescent substance use. The Journal of Primary Prevention, 31(4), 191–208. https://doi.org/10.1007/s10935-010-0220-x

Statistic Brain Research Institute. Electronic Cigarette Statistics. Retrieved from: https://www.statisticbrain.com/electronic-cigarette-statistics/

The Royal Children’s Hospital Melbourne. Differences between children and adults. Retrieved from https://www.rch.org.au/studentorientation/5_children_and_adults/Differences_between_children_and_adults/

Tobacco Tactics (2011). E-cigarettes. Retrieved from: https://www.tobaccotactics.org/index.php/E-cigarettes

Tyas, S. & Pederson, L. (1998). Psychosocial factors related to adolescent smoking: A critical review of the literature. Tobacco Control, 7(4). https://dx.doi.org/10.1136.tc.7.4.409

Vogt, D. W. (2017, April 16). Personal communication about addictive nature of nicotine. Ph.D. in Genetist in cytogentics, statistical genetics and population genetics.

Wahba, P. (2014, June 10). U.S. e-cigarette sales seen rising 24.2% per year through 2018. Retrieved from https://fortune.com/2014/06/10/e-cigarette-sales-rising/

WHO (2010). 10 facts on gender and tobacco. Retrieved April 6, 2017 from https://www.who.int/gender/documents/10facts_gender_tobacco_en.pdf 10.2105/AJPH.92.6.917

Contributions

Title Page – Andrea

Table of Contents – Maria

Abstract – Leslie

Evaluation of the Problem in Target Population

1)   Population Health Impact – Andrea

2)   Youth Impact – Andrea

3)   Tobacco Industry Targeting Adolescents – Maria, Leslie, & Nneka

4)   Economic Impact – Maria

5)   Future Implications – Maria

Unique Characteristics of Adolescent Population That Interact with the Health Issues – Nneka

1)   Social Environment – Nneka

2)   Physiology – Nneka

3)   Self-efficacy – Nneka

Factors that Need to be Taken into Account for an Intervention to be Successful

1)   Sociodemographic – Leslie

2)   Environmental – Leslie

3)   Behavioral – Leslie

Successful Interventions/Programs that Address the Issue/Population

1)   Price Inflation – Maria & Nneka

2)   Ban on Broadcast Advertisements – Maria & Nneka

3)   Restricted Access – Maria

4)   Media Campaigns – Nneka

5)   School-Based Programs – Andrea & Nneka

Other Approaches, Community Enhancements or System Changes to Address the Issue-Andrea

1)   Social Media – Andrea

2)   Changes in Curriculum – Leslie

3)   Mirror Target Corporations – Leslie

4)   Community Involvement – Leslie

Applicable Behavior Principles, Theories, and Models

1)   Trans-theoretical Model of Behavioral Change – Nneka

2)   Theory of Planned Behavior – Nneka

3)   Health Belief Model – Nneka

4)   Social Cognitive Theory – Nneka

Suggested Intervention Ideas/Objectives

1)   Emulate Already-Successful Youth Programs – Andrea

2)   System Changes/Policies – Andrea

3)   Health System Changes: Chronic Care Model of Smoking – Maria

4)   Program Development Objectives – Nneka

Editing was a collaborative team effort.