Nicotine abstinence programs for adolescent high-school students have been proposed as a prospective response to the physical and economic burden caused by chronic obstructive lung diseases and disability experienced by most tobacco users. Tobacco use resulted in over 400,000 annual deaths and continues to represent the single most preventable cause of death and disability in the United States.1 It has been estimated that 4,000 young people smoke their first cigarette daily,2 and there are more than 2.8 million smokers under the age of 18 in the United States.3 In the past 10 years, more than 500,000 children under the age of 18 started a daily smoking habit, and 3.4 million high-school students are current smokers, with an average of 19.5% reporting they smoked within the past month. Approximately 400,000 adults die annually from their own smoking, with 30,000 children a year losing at least one parent to a smoking-caused death. In addition, 33% of children alive today will die prematurely from smoking-related illnesses.4
REVIEW OF THE LITERATURE
Tobacco use is responsible for 90% of lung cancers and over 75% of oral and throat cancers.5 Approximately 90% of adult smokers indicated they initiated smoking (and 70% indicated they were daily smokers) before the age of 18.6 The severe health problems associated with tobacco use are seldom present during the initial years of use, although there are some short-term health effects of smoking/tobacco use, including respiratory effects, oral cavity problems, addiction to nicotine, and the associated risk of other drug use. Young smokers were three times more likely to use alcohol, eight times more likely to use marijuana, and 23 times more likely to use cocaine.5 Smoking is considered a “gateway” to these drugs and other risky behaviors, such as violence and unprotected sexual activity. In this regard, interventions to address smoking or tobacco use may serve to assist a person who is also involved in or at risk for other self-destructive behaviors. It is interesting that, when questioned, almost all smokers vastly underestimate the difficulty of quitting tobacco.
Plano Clark7 and associates studied student smoking habits by conducting interviews with high-school student smokers and analyzing statements that reflected the influences on adolescent smokers and their readiness to quit. Calvert and associates8 revealed the influence of adolescent nicotine use on risky behaviors such as drinking alcohol. McVea et al9 conducted adolescent smoking cessation training, using high-school students as peer researchers to lead focus groups concentrating on teen perceptions of tobacco use and the perceived toleration of smoking in high schools. Baillie and colleagues10 interviewed adolescents in an attempt to find factors that influenced their decision to transition from experimental to regular smoking.
Most intervention efforts involved tobacco control policies aimed at reduction of youth access to tobacco and educational campaigns that emphasized primary prevention of tobacco use. Guidelines were often developed for school health programs to prevent tobacco use and addiction, but little information existed to describe effective youth cessation programs. A common finding was to have a drug education prevention program in grades K-12, a punitive “zero tolerance” policy for possession or use of illicit drugs/alcohol on school campuses, and a school policy for tobacco use that involved incremental suspensions for each violation. Schools with policies disallowing tobacco possession and use on school grounds seldom offered cessation programs for violators. In fact, it was unclear whether adult cessation models were applicable to adolescent tobacco cessation. Studies involving adolescents and youth have increasingly appeared in the literature, but these studies lack stringent scientific design or effectiveness compared to the more established adult cessation literature. For example, cessation rates have not been quantified or subjected to biochemical verification, although self-report evaluations revealed that adolescents became physically dependent on nicotine soon after daily tobacco use was initiated. Additionally, the literature reflected the fact that it was difficult to recruit and retain adolescents in formal smoking cessation programs. Prochaska and colleagues11 described changing smoking behaviors as a progression through multiple stages, where the smoker might not observe the signs that smoking was a problem behavior.
According to a National Institutes of Health study, greater than 90% of adolescents interviewed believed they would quit smoking before they were adults, three out of four teen smokers will make at least one quit attempt, but 75% of teens who smoked daily continued to smoke into adulthood.6 Efforts to prevent smoking initiation and to promote cessation have been only partially successful. While the rate of daily smoking has now decreased to approximately 24% of all adults, greater than 36% of high-school students reported smoking in the past month and 11% reported using smokeless tobacco (21% of white males).12 The rate of tobacco use was higher in specific regions of the country (Southeast) and in tobacco-producing states. For instance, the rate of smoking for high-school students in Tennessee was 39% and the rate of smokeless tobacco use was 14%.13
READINESS TO QUIT
The transtheoretical model of change is a theory of behavior change that has been successfully applied to adult smoking cessation.14 This model predicts that smokers will move through a series of stages leading up to quitting. Smokers in the earliest stage of precontemplation do not perceive their behavior as problematic and have no intention of changing. The contemplation and preparation stages indicate an increasing awareness of a problem behavior and a willingness to attempt change. The action stage is represented by a person actively trying to change a behavior, ie, is using nicotine patches and not smoking. Readiness to change can be affected by a number of environmental and personal variables. These variables interact and lead to progress toward a behavior change or can combine and lead to relapsing behavior or a return to a baseline problem behavior. For a person to change from stage to stage, the appropriate process variable(s) must be applied for that stage. Approximately 40% of smokers are in the earliest stage of readiness to change, another 40% to 45% are thinking about quitting (contemplation stage), and approximately 15% to 20% of smokers are represented in the preparation or action stages of readiness. For individuals in the earliest precontemplation stage, an intervention emphasizing stage progression rather than quitting is most appropriate. The initial applications of this model for youth tobacco users revealed that they were not a homogenous group, rather there were percentages of smokers in all stages of readiness to change. Approximately 50% were in the precontemplation stage, 30% to 35% in the contemplation stage, and only 15% to 20% in the preparation or action stages of change.
Variables that predict a transition from stage to stage in becoming a regular smoker have been examined, and factors that predict cessation or continued tobacco use have also been evaluated.15 These variables include smoking history, demographic variables and alcohol use, reasons for quitting, and psychosocial variables pertaining to peers, adults, coping, rebelliousness, and antismoking attitudes. In the latter stages of smoking acquisition, there are a few differences between adolescent male and female smokers. Social influence variables of parental and friends’ smoking, cigarette offerings by friends, and parent-child conflict tend to predict a transition from experimental to regular use only among females. The interpersonal variables of risk-taking and rebelliousness have been identified as factors linked to transition from trial use to more advanced stages of smoking behavior in males.
In regard to cessation of tabacco use, those who use more tobacco and for longer periods of time are generally less likely to make a quit attempt or to succeed in an attempt, and adolescents who have made a greater number of quit attempts are more likely to quit. Their reasons for quitting are generally linked to personal health, social pressure from family or friends, interpersonal reasons of cost, or dislike with the feeling of addiction.
Kevin Everett, PhD, associate professor in the department of family and community medicine at the University of Missouri, and colleagues conducted a survey of high-school students that measured behaviors and attitudes concerning tobacco and alcohol use. The design of this program was based on intervention efforts found in the literature. The survey was completed by 698 local high-school students, with 34% of these students stating they had smoked in the past month, 23% smoked at least weekly, and 16% used smokeless tobacco in the past month; 31% of tobacco users had used tobacco on school grounds. The researchers were challenged to design a program that addressed the above issues and other factors specific to the adolescent study participants. Factors considered were the number of students who would be enrolled in the study and the time of treatment for the study participants, as these variables influence the power of the analysis in regard to the test, test conditions, and treatment efficacy. The study focused on nonpunitive treatment, and the investigator/group leader was seen as a caring role model rather than authoritarian. The authoritarian role was assumed by the school resource officer and school administrators. Investigators were able to fit participant schedules into the time constraints imposed by the academic schedule of the school system and that of the local health system. These accommodations and careful planning allowed the school districts to offer students their respective treatment programs and an established referral process, with pretreatment assessment and posttreatment follow-up.
Participants in the study included county and city school students who were caught using, or in possession of tobacco products, on a school campus during the academic year, an offense that could be charged as a misdemeanor. Students were given the option of appearing in juvenile court and facing civil penalties (in accordance with state laws) or attending the current school-board-approved programs. Informed consent was obtained from each parent or guardian as part of the referral process. Confidentiality of the research data was assured by compliance with the rigorous guidelines approved by the institutional review board (IRB). Based on the pilot work, about 60 to 80 students per group would be referred to the treatment programs during the academic year. Students completed pretreatment assessment forms that covered demographic variables as well as variables associated with tobacco use (stage of readiness for change, tobacco use status, and attitude change regarding tobacco). These variables served as the primary dependent or outcome measures. Secondary dependent measures included psychological measures—mood, depression, and anxiety; interpersonal variables of risk taking/rebelliousness; and coping strategies. The independent variables were three compared groups (two active treatment groups and a minimal treatment/control group). In the two active treatment groups, a full course of treatment took place in the time frame of 1 month.
Treatment A was a commercially purchased program implemented by trained professional counselors. This program involved small group sessions in a revolving three-session series. Participants were to attend all three sessions, but were allowed to continue to come to sessions as long as they wished. These sessions educated participants about the problems associated with tobacco use through lectures, videos, demonstrations, and cooperative learning. The intent of the sessions was to give young people the knowledge, motivation, and action steps to move toward a healthier, tobacco-free lifestyle.
Treatment B was designed to change behavior through three interactive learning sessions. Treatment activities included: 1) participation in a small group activity designed to elicit personal tobacco use experiences, identify the pros and cons of use, and personalize the health risk of tobacco use; 2) visiting a pulmonary rehabilitation facility to talk with a patient, try an exercise designed to simulate breathing with emphysema, and receive personalized feedback concerning the status of their pulmonary functioning; followed by 3) a one-to-one counseling session designed to enhance motivation to change.
Treatment C was a minimal intervention program that was designed to serve as a control group. This group was given advice to seek assistance from their school counselor or a referral to local health care providers for cessation intervention.
The dependent variables were measured immediately post-treatment, and at a 3-month post-treatment follow-up. Categorical and simple statistics were calculated on demographic and dependent variables. If baseline variables were significantly different between the treatment groups, utilization of statistical models corrected for these differences. Statistical process was designed to identify significant differences in the treatment effects, and regression equations were developed to find variables that best predicted a positive response to treatment, or, conversely, variables that predicted continued tobacco use.
FINDINGS RELATED TO PROGRAM DESIGN
The approval of an IRB and the research team’s maintenance of stringent IRB guidelines were critical attributes that must be considered when research is conducted on protected populations such as adolescents. Gaining the signatures of the parents and/or guardians of minors who lived in alternative family units was a problem that required the researchers to actively pursue this component of informed consent. Scheduling a group process for high-school students was difficult, and required negotiations with the high-school principal, resource police officer, teachers, and counselors. In retrospect, coordination of this program as an after-school session allowed them to maintain their presence at normal academic schedules. While these sessions worked for school personnel, they were not viewed positively by all student participants. Almost all participants worked or played sports after school and were forced to miss practice or be late for work, perceived as a punitive measure. The sessions at the local pulmonary rehabilitation center, which were scheduled at the same time, seemed popular with participants, however, and intrigued the young smokers so that they tested their fitness and lung function on elevated treadmills, breathed through drinking straws to emulate airway obstruction, and saw their measurements after performing forced vital capacities during pulmonary function tests.
While many of the participants were lost to follow-up, those who responded had a low nicotine abstention rate that was similar to that reported by McVea et al.9 Adolescent children recruited for this study strongly valued adult figures who smoked, particularly family members and those in authority, including coaches and teachers who used tobacco products; hence, when parents, grandparents, and other authority figures smoked or used smokeless tobacco, it decreased the probability that the participant would become smoke free. In the small group sessions, student discussions centered on their access to tobacco products, perceptions of addiction and habituation, and their life with tobacco—they were guided to discuss when and where they smoked, cost of the habit, how they smoked and what they smoked or chewed, who they were with when they smoked, what time they smoked the most and/or the least, and smoking’s impact within relationships, ie, siblings, significant boy and girl friends, parents, etc. Several of the male participants voiced a desire to control tobacco use within their families, in particular asking how to keep their children tobacco free. Positive feedback was offered for those who had attempted smoking cessation but were unsuccessful, with efforts to educate those who had made multiple unsuccessful attempts and suggestions on how they would be successful in future attempts.
Study findings point to important considerations for future studies. Voluntary participants were likely to be ready to quit tobacco use, but represented only a minority of smokers. Involuntary participants, such as court-ordered monitors or students required to participate as a consequence of violating school policy, were likely to have low motivation to quit and represented the precontemplation stage of readiness to change. Students might have had academic deficiencies, other substance use problems, and significant family conflicts or personal mood syndromes. The resurgence of teen smoking16 required innovative and collaborative interventions. Sessions were nonconfrontational, provided personalized feedback, emphasized informed choice, and recognized and applauded modest behavior changes. Additionally, the design emphasized communication and cooperative efforts between school administration, law enforcement and juvenile courts, and community health care providers. This program’s design offered a positive, in-school education about tobacco use, and reinforced the tobacco abstinence message while allowing students the choice to avoid a criminal record. Program participants had a nonjudgmental audience that learned from their reflections upon their own tobacco use, and it served as an intervention that better defined their tobacco use and its impact on their young lives. The researchers caution that the constructs of this program, its design, and all of the findings should be viewed as preliminary, and replication of these findings would be needed to clarify the most effective interventions for adolescent tobacco users.
Douglas E. Masini, EdD, RRT, FAARC, is associate professor and director of respiratory therapy, department of respiratory therapy, Armstrong Atlantic State University, and clinical assistant professor, internal medicine, Mercer University College of Medicine, Savannah, Ga; Kevin Everett, PhD, is associate professor, department of family and community medicine, University of Missouri, Columbia. For further information, contact [email protected]
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