Head Start

ACYF Administration on Children, Youth and Families	U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Administration for Children and Families
	1. Log No. ACYF-PI-HS-95-04	2. Issuance Date: 03/07/95
	3. Originating Office: Head Start Bureau
	4. Key Word: Smoke-Free Environment

PROGRAM INSTRUCTION

TO: Head Start Grantees and Delegate Agencies

SUBJECT: Establishing a Smoke-Free Environment in Head Start Programs: Final Program Instruction

LEGAL AND RELATED REFERENCES : The Head Start Act, as amended, 42 U.S.C. 9801 et seq.; 45 CFR 1304.2-3

SUMMARY: This Program Instruction contains requirements governing all Head Start programs including those programs serving infants, toddlers and pregnant women. It requires all Head Start programs to provide a smoke-free environment for children and adults who participate in their program.

DATES: These Program Instructions are effective May 1, 1995.

SUPPLEMENTARY INFORMATION:

I. Authority for Program Instruction:

The authority for this Program Instruction, which interprets 45 CFR 1304.2-3, is derived from 644 (c) of the Head Start Act (42 U.S.C. 9801 et seg.). The Administration for Children, Youth and Families' (ACYF) authority to issue interpretations of its regulations is a corollary to its obligation under section 644 (c) of the Act to make rules and regulations which supplement the administrative requirements and standards set forth in Section 644 (a).

II. Purpose of the Final Program Instruction :

The purpose of this Program Instruction is to set forth Head Start policy that requires Head Start grantees and delegate agencies to create a smoke-free environment and to eliminate exposure of children, staff and other adults to tobacco smoke. The adverse effects of tobacco smoke on the health of children and adults is described in this Instruction.

III . Program Instruction History:

This Program instruction was published in the Federal Register on December 29, 1993, as a Notice of proposed Program Instruction for the purposes of reaching as many interested parties as possible, including the universe of Head Start programs. It proposed to establish smoke-free environments in all Head Start programs in order to eliminate exposure to tobacco smoke by children, staff and parents in the Head Start program. Information on the adverse effects of tobacco smoke on the health of children and adults was provided in the proposed Program instruction. The development of the proposed Program Instruction emanated from the acquired knowledge of the detrimental effects of passive smoking, especially on young children, as reported in the Environmental Protection Agency's 1992 report titled, "Respiratory Health Effects of Passive Smoking: Lung Cancer and other Disorders," as well as reports from The Coalition For Smoking Or Health (American Cancer Society, American Lung Association and the American Heart Association).

Since the publication of the proposed Program Instruction, a new law, the Pro-Children Act of 1994 (PL 103-227), has been passed that prohibits smoking in any indoor facility or portion thereof owned or leased or contracted for the provision of regular or routine "early childhood development services" or for the use of the employees who provide such services. Subject to certain limitations, the now statute requires Head Start grantees to do many of the same things that this Program Instruction requires. Public Law 103-227 has provided additional impetus for the Head Start Bureau to issue a final Program Instruction requiring all Head Start programs to create smoke-free environments.

This final Program . instruction contains revisions to the proposed Program Instruction which incorporate some of the comments and recommendations received from the general public, local Head Start staff and parents, health agencies, national organizations, universities and a work group convened by the Head Start Bureau and the Centers for Disease Control and Prevention (CDC), Office on Smoking and Health. The work group was created to assist the Head Start Bureau and CDC's Office on Smoking and Health in developing technical assistance materials for Head Start programs for purposes of assuring a smoke-free environment.

IV. Discussion of Comments and Subsequent Changes in the Proposed Program Instruction:

In response to the proposed Program Instruction on Creating a Smoke-Free Environment in Head Start programs; there were 53 letters containing 93 comments. Fifty-two letters were laudatory. Many of the commenters represented Head Start programs that have already established smoke-free environments in their centers and have instituted smoke-free policies.

 Forty-three comments wore received from local Head Start programs, 27 comma-its from health organizations including State Offices of public health and social services, and 23 comments from community organizations, including universities.

General Comments:

General cements an all aspects of the proposed Program Instruction included commendations to ACY for giving credence to the EPA report on the effect of passive smoking on young children and non-smoking adults. Other laudatory comments endorsed the proposed Program Instruction as a public health message to parents, staff and the general public that promotes Head Start's role in modeling positive health behaviors rather than high health-risk behaviors. One Head Start Director stated that, "If it is our mission to promote the healthy development of children and families then a smoke-free environment is a must." A number of commenters from Head Start programs expressed the opinion that smoke-free environments will have a positive benefit on the reduction of discomfort from allergies, not only for themselves but also for the parents and the children.

Comments From Local Head Start Programs, Health Organizations, Community Organizations, Universities, and Professional Organizations:

Several commenters expressed concerns about the provision which extended smoke-free policies to home visits. Many of these commenters suggested that Head Start programs be given the Option to work with their policy councils, staff and families through discussion and education rather than having to abide by the mandate that smoking be prohibited during home-based services and home visits.

We concur that this policy should not extend to parents who smoke in their own homes during the provision of Head start Home-Based services and home visits and the Program Instruction has boon changed accordingly. However, the Program instruction encourages programs to work with their policy councils to develop policies and support for parents and staff who want to stop smoking.

One commenter recommended that the requirement to modify ventilation systems when sharing a building with an organization not required to be smoke-free be deleted due to excessive costs. We agree that the cost of modifying a ventilation system could be prohibitive and night not be within the control of the Head Start program. Therefore, the requirement for modifying this aspect of a physical plant has been deleted.

Several commenters strongly encouraged ACYF to promote the provision at an array of educational/wellness activities, consisting of smoking cessation programs for staff and those parents who are interested and comprehensive health education for adults and children containing information on smoke-free environments. We concur and have added this as a recommendation.

A verbal expression of concern emanated from representatives of three American Indian tribes to the effect that although they were generally supportive of the smoke-free concept, they did not want to see this Program Instruction interfere with American Indian cultural customs where tobacco is utilized.

The Administration on Children, Youth and Families recognizes that our role does not include interfering with American Indian cultural customs where tobacco is utilized. Rather, it has been primarily concerned with creating a smoke-free environment for the children at centers and on field trips to prevent them from being exposed to passive smoking. The Program Instruction has been amended to reflect this thinking.

V. Inquiries:

Questions regarding this Program instruction should be referred to your Regional Office or the Head Start Bureau at 202-205-8398. However, informational materials to help with the implementation of a smoke free environment will be mailed under separate cover as an Information memorandum.

/S/
Olivia A. Golden,
Commissioner

CC: Regional Administrators, ACF, Regions I-X, American Indian and Migrant Program Branches

Attachment (1)

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FINAL PROGRAM INSTRUCTION:

ESTABLISHING A SMOKE-FREE ENVIRONMENT IN HEAD START

PURPOSE : The purpose of this Program Instruction is to set forth Head Start policy that requires Head Start grantee and delegate agencies to create a smoke-free environment and to eliminate exposure to tobacco smoke by children, staff and parents in the Head Start program. Information on the adverse effects of tobacco smoke on the health of children and adults is provided in this Instruction.

BACKGROUND : There has been a growing concern in America about the harmful effects of exposure to tobacco smoke on both young children and adults. Recent research, cited below, has established that non-smokers can suffer health damage from exposure to tobacco smoke. This is known as passive smoking or environmental tobacco smoking (ETS) and comes from exposure to the smoke given off by burning cigarettes, cigars and pipes and the smoke exhaled by someone who is smoking.

Passive smoking or ETS is one of the most harmful indoor air pollutants according to an officially released scientific report published by the U.S. Environmental Protection Agency (EPA) in 1992, entitled, "Respiratory Health Effects of Passive Smoking: Lung Cancers and Other Disorders." The report reveals that ETS contains 43 carcinogenic (cancer causing) compounds. These compounds are known to produce lung cancer and other respiratory complications in adults and children.

 The EPA Fact Sheet entitled "Respiratory Effects of Passive Smoking" (January, 1993) reports the following conclusions based on scientific evidence:

• ETS is responsible for approximately 3,000 lung cancer deaths annually among U.S. adult non-smokers;
• Between 150,000 to 300,000 of the lower respiratory tract infections reported annually in infants and young children under 18 months of age are attributable to ETS exposure;
• ETS exposure increases the prevalence of fluid in the middle ear in children, which is a sign of chronic middle ear disease;
• ETS exposure in children irritates the upper respiratory tract and is associated with a small but significant reduction in lung functioning; and
• ETS exposure in children increases the frequency of episodes and severity of symptoms in asthmatic children. An estimated 200,000 to 1,000,000 asthmatic children have their condition worsened by exposure to ETS.

The detrimental effects of maternal smoking upon prenatal development are widely recognized [National Academy of Sciences Committee to Study the Prevention of Low Birthweight (1985), Preventing Low - Birthweight, National Academy Press, Washington, D. C.]. Maternal smoking increases the likelihood of low birth weight which correspondingly increases risks for developmental and health impairment. Lactating mothers who continue to smoke after giving birth not only place their children at risk due to the environmental effects of passive smoking, but also expose their children to toxic substances through breast feeding.

Many Head Start centers are required to comply with State and local regulations regarding smoke-free environments for child care facilities. Most States have regulations limiting smoking in child day care centers, although few require the centers to be completely smoke-free [Nelson, D.E., Sacks, J.J. and Addiss, D.G. (1193), "Smoking Policies of Licensed Child/Day Care Centers in the United States," Pediatrics 91:460-463]. However, the American Academy of Pediatrics and the American Public Health Association have published guidelines recommending that day care centers adopt smoke-free indoor policies (in "Caring for Our Children - National Health and Safety Performance Standards: Guidelines for Out of Home Child Care Programs, (1992)]. Recently passed Federal legislation, the Pro-Children Act Of 1994 (PL 103-227), prohibits smoking in any indoor facility or portion thereof owned or leased or contracted for the provision of regular or routine "early childhood development (Head Start) services" or for the use of the employees who provide such services. Subject to certain limitations, the now statute requires Head Start grantees to do many of the same things that this policy requires.

A number of Head Start programs have already initiated policies regarding a smoke-free environment. Policy councils, parents, and staff of those agencies have endorsed smoke-free initiatives and are to be commanded for their leadership.

INSTRUCTION: Because there in considerable evidence that environmental tobacco smoke is harmful to children and adults,--and because Head Start has the mission of promoting the healthy development of the children and families it serves, it in imperative that all Head Start programs create smoke-free environments. Therefore, we are requiring all grantees to work with their policy councils, Health Advisory Committees, parents, and staff in order to establish and enforce written policies which will ensure that, effective May 1, 1995, their Head Start program sites will be smoke-free.

These smoke-free policies contained in this Program Instruction are not intended to prohibit parents from smoking in their own homes during home-based services and home visits. Rather, the intention in to encourage local planning,, education, and policy development (related to smoke-free environments during home-based services and home visits) by policy councils, parents and staff. Additionally, all programs should give consideration to providing smoking cessation support for those adults who are interested.

Head Start programs must prohibit smoking at all times in all space utilized by the program. This includes classrooms, staff offices, kitchens, restrooms, parent and staff meeting rooms (used in the evenings as well as during the day), hallways, outdoor play areas, and vehicles used for transporting children.

Head Start programs must develop policies that address group socialization activities (which include field trips, neighborhood walks or other outdoor group activities) and that are intended to have parents and staff refrain from smoking when Head Start activities are taking place. Parents and staff should recognize that they serve as role models for the children and should not smoke in front of them. The only situation under which this does not apply is during a presentation or field trip related to American Indian cultural customs in which tobacco is utilized.

Educational and wellness activities, such as smoking cessation programs for adults and inclusion of developmentally appropriate activities in health education for children should be developed, with input from policy councils, staff and parents, to assist in carrying out smoke-free policies.

For Head Start programs that share a building with other occupants, grantees should take steps to reduce children's exposure to smoke from other sources in the building, for example, by altering traffic patterns, and/or establishing a "smoke-free zone" around the Head Start site.

To assist Read Start programs in their efforts to provide a smoke-free environment for Head Start children and their families, a listing of Federal and private information resources (such as an annotated bibliography regarding smoke-free environments and ETS, guides to implement smoke-free environments, additional sources of Federal information, etc.) will be made available at a later date to all grantees by the Administration on Children, Youth and Families.

We expect that a smoke-free environment will increasingly be recognized as a basic safety and health requirement of any program serving children. We know that Head Start programs will continue their tradition of being in the forefront of advocacy and best practice in promoting the healthy development of young children by establishing a smoke-free environment.

IMPLEMENTATION : This Program Instruction is effective May 1, 1995. Please be advised that a smoke-free environment will be one of the requirements monitored during on-site program reviews. Evidence of compliance will include:

• the posting of written policies, approved by Policy Councils, regarding a smoke-free environment;
• evidence that all staff have been informed about these policies;
• correspondence, meeting notices, and flyers which advise parents and staff of the new policies and related activities such as smoking cessation programs for adults and the inclusion of developmentally appropriate smoke-free activities in health education for children.
• evidence of compliance with a no-smoking policy through physical inspection of the facility; and
• for programs that share space in a building with other occupants, evidence of efforts to limit the introduction of environmental tobacco smoke (ETS) from outside sources into the Head Start space.

Suggestions for CreatingSmoke-Free Environments

I. Introduction

The Head Start Bureau has been working with the Centers for Disease Control and Prevention, Office on Smoking and Health (OSH), to develop a model smoke-free policy for use in Head Start and other early child cue settings. Head Start agrees with other federal authorities, such as the Surgeon General and the Environmental Protection Agency, that "secondhand smoke" or environmental tobacco smoke (ETS -- the smoke given off by burning tobacco products as well as smoke exhaled by someone who is smoking), is a dangerous pollutant. The recent EPA report on the respiratory health effects of passive smoking demonstrated that young children are especially at risk:

• between 150,000 to 300,000 of the lower respiratory tract infections reported annually in infants and young children under 18 months of age are attributable to ETS exposure
• ETS exposure increases the prevalence of fluid in the middle ear in children, which is a sign of chronic middle ear disease
• ETS exposure in children irritates the upper respiratory tract and is associated with a small but significant reduction in lung functioning
• ETS exposure in children increases the frequency of episodes and severity of symptoms in asthmatic children. An estimated 200,000 to 1,000,000 asthmatic children have their condition worsened by exposure to ETS

With an awareness of these risks to the children they serve, the Head Stan Bureau has taken an important leadership position by promulgating a new Program Instruction that seeks to protect children, staff, parents, and volunteers from exposure to ETS. The new Program Instruction will require that each Head Start program provide a smoke-free environment to all of its participants.

OSH has collaborated with the Head Start Bureau, including representatives of the Head Start community, and developed a model smoke-free policy that will assist Head Start programs to comply with the new Program Instruction. Through a variety of needs assessment mechanisms that included a series of fourteen focus groups conducted across the country, telephone interviews of selected participants, and a Smoke-free Policy Working Group, a model policy was developed to address the needs of the Head Start community. One of the final, and most important steps that helped to lay the groundwork for implementation of the smoke-free policy nationwide, was a pilot program in which these processes and materials were tested.

In this package you will find two documents:

1. Implementation Guidance (this document)

2. Sample Policy and Procedure

These will be the tools for you to use to develop and implement your smoke-free policy. This document, "Implementation Guidance," will help you plan for the development and implementation of your smoke-free workplace policy. This guidance lists and explains several steps that you will want to consider during this process. You will need to tailor the suggestions to fit your program's needs, therefore you should consider them all as options.

II. Policy Development and Implementation Steps

The following are suggested steps for you to consider taking while development and implementing your policy:

1. Define Current Smoking Policy Situation

• Read the Program Instruction so you know what the requirements are.
• What level of smoking restriction currently exists, both in policy and in compliance to the policy?
• What are the potential challenges to changing that situation, if change is needed to conform with the Program Instruction?

For example, you may already have a policy that bans smoking indoors, but you are aware that certain staff still smoke in places they shouldn't. You will need to know this fact so you can address it in the policy. A potential challenge might be that one of the '"n-office" smokers is a supervisor. You will need all of your supervisors' help in implementing and enforcing the policy, and you would need to determine the best way to have that supervisor comply with, and enforce, the policy.

Following is a checklist to help you define your current smoking policy and compliance situation:

Your current smoking policy allows smokers to smoke (including staff, parents, and volunteers): YES OR NO

In offices

In lounges

Other places inside (list: )

Just outside the front door

On the playground

In the parking lot

In a designated smoking area (DSA) outside

In transport vehicles

On field trips

Other places outside (list: )

Smokers currently Smoke: YES OR NO

In offices

In lounges

Other places inside (list: )

Just outside the front door

On the playground

In the parking lot

In a designated smoking area (DSA) outside

In transport vehicles

On field trips

Other places outside (list: )

a. If your policy allows smokers to smoke inside, then You will need to change your policy to be responsive to the Program Instruction.

b. If your policy only allows smokers to smoke outside, then you may just need to determine where they should smoke so they are not in view of the children.

c. If there are differences between what your policy allows and what your staff, parents, and volunteers are doing, then you need to think about the types of meetings that need to occur and who needs to be a part of the process to determine ways to increase responsiveness to the policy on a smoke-free environment.

d . If it is determined that there is a problem, i.e., you believe that your smokers will not be willing to change their behavior, then you will need to think about the types of meetings that need to occur and who needs to be a part of the process to determine ways to convince them to change. Options include incentives, training programs, and clearly communicating the consequences of violating the policy.

2. Meet and Discuss Next Steps with Parent Policy Council and Staff

Meet separately with your staff and your parent policy council.

Explain what is happening, utilizing the Program Instruction to explain and justify what needs to happen, and using the enclosed questions an suggested answers (following) to review the changes that will be made. You cm utilize the questions as a discussion guide for your meetings. Your parent policy council needs to be involved with this process. It may be wise to delegate certain tasks to them, such as adapting the model policy to meet your needs or exploring what smoking cessation support may be available in your community.

Listen to their questions and concerns and modify and adapt your smoking policy to accommodate them while still maintaining a smoke-free environment. For example, precisely, where smokers will be able to smoke outside will need to be decided based primarily on both protecting the children and non-smokers and on presenting non-smoking role models for the children, but also with some consideration of smokers' needs. Another example would be providing more generous smoking cessation support if smokers are very interested in it.

Ensure that your staff and PPC both understand and support the policy.

Your supervisory staff should comprehend and be comfortable with their role in implementing the new policy. Methods to achieve this level of comfort and comprehension include: discussing their concerns about the policy at staff meetings, holding a special meeting or "brown bag lunch," or providing special training sessions.

Consider providing training sessions, possibly with role plays, to help supervisors assume the added responsibility of enforcing the policy

3. Identify Cessation Opportunities:

You will want smoking cessation resources to be available to your smoking employees. parents, and volunteers in the event that they decide to try to quit smoking as a way of dealing with the policy. You will not need to finish this step before going to Step 4 However, it will take time for materials to arrive, and you Will want to order them early enough so that you will have them when you implement the policy.

Contact community resources, such as local chapters of the American Lung Association, the American Heart Association, or the American Cancer Society, and local hospitals or clinics, to see what resources they have available.

Contact your state or local public health department to inquire what cessation and prevention materials they have that may be well suited to your needs.

Contact the National Cancer Institute's Cancer Information Service at 1-800 4CANCER for the following materials:

(a) CLEARING THE AIR: A GUIDE TO QUITTING SMOKING . This pamphlet, designed to help the smoker who wants to quit, offers a variety of approaches to cessation. 24 pages (Maximum order, 200 copies)

(b) WHY DO YOU SMOKE? This brochure contains a self-test to determine why people smoke and suggests alternatives and substitutes that can help them stop (Maximum order, 200 copies)

(c) DATOS SOBRE EL HABITO DE FUMAR Y RECOMENDACIONES PARA DEJAR DE FUMAR. This bilingual pamphlet describes the health risks of smoking and tips on how to quit and stay quit. 8 pages (Maximum order 100 copies)

(d) GUIA PARA DEJAR DE FUMAR . This booklet is a full-color, self-help smoking cessation booklet prepared specifically for Spanish-speaking Americans. It was developed by the University of California, San Francisco, under an NCI research grant. 36 pages. (Maximum order, 100 copies)

Contact the Centers for Disease Control and Prevention Office on Smoking and Health at 1-800-CDC-1311 or by writing at the address below for the following materials:

a. PATHWAYS TO FREEDOM. This booklet is a smoking cessation and community organizing self-help guide targeted at African Americans

b. SMOKING, TOBACCO AND HEALTH: A FACT BOOK. This booklet provides detailed facts and charts showing the relationship between tobacco use and health risks. (Maximum order, 20 copies)

c. ITS TIME TO STOP BEING A PASSIVE VICTIM. This packet. available in both English and Spanish, provides glossy posters and fact sheets offering suggestions to reduce risks from environmental tobacco smoke.

d . REDUCING THE HEALTH RISKS OF SECONDHAND SMOKE. This pamphlet from the American Lung Association and the CDC that describes ways to avoid secondhand smoke at home, at work, and in public places (Single copy only)

e. SGR 4 KIDS MAGAZINE. This full-color magazine, adapted from the 1994 Surgeon General's Report, delivers a tobacco use prevention message, as well as facts and guidance for youth and adults to reduce their risk from environmental tobacco smoke.

f. SGR 4 KIDS LEADER'S GUIDE. A supplement to the SGR 4 Kids magazine to help coaches, teachers, and youth leaders effectively combine the magazine with other health education programs for young people.

g . FASHION'S IN/SMOKING'S OUT. This brightly colored poster graphically contrasts what's "in" (teen fads) and what's out (cigarettes).

h. HEART TUG. This poster provides a straightforward smoking cessation message to adults.

i. IS YOUR BABY SMOKING? This informative series consisting of a pamphlet, easel, and poster is available in English and Spanish, and it encourages mothers who smoke cigarettes to quit smoking.

j. PREGNANT? THAT'S TWO GOOD REASONS TO QUIT SMOKING. This poster, available in English and Spanish, encourages mothers who smoke cigarettes to quit smoking.

OFFICE ON SMOKING AND HEALTH
Mail Stop K-50
4770 Buford Highway, NE
Atlanta, GA 30341-3724

(Allow 3-6 weeks for delivery, and be sure to include the address to which you would like the materials sent).

A catalog is available from the Tobacco Education Clearinghouse of California (c/o ETR Associates, P.O. Box 1830, Santa Cruz, CA 95061-1830, 408-4384822). Included are materials developed as part of California's extensive tobacco control effort, and they are available at cost.

Cessation resources range from simple brochures and booklets to intensive group counseling. Ideally, you will make your staff members who smoke aware of this range and have some of the easier (and less expensive) options on site.

Roughly, estimate the possible demand for cessation services. The following table can help you measure the demand:

Questions/Answers

How many employees smoke?

How many volunteers smoke?

How many parents smoke?

How many smoking employees would try to quit smoking?

How many smoking volunteers would try to quit smoking?

How many smoking parents would try to quit smoking?

(1) If you have a substantial number of employees/volunteers/parents who would try to quit smoking as a way of dealing with the policy change, consider organizing a formal group program on-site.

(2) If there is little or no interest for such a program, focus your efforts on getting less formal cessation aids, such as self-help guides, brochures, and pamphlets.

4. Refine the Policy

Adapt the "Sample Smoke-free Policy and Procedure" to your particular and unique situation. You, with guidance and assistance from your PPC, will be the best judge of how to implement the changes. Important elements that you will want to address in your policy are:

a. Scope - where the policy is in effect. For example, does it include just inside the building where your program is held, does it cover the entire property, does it include social activities that are based around Head Start, does it include Head Start vehicles?

b. Who is Affected - who is covered under the policy. Staff, parents, volunteers?

c. Operational Issues - how will smoking breaks be handled? How will other issues be resolved?

d. Compliance - how will policy compliance be assured?

e. Cessation Support - what cessation resources will be available to the staff, parents, and volunteers?

5. Communicate the Policy

Communicate the Policy and its effective date to parents, volunteers, and staff through letters, memos, and posters, preferably at least one month before the effective date.

Refer to the questions and answers section (following) for suggestions on how to best communicate the policy.

Communicate the policy to the children so that they are aware of possible changes. Take care to avoid creating the image of the "evil smoker."

6. Implement the Policy

Implement changes to bring about a smoke-free environment that demonstrates concern for the health and well-being of children and adults.

Evaluate the changes.- Where are the problems? What do you need to consider changing to make it work better?

III . Questions and Suggested Answers

The following questions and answers have been developed in response to situations and questions that arose from the needs assessment process, the Smoke-free Policy Working Group, and the pilot program. They are 'intended to guide the interpretation of specific issues related to the development and implementation of a smoke-free policy by each Head Start grantee and delegate agency.

A. SCOPE OF THE POLICY

1. Does it apply to homes when used for Head Start purposes? All Head Start offices?

The policy applies to all Head Start offices and program sites. Programs are encouraged to request that parents and other adults at home please refrain from smoking when Head Start activities are occurring in their residences. One way to handle this is through a letter that accompanies registration information sent to the parents before the commencement of the home-based program.

2. Does the policy apply to spit tobacco?

The policy does not address spit tobacco at this time in a formal way, but we recommend that the education and prevention materials used to support the policy also explain the dangers of using spit tobacco and how not using it is a prevention message for youth.

3. Does the policy apply to vehicles when no children nor non-smokers are present?

The policy should apply to a Head Start-owned vehicle that is used for transporting children, regardless of whether or not it is occupied by children or nonsmokers.

4. Can programs ban smoking on property?

Programs can increase the level of restriction to include a smoking ban for the entire property. This measure should be carefully considered in terms of its impact on morale, the extent to which smokers may congregate in an undesirable area, and the extent to which moving all smoking off the property may increase the time smokers spend away from their assigned tasks. The goal is to provide positive role models for the children

5. Does it apply to field trips?

The policy does apply to field trips. Staff, parents, and volunteers must refrain from smoking during field trips. The only exception, as described in the program instruction is during a presentation or field trip related to American Indian cultural customs in which tobacco is utilized.

6. How does it apply to volunteers?

 Volunteers must comply with the policy while they are participating in Head Start activities.

7. Does the policy apply to non-program site administrative offices?

Yes.

B. OPERATIONAL ISSUES

1. Breaks:

(a) How to deal with non-smokers not taking breaks (equity, coverage)?

(b) What if there are currently no formal breaks?

(c) How to deal with smoking breaks in administrative offices, on field trips, during home-based day care, etc.?

(d) How to treat "socializing" during smoking breaks?

The issue of breaks is best addressed on a case-specific basis by the official responsible for administrative and personnel policies for each program. The majority of Head Start programs do not appear to have formal break policies and smokers taking "smoking breaks" can result in resentment among non-smokers who do not have an "excuse" to take a break but also may end up covering for the smokers. Smokers' addiction to nicotine is powerful, and smokers often feel that they "need" a cigarette. However, smokers can go for relatively long periods without smoking with few real problems. Supervisors will have to make satisfactory arrangements for their programs that balance smokers' "need" to smoke, productivity, equity with non-smokers, proper staff to student ratios, and the need to protect the children and non-smokers from secondhand smoke.

2. Other disruptions related to the need to smoke? (e.g., withdrawal)

Supervisors will have the primary responsibility to manage issues arising from withdrawal symptoms smokers may suffer if they are unable to smoke. Supervisors should consult with employees and volunteers who smoke to discuss any problems they anticipate in complying with the policy, and seek practical solutions that do not violate or undermine the policy. Smoking cessation assistance should be offered on an ongoing basis.

3. How to deal with smoking by directors and other senior staff who do not comply with or do not enforce the policy.

The smoke-free policy is just like other policies implemented and enforced by Head Start -- the Program instruction makes very clear the significance of enforcing this policy: "a smoke-free environment will be one of the requirements monitored duping on-site program reviews. "It is recommended that problems related to compliance with the smoke-free policy be managed through the standard grievance process.

4. Can any exceptions be made to the policy for operational or personal reasons?

In general, any exception to or deviation from the policy is discouraged Local supervisors should have some flexibility with regard to decisions about handling of violations of the policy, but great care must be taken not to undermine the policy or to create a situation in which children and nonsmokers are exposed to environmental tobacco smoke.

5. How should problems be identified and resolved?

Communication channels (e.g., -a designated senior administrator) should be made available to a11 Head Start staff who wish to raise issues and seek guidance on dealing with policy compliance or managerial problems. The Head Start national and regional I staff should disseminate information on how problems can be resolved and highlight local successes; technical assistance should be available for complex problems involving labor relations or other technical/legal concerns.

C. PARENTS

1. Does the Policy apply to parents? Under what circumstances?

The Policy applies to parents whenever they are participating in Head Start activities. One exception is that parents can only be asked to comply during home-based visitations but the policy does include field trips and social events for Head Start.

2. How to ensure policy compliance by parents?

When on-site or on a field trip, parents a required to follow the smoke-free policy Head Start staff should receive adequate training, education, and information materials to allow them to communicate to parents the reasons behind and the importance of following the policy. In other areas, Head Start encourages parents to adopt beneficial and healthful behaviors. These same principles should be applied to parents' smoking in order to protect their children.

3. How to gain parental involvement in policy implementation?

Parents should be a target audience for the same communication/education campaign to "sell" the policy to the Head Start staff. The site-specific policies should originate from the Parent Policy Councils, and this should also encourage parental involvement.

D. FACILITIES AND VEHICLES

1. How to deal with lax policies, no policies, or smoking by non-Head Start tenants in shared space?

Head Start directors should respond to lax enforcement of policies, even in shared space. With shared space, efforts should be made to secure a consistent smoke-free policy within the building. When this is not possible, Head Start programs need to take actions necessary to protect the children. This is an example where technical assistance may be required. Head Start staff should also anticipate that in shared space, smokers may go to other tenants' space if smoking is allowed in that space. Staff need to know that this is not appropriate.

2. Where to establish outside smoking areas (pretty to entrances and play areas, in autos, etc.)?

For Designated Smoking Areas (DSA) outside, the key factor is to keep the smokers away from children and intake vents so that children and nonsmokers are not exposed to ETS. Another goal is to avoid displaying unhealthy behaviors to the children, and therefore it is advised to establish the outdoor DSA out of sight of the children. Other factors include concerns for the safety of smokers and the length of time required to reach outside areas. All of these factors should be weighed, but protection of children and non-smokers, as well as maintaining the integrity of the policy, should take precedence. Some staff may choose to smoke in their automobiles parked on or near Head Start property. Local policies should anticipate this and clearly address whether or not such activity is to be permitted.

3. What kind of signage should be used, in facilities and vehicles, and from where is it available?

Polite signage, emphasizing positives (e.g. "Smoke-Free Zone - Thank You For Not Smoking") and not negatives or prohibitions (e.g., "No Smoking") is strongly encouraged based on widespread experience and the results of the Head Start needs assessment and pilot program. Signs should communicate the positive "smoke-free' message and emphasize protection of children, while remaining unambiguous about the importance of compliance. Some research needs to be performed to find the most appropriate signs to be recommended, though such signs are available from federal agencies and from national voluntary associations such as the American Lung Association and the American Cancer Society. Also, signs could be developed as art work projects for the children.

 4. How to minimize the risk of fire from smoking in out-of-the-way places?

DSAs should be clearly marked (for staff and parents) and should not be so inaccessible for smokers that they will violate the policy and smoke in dangerous places.

E. ENFORCEMENT AND SANCTION

1. How to treat non-compliance?

Non-compliance with the smoke-free policy should be handled in the same manner as other violations of established policies and work rules. If a progressive disciplinary policy is in effect, violations should be handled according to established procedures. Employees should understand that repeated or flagrant violations of the policy could result in termination.

2. How to deal with senior managers who smoke and do not enforce the policy?

The standard grievance process should be used to deal with compliance problems. Staff should not fear any consequences from taking action to report violations of this type; this is a health and safety policy and the welfare of Head Start children should not be jeopardized by anyone, regardless of their position.

SAMPLE SMOKE-FREE POLICY AND PROCEDURE

PROGRAM INSTRUCTION:

As per the Program Instruction #ACYF-PI-HS-95-04 ("Establishing a Smoke-Free Environment in Head Start Programs"), all Head Start grantees and delegate agencies are required to create smoke-free environments and to eliminate exposure to tobacco smoke by children, staff, and parents in the Head Start program.

POLICY:

Due to the acknowledged hazards, both to adult non-smokers and especially to young children arising from exposure to environmental tobacco smoke, it shall be the policy of (name of Head Start program) to provide a smoke-free environment for staff, children, and participants. This policy covers the smoking of any tobacco product and applies to both employees and non-employee participants of . will serve as an example to other child care and community agencies. staff and volunteers will serve as role models by not smoking in the presence of children, parents, and participants.

DEFINITION:

1. There will be no smoking in any facility at any time.

The decision to provide or not provide designated smoking area outside the building will be at the discretion of the program director or local decision-making body.

The designated smoking area will be located out of children's sight, away from main entrances to the building, and at least 20 feet away from the main entrance.

All smoking trash including cigarette butts and matches, will be extinguished and disposed of in appropriate containers. Program supervisors will ensure periodic clean-up of the designated smoking area. If the designated smoking area is not properly maintained (for example, if cigarette butts are found on the ground), it can be eliminated at the discretion of the program director.

2. There will be no smoking in any vehicle.

There will be no smoking in vehicles at any time.
There will be no tobacco use in personal vehicles when transporting persons on authorized business.

3. There will be no smoking by staff or volunteers when children are present. This includes both indoor and outdoor activities.

Field trips, walks, and other off-site activities will be smoke-free to the fullest extent possible. There will be no smoking by staff or volunteers during off-site activities. Because of the need to maintain a high staff/child ratio during field trips, staff or volunteers will not leave the children for the purpose of a smoking break.

Staff, parents, and participants will not smoke during on-site conferences. Staff will not smoke and will request that parents not smoke during home visits. Parents will be informed of the smoke-free request prior to the home visit.

4. ____'s smoke-free policy shall apply to all off-site activities and functions .

During indoor activities, the designated smoking area shall be outside the building and out of sight of the children at least 20 feet away from the main entrance of the building.

During outdoor functions, the designated smoking area will be out of sight of the children and at least 100 feet away from the activity area.

5. Breaks

Supervisors will discuss the issue of smoking breaks with their staff and together they will develop effective solutions that do not interfere with the productivity of the staff.

PROCEDURE:

1. Staff will be informed of this policy through signs posted in facilities and vehicles, the Procedures Manual, and orientation and training provided by their supervisors.

2. Volunteers, parents, and participants will be informed through the following methods

a. The policy will be stated in the parent handbook.

b. Signs will be posted in Agency facilities and vehicles.

c. Signs will be posted on parent bulletin boards on the effective date of the policy, and if necessary, at other times during the year.

d. Announcements will be made during parent orientation, center committee meetings, and Policy Council training.

e. Explanations of the policy will be attached to field-trip and home visit notifications.

f . Other communication mechanisms deemed appropriate by the director.

3. The will assist staff who wish to quit smoking by facilitating access to recommended smoking cessation programs and materials.

4. Any violations of this policy will be handled through the standard grievance procedure.
 

BIBLIOGRAPHY OF SELECTED ARTICLES

Evans, D., Levinson, M.J., Feldman C.H., et al. (Mar. 1987). "The impact of passive smoking on emergency room visits of urban children with asthma." American Review of Respiratory Disease 35(3):567-72.

Data obtained from a study of 276 children with asthma from 259 low-income families were analyzed to determine if passive smoking is associated with frequency of emergency room (ER) visits, hospitalizations, and impaired pulmonary function. The analysis revealed that passive smoking was positively associated with ER visits, but not with hospitalizations or abnormalities in pulmonary function. The estimated annual increase in ER visits attributable to the presence of one or more smokers in the household increased 63% over non-smoking children..

Hinton, A.E., Buckley, G. (Nov. 1988). "Parental smoking and middle ear effusions in children." Journal of Laryagology and Otology 102(11):992-6.

A study was conducted on seventy children to ascertain any relationship between parental smoking and the presence of middle ear effusions in the children. Findings revealed that the presence of middle ear effusions and an increase in related symptoms like wheezing, coughing and sputum production was associated with an increased incidence of parental smoking.

Moessinger, A.C. (1989). ""Mothers who smoke and the lungs of their offspring." Annals of the New York Academy of Sciences 562:101-4.

Maternal smoking was reported to be associated with an increase in respiratory infections such as pneumonia and bronchitis in young children. Researcher indicated that there is also mounting evidence that maternal smoking during pregnancy adversely affects fetal lung development.

National Academy Of Sciences Committee to Study the Prevention of Low Birthweight. (1985). Preventing Low Birthweight. National Academy Press, Washington, D.C.

Findings of an interdisciplinary committee of the National Academy of Sciences that studied the problems of prematurity and intrauterine growth retardation note that maternal cigarette smoking is one of the most important determinants of low birth weight in the United States, contributing significantly to 20 to 40 percent of low birth weights.

Nelson, D.E., Sacks, J.J. and Addiss, D. G. (1993). "Smoking policies of licensed child/day-care centers in the United States." Pediatrics 91:460-463.

Data from a national survey of 2003 directors of licensed child day-care centers were analyzed to determine employee smoking policies, measure compliance with state and local employee smoking regulations for child day-care centers and state clean indoor air laws, and to estimate the extent of exposure to environmental tobacco smoke in these settings. According to the authors of this study, despite the presence of strong smoking policies at the majority of the child day-care centers, 752,000 children in the United States are still at risk for environmental tobacco smoke exposure in these settings. (Presumably, the non-smoking policies are not rigorously enforced.) The study indicates that the best predictors of more stringent employee smoking policies were locations in the West or South, smaller size, independent ownership, or having written smoking policies.

Schoendorf, K.C., Kiely, J.L. (1992). "Relationship of sudden infant death syndrome to maternal smoking during and after pregnancy."

The authors conducted a case-control analysis of sudden infant death syndrome (SIDS) and maternal smoking (i.e., maternal smoking both during and after pregnancy [combined exposure], maternal smoking only after pregnancy [passive exposure], and no maternal smoking). The conclusions of the researchers "suggest that both intrauterine and passive tobacco exposure are associated with increased risk of SIDS."

U.S. Environmental Protection Agency. (1992). "Respiratory health effects of passive smoking: lung cancer and other disorders" Office of Research and Development, Office of Health and Environmental Assessment, Washington, D.C. EPA/600/6-90-006B.

The U. S. Environmental Protection Agency (EPA) has published a major assessment of the respiratory health risks of passive smoking. Conclusions from the findings in this report are that exposure to environmental tobacco smoke (ETS) commonly known as secondhand or passive smoking - is responsible for approximately 3,000 lung cancer deaths each year in nonsmoking adults and impairs the respiratory health of hundreds of thousands of children.

NATIONAL, STATE, AND LOCAL PROGRAMS INVOLVED IN PUBLIC EDUCATION ON THE DANGER OF SMOKING, SMOKING CESSATION, AND OTHER RELATED TOPICS

AMERICAN CANCER SOCIETY

Every year, the 57 divisions and 3,400 local units of the American Cancer Society (ACS) reach millions of adults and young people through smoking education, prevention and cessation programs. In addition to its mass media efforts and physician counseling, the ACS makes special efforts, such as November's Great American Smokeout and April's Cancer Crusade, to reach all smokers.

Descriptions of some of the most widely disseminated ACS smoking prevention programs are listed below:

- Starting Free, Good Air For Me is a program that helps preschoolers understand that they can leave the room when someone is smoking, tell an adult how smoking makes them feel and ask and adult not to smoke in their presence. The program includes five different story books, hand puppets, a classroom poster, stickers, coloring books, and home activity sheets.

- Where there's No Smoke is a public education initiative for motivating community leaders and citizens to protect themselves and their communities from the hazards of environmental tobacco smoke.

- Smart Move is an introductory program for smoking cessation. The goals of Smart Move are to inform, motivate, and offer smokers another opportunity to stop smoking, as opposed to guiding smokers through the quitting process. The program consists of a slide tape presentation, script, notes to the presenter, and a list of common questions and answers on smoking and quitting.

- Guide to Community Action Toward a Smoke-Free Indoors assists volunteers in educating and persuading community decision-makers to adopt voluntary clean indoor air policies. This guide supplies the basic information and tools to recruit, inform, and motivate volunteers toward community action.

- Special Delivery is a smoking cessation program to help low-income pregnant women stop smoking. Special Delivery provides stop smoking information in settings where low-income women already receive health, education, and social services. Specific guidance and program materials have been developed to support and enhance each step of the implementation process at these various settings (clinic, community centers, local programs serving pregnant women).

For information on the above programs and additional programs and material available through the American Cancer Society, contact your local division of the American Cancer Society and they will also be able to provide costs associated with their materials and programs. The phone numbers for local chapters of the American Cancer Society can be located in the white pages of telephone directories.

AMERICAN HEART ASSOCIATION

The smoking intervention programs of the American Heart Association (AHA) are designed to prevent young people starting to smoke and to help those smokers who want to quit. These programs are promoted in three primary delivery sites: schools, places of work, and health care delivery sites. Program modules are developed at the AHA National Center and tested in the field for one or more years to determine their effectiveness. Modules with a demonstrated benefit are packaged and delivered to affiliates for implementation. The following programs have been developed for those adults.

- Heart At Work is an intervention program for adults designed for implementation in the workplace. The program includes modules on hypertension, nutrition, exercise, signals and action for survival, and smoking reduction. The smoking reduction module consists of two components: a model policy for restricting smoking in the workplace and a self-help cessation kit. The model policy provides companies with practical guidance for restricting smoking among employees. Posters are included that associate a smoke-free work environment with Job satisfaction and success.

- Calling It Quits is a self-help smoking cessation kit contained in the module that was adapted from the Quit It program developed by the National Cancer Institute. This kit is offered to employees who want to quit smoking. Supportive posters are provided that present a powerful message to smokers who are parents of young children..

For additional information on the above programs and other programs sponsored by the American Heart Association as well as costs associated with materials, contact your local chapter of the American Heart Association. Telephone numbers for local chapters can be located in the white pages of local telephone directories.

AMERICAN LUNG ASSOCIATION

The American Lung Association (ALA) and its 139 affiliates nationwide conduct a comprehensive range of programs and activities that encourage smokers to quit, prevent those people who do not smoke from beginning and protect the right of non-smokers. The new Smoke-Free Campaign, the ALA's response to the Surgeon General's challenge for a smoke-free society by the year 2000, provides smoking prevention, education, and cessation programs, activities, materials, etc. The ALA Minority Outreach Initiative strives to reduce lung disease and promote lung health in minority populations. Through networking with minority agencies and developing culturally appropriate material such as Freedom From Smoking For You--And Your Family, the ALA is endeavoring to meet the needs of multi-cultural, minority families. Some of the programs listed below, which have been developed by the American Lung Association, address smoking cessation, education for Young children to prevent smoking, and guides for protecting the rights of non-smokers.

- Freedom From Smoking Self-Help Manuals consist of two colorful, extensively illustrated guides to the quitting process.

- Freedom From Smoking in 20 Days is a basic day-by-day approach to quitting, and A Lifetime of Freedom From Smoking reinforce smokers' commitment to their new, non-smoking lifestyle.

- Octopuff in Kumquat is the ALA animated feature film designed to present positive health values to children between the ages of 4 and 8. Octopuff is a full-color, 9 minute film that tells the story of an imaginary character named Octopuff who, despite protests from the elders and the children, introduces smoking to the village of Kumquat. Solutions to the resulting environmental problems and Octopuff's subsequent reformation are effected by the intervention of the village children. A teacher's guide is available to suggest supplementary classroom activities.

- Freedom From Smoking At Work consists of trained ALA staff who help companies develop a comprehensive approach to reducing smoking at the workplace. Two manuals, Taking Executive Action and Creating Your Company Policy, are available to management and employees to help them develop effective policies on smoking. Freedom From Smoking self-help clinics and video programs can be adapted to the workplace, and company personnel can be trained by ALA staff to lead clinics. Special posters are available to help initiate a company-wide campaign on smoking.

The ALA and its affiliates also conduct public education campaigns by distributing written materials such as the ALA leaflet, Second-Hand Smoke as well as a guide to creating a smoke-free environment. ALA requests that interested organizations contact their local affiliates whose telephone numbers can be found in the white pages of local telephone directories.

FEDERAL PUBLICATIONS

U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

U.S. Department of Health and Human Services. (1990) The Health Benefits of Smoking Cessation. U.S. Department of Health and Human Services, Public Health Services, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 90-8416. The executive summary is free of charge. CONTACT: Public Information Branch (Office on Smoking and Health) 404-488-5703.

U.S. Department of Health and Human Services. (June, 1991). Environmental Tobacco Smoke In The Workplace, U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health. Current intelligence 54. This publication is free of charge. CONTACT: Public information Branch (Office of Smoking and Health) 404-488-3703.

U.S. Environmental Protection Agency., Indoor Air Division. (January, 1993). The Respiratory Effects of Passive Smoking: Lung Cancer and Other Disorders. Request free copy of Executive Summary. CONTACT: IAQ Information Clearing House. Telephone: 1-800-438-4318 or (301) 588-3408.

U.S. Environmental Protection Agency. (June 1989). Indoor Air Facts No. 5: Environmental Tobacco Smoke. U.S. Environmental Protection Agency, Office of Air Radiation (ANR-445). CONTACT: U.S. Environmental Protection Agency, Indoor Air Information Clearinghouse (IAQ INFO), P.O. Box 37133, Washington, D.C. 20013-7133, Telephone: I-800-438-4318 Fax.- 301-588-3408.

ADDITIONAL RESOURCES

ATTACHMENT D

The following agencies can provide general information on smoke-free environments and smoking cessation.

Public Information Center
U.S. Environmental protection Agency
Mail Code PM-211B
401 M Street, SW
Washington, D.C. 204

Action on Smoking and Health
2013 H Street, NW
Washington, D.C. 20006

Office of Cancer Communications
National Cancer Institute
1-800-4-CANCER

Healthy Mothers, Healthy Babies
409 12th Street, SW, Room 309
Washington, D.C. 20024-2188
Phone: 202-863-2458
Contact: Ms. Lori Cooper, Director

Centers for Disease Control
Public Information Center
Office of Health and Smoking
Mail K50
1600 Clifton Road
Atlanta, GA 30333
Phone: 404-488-5705

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