CURRICULUM, INSTRUCTION, AND PEDAGOGY
published: 28 May 2021
doi: 10.3389/fpubh.2021.601890
Frontiers in Public Health | www.frontiersin.org 1 May 2021 | Volume 9 | Article 601890
Edited by:
Ahmed Mohammed Alwan,
Mashhad University of Medical
Sciences, Iran
Reviewed by:
John Denley Lentz,
Private Practitioner, Abingdon,
United States
Kavumpurathu Raman Thankappan,
Central University of Kerala, India
*Correspondence:
Donald Reed
drreed1@liberty.edu;
Specialty section:
This article was submitted to
Public Health Education and
Promotion,
a section of the journal
Frontiers in Public Health
Received: 01 September 2020
Accepted: 06 May 2021
Published: 28 May 2021
Citation:
Reed D, Bowen E, Fint-Clark B,
Clark B, Cobb N, Danberry KM,
Hutson Z, Lusk S, Rine J and
Robinson N (2021) Stopping
Smokeless Tobacco Use: A Call to
Action. Front. Public Health 9:601890.
doi: 10.3389/fpubh.2021.601890
Stopping Smokeless Tobacco Use: A
Call to Action
Donald Reed
1
*
, Elaine Bowen
2
, Becca Fint-Clark
2
, Brent Clark
2
, Nila Cobb
2
,
Kathy M. Danberry
3
, Zona Hutson
2
, Stephanie Lusk
2
, Jason Rine
2
and Natasha Robinson
4
1
McDowell County Commission on Aging, Liberty University, Lynchburg, VA, United States,
2
Extension Service, West
Virginia University, Morgantown, WV, United States,
3
West Virginia (WV) Division of Tobacco Prevention, Charleston, WV,
United States,
4
Athletic Academic Support, Central State University, Wilberforce, OH, United States
In the United States, single smokeless tobacco use continues to increase in conjunction
with the dual use of smokeless tobacco and other nicotine products. Problematically,
much of the tobacco prevention literature and funding inundates tobacco users with
smoking tobacco information while neglecting to provide them any information about
smokeless tobacco. Meanwhile, American tobacco companies continually market new
and dissolvable tobacco products targeted at non-smokers. New data suggests that
smokeless tobacco use is, also, increasing in West Virginia and, in order to address this
increased use, the West Virginia Extension Service recently partnered with the Division of
Tobacco Prevention in the West Virginia Department of Health and Human Resources to
develop a comprehensive spit tobacco curriculum for West Virginia students between
third and sixth grade. This article details the development and assessment of the
spit tobacco prevention curriculum and the resulting report from the initial pilot of the
program. The curriculum was piloted across six counties with the participation of schools,
after-school programs and 4-H clubs. After implementation, survey results demonstrate
that youth have increased awareness of the health effects of smokeless tobacco.
Throughout the article, we explore West Virginia’s Cooperative Extension Service’s
response to this emerging public health issue and release a call to action for the National
Cooperative Extension Serv ice s to join us in spit tobacco prevention.
Keywords: youth, smokeless tobacco, 4-H, oral health, extension service
INTRODUCTION
This article illustrates the development, piloting, evaluation, and implementation of the
Stop Spit Tobacco Curriculum in West Virginia. We highlight both the dangers of spit
tobacco and the potential effects of spit tobacco on communities. The West Virginia
Extension Service partnered with the Division of Tobacco Prevention in the West Virginia
Department of Health and Human Resources to develop a comprehensive spit tobacco
curriculum for West Virginia students in Grades 3–6. We conclude by putting out a call
to action to all American Extension Professionals to prevent spit tobacco use in their
own communities.
The term spit tobacco refers to tob acco that is not burned, is used orally, and produces the
need to spit as by-product—i.e., chewing tobacco and snuff. The term smokeless tobacco refers to
smokeless and spitless tobacco products—i.e., snus and dissolvable tobacco products. The term spit
and smokeless tobacco refer to all tobacco products that are not ignited with fire to use.
Reed et al. Stopping Smokeless Tobacco
THE DANGERS OF SPIT TOBACCO
According to the National Summit on Smokeless and Spit
Tobacco, “Smokeless and spit tobacco (SST) use is a rapidly-
evolving public health threat requiring greater le a dership, a
shift in research and funding priorities, and local public action”
(2015). While t here have been many public interventions in
smoking tobacco access and use—namely: Food and Drug
Administration (FDA) regulations, excise taxes, public service
announcement campaigns, and cessation-based phoneline
services—there are, currently, no strategies to help communities
address Smokeless Spit Tobacco (SST). With the development
of dissolvable tobacco products that attract both curious
young people and longer-term smokers, we need programs
centered around SST research and prevention more than
ever before. Research conducted by t h e National Summit on
Smokeless and Spit Tobacco has demonstrated that SST products
can not only cause oral cancer, gum, and tooth disease, but
can also contribute to other forms of cancer, heart disease,
and strokes (
1).
The harmful properties of spit tobacco have been well-
documented, but many people continue to believe that SLT use
is safer than cigarette use. SLT users, however, “run the same
risks of gum dise ase, heart disease, and addiction as cigarette
users, but [face] an even greater risk of oral cancer” (2). A 2015
analysis of the worldwide healthcare impact of SLT use estimates
that SLT consumption by adults prior to 2010 resulted in more
than 62,000 deaths from oral, pharyngeal, and esophageal cancer
as well as the loss of an estimated 1.7 million disability-adjusted
life years (3). In 2011, SLT sales in the United State totaled
∼124.6 million lbs, a 2 million-lb increase from the 122.6
million lbs sold in 2010 (
4). Additionally, tobacco use costs
the United States billions of dollars in medical expenses and
lost productivity (5).
SLT contains at least 30 carcinogen chemicals that are
known to cause cancer, with tobacco-specific nitrosamines
found to be the most harmful (6). This chemical forms during
the growing, curing, fermenting, and aging of tobacco (
6).
While cancers caused by SLT are most likely to develop
at the site where tobacco is held in the mouth (2), ot h er
places such as the tongue, cheek, gum, esophagus, and
pancreas c an also be affected (
7). According to the American
Academy of Otolaryngology (2), additional ingredients in
SLT include polonium 210 (nuclear waste), n-nitrosamines
(carcinogens), formaldehyde (embalming fluid), nicotine (an
addictive drug), cadmium (a chemical in car batteries and
nuclear reactor shields), cyanide (a poisonous compound),
arsenic (a poisonous metallic element), benzene (a product used
in insecticides and motor fuels), and lead (a chemical that causes
nerve poisoning).
In addition to increasing an individual’s risk of cancer, SLT has
many harmful effects on teeth, gums, and the mouth. The sugar
in spit tobacco, for example, can cause tooth decay (
7), and the
coarse particles in the tobacco can irritate the gums and scratch
away tooth enamel. The product can cause periodontal disease
that destroys soft tissue and bone support and which can lead to
tooth loss. White patches and red sores, known as leukoplakia,
may also appear in the mouth and have the potential to turn
into cancer (
7).
SLT has additional negative health effects on several body
systems. Using the product during pregnancy increases the risk
of early delivery and even stillbirth, a nd can affect the brain
development of the fetus (
8). SLT may even cause nicotine
poisoning if children ingest it (9) . Using SLT increases an
individual’s risk of death from heart disease or stroke because
use of t h e product has been linked to increased heart rate and
blood pressure (10).
HEALTH DISPARITIES AND WEST
VIRGINIAN STATISTICS
“Health disparities are preventable differences in the burden
of disease, injury, violence, or opportunities to achieve
optimal health that are experienced by socially disadvantaged
populations” (11). Such “populations can be defined by factors
such as race or ethnicity, gender, education or income, disability,
geographic location (e.g., rural or urban), and sexual orientation”
(
11). Such “ health disparities are inequitable and are directly
related to the historically and presently unequal distribution of
social, political, ec onomic, and environmental resources” (11).
“Health disparities result from multiple factors,” (also
known as the social determinants of health) “including
poverty, environmental threats, inadequate access to healthcare,
inadequate healthcare, individual behavior choices, and
education inequalities” (11). Citizens with less education are
more likely to experience health risks that may include obesity
and subst ance abuse. In reverse, research has correlated good
health with academic success (11).
With exceptions for deaths due to influenza, pneumonia, and
stroke, West Virginia has some of the highest rates of death due
to preventative measures (
12). The stat e also ranks among the
bottom tier of states across the presented health risk factors, with
even higher rates of obesity and high blood pressure within the
state’s black population (12). Across all populations within the
state, the obesity rate exceeds 25%, nearly the worst in the nation.
According to the 2013 West Virginia Youth Tobacco Survey,
West Virginia had the second-highest ranking for male smokeless
tobacco use among high school students in the nation. The
percentage of male smokeless tobacco users in West Virginia
(15%) was significantly higher than the national percentage
(6.7%). In 2011, 25.5% of youth Surveyed in West Virginia
high schools reported that they were current users of smokeless
tobacco, compared to 12.8% in the United States (13).
While the state is among those in the nation with the
lowest rates of health insurance coverage and dental visits, it
falls within the middle range of sta tes for the other presented
measures of preventive care. As comparable with oth er health
disparities, tobacco-related disparities are, to some extent, caused
and perpetuat ed by social determinants of health: s carcity of
resources for the poor, environment a l threats, and insufficient
admission to healthcare, inadequate healthcare, individual
conduct choices, cultural customs, and teaching inequalities.
Frontiers in Public Health | www.frontiersin.org 2 May 2021 | Volume 9 | Article 601890
Reed et al. Stopping Smokeless Tobacco
LINKING TO TOBACCO USE PREVENTION
AND THE 4-H HEALTHY LIVING MANDATE
4-H is the United States of America’s federal youth development
program, which is administered by the land-grant university
and college system. Since 1914, health and healthy living
have been priorities of the 4-H youth development program
of the United St ates Department of Agriculture and the
Cooperative Extension System (22). In 1994, the national
4-H headquarters established the 4-H mission mandates of
science, citizenship, a nd healthy living to provide a more
cohesive system-wide approach to youth development
programming across t h e country (22). The healthy living
mission mandate focuses on the areas of health, healthy
eating, physical activity, social/emotional health, alcohol
awareness, tobacco awareness, drug use prevention, and
injury prevention (22).
According to the National 4-H Council of Healthy-
Living Logic Model for Prevention of Alcohol, Tobacco,
and Other Drugs (ATOD), activities and curricula should
target youth audiences (with a special focus on new
and underserved audiences), families, staff, volunteers,
community leaders, partner organizations, and collaborators.
Educational efforts should provide tobacco cessation
information, resources, and support to young people
and their families; multi-component programs targeted to
different developmental stages relating to ATOD intervention;
opportunities to model non-use among young people with
family and friends; community mobilization campaigns to
prevent and reduce ATOD use; programs with multiple
components such as using environmental changes, policy
changes, social marketing campaigns, and curricula that
meet ATOD prevention standards for skill-building and
self-efficacy; and opportunities to involve families in
meaningful ways (
14).
According to t he Campaign for Tobacco-Free Kids (CTFK)—
a national advocacy organization working on public policy and
education on the dangers of tobacco use—the vast majority
of all initial tobacco use begins in high school. The CTFK
recommends the following steps to create an environment
that encourages tobacco prevention among young people:
tobacco-free school polici es; comprehensive tobacco prevention
education; involvement of parents and families in school efforts
to prevent tobacco use; help for tobacco-using staff and students
to quit; interactive tobacco-free projects for students; and the
adoption of a school policy that prohibits the acceptance
of funding, curricula, or other materials from any tobacco
companies (
15). We used the recommendations of the CTFK
when developing the Stop Spit Tobacco Curriculum. The CDC
recommends that prevention educators “provide instruction
about the short- and long-term negative physiologic and social
consequences of tobacco use, social influences on tobacco use,
peer norms regarding tobacco use, and refusal sk ills” (16).
Successful programs to prevent tobacco use address multiple
psychosocial factors related to tobacco use among children and
adolescents. By educating our youth about spit tobacco and
promoting prevention, the curriculum specifically follows the
4-H mission mandate.
According to the CDC, there are many factors that influence
young people to begin using tobacco, which include, exposure
to tobacco advertising, low self-image, lack of support or
involvement from parents, the normalization of tobacco use
within peer groups, and a lack of self-efficacy that contributes
to resisting influences of tobacco use (
17, 18). The CDC also
reported that in 2016, 7.2% of middle school students reported
using any form of tobacco, and 2.2–4% of high school male
students reported using smokeless tobacco on or at least 1 day
during the past 30 days. Our Stop Spit Tobacco prevention
curriculum was geared toward students in third-sixth grade and
our objective was to instill them with tobacco resistance skills
for middle school, in line with the CDC’s recommendations. 4-
H does have a smoking prevention curriculum, Health Rocks,
however, its main topic area is smoking. The statistics above
show that a more targeted curriculum geared toward spit tobacco
is needed (19).
Our curriculum utilized six different lessons to address spit
tobacco prevention giving participants the education, media
literacy, confidence to say no, and ability to get civically involved
in spit tobacco policies. These lessons meet the mission mandates
of 4-H. The innovation of linking the 4-H network with tobacco
prevention effort has the potential to c reate a nationwide
movement around the issue.
PROJECT TO STOP SPIT TOBACCO
Over the past 3 years, a team of Extension Agents and
a Curriculum Specialist have worked with West Virginia
University Communications, the West Virginia University
Prevention Research Center, and the West Virginia Division of
Tobacco Prevention to complete a full Stop Spit Tobacco
Curriculum. The curriculum includes speaker scripts,
background information, handouts, resources, and evaluation
tools. In 2014, the team worked individually to aut hor six lessons:
(1) The Body: Tobacco Bad Effects, (2) Addiction: Hard Cycle to
Break, (3) Cost: Can You Afford to Spit? (4) Media: Promotion
of Spit Tobacco – A Deadly Influence, (5) Say No: To Spit
Tobacco, and (6) Advocacy: Your Voice Counts. Other pieces of
the curriculum included a preface, an introduction, a nd a let ter
that was sent home to parents giving them tips on how to talk
to their children about spit tobacco. The curriculum includes
multiple hands-on activities in each section that demonstrate
the topics of each lesson in a way that young people in Grades
3–6 would understand. Before the curriculum was distributed
for wider use, it was piloted by Extension Agents in their home
counties. Feedback was provided by the students who took part
in the pilot lessons and the lessons were edited based on t h e
student feedback.
Depending on how many activities the teacher chose to
use, each lesson took ∼30–45 min to complete. Lessons were
delivered over a 6-week period to students or 4-Her’s. A typical
lesson plan included a list of the required materials, learning
objectives, topic background, introduction, learning activities,
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Reed et al. Stopping Smokeless Tobacco
lesson conclusion, preparation notes, and a list of which national
content standard the lesson met. National content standards were
introduced to persuade teachers and school administrators to use
the curriculum in their classrooms. All lessons came with a script
to follow to encourage active discussion throughout the lesson.
An appendix was included to ensure that all material was readily
available to teachers, club leaders, or other facilitators to use. This
is the final draft of the curriculum after feedback was provided by
the pilot runs of the Stop Spit Tobacco Curriculum.
Lesson one, “The Body: Tobacco Bad Effects,” was designed to
educate students about the dangers of spit tobacco by showing
them the ingredients within the product and explaining how
the ingredients negatively impact the body, both in the short
and long term. The second lesson, “Addiction: Hard Cycle to
Break,” encouraged students to take part in activities about the
perils of spit tobacco addiction. The activities illustrated how
difficult it is to break away from addiction, taug h t ways that
make it easy to say “no” to spit tobacco, and provided better
alternatives to using spit tobacco. Lesson three, “Cost: Can You
Afford to Spit?,” was created to help young people assess the
costs related to spit tobacco use and to learn about the value
of spending money wisely by determining the intrinsic value of
items and activities compared with the value of spit tobacco.
The next lesson, “Media: Promotion of Spit Tobacco – A Deadly
Influence,” helped students analyze how messages from the media
and other sources influenced th eir health behaviors. Lesson fiv e,
“Say No: To Spit Tobacco,” was designed to help young people
manage peer pressure and make thoughtful health decisions by
using verbal and non-verbal skills to say “no” to friends. The
last lesson, “Advocacy: Your Voice Counts,” taught students
about advocacy—how it works and why it is important—through
hands-on learning experiences and a stop spit tobacco advocacy
project. By focusing on these topics, we are providing students
with the skills that they need to make healthy de cisions regarding
spit tobacco while, also, encouraging them to become involved
citizens in tob acco prevention. Letters that were sent home to
parents opened the door for them to be involved in an ongoing
conversation with their children about spit tobacco, and, in the
meantime, students cre a ted media showing the consequences of
using spit tobacco and were encouraged to become a dvocates in
spit tobacco prevention. Ultimately, the educational material in
the curriculum reiterated t h e physical and financial costs of spit
tobacco. In Table 1 below, we detail each lesson name, lesson
objectives, and a sample activity.
Once the initial project was accomplished, the team of
extension agents completed a pilot of the curriculum with
at least 50 young people in their counties. After the pilot
program, the team c ame back together to edit and revise
the lessons based on teacher input and student evaluation. In
2016, we provided the curriculum to teachers, club leaders, and
community members to pilot with their young people. The
following surveys analyzed in this study are from this round of
pilot tests with individuals from outside West Virginia University
Extension teaching the lessons.
The survey was designed with input from the West Virginia
University team, West Virginia University Prevention Research
Center, and West Virginia Divisi on of Tobacco Prevention. The
TABLE 1 | Curriculum Lessons.
Stop spit tobacco lesson overviews
Name of
lesson
Lesson objectives Sample activity
Lesson One, The
Body: Tobacco
Bad Effects
• Students gain an understanding of the
many toxic materials found in spit
tobacco.
• Students understand the short-term
negative impacts of spit tobacco use on
the body and be introduced to some of
the long-term effects.
What’s in that
Can? – Activity
showing
ingredients in spit
tobacco
Lesson Two,
Addiction: Hard
Cycle to Break
• Students understand that addiction to
tobacco makes it very hard to stop the
use of spit tobacco products and the
ways addiction itself is harmful.
• Students understand some of the
external pressures that lead to
experimenting with spit tobacco and
some of the outside supports that help
students say no to experimentation with
tobacco.
• Students discover positive alternate
activities they could practice instead
trying tobacco.
Tied Up–Students
have one string
wrapped around
wrist and break it.
Each time they
use spit tobacco
another string is
added, to show
strength of
addiction with
each use.
Lesson Three,
Cost
• Students understand what it costs to use
spit tobacco for 1 year.
• Students learn how the “value” of using
spit tobacco compares to using other
items and engaging in other activities.
The Cost of Spit
Tobacco–
Students count
total amount of
money in envelope
equaling cost per
year of spit
tobacco use.
Lesson Four,
Media:
Promotion of
Spit Tobacco – A
Deadly Influence
• Students recognize the influence of
media upon their purchasing decisions.
• Students recognize marketing strategies
used in smokeless tobacco advertising.
• Students learn media evaluation skills to
help them better determine the validity of
messages used in advertising smokeless
tobacco products.
Creating Truthful
Spit
Tobacco–Students
make an ad
showing real
impact of spit
tobacco use.
Lesson Five Say
No: To Spit
Tobacco
• Students learn about the conditions that
help someone resist using spit tobacco
or participating in other risky/unhealthy
behaviors.
• Students understand that one cannot get
away from pressure from friends or others
trying to persuade us to do many things,
but one can have strategies that will help
to combat pressure from friends to
participate in unhealthy behaviors.
• Students learn certain facts about verbal
and nonverbal refusal skills so they will be
able to use the skills with confidence
when they are being pressured to try risky
behaviors by their friends.
Discovering
Positive Body
Language –
Students learn
how body
language can
impact the way
their message is
received.
Lesson Six
Advocacy: Your
Voice Counts
• Students learn about the functions of
advocacy and recognize the power of
young people as effective advocates.
• Student learn ways to determine a cause
and how to identify who the most
effective people would be to receive the
advocacy message.
• Students work individually or in groups to
develop messages about the dangers of
spit tobacco to children.
The Power of
Postcards-
Students write
postcards to
community
leaders advocating
for policy change
on spit tobacco
(i.e., use in public).
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Reed et al. Stopping Smokeless Tobacco
TABLE 2 | Evaluation results.
Please select the appropriate response regarding your level of agreement in accomplishing the following tasks:
Strongly disagree Disagree Agree Strongly agree Response total
I can list some of the ingredients in spit
tobacco.
4.5% (49) 11.4% (125) 49.1% (538) 35.0% (384) 1,096
I can explain how trying spit tobacco
can lead to addiction.
2.3% (25) 4.3% (47) 33.0% (361) 60.4% (661) 1,094
I can explain how tobacco company
ads are misleading.
4.8% (53) 6.1% (67) 31.1% (340) 57.9% (633) 1,093
I can list other things I can buy instead
of buying spit tobacco.
2.5% (27) 2.8% (31) 16.0% (175) 78.7% (861) 1,094
I know how to say no to my friends if
they offer me spit tobacco.
3.4% (37) 2.5% (27) 17.1% (185) 77.0% (835) 1,084
I know how to get more involved in
preventing spit tobacco use at my
school or in my community.
5.9% (64) 9.1% (99) 40.5% (439) 44.5% (483) 1,085
subjects cannot be identified by the information obtained. Young
people were required to take part in the Stop Spit Tobacco lessons
in order to take the survey.
The surveys were given to 1,097 students following the
completion of the Stop Spit Tobacco curriculum. The survey
elicited information about gender, age, and location in the Stop
Spit Tobacco lessons. In order to measure the effectiveness of
the curriculum with the students, the survey asked them to what
extent they agreed or disagreed with a statement based on a
four-point Likert scale, with the options ranging from strongly
disagree to strongly agree. The statements were:
• I can list some of the ingredients in spit tobacco
• I can explain how trying spit tobacco can lead to addiction
• I can explain how tobacco company ads are misleading
• I can list other things I can buy instead of buying spit tobacco
• I know how to say no to my friends if they offer me
spit tobacco
• I know how to get more involved in preventing spit tobacco
use at my school or in my community.
PROCEDURES
1. Surveys were designed with input from the West Virginia
University Extension Service, West Virginia Division of
Tobacco Prevention, and West Virginia University Prevention
Research Center.
2. Upon the approval of the IRB, West Virginia University
Extension Service Agents and our community partners
asked permission to voluntarily administer the survey
to young people who participated in the “Stop Spit
Tobacco Curriculum.”
3. Parents received a letter informing them of th e project and
survey and gave them the option to have their child opt out of
the sur vey . Parents were given at least 2 weeks’ notification.
4. Any other Extension Agent (in addition to the PI) who
assisted with survey evaluation implementation was trained
in CITI-Human Subjects and added to the protocol before
survey evaluation administration. Extension agents were also
trained in survey evaluation implementation protocols.
5. Young people who completed all six lessons of the
West Virginia University Extension “Stop Spit Tobacco
Curriculum” (approved by the West Virginia University
Prevention Research Center and West Virginia Division of
Tobacco Prevention) were asked to complete the survey for
the purpose of the program evaluation.
6. Participation in the curriculum did not mandate participation
in t he survey evaluation. Students had the right to refuse and
thus participated volunt arily .
7. Evaluation data from the survey was used to identify the
strengths and weaknesses of the curriculum and allow for
curriculum revisions. The survey assessed their feelings on
spit tobacco use after going through the program.
8. Curriculum instructors were asked to fill out an online survey
concerning lesson evaluation. Participation was voluntary.
A total of 1,097 st udents took part in the 2016 “Stop
Spit Tobacco” pilot run across West Virginia. The results
of the survey, after the implementation of the curriculum,
show that 84.1% of students agree or strongly agree that they
can list some of the ingredients in spit tobacco. Ninety-three
percentage of student said that they strongly agreed or agreed
that they can explain how trying spit tobacco one time can
lead to addiction, while 89% of student agreed or strongly
agreed that they c an explain how tobacco company ads are
misleading. Furth ermore, 94.7% of students agreed or strongly
agreed that they can list other things to buy instead of spit
tobacco, and 94.8% students agreed or strongly agreed that
they know how to say no to their friends if they are offered
spit tobacco. Finally, 85% of the students agreed or strongly
agreed that they know how to get more involved in preventing
spit tobacco use at their school or in their community. The
Table 2 below indicates the self-reported level of knowledge
gained after the entire curriculum was complete. This gained
knowledge will empower these students to resist spit tobacco
in the future and may even provide them with the ability to
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Reed et al. Stopping Smokeless Tobacco
prevent their friends, family, and community at large from using
spit tobacco.
These are fairly complex topics for students in Grades 3–6 to
understand. Following a review of the survey, we know that a
large number of students feel they can identify the ingredients
of spit tobacco and even explain addiction to it. In regard
to identifying misleading spit tobacco advertisements, media
literacy is high among young people. Participants know how
much spit tobacco costs and can identify better ways in which
to spend their money. Many of them report knowing how to say
no to their friends, resist peer pressure, and even how to become
involved in preventing spit tobacco use at their school and in their
community. By educating third-sixth graders on these subjects,
we are helping them make healthy decisions in regard to spit
tobacco use and to develop essential life skills such as media
literacy, leading and promoting a h ealthy lifestyle, and resisting
peer pressure.
CALL TO ACTION FOR THE COOPERATIVE
EXTENSION SERVICE
A growing body of research indicates that school-based
educational interventions—e.g., interventions that engage
elementary and middle school students in interactive educational
programs designed around the principles of the “social influence
resistance model” to equip young people with key skills for
resisting negative social influences—have been shown to be
effective in reducing the age of onset and level of tobacco use
(CTFK). The final lesson encourages youth to think about how
they can get involved with tobacco prevention efforts in their
community. Further, youth-led programs that capitalize on
these principles of civic engagement have been found to be
most effective (
20).
The Cooperative Extension System serves as an integral
partner in the development and facilitation of interactive
educational curricula and programming for elementary and
middle schools. As trusted members of their communities,
local extension agents are equipped to partner with schools
and clubs to provide interactive educational programs in
elementary and middle s chools. With the ability and expertise
to provide effective, short-term, and interactive educational
programs for audiences proven to be most receptive to
prevention programs, 4-H cooperative extension programs
are uniquely poised to help address the need for the
development and intervention of research-based, short-term
tobacco education programs.
Through the development and delivery of educa tional
programs designed to empower young people to reach their full
potential by working and learning in partnership with caring
adults, 4-H programs are able to equip and empower young
people for healthy, tobacco-free lives. As cooperative extension
professionals, we are in a unique situation where we can directly
reach young people throughout our schools and communities to
prevent the use of spit tobacco. Partnering with local and state
partners and using resources such as “Stop Spit Tobacco” will
help us to meet our healthy living mission mandate by preventing
young people from using spit tob acco. Pre vi ous research in West
Virginia shows the need for Extension Service leadership in
addressing tobacco prevention needs (21).
We encourage our colleagues from across the country to
utilize the Stop Spit Tobacco Curriculum in their home counties
to help stop the use of spit tobacco. This curriculum will be
provided to those seeking it free of charge and can be attained
by contacting one of the authors at West Virginia University. As
Extension professionals, we are uniquely positioned to provided
substance abuse prevention education in our communities, and
we should utilize our abilities to do so. Whether it be spit tobacco
or any other substance, we are calling on you to tak e an active
approach in substance abuse prevention!
DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included
in the article/supplementary material, further inquiries can be
directed to the corresponding author/s.
ETHICS STATEMENT
The studies involving human participants were reviewed
and approved by WVU Office of Research Integrity and
Compliance. Written informed consent from the participants’
legal guardian/next of kin was not required to participate in
this study in accordance with the national legislation and the
institutional requirements.
AUTHOR CONTRIBUTIONS
DR and JR: curriculum development and data analysis. EB:
data analysis and manuscript editing. BF-C, BC, NC, ZH,
and SL: curriculum development and manuscript development.
KD: funder and manuscript development. NR: curriculum
development. All authors contributed to the article and approved
the submitted version.
FUNDING
Funding for this project was provided by the West Virginia
Division of Tobacco Prevention (Grant #G160019).
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Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
Copyright © 2021 Reed, Bowen, Fint-Clark, Clark, Cobb, Danberry, Hutson, Lusk,
Rine and Robinson. This is an open-access article distributed under the terms
of the Creative Commons Attribution License (CC BY). The use, distribution or
reproduction in other forums is permitted, provided the original author(s) and the
copyright owner(s) are credited and that the original publication in this journal
is cited, in accordance with accepted academic practice. No use, distribution or
reproduction is permitted which does not comply with these terms.
Frontiers in Public Health | www.frontiersin.org 7 May 2021 | Volume 9 | Article 601890
