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CORK Bibliography: Adolescents and Smoking Cesssation

107 citations. January 2003 to present

Prepared: January 2008

Abdullah ASM; Ho WWN. What Chinese adolescents think about quitting smoking: A qualitative study. Substance Use & Misuse 41(13): 1735-1743, 2006. (18 refs.)

The aim of this study was to investigate the attitudes of Chinese adolescents toward smoking, giving up smoking, and smoking cessation programs presently available. The study was a qualitative study carried out in 2002 by focus groups of 32 male secondary school students in Hong Kong who were either current smokers or had recently given up smoking. Subjects were students (grades 8-10) attending two full-day secondary schools in Hong Kong. Participants did not feel the need to make any serious psychological preparation for quitting. They underestimated the addictive nature of cigarette smoking and felt that they could choose to quit smoking at any time with little difficulty. Several barriers to quitting were reported, including boredom, peer influence, the urge to smoke, school work pressure, the wish to do something with their hands, difficulty in concentrating, and the ready availability of free cigarettes from peers. Those who had attempted to quit smoking (26/32) reported that peer influence and boredom were the main reasons why they started smoking and insisted that willpower and determination could have helped them in their quitting attempt. Participants were unanimous that pressure or encouragement from teachers, parents, or girlfriends did not help them to stay off cigarettes. Most (24/32) of the current smokers knew that smoking cessation services were available in Hong Kong, only 50% (12/24) of those who knew had made use of such services. None of the participants were able to identify any effective way of quitting smoking, though some suggested that the best practical measure was to avoid friends who smoked. The study suggests that attempts to persuade young people to quit smoking might benefit if they were framed to address issues such as the strong influence of their peers, the ease with which tobacco products can be obtained, the casual attitudes of young people toward smoking cessation, the perceived pros and cons of quitting, and (given that underage smoking is frowned upon by many parents and teachers) the need to respect confidentiality when offering support.

Albert DA; Severson HH; Andrews JA. Tobacco use by adolescents: The role of the oral health professional in evidence-based cessation programs. Pediatric Dentistry 28(2): 177-187, 2006. (94 refs.)

The use of tobacco products, especially cigarette smoking, represents the leading cause of preventable illness and death in the developed world. In the United States, major gains have been made to reduce smoking among adults. Similar gains, however, have not been realized with adolescents. In recent years, substantial interest has been directed to tobacco cessation studies with adolescents. The previously limited interest in adolescent cessation programs was attributable in large part to the mistaken assumptions that: (1) adolescent tobacco users were not dependent on nicotine and could stop at any time; (2) adolescents did not want to quit; and (3) adult tobacco cessation programs would be effective with adolescents. The need for programs to increase adolescent cessation attempts is underscored by the Healthy People 2010 goal that calls for an increase in tobacco use cessation attempts by adolescent smokers to 84%. Dental providers need to take steps to prevent tobacco use by adolescent patients. For those who are already addicted, they need to provide cessation Counseling services or referral for appropriate treatment. The purpose of this paper was to provide dental clinicians with information on: (1) tobacco and health; (2) the epidemiology of adolescent tobacco use; and (3) tobacco cessation programs for parents and adolescents that can be implemented in the dental office setting.

Albrecht SA; Caruthers D; Patrick T; Reynolds M; Salamie D; Higgins LW et al. A randomized controlled trial of a smoking cessation intervention for pregnant adolescents. Nursing Research 55(6): 402-410, 2006. (42 refs.)

Background: The smoking prevalence rate among pregnant adolescents has been estimated at 59-62%, and 60-80% of these adolescents continue to smoke throughout their pregnancies. Objectives: The aim of this study was to evaluate the short- and long-term effects. of smoking cessation strategies tailored to the pregnant adolescent to attain and maintain abstinence. The specific aim was to examine differences in short- and long-term smoking behaviors among three groups: Teen FreshStart (TFS), Teen FreshStart Plus Buddy TFS-B, and Usual Care (UC) control. Methods: In this randomized controlled intervention study, a 3-group (TFS, TFS-B, and UC) by 3-occasion (baseline, 8 weeks postrandomization, and 1-year following study entry) design was used. The study included 142 pregnant adolescents who were aged 14 to 19 years. Both self-reported smoking status collected on the Smoking History Questionnaire and saliva cotinine levels were used to identify smoking behaviors. Results: There were no significant differences among the three treatment groups at baseline in terms of the racial, distribution, age, gestational age, age of menses initiation, number in family household, number of family members who smoked, or tobacco use. A significant difference be tween the UC group and the TFS-B group (p = .010) was seen in smoking behaviors measured 8 weeks following treatment initiation. At 1 year following study entry, however, there were no differences between the groups in smoking behaviors. Discussion: The TFS-B intervention was more effective in attaining short-term smoking cessation in the pregnant adolescent than TFS or UC. Findings suggest that the peer-enhanced programming had a limited effect but could not sustain the participant beyond postpartum (1 year following study entry). Future studies should include relapse prevention to sustain smoking abstinence into the postpartum period.

Alouf B; Feinson JA; Chidekel AS. Preventing and treating nicotine addiction: A review with emphasis on adolescent health. Delaware Medical Journal 78(7): 249-256, 2006

This article is the fourth in a series of four providing current, state-of-the-art information about the tobacco problem and how physicians can effectively intervene. The articles review the health effects of second-hand smoke, current treatment strategies for nicotine addiction and the implementation of best practices, such as the "5 As," to effectively intervene with families with smokers. Three of the articles are accredited for free continuing medical education (CME) credit for physicians. To obtain AMA PRA Category 1 Credit(s)TM for this article, please go online to , your source for free continuing medical education from Nemours. Choose "Online Education" and the article, and complete the post-test as directed. CME accreditation for this educational presentation is provided at no cost as a service of Nemours, one of the nation's largest children's health systems. Nemours is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Nemours designates this educational activity for a maximum of .5 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity. This article will focus on the prevention of adolescent smoking and discuss a global approach to the tobacco problem among youth. It also reviews the rationale for and pharmacology of treating nicotine addiction to empower physicians to assist smokers with quitting. By reading the article and completing the post-test, it is anticipated that the following learning objectives will be met: Physicians will become familiar with: 1) Options for treating nicotine addiction, 2) The unique aspects of the tobacco problem in adolescence, 3) The risk factors for teen smoking initiation.

Ames SC; Patten CA; Werch CE; Schroeder DR; Stevens SR; Fredrickson PA et al. Expressive writing as a smoking cessation treatment adjunct for young adult smokers. Nicotine & Tobacco Research 9(2): 185-194, 2007. (35 refs.)

This investigation evaluated the efficacy of expressive writing as a treatment adjunct to a brief office smoking cessation intervention plus nicotine patch therapy in young adults. Participants aged 18-24 years were randomized to a brief office intervention (n=99) or to an expressive writing plus brief office intervention (n=97). Both conditions received four individual visits plus 6 weeks of nicotine patch therapy, which began on the quit date following the week 2 visit. Participants in the expressive writing plus brief intervention condition wrote for 2 consecutive days before and 3 consecutive days after the quit date. The brief office intervention group completed a control writing assignment. At end of treatment (week 8), biochemically confirmed 7-day point-prevalence abstinence for the expressive writing plus brief office intervention condition was significantly greater than for the brief office condition (33% vs. 20%, p=.043, OR=2.0, 95% CI=1.0-3.7, from a logistic regression adjusting for gender). At 24 and 52 weeks, abstinence rates were similar for the brief office intervention versus expressive writing plus brief office intervention (12% vs. 11% at 24 weeks; 11% vs. 11% at 52 weeks). The results suggest that expressive writing has promise as a smoking cessation treatment adjunct for young adults. Lengthier interventions or the use of boosters should be tested to extend treatment effects. However, participants reported a low level of enthusiasm for the expressive writing, which may be a barrier to implementing it over a longer time frame. Therefore, other modes of delivering expressive writing to young adult cigarette smokers should be explored.

Amos A; Wiltshire S; Haw S; McNeill A. Ambivalence and uncertainty: Experiences of and attitudes towards addiction and smoking cessation in the mid-to-late teens. Health Education Research 21(2): 181-191, 2006. (42 refs.)

The late teens is an important transitional period as adolescents move into new social worlds which support or challenge their smoking. This paper draws on research with 99 Scottish 16- to 19-year olds which explored their understanding of their smoking and attitudes towards quitting and cessation support. The study involved qualitative interviews mostly with friendship pairs. Interviewees also completed a brief smoking questionnaire. Most regarded themselves as smokers but few thought they were addicted. Many were interested in quitting but this was not a priority. Perceived barriers to quitting related primarily to habitual and social aspects of dependence including friends' smoking, the smoking culture at work or college, stress and boredom. Few were interested in nicotine replacement therapy or cessation services, which they felt belonged to the world of older addicted smokers. The most effective quitting strategy was thought to be will-power. Traditional cessation services are therefore in their current form unlikely to appeal to older adolescents. Services aimed at this age group need to be grounded in their understandings of smoking and the social factors which support smoking. Young smokers should also be helped to understand how support may increase quitting success and how encourage quitting before smoking becomes entrenched in their daily routines.

Anatchkova MD; Redding CA; Rossi JS. Development and validation of decisional balance and temptations measures for Bulgarian adolescent smokers. (rapid communication). Addictive Behaviors 31(1): 155-161, 2006. (10 refs.)

The goal of this study was to develop measures for Decisional Balance and Situational Temptations for Bulgarian adolescent smokers and to test predicted theoretical relationships with Stages of Change in the same population. Consistent with previous findings for other populations, a 3-factor model for Decisional Balance (CFI = .95) and a hierarchical 4-factor model for Temptations (CFI = .90) best fit the data. The predicted crossover pattern for Decisional Balance and a decreasing trend for Temptations across the Stages of Change were verified. Both measures demonstrated good levels of factorial invariance across gender and across random split-half cross-validation samples. These results support the cross-cultural validity of the TTM constructs and indicate that they can be used as a basis for development of interventions for the population under study.

Aung AT; Hichman NJ; Moolchan ET. Health and performance related reasons for wanting to quit: Gender differences among teen smokers. Substance Use & Misuse 38(8): 1095-1107, 2003. (28 refs.)

Adolescents frequently state health as a broad-ranging reason for wanting to quit smoking. Much less is known regarding performance-related reasons. We hypothesized that more male than female smokers want to quit for performance-related reasons (e.g., to improve athletic performance). As part of a telephone screen to determine eligibility for participation in a cessation trial in Baltimore, Maryland, 1999-2001, 509 teenage smokers [mean age 15.78 +/- 1.65 years (range 11-21), 60.9% female, 32.6% African-American] were asked the open-ended question: "Why do you want to quit?" Responses were subsequently grouped into categories that included health, performance, cost, social influences, setting an example for others, self-efficacy, cosmetics, no perceived positive reinforcement, or unknown reasons. Health was the most commonly stated primary and overall reason for wanting to quit among both boys and girls. Sixty-five percent of teen smokers endorsing health reasons were girls, and 51% of those endorsing performance-related reasons were boys (chi(2)(2) = 7.78, p = 0.02). Recognizing the greater concern for performance-related issues among boys is important for designing and engaging young smokers into cessation interventions.

Backinger CL; Fagan P; Matthews E; Grana R. Adolescent and young adult tobacco prevention and cessation: Current status and future directions. (review). Tobacco Control 12(Supplement 4): 46-53, 2003. (99 refs.)

Objective: To summarise the evidence on adolescent and young adult prevention and cessation, and provide future directions for research. Data sources: Data were collected from published literature. Searches for adolescent prevention were conducted using PubMed, PsycInfo, and ERIC; and for cessation, PubMed, and two major reviews that span January 1978 to May 2002. PubMed, PsychInfo, and SCCI were searched for young adults from January 1990 to May 2002.Study selection: Data included smoking prevention studies published from January 1990 to May 2002 and conducted in the USA; all identified smoking cessation studies for adolescents. Young adult data were limited to initiation and cessation studies. Data extraction: Extraction of data was by consensus of the authors. Data synthesis: Results of the review are qualitative in nature using a consensus approach of the authors. Conclusions: School based curricula alone have been generally ineffective in the long term in preventing adolescents from initiating tobacco use but are effective when combined with other approaches such media and smoke-free policies. Prevention research should consider multiple approaches and the social youth smoking cessation has been understudied to date, scientifically rigorous adolescent smoking cessation studies need to be conducted with attention to high risk smokers and less than daily smokers. Tobacco prevention and cessation for young adults needs focused attention. Prevention and cessation programmes need to address other tobacco products in addition to cigarettes.

Bagot KS; Heishman SJ; Moolchan ET. Tobacco craving predicts lapse to smoking among adolescent smokers in cessation treatment. Nicotine & Tobacco Research 9(6): 647-652, 2007. (36 refs.)

Previous research indicates that tobacco craving predicts relapse to smoking among adult smokers attempting to quit. We hypothesized a similar relationship between craving and lapse (any smoking following a period of abstinence) among adolescent smokers during the treatment phase of a clinical trial. A visit was considered a lapse visit if the participant reported smoking or had a carbon monoxide level of 7 ppm or greater subsequent to an abstinent visit. A total of 34 participants (mean age=14.9 years [SD=1.3]; mean cigarettes/day=18.0 [SD=7.6]; mean Fagerstrom Test for Nicotine Dependence score = 6.8 [SD = 1.34]; 65% female), were included in the present analysis of 167 treatment visits. Logistic regression analyses showed a positive relationship between degree of craving, measured by the Questionnaire on Smoking Urges, and lapse during smoking cessation treatment (p=.013). Additionally, linear regression analyses demonstrated a strong positive association between cigarettes smoked per day and craving scores (p <.001). Taken together with other data, these findings suggest that degree of craving might influence tobacco abstinence for adolescent smokers. Thus monitoring and addressing craving appears useful to increase the success of adolescent smoking cessation.

Balch GI; Tworek C; Barker DC; Sasso B; Mermelstein RJ; Giovino GA. Opportunities for youth smoking cessation: Findings from a national focus group study. Nicotine & Tobacco Research 6(1): 9-18, 2004. (33 refs.)

To, identify opportunities for smoking cessation among adolescents, we conducted six computer-assisted telephone focus groups with 48 male and female high school student smokers and former smokers from six states across the United States, all aged 15-17 years, in two groups each of "established smokers," "late experimenters," and "quitters." These adolescents considered addiction to cigarettes real, powerful, stealthy, insidious, harmful, and avoidable. They considered quitting smoking achievable and desirable. Many of the established smokers and some experimenters would not consider quitting until an indefinite future, when they expected adult responsibilities to help them quit. Quitters had been encouraged by friends who did not smoke around them or offer them cigarettes; they also associated more with nonsmoking friends. Some adolescents, especially quitters, reported that parents had tried to help them quit; some smokers reported,that parents had provided them with cigarettes. Some adolescents reported school rules and enforcement that made it hard to smoke; others reported school rules and enforcement that made it easy and tempting to smoke. These adolescents were not aware of the availability of professional help or interested in it. Many did not consider smoking urgent or "intense" enough for professional help. Perceptions of cessation programs were nonexistent or negative. Participants were aware of nicotine replacement therapies but less so of prescription medications. These findings suggest that it is critical to educate adolescents about what good cessation programming is and is not, why it is needed, how it might help, and where it is offered.

Bloom PN; McBride CM; Pollak KI; Schwartz-Bloom RD; Lipkus IM. Recruiting teen smokers in shopping malls to a smoking-cessation program using the foot-in-the-door technique. Journal of Applied Social Psychology 36(5): 1129-1144, 2006. (27 refs.)

Persuading teen smokers to volunteer for smoking-cessation programs is a challenging yet understudied problem. As a method of dealing with this problem, we used and tested a foot-in-the-door (FITD) approach. Teen smokers were intercepted at malls and were assigned randomly to request compliance with a small behavior request of either (a) answering a few questions (light FITD) or (b) answering the same questions and a few additional ones, plus watching a short video about the effects of nicotine (heavy FITD). Participants were then called back by telephone several weeks later and asked to comply with a large behavior request of joining a cessation program that involved the use of self-help materials and telephone counseling. Although no differences were found in responses from the light and heavy groups, consent to enter the program was obtained from 12% of the pooled qualified intercepts and their parents (for those under 18 years). This recruitment rate was considered good, given that this is one of the only reported studies that recruited teen smokers from the general population to cessation programs.

Brown RA; Ramsey SE; Strong DR; Myers MG; Kahler CW; Lejuez CW et al. Effects of motivational interviewing on smoking cessation in adolescents with psychiatric disorders. Tobacco Control 12(Supplement 4): 3-10, 2003. (49 refs.)

Objective: To test the hypothesis that among adolescent smokers hospitalised for psychiatric and substance use disorders, motivational interviewing (MI) would lead to more and longer quit attempts, reduced smoking, and more abstinence from smoking over a 12 month follow up. Design: Randomised control trial of MI versus brief advice (BA) for smoking cessation, with pre- and post-intervention assessment of self efficacy and intentions to change, and smoking outcome variables assessed at one, three, six, nine, and 12 month follow ups. Setting: A private, university affiliated psychiatric hospital in Providence, Rhode Island, USA. Patients or other participants: Consecutive sample (n=191) of 13-17 year olds, admitted for psychiatric hospitalisation, who smoked at least one cigarette per week for the past four weeks, had access to a telephone, and did not meet DSM-IV criteria for current psychotic disorder.Interventions: MI versus BA. MI consisted of two, 45 minute individual sessions, while BA consisted of 5-10 minutes of advice and information on how to quit smoking. Eligible participants in both conditions were offered an eight week regimen of transdermal nicotine patch upon hospital discharge. Main outcome measures: Point prevalence abstinence, quit attempts, changes in smoking rate and longest quit attempt. Proximal outcomes included intent to change smoking behaviour (upon hospital discharge), and self efficacy for smoking cessation. Results: MI did not lead to better smoking outcomes compared to BA. MI was more effective than BA for increasing self efficacy regarding ability to quit smoking. A significant interaction of treatment with baseline intention to quit smoking was also found. MI was more effective than BA for adolescents with little or no intention to change their smoking, but was actually less effective for adolescents with pre-existing intention to cut down or quit smoking. However, the effects on these variables were relatively modest and only moderately related to outcome. Adolescents with comorbid substance use disorders smoked more, during follow up while those with anxiety disorders smoked less and were more likely to be abstinent. Conclusions: The positive effect of MI on self efficacy for quitting and the increase in intention to change in those with initially low levels of intentions suggest the benefits of such an intervention. However, the effects on these variables were relatively modest and only moderately related to outcome. The lack of overall. effect of MI on smoking cessation outcomes suggests the need to further enhance and intensify this type of treatment approach for adolescent smokers with psychiatric comorbidity.

Camenga DR; Klein JD. Adolescent smoking cessation. (review). Current Opinion in Pediatrics 16(4): 368-372, 2004. (38 refs.)

Purpose of review: Approximately 25% of high school students report current cigarette use, 85% of adolescents think about quitting, and around 80% of current smokers made a quit attempt in the past year. This review analyzes recent additions to the adolescent smoking cessation literature from June 1, 2003 to May 1, 2003. Recent findings: Adolescent attitudes toward smoking cessation are largely affected by their smoking history. Youth cessation interventions largely focus on behavioral interventions, and research concerning these interventions has yielded mixed results. Little data exist about the effectiveness of nicotine replacement therapy in adolescents, but there is growing evidence that youth use this pharmacotherapy. Recent research has explored the use of nicotine replacement therapy as an adjunct for enhanced smoking reduction in adults, and future research may focus on this tactic for youth as well. Internet cessation adjuncts and telephone quit lines also serve as future frontiers for adolescent smoking cessation research. Summary:Information concerning adolescent smoking behaviors, effective interventions, and smoking cessation therapy continue to grow and provide data that improve our understanding of adolescent smoking cessation. Although we cannot directly extrapolate the adult findings to this population, adult cessation research continues to inform future adolescent cessation efforts.

Chassin L; Presson CC; Sherman SJ. Parental smoking cessation and adolescent smoking: A commentary on Bricker et al. Addiction 98(5): 595-596, 2003. (11 refs.)

Chen HH; Yeh ML. Developing and evaluating a smoking cessation program combined with an Internet-assisted instruction program for adolescents with smoking. Patient Education and Counseling 61(3): 411-418, 2006. (32 refs.)

Objective: The purpose of this study was to develop a smoking cessation program combined with an Internet-assisted instruction (IAI) program to help youth smokers quit smoking, and to evaluate the effectiveness of the program in changing youth's attitudes toward smoking, smoking behavior, and self-efficacy for smoking cessation. Methods: To achieve this goal, a comparative study of 77 senior high students divided into two groups was conducted. One group, designated as the experimental group, accepted a 6-week smoking cessation program plus an IAI program and the other group did not receive any intervention as the comparison group. All participants completed questionnaires before and after the program. Results: The results showed that the strategy of combining the smoking cessation program and an IAI program was highly effective in terms of effects upon the youth's attitude towards smoking, smoking behavior, and self-efficacy. There was a highly positive correlation between the participants' attitude toward smoking and self-efficacy. In contrast, cigarette consumption was in a strongly negative correlation with selfefficacy. Conclusion: Most of all participants in the experimental group recognized the effectiveness of the program, and thought the smoking cessation program with an IAI program was helpful and welcomed by youth. This study can serve as reference for future design and implementation of IAI programs for youth smoking cessation.

Chinet L; Broers B; Humair JP; Narring F. Youth smoking cessation: An update for primary care physicians. Substance Use & Misuse 41(9): 1251-1261, 2006. (60 refs.)

Tobacco use is a major public health problem, and onset usually begins in youth. This article reviews current knowledge and evidence of specific aspects of smoking in youth, tobacco control strategies, and smoking cessation interventions that target young people. Finally, it provides recommendations for primary care physicians.

Christakis DA; Garrison MM; Ebel BE; Wiehe SE; Rivara FP. Pediatric smoking prevention interventions delivered by care providers: A systematic review. (review). American Journal of Preventive Medicine 25(4): 358-362, 2003. (28 refs.)

Objective: To conduct a systematic review of randomized controlled trials of smoking prevention interventions for youth delivered via medical or dental providers' offices. Methods: Online bibliographic databases were searched as of July 2002, and reference lists from review articles and the selected articles were also reviewed for potential studies. The methodology and findings of all retrieved articles were critically evaluated. Data were extracted from each article regarding study methods, intervention studied, outcomes measured, and results. Results: The literature search returned 81 abstracts from MEDLINE and 49 from Cochrane Clinical Trials Registry (CCTR); of these, four articles met the inclusion criteria. Included were two studies conducted in primary care, and one each in dental and orthodontic offices. Only one study demonstrated a significant effect on smoking initiation; in that study, 5.1% of the intervention group and 7.8% of the control group reported smoking at 12-month follow-up (odds ratio = 0.63; 95% confidence interval, 0.44-0.91). None of the studies had follow-up times greater than 3 years. Conclusions: There is very limited available evidence demonstrating efficacy of smoking prevention interventions in adolescents conducted in providers' offices and no evidence for long-term effectiveness of such interventions.

Colby SM; Monti PM; O'Leary T; Barnett NP; Spirito A; Rohsenow DJ et al. Brief motivational intervention for adolescent smokers in medical settings. Addictive Behaviors 30(5): 865-874, 2005. (19 refs.)

This study evaluated the efficacy of using a brief motivational intervention to reduce smoking among adolescent patients treated in a hospital outpatient clinic or Emergency Department. Patients aged 14-19 years (N=85) were randomly assigned to receive either one session of motivational interviewing (MI) or standardized brief advice (BA) to quit smoking. The assessment and intervention were conducted in the medical setting proximal to the patient's medical treatment. Patients were proactively screened and recruited, and were not seeking treatment for smoking. Follow-up assessments were conducted at 1, 3, and 6 months post-intervention. Self-report data indicated that 7-day abstinence rates at 6-month follow-up were significantly higher in the MI group than in the BA group, but this difference was not confirmed biochemically. Self-reported smoking rate (average cigarettes per day) was significantly lower at 1, 3, and 6 months follow-up than it was at baseline. Cotinine levels indicated reduced smoking for both groups at 6 months, but not at 1 month. At 3-month follow-up, only those in MI showed cotinine levels that were significantly reduced compared to baseline. Findings offer some support for MI for smoking reduction among non-treatment-seeking adolescents, but overall changes in smoking were small.

Commission on Adolescent Substance and Alcohol Abuse. Treatment of substance use disorders. IN: Evans, DL; Foa, EB; Gur, RE; Hendin H; O'Brien, CP; eds. Treating and Preventing Adolescent Mental Health Disorders: What we Know and What We Don't Know. New York: Oxford University Press, 2005. pp. 391-410. (book refs.)

This chapter adresses the treatment of substance use disorders. Psychosocial treatments, such as: randomized clinical trials, family and multisystem therapies, behavioral therapies, cognitive-behavioral approaches, motivational approaches, and disease model treatments, among others are highlighted. Pharmacological treatments, such as detoxification, and medications for smoking cessation and alcohol abuse in adolescents are also discussed.

Cornelius MD; Leech SL; Goldschmidt L. Characteristics of persistent smoking among pregnant teenagers followed to young adulthood. Nicotine & Tobacco Research 6(1): 159-169, 2004. (52 refs.)

Pregnant teenagers (N=344) were interviewed during first and third trimesters (average age=16.2 years) and interviewed again as young adults (average age= 23.0 years). Nearly 47% were smokers during the first trimester, 58% smoked during the third trimester, and 61% were smokers in their early adult years. Some 40% (n=137) continued smoking into young adulthood (persistent smokers); 7% quit. Average number of cigarettes per day was 10.0 among persistent smokers and 6.8 among quitters (p <.05). Nearly 20% started smoking by young adulthood (late-onset smokers). Persistent smokers and quitters were most similar to one another, and they differed from the late-onset smokers and, persistent nonsmokers on demographic, psychological, and behavioral measures. These variables from the teenage years included White race, lower maternal education, lower school grades, more aggression and delinquency problems, and earlier and more peer use of substances. Characteristics from the adult years included White race; lower education; and more anxiety, hostility, and alcohol use. Multivariate analyses using discriminant function analyses showed that three characteristics from the teenage years discriminated across the three smoking groups (persistent, late-onset, quitters): White race, friends' smoking, and lower maternal education. The same analyses using the adult characteristics showed that White race and lower personal educational level discriminated the persistent smokers and quitters from the late-onset smokers. Lower gravidity discriminated the persistent smokers from the quitters. Characteristics of women who are at highest risk of persistent smoking can be identified in both the teenage years and the early adult years, and appropriate interventions can be targeted to those women at highest risk of persistent smoking.

Croghan IT; Campbell HM; Patten CA; Croghan GA; Schroeder DR; Novotny PJ. A contest to create media messages aimed at recruiting adolescents for stop smoking programs. Journal of School Health 74(8): 325-328, 2004. (13 refs.)

This project engaged adolescents in a contest to create advertising messages aimed at recruiting teens for stop smoking programs. Middle school students were invited to design a media message for television, radio, Web, or print (newspaper or billboard). Of 4,289 students in eight middle schools of Rochester, Minn., 265 (6.2%) developed 172 stop smoking messages. The quality of their work confirmed that teens can design media messages to encourage their smoking adolescent peers to enroll in a program to stop smoking.

Curry SJ; Emery S; Sporer AK; Mermelstein R; Flay BR; Berbaum M et al. A national survey of tobacco cessation programs for youths. American Journal of Public Health 97(1): 171-177, 2007. (26 refs.)

Objectives. We collected data on a national sample of existing community-based tobacco cessation programs for youths to understand their prevalence and overall characteristics. Methods. We employed a 2-stage sampling design with US counties as the first-stage probability sampling units. We then used snowball sampling in selected counties to identify administrators of tobacco cessation programs for youths. We collected data on cessation programs when programs were identified. Results. We profiled 591 programs in 408 counties. Programs were more numerous in urban counties; fewer programs were found in low-income counties. State-level measures of smoking prevalence and tobacco control expenditures were not associated with program availability. Most programs were multisession, school-based group programs serving 50 or fewer youths per year. Program content included cognitive-behavioral components found in adult programs along with content specific to adolescence. The median annual budget was $2000. Few programs (9%) reported only mandatory enrollment, 35% reported mixed mandatory and voluntary enrollment, and 56% reported only voluntary enrollment. Conclusions. There is considerable homogeneity among community-based tobacco cessation programs for youths. Programs are least prevalent in the types of communities for which national data show increases in youths' smoking prevalence.

Dino G; Kamal K; Horn K; Kalsekar I; Fernandes A. Stage of change and smoking cessation outcomes among adolescents. Addictive Behaviors 29(5): 935-940, 2004. (12 refs.)

This study examined the association between stage of change and smoking cessation outcomes among youth receiving two interventions of varying intensity: a 10-min brief self-help smoking cessation intervention (BI) or the American Lung Association's 10-week, Not-on-Tobacco (N-O-T) smoking cessation program. At baseline, the participants were classified into three stages (e.g., precontemplation, contemplation, and preparation) based on their intention to change their smoking behavior. Smoking behavior, stage of change, self-efficacy, and beliefs about smoking were assessed at baseline and 3 months postbaseline. Results demonstrated that the relationship between stage of change and cessation outcomes varied by treatment intensity. Logistic regression analyses revealed that BI participants in the preparation stage were 25 times more likely to quit smoking at postbaseline than were participants in the contemplation or precontemplation stages. In contrast, N-O-T was effective for youth regardless of baseline stage. Additionally, N-O-T participants demonstrated greater forward stage movement from baseline to postbaseline than did BI participants.

Diviak KR; Curry SJ; Emery SL; Mermelstein RJ. Human participants challenges in youth tobacco cessation research: Researchers' perspectives. Ethics & Behavior 14(4): 321-334, 2004. (16 refs.)

Recruiting adolescents into smoking cessation studies is challenging, particularly given institutional review board (IRB) requirements for research conducted with adolescents. This article provides a brief review of the federal regulations that apply to research conducted with adolescents, and describes researchers' experiences of seeking IRB approval for youth cessation research. Twenty-one researchers provided information. The most frequently reported difficulty involved obtaining parental consent. Solutions to commonly reported problems with obtaining IRB approval are also identified. Waivers of parental consent can facilitate recruitment of youths into studies; however, researchers must ensure that their protocols comply with federal regulations when requesting a waiver.

Epstein JA; Botvin GJ; Spoth R. Predicting smoking among rural adolescents: Social and cognitive processes. Nicotine & Tobacco Research 5(4): 485-491, 2003. (49 refs.)

Although considerable literature can be found concerning the etiology of cigarette smoking, a major gap exists pertaining to predictors of adolescent smoking for rural populations in the United States. To address this gap in the literature, the present study focused on rural adolescents and investigated a model of social and cognitive cross-sectional predictors of smoking. Gender-specific differences in etiology were examined by testing the same model separately for boys and girls. Seventh graders (N = 1,673) residing in northeastern Iowa self-reported smoking, peer smoking norms, adult smoking norms, drug refusal assertiveness, drug refusal techniques, life skills, prosmoking attitudes, risk-taking tendency, and family management practices. Data were collected during a class period in 36 junior high schools. Peer smoking norms, adult smoking norms, drug refusal assertiveness, drug refusal techniques, prosmoking attitudes, and risk-taking tendency were associated cross-sectionally with smoking. As for gender-specific effects, family management skills, life skills, and risk-taking tendency were concurrently related to smoking for girls only. Based on the results of the present study and on prevention research, it would appear that smoking prevention programs for rural adolescents would benefit from incorporating normative education, drug refusal training, parent skills training, and competence enhancement skills training.

Everson ES; Daley AJ; Ussher M. Does exercise have an acute effect on desire to smoke, mood and withdrawal symptoms in abstaining adolescent smokers? Addictive Behaviors 31(9): 1547-1558, 2006. (50 refs.)

Objective: Previous studies have shown that exercise acutely reduces desire to smoke and withdrawal symptoms among adult smokers; however, no study has examined these effects in younger smokers. This study investigated the impact of a short bout of moderate intensity exercise on desire to smoke, withdrawal symptoms and exercise-induced affect in temporarily abstinent adolescent smokers. Methods: Thirty-seven low-active male and female smokers aged 16-19 years, abstained from smoking overnight and were assigned to either (i) 10 min of moderate intensity cycle ergometry (n = 18) or (ii) a placebo control condition that involved very light intensity cycle ergometry (n = 19). Measures of desire to smoke, the Mood and Physical Symptoms Scale (MPSS) and Subjective Exercise Experience Scale (SEES) were administered at baseline, 5 min during, 5 min after and 30 min after both conditions. Results and conclusion: A significant interaction effect for group by time was recorded for psychological distress scores, when the baseline value was covaried. Follow-up tests indicated that the exercise group reported significantly higher PD scores than the placebo control during exercise, but not at any other time point. No other significant effects were found for any other variables. Unlike research involving adult populations, a short bout of moderate intensity exercise did not alter desire to smoke among abstaining adolescent smokers and may negatively impact affective responses during exercise.

Falkin GP; Fryer CS; Mahadeo M. Smoking cessation and stress among teenagers. Qualitative Health Research 17(6): 812-823, 2007. (26 refs.)

The authors describe the experience of quitting smoking, focusing on the obstacles youth struggle with, based on individual interviews and focus groups with 54 teenagers in New York City. A major obstacle was the belief that people should stop smoking forever. The youth had to cope with temptation, frequent and often intense urges or cravings for cigarettes, and lack of social support from their family and friends. The young participants not only had to cope with general life stresses without being able to use cigarettes to reduce tensions but also had to contend with new stressful situations, such as friends who put them down for not smoking. In addition, the teens had to give up things that were important to them, such as friendships, during their quit attempts. The study describes how quitting can be a much more stressful experience for youth than research typically acknowledges. The authors discuss public health implications.

Franken FH; Pickworth WB; Epstein DH; Moolchan ET. Smoking rates and topography predict adolescent smoking cessation following treatment with nicotine replacement therapy. Cancer Epidemiology, Biomarkers & Prevention 15(1): 154-157, 2006. (24 refs.)

Establishing measurement invariance of tobacco addiction among adolescents remains challenging. In adult smoking cessation trials, poor outcome is predicted by high cigarette consumption and large puff volume at baseline. We examined the predictive value of pretreatment smoking rates and topography variables for abstinence outcomes among 66 adolescents enrolled in a 3-month smoking cessation trial using nicotine replacement and cognitive behavioral therapy. Pretreatment variables included cigarettes per day (CPD), puff volume, puff duration, and several youth-adapted Fagerstrom-derived questionnaire scores. Outcome measures included prolonged abstinence at end of treatment and point-prevalent abstinence 3 months after the end of the trial. Logistic regression controlling for treatment group showed that increases in baseline CPD (odds ratio, 1.438; 95% confidence interval, 1.051-1.967) and average puff volume (odds ratio, 1.168; 95% confidence interval, 1.030-1.326) predicted continued smoking at the end of treatment. Puff volume (P = 0.013), but not CPD, predicted abstinence at the 3-month follow-up. None of the youth-adapted Fagerstrom questionnaires predicted outcome on either abstinence measure. If confirmed in a larger sample, our findings suggest that puff topography, and possibly CPD, might predict cessation outcome better than Fagerstrom scores in adolescent smokers.

Garrison MM; Christakis DA; Ebel BE; Wiehe SE; Rivara FP. Smoking cessation interventions for adolescents: A systematic review. (review). American Journal of Preventive Medicine 25(4): 363-367, 2003. (34 refs.)

Objective: To conduct a systematic review of controlled trials for adolescent smoking cessation. Methods: Online bibliographic databases were searched as of June 2002, and reference lists from review articles and the selected articles were also reviewed for potential studies. The methodology and findings of all retrieved articles were critically evaluated. Data were extracted from each article regarding study methods, intervention studied, outcomes measured, and results. Results: The abstracts or full-text articles of 281 relevant studies were examined, of which six met the selection criteria. Included were three school-based studies, a study in pregnant adolescent girls, a hospital-based study, and a trial of laser acupuncture. All three of the school-based studies reported significant impacts on cessation rates, although only one of these was a randomized trial. None of the studies had follow-up times of >5.2 months. Conclusions: There is very limited evidence demonstrating efficacy of smoking-cessation interventions in adolescents, and no evidence on the long-term effectiveness of such interventions. Smoking-cessation interventions that have proven most effective in adults, such as nicotine replacement and antidepressant use, have not been studied in adolescents in a controlled manner.

Grimshaw G; Stanton A; Blackburn C; Andrews K; Grimshaw C; Vinogradova Y et al. Patterns of smoking, quit attempts and services for a cohort of 15-to 19-year-olds. Child: Care, Health and Development 29(6): 457-464, 2003. (31 refs.)

Objectives: To establish patterns of smoking among 15-to 19-year-olds within mixed urban and suburban area and explore preference for the nature of services to assist quitting. Design Postal survey and depth interviews with focus group validation. Setting: People registered with health services in the Borough of Solihull, UK. The borough has a diverse population with areas of high deprivation to the north and a range of prosperity elsewhere. Participants: Questionnaires were sent to 50% of those registered and 20 people interviewed aged from 15 to 19 years. Main outcome measures The survey contained demographic questions relating to educational attainment and family, smoking status, history and quit attempts, use of facilities for quit attempts. Qualitative themes explored attitudes and experience of quitting, utilization of cessation services, barriers to access and nicotine replacement therapy. Results: Total survey response rate was 32.6%. Three in five reported smoking a cigarette sometime, 17.2% current regular smokers, 7.2% current occasional smokers. Median age of starting smoking was significantly lower (P=0.004) for current regular smokers, distinguishable in two groups; weekend smokers and all week smokers. More quit attempts had been made or planned by current regular smokers but were often short lived. Weekend smokers had a slightly longer duration of quitting (P=0.03). Eight-two per cent were optimistic about quitting in the future although the majority (80%) had already made one quit attempt. Knowledge and use of existing services was poor, with concerns about privacy and confidentiality. Models based on autonomy were identified as potentially useful. Conclusion: Teenage smoking is characterized by optimism about quitting despite the failure of many quit attempts, lack of regard for existing services and barriers to uptake.

Grimshaw GM; Stanton A. Tobacco cessation interventions for young people. (review). Cochrane Database of Systemic Reviews 4(article no. CD003289), 2006. (110 refs.)

Background: Teenage smoking prevalence is around 15% in developing countries (with wide variation from country to country), and around 26% in the UK and USA. Although most tobacco control programmes for adolescents are based around prevention of uptake, there are also a number of initiatives to help those who want to quit. Since those who do not smoke before the age of 20 are significantly less likely to start as adults, there is a strong case for programmes for young people that address both prevention and treatment. Objectives: To evaluate the effectiveness of strategies that help young people to stop smoking tobacco. Search strategy We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Tobacco Addiction Group's Specialized Register, MEDLINE, EMBASE, PsyclNFO, ERIC, CINAHL, and the bibliographies of identified trials. We also searched the 'grey' literature (unpublished materials), and contacted authors and experts in the field where necessary. Selection criteria Types of studies: Randomized controlled trials, cluster-randomized controlled trials and controlled trials. Types of participants: Young people, aged less than 20, who are regular tobacco smokers. Types of interventions: The interventions ranged from simple ones such as pharmacotherapy, targeting individual young people, through complex programmes targeting people or organizations associated with young people (for example, their families or schools), or the community in which young people live. We included cessation programmes but excluded programmes primarily aimed at prevention of uptake. Types of outcome measures: The primary outcome was smoking status at six months follow up, among those who smoked at baseline. We report the definition of cessation used in each trial (e. g seven-or thirty-day point prevalence abstinence, or sustained or prolonged abstinence), and we preferred biochemically verified cessation when that measure was available. Data collection and analysis Both authors independently assessed the eligibility of candidate trials identified by the searches, and extracted data from them. We categorized included trials as being at low, medium or high risk of bias, based on concealment of allocation, blinding (where applicable) and the handling of attrition and losses to follow up. We conducted limited meta-analyses of some of the trials, provided that it was appropriate to group them and provided that there was minimal heterogeneity between them. We estimated pooled odds ratios using the Mantel-Haenszel method, based on the quit rates at longest follow up for trials with at least six months follow up from the start of the intervention. Main results We found 15 trials, covering 3605 young people, which met our inclusion criteria (seven cluster-randomized controlled trials, six randomized controlled trials and two controlled trials). Three trials used or tested the transtheoretical model (stages of change) approach, two tested pharmacological aids to quitting (nicotine replacement and bupropion), and the remaining trials used various psychosocial interventions, such as motivational enhancement or behavioural management. The trials evaluating TTM interventions achieved moderate long-term success, with a pooled odds ratio (OR) at one year of 1.70 (95% confidence interval (CI) 1.25 to 2.33) persisting at two-year follow up with an OR of 1.38 (95% CI 0.99 to 1.92). Neither of the pharmacological intervention trials achieved statistically significant results (data not pooled), but both were small-scale, with low power to detect an effect. The three interventions (5 trials) which used cognitive behavioural therapy interventions did not individually achieve statistically significant results, although when the three Not on Tobacco trials were pooled the OR 1.87; (95% CI 1.00 to 3.50) suggested some measure of effectiveness. Although the three trials that incorporated motivational interviewing as a component of the intervention achieved a pooled OR of 2.05 (95% CI 1.10 to 3.80), the impossibility of isolating the effect of the motivational interviewing in these trials meant that we could not draw meaningful inferences from that analysis. Authors' conclusions: Complex approaches show promise, with some persistence of abstinence (30 days point prevalence abstinence at six months), especially those incorporating elements sensitive to stage of change. There were few trials with evidence about pharmacological interventions (nicotine replacement and bupropion), and none demonstrated effectiveness for adolescent smokers. Psycho-social interventions have not so far demonstrated effectiveness, although pooled results for the Not on Tobacco trials suggest that that this approach may yet prove to be effective; however, their definition of cessation (one or more smoke-free days) may not adequately account for the episodic nature of much adolescent smoking. There is a need for well-designed adequately powered randomized controlled trials for this population of smokers, with a minimum of six months follow up and rigorous definitions of cessation (sustained and biochemically verified). Attrition and losses to follow up are particularly problematic in trials for young smokers, and need to be kept to a minimum, so that management and interpretation of missing data need not compromise the findings.

Ham OK. Stages and processes of smoking cessation among adolescents. Western Journal of Nursing Research 29(3): 301-315, 2007. (30 refs.)

The purpose of this study was to identify the stages and processes of change related to smoking cessation among vocational technical high school students to provide baseline data for smoking cessation programs. Cross-sectional data were collected in April and May, 2004, from 300 mate students at three vocational technical high schools in Korean metropolitan areas. The survey instruments included: decisional balance; self-efficacy; nicotine dependence; stages and processes of change; and knowledge related to smoking. The results indicated that 31.7%, 39.2%, and 29.1% of current smokers were in the precontemplation, contemplation, and preparation stages, respectively, and that 42.6% and 57.4% of former smokers were in the action and maintenance stages, respectively. Decisional balance, self-efficacy, and nicotine dependence were significantly associated with the stages of change. Regarding the processes of change, only behavioral processes were significantly associated with the stages of change, with experiential processes showing no significant relationship. The study results suggest that smoking cessation programs should emphasize behavioral strategies to help students progress through the stages.

Ham OK; Lee YJ. Use of the transtheoretical model to predict stages of smoking cessation in Korean adolescents. Journal of School Health 77(6): 319-326, 2007. (34 refs.)

Background: Smoking is popular among Korean male high school adolescents, with the prevalence of 20.7% differing markedly with the type of school, being 16.3% and 27.6% in academic and vocational technical high schools, respectively. The purpose of this study was to identify significant variables that predict stages of smoking cessation among Korean high school students using the transtheoretical model (TTM), in order to provide an empirical basis for developing smoking cessation programs. Methods: Cross-sectional data were collected in April and May 2004 from 300 male students at 3 vocational technical high schools in Korean metropolitan areas. The survey variables comprised decisional balance, self-efficacy, stages and processes of change, nicotine dependence, and use of smoking cessation aids. Results: Current and former smokers comprised 26.3% and 22.7% of the cohort, respectively, of which 71.4% had experienced smoking cessation at least once and 55.1% utilized smoking cessation aids to help stop smoking. Nicotine-free tobacco and nicotine gum were the most common smoking cessation aids. Decisional balance, use of behavioral processes, and higher self-efficacy were significant in explaining stages of smoking cessation after controlling for nicotine dependence. Conclusions: The study results suggest that smoking cessation programs developed based on the TTM may help adolescents to progress through stages, with it being important to include information regarding the use of smoking cessation aids.

Hanson K; Allen S; Jensen S; Hatsukami D. Treatment of adolescent smokers with the nicotine patch. Nicotine & Tobacco Research 5(4): 515-526, 2003. (36 refs.)

This study examined the effects of the nicotine patch on craving and withdrawal symptoms, safety, and compliance among adolescents. The secondary goal was to conduct a preliminary investigation of the effectiveness of the nicotine patch in helping adolescents quit smoking. The study design was a double-blind, placebo-controlled, randomized trial of the nicotine patch. The intervention also provided intensive cognitive-behavioral therapy and a contingency-management procedure. Participants (n=100) attended 10 treatment visits over 13 weeks. Compared with the placebo patch group, the active nicotine patch group experienced a significantly lower craving score and overall withdrawal symptom score (p = .011 and p = .025, respectively), as well as a time trend toward lower scores (p <.001) in craving only. Moreover, the nicotine patch appeared safe for adolescents to use. No differences by treatment group were found in experiencing adverse events, except that the participants in the placebo patch group reported more headaches than those in the active nicotine patch group. As another measure of safety, the overall mean salivary cotinine levels were significantly lower at 1, 6, 8, and 10 weeks postquit (all p <.05) compared with baseline levels, although these results were confounded by dropouts. Additionally, a significant number of participants were compliant with using the nicotine patch daily. Finally, point prevalence (7-day and 30-day abstinence rates) and survival analysis of participant abstinence indicated no significant differences between treatment groups. The results of this study suggest that the nicotine patch is a promising medication and a larger clinical trial of the nicotine patch among adolescents is warranted.

Henriksen L; Dauphinee AL; Wang Y; Fortmann SP. Industry sponsored anti-smoking ads and adolescent reactance: Test of a boomerang effect. (review). Tobacco Control 15(1): 13-18, 2006. (48 refs.)

Objective: To examine whether adolescents' exposure to youth smoking prevention ads sponsored by tobacco companies promotes intentions to smoke, curiosity about smoking, and positive attitudes toward the tobacco industry. Design: A randomised controlled experiment compared adolescents' responses to five smoking prevention ads sponsored by a tobacco company (Philip Morris or Lorillard), or to five smoking prevention ads sponsored by a non-profit organisation (the American Legacy Foundation), or to five ads about preventing drunk driving. Setting: A large public high school in California's central valley. Subjects: A convenience sample of 9th and 10th graders (n = 832) ages 14 - 17 years. Main outcome measures: Perceptions of ad effectiveness, intention to smoke, and attitudes toward tobacco companies measured immediately after exposure. Results: As predicted, adolescents rated Philip Morris and Lorillard ads less favourably than the other youth smoking prevention ads. Adolescents' intention to smoke did not differ as a function of ad exposure. However, exposure to Philip Morris and Lorillard ads engendered more favourable attitudes toward tobacco companies. Conclusions: This study demonstrates that industry sponsored anti-smoking ads do more to promote corporate image than to prevent youth smoking. By cultivating public opinion that is more sympathetic toward tobacco companies, the effect of such advertising is likely to be more harmful than helpful to youth.

Hollis JF; Polen MR; Whitlock EP; Lichtenstein E; Mullooly JP; Velicer WF. Teen Reach: Outcomes from a randomized, controlled trial of a tobacco reduction program for teens seen in primary medical care. Pediatrics 115(4): 981-989, 2005. (38 refs.)

Objective. To test the long-term efficacy of brief counseling plus a computer-based tobacco intervention for teens being seen for routine medical care. Methods. Both smoking and nonsmoking teens, 14 to 17 years of age, who were being seen for routine visits were eligible for this 2-arm controlled trial. Staff members approached teens in waiting rooms of 7 large pediatric and family practice departments within a group-practice health maintenance organization. Of 3747 teens invited at >= 1 visits, 2526 (67%) consented and were randomized to tobacco intervention or brief dietary advice. The tobacco intervention was individually tailored on the basis of smoking status and stage of change. It included a 30-second clinician advice message, a 10-minute interactive computer program, a 5-minute motivational interview, and up to two 10-minute telephone or in-person booster sessions. The control intervention was a 5-minute motivational intervention to promote increased consumption of fruits and vegetables. Follow-up smoking status was assessed after 1 and 2 years. Results. Abstinence rates after 2 years were significantly higher for the tobacco intervention arm, relative to the control group, in the combined sample of baseline smokers and nonsmokers (odds ratio [OR]: 1.23; 95% confidence interval [CI]: 1.03-1.47). Treatment effects were particularly strong among baseline self-described smokers (OR: 2.42; 95% CI: 1.40-4.16) but were not significant for baseline nonsmokers (OR: 1.25; 95% CI: 0.97-1.61) or for those who had "experimented" in the past month at baseline (OR: 0.95; 95% CI: 0.45-1.98). Conclusions. Brief, computer-assisted, tobacco intervention during routine medical care increased the smoking cessation rate among self-described smokers but was less effective in preventing smoking onset.

Horn K; Dino G; Kalsekar I; Massey CJ; Manzo-Tennant K; McGloin T. Exploring the relationship between mental health and smoking cessation: A study of rural youth. Prevention Science 5(2): 113-126, 2004. (62 refs.)

This study examined the association between mental health and smoking cessation among rural youth. Participants were 113 male and 1.45 female adolescents ages 14-19 from rural West Virginia and North Carolina. Participants were enrolled in the American Lung Association's 10-week Not On Tobacco (N-O-T) program or a 15-min single-dose brief intervention. Baseline and postprogram measures were completed on smoking status (i.e., quit, reduction), nicotine dependence, smoking history, and depression and anxiety. Results showed that more N-O-T participants quit and reduced smoking than did brief intervention participants. Intervention group, baseline smoking rate, and the Group x Gender, Group x Anxiety, and Group x Depression interactions were significant predictors of change in smoking behavior from baseline to postprogram. In conclusion, more N-O-T participants demonstrated favorable changes in smoking than did brief intervention participants. Approximately 1/3 of youth exhibited mental health pathology; more females than males. Levels of depression and anxiety improved from baseline to postprogram, overall. Although the extent of the impact of mental health on cessation outcomes was inconclusive, findings suggest that rural youth who smoke may be at risk for pathological depression and anxiety. Future cessation programming with rural youth should consider the inclusion of coping and stress management skills and mental health referral protocols as significant program components.

Horn K; Dino G; Kalsekar I; Mody R. The Impact of Not on Tobacco on teen smoking cessation: End-of-program evaluation results, 1998 to 2003. Journal of Adolescent Research 20(6): 640-661, 2005. (34 refs.)

This review summarizes end-of-program quit rates from 6 controlled and 10 field-based Not on Tobacco (NOT) evaluations. Approximately 6,130 youth from 5 states and 489 schools participated. Intent-to-treat and compliant quit rates were calculated at 3 months postbaseline (end-of-program). Results from controlled evaluations revealed an aggregate quit rate of 15% and 19%, respectively. The field-based evaluations revealed an aggregate quit rate of 27% and 31%, respectively. NOT youth were two times more likely to quit than comparison youth (OR = 1.94; p = .002; 95% CI 1.267-2.966). This is the first multiyear, multisite review of a teen smoking cessation program reported in the literature and the first longitudinal review of NOT. NOT participants showed consistent, significant positive smoking behavior change across evaluations.

Horn K; Fernandes A; Dino G; Massey CJ; Kalsekar I. Adolescent nicotine dependence and smoking cessation outcomes. Addictive Behaviors 28(4): 769-776, 2003. (15 refs.)

The purpose of the present study was to examine adolescent nicotine dependence and its impact on smoking cessation outcomes with two treatments of varying intensity: a brief, self-help intervention and an intensive, multisession, school-based cessation curriculum called Not On Tobacco (N-O-T). A majority (80%) of adolescent smokers in this study were moderately to highly nicotine-dependent, using the Fagerstrom Tolerance Questionnaire. Further, nicotine dependence was positively correlated with duration of smoking and number of cigarettes smoked daily (P<.05). Data showed that the more cigarettes teens smoked daily and the longer they had smoked, the more dependent they were. Some teens (20%), however, had low nicotine dependence despite years of smoking and high smoking rates. Results showed that the relationship between nicotine dependence and cessation outcomes varied by treatment intensity. The brief intervention was successful with only low-dependent smokers, whereas the intensive, multisession, N-O-T intervention was effective with smokers possessing a range of nicotine dependence, including high-dependent smokers.

Horn KA; Dino GA; Kalsekar ID; Fernandes AW. Appalachian teen smokers: Not on tobacco 15 months later. American Journal of Public Health 94(2): 181-184, 2004. (13 refs.)

High school smokers from 2 central Appalachian states received the American Lung Association's 10-session Not On Tobacco (N-O-T) program or a 15-minute brief self-help intervention. Our study compared the efficacy of N-O-T with that of the brief intervention by examining group differences in the 15-month-postbaseline (12-month-postprogram) smoking quit rates. N-O-T youths had higher overall quit rates. Review of end-of-program (3-month-postbaseline) and 3-month-postprogram (6-month-postbaseline) follow-up data showed state-level differences and positive cessation trends over time, regardless of treatment intensity. Quit rates were lower than rates found in other N-O-T studies of nonrural youths, suggesting that Appalachian youths are a recalcitrant smoking sample. Findings suggest that N-O-T is one option for long-term smoking cessation among rural teens.

Hoving C; Reubsaet A; de Vries H. Predictors of smoking stage transitions for adolescent boys and girls. Preventive Medicine 44(6): 485-489, 2007. (44 refs.)

Background. Aim of this study was to identify predictors of transition from never smoking to smoking monthly or more often in a European sample of adolescents. To show whether predictors differed between genders, analyses were run for boys and girls separately. Methods. From six European countries, 4055 never smokers participated at baseline (1998). One year later, respondents were asked to indicate their smoking status. Respondents were categorized as smoker (smoking monthly or more) or non-smoker (smoking less than monthly). The predictive qualities of predisposing, motivational and intentional concepts were assessed using logistic regression analyses. Results. Girls were more likely to be a smoker at follow-up. More spending money, modeling from parents and a higher intention to start smoking were predictive of smoking uptake in both genders. Boys were more likely to start smoking when perceiving less cons of smoking, drinking more alcohol and perceiving a social norm towards not smoking from parents. Girls experiencing higher social pressure to smoke from friends were more likely to start smoking. Conclusions. Separate uptake prevention interventions for boys and girls do not seem warranted. Boys may benefit from a program also addressing other deviant behaviors. Girls should continue to be supplied with specific skills to resist social pressure.

Hunt MK; Fagan P; Lederman R; Stoddard A; Frazier L; Girod K et al. Feasibility of implementing intervention methods in an adolescent worksite tobacco control study. Tobacco Control 12(Supplement 4): 40-45, 2003. (39 refs.)

Objective: To present feasibility data on SMART, the first teen worksite behavioural tobacco control intervention. Design: This phase II study was designed to estimate the efficacy and feasibility of a small scale, randomised, controlled intervention. Setting and subjects: This study, addressing youths aged 15-18 years, was implemented in four intervention and five control grocery stores that had an average of 44 eligible teens. Interventions: The tobacco use cessation and prevention interventions were based on social influences and peer leader models. Employee break rooms served as centres both for interactive activities including open houses, teen advisory boards, peer leader interviews, games and contests; and non-interactive interventions including bulletin boards and table tents with health messages and home mailings. Main process measures: Project staff collected process data on the extent of implementation of intervention activities, participation rates in activities, and contacts with peer leaders. On the final survey, teens reported on awareness of, participation in, and motivation for participating in project activities. Results: Indicators of feasibility were identified and discussed, including the number of activities implemented, teen participation, management support, cost, and barriers to and facilitators of implementation. During the 12 month intervention, a mean of 24.1 interactive activities and 55.3 non-interactive activities were implemented, and a mean 14.2% participation rate per activity per site was achieved. Eighty four per cent of teens reported being aware of SMART, and 39% reported participating in interactive and 67% in non-interactive activities. Conclusions: Teen smoking cessation rates in worksite programmes might be improved if they are conducted in companies where there is job stability and if teen programmes are part of worksite-wide tobacco control programmes that include both teens and adults.

Johnson KC; Klesges LM; Somes GW; Coday MC; DeBon M. Access of over-the-counter nicotine replacement therapy products to minors. Archives of Pediatrics & Adolescent Medicine 158(3): 212-216, 2004. (18 refs.)

Background: Public health policy guidelines recommend that health care providers (eg, physicians, nurses, others) counsel adolescent smokers to quit and that nicotine replacement therapy (NRT) may be considered to aid in smoking cessation for nicotine-dependent youth. This recommendation is discrepant with Food and Drug Administration-approved labeling of NRT products, stating that they not be sold to persons younger than 18 years. It is not clear how easily minors are able to purchase NRT products in retail markets. Objective: To explore youth access to NRT by conducting the first study, to our knowledge, to determine the ability of minors to purchase over-the-counter NRT products. Design: Observational case series of NRT purchase attempts and survey description of store characteristics. Setting: Retail businesses in Memphis, Tenn. Participants: Population-based sample of 165 stores that sold over-the-counter medications. Main Outcome Measure: Successfully completed purchase attempts of NRT by the minor buyer. Results: In most stores that stocked NRT products, the age of the minor was not queried at any time during the purchase attempt (79%) and the minor was able to successfully purchase the product (81%). If the minor was asked her age, the store was much less likely to sell the NRT product. Stores in which a cash register gave an age query prompt or in which alcohol was sold were more likely to inquire about the minor's age and less likely to sell NRT products. Conclusions: Nicotine replacement therapy products were successfully obtained in most purchases by a minor buyer without proof of age. While ease of purchasing NRT products is potentially beneficial to young smokers attempting to quit, these purchases are discrepant with Food and Drug Administration labeling regarding the sale of NRT products to minors.

Jones DN; Schroeder JR; Moolchan ET. Time spent with friends who smoke and quit attempts among teen smokers. [rapid communication]. Addictive Behaviors 29(4): 723-729, 2004. (16 refs.)

Social interactions, as well as pharmacological effects, can reinforce smoking behavior in adolescents and pose challenges to smoking cessation. We hypothesized that time spent with friends who smoke would be inversely related to both the number and duration of previous quit attempts for teens receiving smoking cessation treatment. Demographic- and smoking-related data were collected from 98 adolescent smokers enrolled in an accruing smoking cessation study (68% female, 70% Caucasian, mean age 15.3 years). Among smokers who had at least one quit attempt, time spent with friends who smoke was inversely associated with the number of prior quit attempts (2=9.55, P=.0085) but not with their duration, suggesting a potential relationship between an adolescent's affiliation with smoking peers, smoking identity, and fewer quit attempts.

Kealey KA; Ludman EJ; Mann SL; Marek PM; Phares MM; Riggs KR et al. Overcoming barriers to recruitment and retention in adolescent smoking cessation. Nicotine & Tobacco Research 9(2): 257-270, 2007. (51 refs.)

Participant recruitment and retention have been identified as challenging aspects of adolescent smoking cessation interventions. Problems associated with low recruitment and retention include identifying smokers, obtaining active parental consent, protecting participants' privacy, respecting participants' autonomy, and making participation relevant and accessible to adolescents. This paper describes nine strategies for minimizing these recruitment and retention problems via a proactive telephone counseling intervention, and reports on their simultaneous implementation among 1,058 smokers from 25 high schools in Washington state. Results are as follows: (a) 85.9% of parents of minor-age seniors provided active consent for their teen's participation, (b) 89.8% of eligible smokers were successfully contacted by counselors, (c) 86.5% of contacted smokers consented to participate in the cessation counseling, (d) 93.8% of consented smokers participated in smoking cessation counseling calls, and (e) 72.2% of participating smokers completed their full intervention. These results demonstrate that older teens who smoke, and their parents, are receptive to confidential cessation counseling that is personally tailored, supportive of their autonomy, and proactively delivered via the telephone.

Kerjean J. Smoking in adolescents. How can we convince them not to smoke? How can we help them to stop smoking? Revue Francaise d'allerogologie et d'immunologie Clinque 45(7): 561-564, 2005. (14 refs.)

Adolescence is an age prone to emerging addictive behaviours such as smoking. The relationship of adolescents with adults at home and at school is complex during this period of transition to adulthood. It is important that the bond between adolescents and adults should be secured and enriched. Smoking, starts as a social behaviour that is still valued in our culture and by our peers. Youngsters are then trapped into this pattern, and a strong addiction makes is difficult for them to change. This article will look at the specificities of smoking in adolescents, the specific ties of withdrawal, and the means recognised as the most efficient for prevention and for withdrawal support. Documented by recent articles on the subject and by my personal experience in a school environment and with adolescents, this article will aim at defining the most appropriate means in this struggle against this undesirable smoking behaviour in young people.

Killen JD; Robinson TN; Ammerman S; Hayward C; Rogers J; Samuels D et al. Major depression among adolescent smokers undergoing treatment for nicotine dependence. Addictive Behaviors 29(8): 1517-1526, 2004. (30 refs.)

This is the first study to examine the prevalence and effects of major depression (MDD) in a sample of adolescent smokers (N=211) undergoing treatment for nicotine dependence. We assessed MDD at baseline and end of treatment with the mood disorders portion of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Eleven percent of participants reported a history of MDD (6% of males and 21% of females). Study variables did not distinguish those with and without a history of MDD. End of treatment abstinence rates and relapse rates were similar in both groups. Two participants (1%), both female, experienced onset of MDD during the treatment. The findings provide further evidence that MDD is a comparatively common disorder among children and adolescents and that clinicians should monitor and be prepared to respond to depression that may emerge during the treatment of nicotine-dependent adolescents.

Killen JD; Robinson TN; Ammerman S; Hayward C; Rogers J; Stone C et al. Randomized clinical trial of the efficacy of bupropion combined with nicotine patch in the treatment of adolescent smokers. Journal of Consulting and Clinical Psychology 72(4): 729-735, 2004. (16 refs.)

Adolescent smokers (N = 211) were randomized to 1 of 2 groups: (a) nicotine patch plus bupropion SR (sustained release; 150 mg per day) or (b) nicotine patch plus placebo. Group skills training sessions were conducted each week by research staff. Abstinence rates at Weeks 10 and 26 were as follows: (a) patch plus bupropion, 23% and 8%, (b) patch plus placebo, 28% and 7%. Despite the lack of a treatment effect, a large majority of adolescents in both treatment groups reduced their consumption to a few cigarettes per day or less and maintained this reduction over time. Similarly, an examination of survival curves revealed that by the end of treatment many had managed to avoid a return to daily smoking. These findings are encouraging and suggest new avenues for research. For example, treatments of the kind examined in this report, augmented by extended maintenance therapies, may yield higher long-term success rates.

Kinzie MB. Instructional design strategies for health behavior change. (review). Patient Education and Counseling 56(1): 3-15, 2005. (27 refs.)

To help health educators build upon the best of different health behavior change theories, this paper offers a unified set of instructional design strategies for health education interventions. This set draws upon the recommendations of Rosentock (Health Belief Model). Bandura (Social Cognitive Theory), and Dearing (Diffusion Theory). and uses a modified Events of Instruction framework (adapted from Robert Gagne): gain attention (convey health threats and benefits), present stimulus material (tailor message to audience know-ledge and values, demonstrate observable effectiveness, make behaviors easy-to-understand and do). provide guidance (use trustworthy models to demonstrate), elicit performance and provide feedback (to enhance trialability, develop proficiency and self-efficacy), enhance retention and transfer (provide social supports and deliver behavioral cues). Sample applications of these strategies are provided. A brief review of research on adolescent smoking prevention enables consideration of the frequency with which these strategies are used, and possible patterns between strategy use and behavioral outcomes.

Klesges LM; Johnson KC; Somes G; Zbikowski S; Robinson L. Use of nicotine replacement therapy in adolescent smokers and nonsmokers. Archives of Pediatrics & Adolescent Medicine 157(6): 517-522, 2003. (22 refs.)

Background: Assessing whether and how adolescents use nicotine replacement therapy (NRT) will be important given recent recommendations to make NRT more accessible by lowering its price, increasing its distribution, and advising health care professionals to suggest its use for smoking cessation. Objectives: To report the prevalence, ease of access, and reasons for NRT use and describe inappropriate use in adolescent smokers and nonsmokers. Design: Cross-sectional survey of 4078 high school students during the school term of 1998. Setting: City schools in Memphis, Tenn. Main Outcome Measures: Community-based self-reported prevalence of NRT use and characteristics of those using NRT. Results: Approximately 5% of adolescents reported trying or using nicotine gum or patches. Females were less likely than males and African Americans were less likely than others to use NRT. For African American smokers, NRT use was highest at lower smoking levels, while other smokers showed the opposite pattern. Almost 40% of former smokers reported using NRT to try to quit smoking; however, 75% of current smokers endorsed using NRT for reasons other than trying to quit smoking. Other inappropriate use of NRT was reported; 18% of NRT users reported themselves as never smokers. More than 50% of students reported that it would be easy for them to get NRT. Conclusions: Nicotine replacement therapy is used by adolescent smokers and nonsmokers, is easily accessible, and is used for reasons other than trying to quit smoking. Efforts are needed to discourage NRT use in nonsmoking youth and to encourage appropriate use of NRT in young smokers to maximize its potential for successful cessation.

Krishnan-Sarin S; Reynolds B; Duhig AM; Smith A; Liss T; McFetridge A et al. Behavioral impulsivity predicts treatment outcome in a smoking cessation program for adolescent smokers. Drug and Alcohol Dependence 88(1): 79-82, 2007. (16 refs.)

Objective: To examine the relationship between impulsivity and smoking cessation treatment response among adolescents. Methods: Thirty adolescent smokers participated in a high school based smoking cessation program combining contingency management and cognitive behavioral therapy. Self-report (Barratt impulsiveness scale (BIS-II); Kirby delay discounting measure (DDM)) and behavioral (experiential discounting task (EDT); continuous performance task (CPT)) measures of impulsivity were assessed at treatment onset. Results: Sixteen participants (53%) were abstinent from smoking at completion of the four-week study. Compared to abstinent adolescents, those not achieving abstinence discounted monetary rewards more on the EDT and committed more commission errors on the CPT. Group differences were not observed on the BIS-II or DDM. Conclusions: These preliminary results suggest that specific behavioral measures of impulsivity may be associated with the ability to initiate and/or maintain abstinence from smoking among adolescent smokers.

Leatherdale ST. School-based smoking cessation programs: Do youth smokers want to participate in these programs? Addictive Behaviors 31(8): 1449-1453, 2006. (10 refs.)

The purpose of the present study was to examine characteristics that predict interest in school-based cessation programs among 3136 youth smokers with intentions to quit smoking. The majority of youth smokers report that they would not join a school-based smoking cessation program. However, improving awareness of these types of programs among students is important as sub-populations of youth smokers were more likely to be interested in school-based cessation initiatives when aware that such programs exist. Future school-based cessation intervention outcomes might be improved if programs are targeted to the youth that are most likely to use them, if more youth can be made aware of existing programs, and if the benefits of participating in such programs can be more adequately conveyed to youth smokers.

Leatherdale ST; McDonald PW. What smoking cessation approaches will young smokers use? (rapid communication). Addictive Behaviors 30(8): 1614-1618, 2005. (10 refs.)

The purpose of this study was to examine the attitudes of youth smokers toward nine common smoking cessation approaches. Attitudes were examined among 3660 youth smokers who intended to quit smoking. The majority of youth smokers report that they would never use the smoking cessation approaches that are commonly recommended for youth populations. The approaches that were appealing to youth are quitting on their own and using the advice of friends. Future initiatives need to more effectively communicate to youth the benefits of existing cessation approaches, make existing interventions more appealing, or develop new approaches that address youth needs.

Ling PM; Glantz SA. Tobacco industry research on smoking cessation: Recapturing young adults and other recent quitters. Journal of General Internal Medicine 19(5, Part 1): 419-426, 2004. (70 refs.)

Background: Smoking rates are declining in the United States, except for young adults (age 18 to 24). Few organized programs target smoking cessation specifically for young adults, except programs for pregnant women. In contrast, the tobacco industry has invested much time and money studying young adult smoking patterns. Some of these data are now available in documents released through litigation. Objective: Review tobacco industry marketing research on smoking cessation to guide new interventions and improve clinical practice, particularly to address young adult smokers' needs. Methods: Analysis of previously secret tobacco industry documents. Results: Compared to their share of the smoking population, young adult smokers have the highest spontaneous quitting rates. About 10% to 30% of smokers want to quit; light smokers and brand switchers are more likely to try. Tobacco companies attempted to deter quitting by developing products that appeared to be less addictive or more socially acceptable. Contrary to consumer expectations, "ultra low tar" cigarette smokers were actually less likely to quit. Conclusions: Tobacco industry views of young adult quitting behavior contrast with clinical practice. Tobacco marketers concentrate on recapturing young quitters, while organized smoking cessation programs are primarily used by older smokers. As young people have both the greatest propensity to quit and the greatest potential benefits from smoking cessation, targeted programs for young adults are needed. Tobacco marketing data suggest that inspirational messages that decrease the social acceptability of smoking and support smoke-free environments resonate best with young adult smokers' motivations.

Liu JM; Peterson AV; Kealey KA; Mann SL; Bricker JB; Marek PM. Addressing challenges in adolescent smoking cessation: Design and baseline characteristics of the HS Group-Randomized trial. Preventive Medicine 45(2/3): 215-225, 2007. (75 refs.)

Objective. Well-documented challenges have hampered both intervention development and research in teen smoking cessation. Addressing these challenges, the Hutchinson Study of High School Smoking (HS Study), the largest group-randomized trial in adolescent smoking cessation to date, incorporates several design innovations to investigate the effect of a counselor-initiated, individually tailored telephone counseling smoking cessation intervention for older adolescents. This paper presents and discusses these innovative design features, and baseline findings on the resulting study population. Method. The trial used a population-based survey to proactively identify and recruit all high school juniors who had smoked in the past month - potentially expanding intervention reach to all smokers, even those who smoked less than daily and those not motivated to quit. For ethical and intervention reasons, some nonsmokers were enrolled in the intervention, also. Other important design features included the random allocation of schools into experimental conditions (intervention vs. no-intervention control) and a multi-wave design. Results and conclusion. The design innovations address problems and challenges identified in adolescent smoking cessation literature. The heterogeneous baseline characteristics of the study population, well-balanced between the two arms, have three significant implications: They (1) demonstrate the effectiveness of the trial's design features, (2) highlight several intervention-related issues, and (3) provide assurance that the trial's evaluation of intervention effectiveness will be unbiased.

Luther EJ; Bagot KS; Franken FH; Moolchan ET. Reasons for wanting to quit: Ethnic differences among cessation-seeking adolescent smokers. Ethnicity & Disease 16(3): 739-743, 2006. (23 refs.)

Objective: Enhancing adolescent cessation requires an understanding of approaches that will motivate youths to quit smoking. Methods: We compared reasons for wanting to quit expressed by European Americans to those of African American youths. Adolescent cessation-seeking smokers completed telephone interviews regarding their smoking behavior and reasons for wanting to quit in an open-ended format. Responses were then classified into nine categories. Results: Participants included 1,268 Baltimore-area adolescents (mean age 15.6 +/- 1.7 years, 60% female, 58% European American, mean Fagerstrom Test for Nicotine Dependence 5.8 +/- 2.2). While both groups broadly cited health as the predominant reason for wanting to quit, chi-square analyses of further stratification of health into general, future, and current health concerns showed that European Americans were more likely to endorse current health reasons (P <.001), while African Americans were more likely to state general health reasons (P=.004). European Americans were more likely to state cost (P=.002) or to not give a reason for wanting to quit (P=.008), while African Americans more frequently reported a lack of positive (pharmacologic or social) reinforcement (P <.001). Conclusions: The development of culturally tailored messages may help enhance smoking cessation efforts among adolescents.

MacDonald S; Rothwell H; Moore L. Getting it right: Designing adolescent-centred smoking cessation services. Addiction 102(7): 1147-1150, 2007. (25 refs.)

Aims: To demonstrate the importance of identifying adolescent preferences for smoking cessation in order to inform the design of effective adolescent cessation services. Design Structured qualitative interviews drawing on means-end theory. Setting Three youth-clubs and two secondary schools in south-east Wales. Participants: Twenty-five male and female 13-18-year-olds, mainly daily smokers. Findings Interviewees did not assume immediately that a smoking cessation service is something that will be available to them, and therefore they initially encountered difficulties in identifying attributes of such support. With further prompting interviewees were able to express a preference for support attributes, but these were not attributes that traditionally form part of cessation provision. Their main preference was for support from friends and family, access to nicotine replacement therapy and non-school-based, flexible support and guidance. Conclusion: The results re-emphasize the inadequacies of existing cessation provision for meeting adolescent preferences and suggest that developing more adolescent-appropriate support requires a reconceptualization of existing interventions, with service users situated at the core of intervention design. The study highlights a number of service development points for intervention planners including: rethinking the timing and location of provision; placing more emphasis on the selection of facilitators; harnessing support from friends and family; and rooting these developments in broader tobacco control strategies.

Maher JE; Rohde K; Pizacani B; Dent C; Stark MJ; Dilley JA et al. Does free nicotine replacement therapy for young adults prompt them to call a quitline? (letter). Tobacco Control 16(5): 357-358, 2007. (2 refs.)

McCuller WJ; Sussman S; Wapner M; Dent C; Weiss DJ. Motivation to quit as a mediator of tobacco cessation among at-risk youth. Addictive Behaviors 31(5): 880-888, 2006. (22 refs.)

The purpose of this study is twofold: 1) to evaluate the effects of a smoking cessation clinic (Project EX) on changing motivation to quit smoking, and 2) to assess differences in quit rates based on these changes in motivation. Student smokers in 18 continuation high schools in the Los Angeles county area were invited to participate in a tobacco cessation clinic designed to enhance motivation to quit tobacco use. The 18 schools were randomly assigned to one of three conditions. Compared to students in the control group, students who participated in the program conditions were more likely to express higher motivation to quit tobacco use. Higher motivation was also significantly related to higher quit rates. Motivation to quit as defined by constituents of the energy/direction model of motivation appears to be a plausible mediator of cessation program effects.

McIntosh S; Ossip-Klein DJ; Hazel-Fernandez L; Spada J; McDonald PW; Klein JD. Recruitment of physician offices for an office-based adolescent smoking cessation study. Nicotine & Tobacco Research 7(3): 405-412, 2005. (15 refs.)

Physician office settings play an important role in tobacco cessation intervention. However, few tobacco cessation trials are conducted at these sites, in part because of the many challenges associated with recruiting community physician offices into research. The present study identified and implemented strategies for recruiting physician offices into a randomized clinical trial of tobacco screening and cessation interventions with adolescent patients. A total of 30 community physicians participated in focus groups to elicit their perceptions of facilitators of and barriers to initial engagement of physician practices and the subsequent enrollment of the practices in long-term research projects. Physicians identified facilitators such as (a) the involvement of office staff in the recruitment process and (b) on-site presentations of the study's background and aims. Some of the barriers identified were time commitment concerns and the lack of incentives in exchange for participation. These focus group findings were then integrated with theory-based and empirically driven recruitment strategies for a 12-month randomized tobacco intervention trial with adolescent patients. Of 185 office practices approached to participate (screened from a pool of 273 practices), 103 agreed to on-site presentations of the study. Subsequently, almost all of the practices (101) that received the presentation agreed to enroll in the study. Conclusions are that (a) recruitment is a multicomponent process, (b) the processes of communication, engagement, and enrollment must be carefully planned and implemented to achieve maximal results, and (c) the development of effective strategies for recruiting health care provider practices presents an important infrastructure for testing adolescent smoking cessation interventions.

McVea KLSP. Evidence for clinical smoking cessation for adolescents. Health Psychology 25(5): 558-562, 2006. (40 refs.)

Objective: This report reviews the evidence that informs the role of health and mental health care providers in addressing youth smoking cessation. Design: Qualitative literature review. Results: Physicians do not consistently screen adolescents for tobacco use and fail to provide recommended cessation advice. Challenges to addressing smoking cessation include the need for procedures to ensure confidentiality and the existence of competing demands to provide other services. Few published studies have specifically addressed the effectiveness of clinical interventions. Interventions that require return visits or follow-up phone contacts are technically difficult to implement in this population. Successful interventions may require resources not available in nonresearch settings. Most studies have used brief clinical intervention as a control condition, making it impossible to evaluate its effectiveness. Conclusion: There is little evidence that supports current clinical smoking cessation guidelines for adolescents. More research is needed to develop inexpensive, efficient clinical interventions that can provide youths access to smoking cessation help. Future challenges include reorganizing clinical systems to offer greater counseling by support staff or in electronic formats and to provide effective booster messages and follow-up care in a population that is difficult to track.

Mermelstein R. Teen smoking cessation. Tobacco Control 12(2): I25-I34, 2003. (52 refs.)

Interest in adolescent smoking cessation has increased dramatically over the past several years, as researchers and practitioners have acknowledged the high rates of adolescents who smoke regularly and the low probability that adolescents who are regular smokers will stop on their own. The evidence base behind smoking cessation interventions for adolescents is also now starting to grow, but unfortunately the studies to date have frequently been plagued by major methodological problems. This paper summarises research conducted on adolescent smoking cessation, notes some of the methodological limitations of prior work, highlights approaches that show promise, discusses some of the challenges involved in addressing adolescent smoking cessation, and makes recommendations for future work.

Milne B; Towns S. Do paediatricians provide brief intervention for adolescents who smoke? Journal of Paediatrics and Child Health 43(6): 464-468, 2007. (24 refs.)

Aims: This study aimed to describe the self-reported practice of paediatricians in brief interventions for adolescents who smoke. We also aimed to compare practice with confidence, skills and knowledge of brief intervention and nicotine replacement therapy after a targeted training programme. Methods: Medical staff at The Children's Hospital at Westmead completed a questionnaire of clinical practice and confidence in brief intervention for smoking cessation. Data were analysed comparing self-reported practice with confidence, skill and knowledge of brief interventions, based on Fiore's 5A's approach (Ask about smoking at every opportunity, Assess willingness to quit, Advise patients to quit smoking, Assist quit attempts and Arrange follow up). Results: Fifty-seven clinicians completed questionnaires, 55 (96%) recognised the importance of asking adolescents about smoking. Thirty-one (54%) identified adolescent smokers all or most of the time, increasing to 50 (88%) if their presenting condition was associated with smoking. Twenty-five (44%) clinicians assessed the stage of change, 33 (58%) advised the adolescent to quit smoking, nine (16%) assisted quit attempts and 10 (17.5%) arranged follow up. Clinicians more confident in brief intervention skills, motivational interviewing and relapse prevention were more likely to use the 5A's (P < 0.05). Training increased clinician's confidence in brief intervention skills and knowledge of nicotine replacement therapy (P < 0.01); however, there was no statistically significant change in clinical practice 1 month post training. Conclusion: Training paediatricians in brief intervention skills, motivational interviewing and relapse prevention can increase the use of 5A's brief intervention in clinical practice, potentially increasing quit attempts in adolescents who smoke.

Molyneux A. ABC of smoking cessation: Nicotine replacement therapy. British Medical Journal 328(7437): 454-456, 2004. (4 refs.)

Although products for nicotine replacement therapy (NRT) have been available for over 20 years, they have been excluded until recently from state or insurance based health service provision in the United Kingdom and many other countries. They have therefore not been widely prescribed by doctors who help smokers wanting to quit. Recent changes in funding policy in the United Kingdom and new guidance from the National Institute for Clinical Excellence (which covers England and Wales) mean that NRT products can and should now be made available to all smokers who want to stop smoking. Like other pharmacological interventions for helping smokers to quit (see the next article in this series), NRT is most effective when used in conjunction with behavioural and other types of non-pharmacological cessation interventions. This review discusses mechanisnms of action, evidence for effectiveness, who should receive NRT, formulations and use of NRT, and safety. There is also discussion of use in younger smokers. [NB. A correction has been published in volume 328(7441): 686, 2004.]

Molyneux A; Lewis S; Coleman T; McNeill A; Godfrey C; Madeley R et al. Designing smoking cessation services for school-age smokers: A survey and qualitative study. Nicotine & Tobacco Research 8(4): 539-546, 2006. (32 refs.)

To identify the preferred design characteristics of smoking cessation services for school-age smokers, we conducted focus groups with teenage smokers motivated to stop smoking. We surveyed all pupils in years 9-11 ( aged 13-16) in a random sample of 10 schools in Nottinghamshire, United Kingdom, to elicit details of smoking behavior, and conducted 25 focus groups in 6 schools with current smokers who wanted to stop smoking. Of 4,065 pupils surveyed, 888 (22%) were current smokers, and 438 (50% of smokers) wanted to quit smoking. We sampled 226 of these individuals for focus group studies, and 135 (60%) participated. These participants were motivated to quit, and almost all had tried to do so but had found it too difficult. Many were aware of smoking cessation methods but had low perceptions of their effectiveness based on their own or others' poor experiences of these interventions, and few were aware of the possibility of professional cessation support. Given clear, nondirective information about interventions, participants reported a preference for confidential, nonjudgmental services delivered during school time by a trained counselor, allowed the option to attend with friends, and offered nicotine replacement therapy (NRT). School-age smokers in Nottinghamshire, United Kingdom, who are motivated to stop smoking have low knowledge and opinions of smoking cessation interventions. Our findings indicate that young smokers would favor school-based services offering confidential professional counseling and NRT.

Moolchan ET; Aung AT; Henningfield JE. Treatment of adolescent tobacco smokers: Issues and opportunities for exposure reduction approaches. (review). Drug and Alcohol Dependence 70(3): 223-232, 2003. (88 refs.)

The cycle of tobacco dependence typically begins with the initiation of tobacco use during adolescence. Many teenagers try to quit smoking, fail and subsequently desire treatment for their tobacco dependence. Adolescents do not currently benefit from the same level of societal support for quit attempts as adults, and they may be less motivated for total cessation despite the short and long-term health consequences of smoking. Overall, the combination of low participation, high attrition and low complete cessation rates for adolescent smokers in treatment prompts the consideration of alternative treatment endpoints. It is likely that interactions among the processes of child and adolescent development, smoke exposure and trajectory influence patterns of tobacco use and treatment for tobacco dependence in adolescents. A rational framework is needed to integrate the study of these dynamic interactions to address tobacco dependence among youth from an exposure reduction, in addition to a cessation, perspective. This paper considers the issues and potential implications of tobacco exposure reduction therapy as an intermediate treatment goal for adolescent smokers who are dependent or dependence-prone, but for whom initial treatment interventions do not yield complete tobacco cessation.

Moolchan ET; Berlin I; Robinson ML; Cadet JL. Characteristics of African American teenage smokers who request cessation treatment: Implications for addressing health disparities. Archives of Pediatrics & Adolescent Medicine 157(6): 533-538, 2003. (45 refs.)

Background: Ethnoracial disparities in both tobacco-related mortality and treatment outcome for smoking cessation have been reported among adults, but there is a dearth of information on ethnoracial differences among adolescent smokers. Objective: To compare smoking-related characteristics in African American and non-African American teen-aged applicants for a smoking cessation trial. Participants, Design, and Setting: Four hundred thirty-two teenaged smokers (mean [SD] age, 15.6 [1.5] years; 61.8%, female; 31.9%, African American) responded via telephone to various media advertisements. Self-reported sociodemographic, smoking-related, and clinical data were obtained to determine preeligibility for trial participation. Main Outcome Measures: The number of cigarettes smoked per day, Fagerstrom Test for Nicotine Dependence (FTND) score, motivation to quit, self-reported health problems, and medication use. Results: Compared with non-African Americans, African Americans had lower FTND scores (mean [SD] score, 5.31 [2.24] vs 6.18 [2.18]; P < .01), and smoked fewer cigarettes per day (mean [SD] number of cigarettes, 12.6 [8.3] vs 15.4 [7.5] cigarettes/d; P < .04). The FTND scores were similar in both groups when adjusted for the number of cigarettes smoked per day. African American and non-African American teenagers reported similar motivation to quit (mean [SD] score, 8.64 [1.68] vs 8.53 [1.59], respectively). No difference was found in frequency of physical health problems (eg, asthma), diagnosed psychiatric conditions, or prescribed psychiatric medication although fewer African American teenaged smokers took medication for physical problems (21.2% vs 36.7%). Conclusions: Cessation treatment interventions designed for African American youths should include lower FTND-defined levels, or the use of other instruments that do not focus on the number of cigarettes smoked per day. Our findings also highlight the importance of ethnocultural issues in treatment research that aims to address health disparities.

Moolchan ET; Frazier M; Franken FH; Ernst M. Adolescents in smoking cessation treatment: Relationship between externalizing symptoms, smoking history and outcome. Psychiatry Research 152(2/3): 281-285, 2007. (25 refs.)

Previous research has indicated a potential bi-directional link between youth substance use and externalizing psychiatric comorbidities. We hypothesized that the degree of externalizing symptoms predicts the likelihood of successful smoking cessation (prolonged abstinence) among adolescent smokers participating in a cessation trial. We also explored the association of extemalizing symptoms with age at smoking initiation. Ninety one adolescents (mean +/- S.D.; age 15.1 +/- 1.4 years, cigarettes per day 18.4 +/- 8.1, Fagerstrom Test for Nicotine Dependence 7.1 +/- 1.3) were included. The Child Behavior Checklist/4-18 and Youth Self-Report assessed the degree of externalizing symptoms. Regression analysis indicated that lower CBCL externalizing scores significantly predicted the likelihood of prolonged abstinence. Pearson's correlation analysis indicated a significant association of lower externalizing scores with later onset of smoking initiation. Our findings highlight the importance of addressing externalizing behaviors in adolescent smoking cessation programs.

Moolchan ET; Schroeder JR. Quit attempts among African American teenage smokers seeking treatment: Gender differences. Preventive Medicine 39(6): 1180-1186, 2004. (35 refs.)

Background. African Americans experience disproportionate smoking-related mortality. Because established smoking during youth predisposes to adult smoking and serious health consequences, characterizing ethnic differences in adolescent smokers' self-quit attempts may inform ethnic-specific approaches to youth smoking cessation. Methods. African American and European American teenage smokers applying to a teenage smoking cessation study (2000-2003) provided smoking-related data, including characteristics of previous cessation attempts and prior use of nicotine replacement therapy (NRT). Tobacco dependence was assessed using the Fagerstr�m Test of Nicotine Dependence (FTND). Results. Of 980 (15.5 plus or minus 1.3 years, 41.8% African American, 59.9% female) participants, African Americans boys were significantly less likely than European American boys to report a prior quit attempt (OR = 0.35, 95% CI 0.17-0.73, P = 0.0049) or to have used NRT (OR = 0.60, 95% CI 0.36-0.998, P = 0.049) after adjusting for years smoked and FTND score. African American girls were more likely to report a prior request for cessation treatment than European American girls after adjusting for FTND and years smoked (OR = 2.19, 95% CI 1.37-3.48, P = 0.001). Conclusions. While increasing education and outreach to African American boys and enhancing access to formal cessation programs for African American girls who smoke may be beneficial, our findings warrant extension to non-treatment-seeking teenage smokers.

Moolchan ET; Zimmerman D; Sehnert SS; Zimmerman D; Huestis MA; Epstein DH. Recent marijuana blunt smoking impacts carbon monoxide as a measure of adolescent tobacco abstinence. Substance Use & Misuse 40(2): 231-240, 2005. (27 refs.)

Adolescent tobacco smokers have a higher prevalence of marijuana (MJ) smoking than adolescents who do not smoke tobacco. As part of all adolescent smoking cessation trial, we examined whether MJ smoking, and specifically "blunt" (gutted cigars filled with MJ) smoking, elevated participants' likelihood of a false indication of cigarette smoking on the basis of breath carbon monoxide (CO) testing. Using clinical data from 37 adolescents (mean age 15.1 +/- 1.4 years, 78% female) who participated in a smoking-cessation trial in Baltimore between 1999 and 2002, and who on at least one occasion, reported abstinence from tobacco smoking for at least 7 days, we analyzed 146 cigarette-abstinent-visit exhaled CO concentrations classified into blunt occasions (12 participants, 33 visits), nonblunt MJ occasions (seven participants, 20 visits), and non-MJ occasions (27 paricipants, 93 visits). Repeated-measures logistic regression revealed that blunt occasions were associated with CO >= 8 ppm, compared to nonblunt occasions (p = 0.013). Blunt occasions also tended to be associated with the more youth-appropriate cutoff CO >= 6 ppm, compared to non-MJ occasions (p = 0.054). Blunt smoking impacted the interpretation of measures of exhaled CO for tobacco cessation.

Myers MG; Brown SA. A controlled study of a cigarette smoking cessation intervention for adolescents in substance abuse treatment. Psychology of Addictive Behaviors 19(2): 230-233, 2005. (14 refs.)

Tobacco use is prevalent among youth with alcohol and other drug problems, yet this issue has received limited research and clinical attention. This study reports on a controlled evaluation of a cigarette smoking intervention with 54 adolescents in treatment for substance abuse, ages 13-18 (22% female). Participants were assessed at 4 time points. A greater proportion of participants in the treatment condition (n = 26) reported cessation attempts and point abstinence than did control participants (n = 28) at all time points. However, significant differences were found only for point abstinence at a 3-month follow-up. These findings provide initial support for the efficacy of a smoking cessation intervention delivered in the context of adolescent substance abuse treatment.

Myers MG; Kelly JF. Cigarette smoking among adolescents with alcohol and other drug use problems. Alcohol Research and Health 29(3): 221-227, 2006. (23 refs.)

Cigarette and alcohol use often develop concurrently, and smoking is especially common among youth treated for alcohol and other drug (AOD) use disorders. Special considerations for adolescent smoking cessation treatment include peer influences, motivation, and nicotine dependence. Little research has addressed smoking cessation treatment for youth with AOD use disorders, but the few available studies suggest that tobacco cessation efforts are feasible and potentially effective for this population. Findings to date suggest that adolescents with AOD use disorders may benefit more from relatively intensive multicomponent programs rather than brief treatment for smoking cessation. Additional research is needed to further address the inclusion of tobacco-specific interventions for adolescents in AOD use disorder treatment programs.

Public Domain

Myers MG; MacPherson L. Smoking cessation efforts among substance abusing adolescents. Drug and Alcohol Dependence 73(2): 209-213, 2004. (21 refs.)

Available research demonstrates that substance abusing youth are heavy cigarette smokers for whom the behavior persists into adulthood. As such this population represents an important target for intervention. In order to inform treatment design, the present paper described cessation efforts, including motives and methods for quitting, in a sample of cigarette smoking adolescents who received inpatient or outpatient treatment for substance abuse. The 183 participants were on average 16.2 years old, 45% were females, and 72% were white. Consistent with studies of community and high risk youth samples, the majority of participants had previously attempted cessation, yet reported little success in maintaining abstinence. Health emerged as a frequently endorsed motive for cessation and stopping abruptly (cold turkey) was the most commonly reported strategy for quitting.

Niederhofer H; Huber M. Bupropion may support psychosocial treatment of nicotine-dependent adolescents: Preliminary results. Pharmacotherapy 24(11): 1524-1528, 2004. (19 refs.)

Study Objective. To assess the efficacy and safety of long-term bupropion therapy for nicotine dependence in adolescents. Design. Prospective, double-blind, placebo-controlled trial. Setting. Outpatient clinic in Innsbruck, Austria. Subjects. Twenty-two adolescents, aged 16-19 years, with nicotine dependence. Intervention. Participants were randomly assigned to receive bupropion 150 mg/day or placebo for 90 days. Measurements and Main Results. Patients were classified as abstinent or relapsed on day 0 (when study drug was started) and again on days 30 and 90, according to their self-reports. Treatment failure was defined as relapse or nonattendance. Time to first treatment failure was the primary outcome measure. Mean cumulative abstinence duration was significantly greater in the bupropion group than in the placebo group (78.4 +/- 39.6 vs 30.2 +/- 19.2 days. p=0.0042). Conclusion. Bupropion seems to be an effective and well-tolerated pharmacologic adjunct to psychosocial and behavioral treatment programs for some adolescent nicotine-dependent patients. However, experienced clinicians should continuously monitor patients for adverse effects.

O'Loughlin J; DiFranza J; Tyndale RF; Meshefedjian G; McMillan-Davey E; Clarke PBS et al. Nicotine-dependence symptoms are associated with smoking frequency in adolescents. American Journal of Preventive Medicine 25(3): 219-255, 2003. (27 refs.)

Background: Although many sociodemographic and psychosocial factors have been identified as related to adolescent smoking, few studies have examined the role of nicotine-dependence (ND) symptoms. The objective was to study the association between ND symptoms and smoking status among adolescents in the early stages of the smoking onset process. Methods: The McGill University Study on the Natural History of Nicotine Dependence is an ongoing 6-year prospective investigation of the natural history of ND among 1267 grade 7 students in ten Montreal high schools. The baseline response was 55.4%. Subjects for this cross-sectional analysis of baseline data, collected in 1999, included 241 past 3-month smokers (mean age [SD] =13.0+/-0.7 years at baseline). ND symptoms were measured in five indicators, including a measure based on the criteria for tobacco dependence in the International Classification of Diseases-10th Revision (ICD-10), the Hooked on Nicotine Checklist, and three symptom clusters (withdrawal, self-medication, and ND/cravings symptoms). The association between ND symptom indicators and each of sporadic, monthly, weekly, and daily smoking relative to less Frequent smoking was investigated in multiple logistic regression analysis. Results: Despite low cigarette exposure, 16.6% (95% confidence interval [CI], 11.9%-21.3%) of past 3-month smokers were tobacco dependent. The proportion increased from 0%, 3.1% (95% CI, 0.0%-9.2%), and 4.6% (95% CI, 0.2%-9.0%) among triers, sporadic smokers, and monthly smokers, respectively, to 19.4% (95% CI, 5.5%-33.3%) and 65.9% (95% Cl, 51.9%-79.9%) among weekly and daily smokers, respectively. ND/cravings consistently distinguished each smoking category from less frequent smokers; the odds ratios (95% CI) for ND/cravings symptoms were 1.16 (0.99-1.35) in sporadic smokers; 1.17 (1.06-1.29) in monthly smokers; 1.34 (1.19-1.50) in weekly smokers; and 1.39 (1.22-1.59) in daily smokers. Conclusions: These data challenge current smoking onset models, which suggest that ND develops only after several years of heavy or daily smoking. ND symptoms are associated, at least cross-sectionally, with increased smoking in adolescents. To increase the likelihood of being effective, tobacco-control programs for children and adolescents will need to take early ND symptoms into account.

Panday S; Reddy SP; Ruiter RAC; Bergstrom E; de Vries H. Determinants of smoking cessation among adolescents in South Africa. Health Education Research 20(5): 586-599, 2005. (46 refs.)

Data is required on the motivational determinants of smoking cessation among a multi-ethnic sample of adolescents in South Africa. The I-Change Model was used to explore the determinants of smoking cessation among a sample of 1267 Black African, Colored and White Grade 9-11 monthly smokers and former smokers in the Southern Cape-Karoo region. Across the ethnic groups, former smokers displayed a more positive attitude toward non-smoking, were surrounded by a social environment that was more supportive of non-smoking, displayed higher self-efficacy not to smoke in stressful, routine and social situations, and were more positive about their intention not to smoke in the next year. The I-Change Model can be used to address the cognitions of smoking in a multi-ethnic society like South Africa. However, some ethnic tailoring will be required. Black African students will benefit from a focus on attitudinal cognitions and cultural factors that motivate smoking. Colored students require the involvement of their social environment, while White students will benefit from the development of refusal skills in social situations.

Patten CA; Lopez K; Thomas JL; Offord KP; Decker PA; Pingree S et al. Reported willingness among adolescent nonsmokers to help parents, peers, and others to stop smoking. Preventive Medicine 39(6): 1099-1106, 2004. (46 refs.)

Background. This study of 1025 adolescent nonsmokers aged 11-19 years examined level of interest and factors associated with reported willingness to help someone stop smoking. Methods. Data were collected from a survey distributed primarily in the schools at four geographic and ethnically diverse study sites. Results. A total of 692 adolescents identified someone close to them who smokes whom they thought should quit. Of these, 90% reported that they would be willing to help this person stop smoking. Multivariate predictors of willingness to help were female gender, less difficulty reading English, and greater level of comfort with talking to the smoker about their smoking. The smoker that the adolescents were willing to help was most often a parent or same age friend. Conclusions. If this strong interest among adolescents could be tapped, engaging teens as support persons could be