Partners In Health Network

It’s no secret that West Virginia has long ranked high for its rate of tobacco use. In fact, the state currently leads the nation in adults who smoke cigarettes, with over a quarter of the population using cigarettes every day or some days. As tobacco prevention advocates work to lower the adult smoking rate, some are shifting their approach and looking at the ways in which youth first use tobacco.

New research on youth tobacco use has exposed vaping as a key gateway to smoking and a growing epidemic among middle and high school students. A study released by consumer advocacy organization DrugWatch noted that over three-fourths of teens who use tobacco say their first tobacco-related product was an e-cigarette. The study also ranked West Virginia first in teen vaping, with 35% of high schoolers vaping (more than double the national average) and 17% of middle schoolers vaping (more than five times the national average).

These staggering numbers, along with other studies that show most smokers start before age 18, underscore the need for continued tobacco use and vaping prevention efforts. However, in recent years, the West Virginia Legislature has significantly reduced funding for these types of programs, forcing tobacco prevention advocates to rely on foundations and other organizations for support.

Partners in Health Network (PIHN), based in Charleston, is one of the organizations working to reduce tobacco use in West Virginia. In 2018, its Appalachian Pulmonary Health Project (APHP), which provides access to pulmonary services in rural areas, expanded its mission to include tobacco use prevention.

“Primary prevention means preventing a health problem before it ever gets started,” said Daniel Doyle, M.D., a family physician and community health leader who serves as the clinical director for APHP. “That means influencing people to never become addicted to tobacco products in the first place, which led us to schools where the habit and addiction begins.”

A Refined Focus

As part of its expanded mission, the PIHN team began meeting with teachers, principals, and nurses to explore existing curricula for tobacco use prevention. In doing so, they learned about the changing culture of tobacco use in middle and high schools and the growing concern over the youth vaping epidemic.

“School staff alerted us to the vaping epidemic and noted that youth were taking up vaping in fifth grade and earlier,” Doyle said. “Two school-based health educators in Fayette County told us about the national CATCH My Breath curriculum. We investigated it, studied it, and began teaching it ourselves in 2018.”

CATCH My Breath is a national, evidence-based youth vaping prevention program developed by The University of Texas Health Sciences Center at Houston School of Public Health. The program provides up-to-date information to teachers, parents, and health professionals to equip students with the knowledge and skills needed to make informed decisions about the use of e-cigarettes, or vapes. CATCH My Breath is the only vaping prevention curriculum endorsed by the U.S. Substance Abuse and Mental Health Services Administration.

The school-based curriculum consists of four 40-minute sessions that are interactive and hands-on. Topics include how to recognize health hazards and dangers, resist personal influences and marketing tactics, and role play refusal skills.

In 2019, PIHN approached the Pallottine Foundation of Huntington about a partnership to pilot the CATCH My Breath program in six West Virginia counties and 10 schools, with the goal of reaching 2,400 students over a two-year period. The discussion resulted in a formal application from PIHN and a $267,307 Core Priorities Initiative grant from the Foundation to fund the program’s delivery.

“We were enthusiastic about this program from the start,” said Janell Ray, CEO of the Pallottine Foundation of Huntington. “Tobacco use prevention and cessation is one of our core focus areas, and prevention programs are vital given the high smoking rates, the growing vaping epidemic among youth, and the absence of any significant statewide tobacco prevention strategies. We were eager to work with Partners in Health on a program that had the potential to create a large, lasting impact in the counties we serve.”

PIHN’s CATCH My Breath program began as a partnership with schools and federally qualified health centers (FQHCs) to deliver the curriculum in Lincoln, Logan, Mingo, and Kanawha counties in West Virginia, and Floyd and Martin counties in Kentucky. Healthcare providers, respiratory therapists, and nurse practitioners from the FQHCs co-presented the information with classroom teachers.

The Pandemic Effect

When the COVID-19 pandemic occurred, delivery of the CATCH My Breath curriculum had just begun. Schools abruptly closed and clinical staff from partnering FQHCs were forced to divert their attention to patient care. These circumstances led PIHN to reexamine how the program was being delivered to ensure it would continue and be adaptable throughout the pandemic.

The national CATCH My Breath program responded to the pandemic by providing curriculum in a video format that could be delivered to homebound students through virtual learning platforms used by West Virginia schools. As a result, PIHN and the Foundation team worked together to reallocate funds for the purchase of video licenses, enabling existing CATCH My Breath programs to continue.

“We understand that programs may need to evolve in order to be successful and impactful,” Ray noted. “So, we gave Partners in Health the freedom to adapt during the pandemic, which posed extreme challenges for many of our nonprofit partners. We are always available to discuss challenges and will try to be flexible to ensure the work continues.”

The Foundation ultimately granted PIHN two one-year extensions for the CATCH My Breath program, changing the original grant performance period from two to four years.

When schools resumed in-person instruction, PIHN determined that the curriculum could be delivered just as effectively, with fewer scheduling logistics and at a much lower cost, if teachers or school staff provided instruction without the previously required FQHC assistance. This led to the proposal of a new model that would create “teacher champions” within the schools and provide incentives for school participation. Without reliance on FQHCs, more schools could implement the curriculum themselves, and PIHN could reach more students.

“The PIHN team understood very early on that their intended delivery model would be significantly impacted and likely for an extended period of time,” said Laura Boone, Senior Program Officer with the Pallottine Foundation of Huntington. “They did not cling tight to their original plan. Instead, they brainstormed creatively and realistically about who the key stakeholders needed to be to get the program implemented in more schools across the region.”

When approached with the new program concept, schools were eager to participate and quick to accept the “Principal’s Challenge,” which provided monetary awards that could be used for health and wellness programming and equipment for students. The incentives gave schools a new way to engage students and opportunities to celebrate participation through check presentations from PIHN, which were incorporated into pep rallies and student assemblies.

“Designing an incentive model that schools responded to was a key victory,” Boone noted. “The offer of an incentive at the outset kept the interest of school leadership during initial conversations. They could receive flexible funding for participating in a program that was going to help them meet their health curricular objectives, and that was a much more exciting sell.”

PIHN’s CATCH My Breath initiative has far surpassed its original goal. Since 2020, the program has been implemented in 25 schools, reaching over 9,000 students in Boone, Kanawha, Logan, Lincoln, Mingo, Cabell, and Wayne counties in West Virginia, and Pike and Martin counties in Kentucky.

“By Spring 2021, participation took off,” Doyle continued. “Although the project ran for eight school semesters, 90% of students got it in the last five semesters. There is a lesson there for funders and program leaders about how long it takes for a planted seed to germinate, sprout, and grow.”

Measuring Impact

All students who participate in the CATCH My Breath program are asked to complete pre- and post-course surveys that collect information such as students’ personal vaping experiences, their knowledge of e-cigarette ingredients, and associated dangers and risks of vaping. PIHN recently released its first progress report, which summarizes survey results from students and staff in six Cabell County schools.

The report, prepared by the WV Alliance for Creative Health Solutions in collaboration with Dr. Ashley Stephens of the Cabell County Board of Education, notes that from August 2021 through December 2022, the CATCH My Breath program reached 96 teachers and 2,099 middle and high school students in Cabell County.

Five of the six questions asked of students showed statistically significant knowledge improvement. Post-program surveys indicated students were much more aware of e-liquid ingredients, legal restrictions on tobacco use, and identifying direct and indirect pressures. In addition, 89% of students agreed that all children in middle and high school should go through the CATCH curriculum, and 85% of them said they were less likely to vape after participating in the program.

“I strongly believe that students need to be educated and empowered to make the best decisions they can about the dangers around them,” Stephens said. “We cannot dictate how a student will behave in terms of their decision to vape or not, but we can equip them with the knowledge of what vaping involves, an understanding of the money and intention being put into enticing them to vape, and a menu of refusal tactics. Based on student feedback, CATCH My Breath is an effective tool to help advance these goals.”

Survey results from teachers noted several positive themes that developed during the classes, including high engagement and conversation by students; repeated use of key words like “chemicals” and “effects on the brain”; repeated references to addiction; appreciation of the emphasis on refusal skills in the curriculum; and a focus on coping with stress.

Teacher buy-in is key to the program’s continued success and expansion. In May 2023, the Pallottine Foundation of Huntington awarded PIHN a second grant for $50,000 through its Healthy Communities Initiative to expand the CATCH My Breath initiative. The grant will support contracted health teachers who will act as consultants, recruiting more teachers and schools to adopt the curriculum. The award also provides continued support and incentives for schools.

A Model for Systemic Change

The CATCH My Breath program in West Virginia has caught the attention of state leaders looking to make a lasting impact on tobacco prevention and cessation.

“We are very engaged with the West Virginia Department of Health’s Division of Tobacco Prevention right now in preparing to take this program statewide in all 55 counties and 153 middle schools beginning in the fall of the 2023-2024 school year,” Doyle said. “With statewide expansion and sustained inclusion in the health curriculum, we hope to see impact on national youth tobacco surveys that provide state-specific data.”

However, Doyle noted that changes in public health measures like the National Youth Tobacco Survey and the Youth Behavioral Risk Survey are affected by many other environmental factors, including state and federal legislation and regulation, industry advertising that targets youth, and other culture and economic factors. He also said funding for educational programs like CATCH My Breath is key in the continued efforts to prevent youth tobacco use.

“We are hoping that the state and foundations will continue to provide funds for wellness educators, incentives for schools, and training for teachers in the coming years so this effort can be sustained,” Doyle said. “The fact that the Division of Tobacco Prevention has taken on vaping prevention as a statewide effort is admirable and deserves enthusiastic support from all quarters. So far, foundations have responded very generously, and we hope the Governor and Legislature will follow their lead.”

To learn more about the Partners in Health Network, visit www.pihn.org.