Date of Award


Degree Type


Degree Name

Master of Public Health (MPH)


Public Health

First Advisor

Dr. Sheryl Strasser

Second Advisor

Megan Smith, MPH


Background: Tobacco use is a major public health problem associated with a host of preventable morbidities and premature mortality. It is a behavior that most often is initiated during adolescence; therefore schools are an ideal setting for intervention. Policy interventions have the greatest impacts on changing behaviors on a population scale. Comprehensive tobacco-free school (TFS) model polices can be replicated and applied throughout the State of Georgia to help prevent youth from initiating smoking and support their attempts to quit. Engaging stakeholders is necessary in order to ensure proper implementation and enforcement of these policies. Creating healthier school environments that support a 100% TFS policy will continue to demonstrate health improvements resulting from Public Health interventions. The following study assesses associations of key stakeholders in Georgia school districts responsible for overseeing their tobacco-free school policies with the implementation and enforcement of evidence-based components of a comprehensive tobacco-free school policy.

Methods: Developed in collaboration with the Tobacco Use Prevention Program of the State of Georgia (GTUPP), a cross-sectional survey design was used to conduct this study. The survey instrument (based on a previously used survey) consists of 49 items related to 100% tobacco-free school policy adoption and enforcement for students, staff, and visitors. The survey was electronically administered to 3,000 school stakeholders (principals, administrators, school board members). Chi-square tests examined association among those stakeholders in charge of policy enforcement and the various components of Georgia’s model comprehensive TFS policy. A p-value of <0.05 and 95% confidence intervals were used to determine statistical significance of analytic tests.

Results: 328 stakeholders who were invited to participate completed surveys. This represents a response rate of 10.9%. Of the 328 total stakeholders, 315 actually had a TFS policy in place within the surveyed school district and only thirteen respondents replied from schools that did not have any policy in place. Therefore, those surveys completed by non-adopting school officials were not included in the associative analyses for this study. Results indicated that assistant principals who carried the charge of TFS enforcement had the greatest compliance with model policy enforcement (92.9%) regarding posting signage, although the majority of respondents indicated that there was no single stakeholder identified as the policy ‘champion’ (n=65, 40.8%). In schools where ‘other stakeholders’ were identified as being in charge of enforcement of TFS policies—respondents indicated 100% compliance with posting of signage at school. However, these results were not found to be statistically significant [χ=.844(3), p>0.05]. In terms of mass media messaging, while assistant principals and other stakeholders less frequently were champions of TFS policy messaging, they had the highest reports of sharing information about mass media messaging and community-based tobacco prevention efforts (71.4% and 82.6%, respectively). In comparison, among respondents who identified as principals or as another type of stakeholder, reports of sharing information were remarkably lower (55%), although this association was not found to be statistically significant. One point to consider is that all respondents of the survey may or may not have been the actual stakeholder targeted for that school district, but rather a possible representative completing the survey in lieu of the stakeholder.

Conclusions: Study results can help the State of Georgia enhance resource allocation of tobacco prevention funds so that districts with the greatest health threats/greatest opportunities to improve can be targeted. Findings suggest that perhaps assistant principals or other stakeholders who champion the implementation and enforcement of policies may be more compliant with all elements of the Georgia model policy. The analysis conducted for this thesis and the results provided show the need for further in-depth research that examines the roles key stakeholders play in TFS policy adoption, implementation and enforcement.