Cost-Effectiveness Analysis of the Not On Tobacco Program for Adolescent Smoking Cessation

The cost-effectiveness of school-based interventions for chronic diseases: a systematic review

BACKGROUND

Chronic diseases, or non-communicable diseases (NCD), are conditions of long duration and often influenced and contributed by complex interactions of several variables, including genetic, physiological, environmental, and behavioral factors. These conditions contribute to death, disability, and subsequent health care costs. Primary and secondary school settings provide an opportunity to deliver relatively low cost and effective interventions to improve public health outcomes. However, there lacks systematic evidence on the cost-effectiveness of these interventions.

METHODS

We systematically searched four databases (PubMed/Medline, Cochrane, Embase, and Web of Science) for published studies on the cost-effectiveness of chronic-disease interventions in school settings. Studies were eligible for inclusion if they assessed interventions of any chronic or non-communicable disease, were conducted in a school setting, undertook a full cost-effectiveness analysis and were available in English, Spanish, or French.

RESULTS

Our review identified 1029 articles during our initial search of the databases, and after screening, 33 studies were included in our final analysis. The most used effectiveness outcome measures were summary effectiveness units such as quality-adjusted life years (QALYs) (22 articles; 67%) or disability-adjusted life years (DALYs) (4 articles; 12%). The most common health condition for which an intervention targets is overweight and obesity. Almost all school-based interventions were found to be cost-effective (30 articles; 81%).

CONCLUSION

Our review found evidence to support a number of cost-effective school-based interventions targeting NCDs focused on vaccination, routine physical activity, and supplement delivery interventions. Conversely, many classroom-based cognitive behavioral therapy for mental health and certain multi-component interventions for obesity were not found to be cost-effective.

Costs and cost-effectiveness of Shamiri, a brief, layperson-delivered intervention for Kenyan adolescents: a randomized controlled trial

BACKGROUND

Low- and middle-income countries (LMICs) have the highest socio-economic burden of mental health disorders, yet the fewest resources for treatment. Recently, many intervention strategies, including the use of brief, scalable interventions, have emerged as ways of reducing the mental health treatment gap in LMICs. But how do decision makers prioritize and optimize the allocation of limited resources? One approach is through the evaluation of delivery costs alongside intervention effectiveness of various types of interventions. Here, we evaluate the cost-effectiveness of Shamiri, a group- and school-based intervention for adolescent depression and anxiety that is delivered by lay providers and that teaches growth mindset, gratitude, and value affirmation.

METHODS

We estimated the cost-effectiveness of Shamiri using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines for economic evaluations. Changes in depression and anxiety were estimated using the Patient Health Questionnaire (PHQ-8) and Generalized Anxiety Disorder questionnaire (GAD-7) at treatment termination and 7-month follow-up using two definitions of treatment benefit. Cost-effectiveness metrics included effectiveness-cost ratios and cost per number needed to treat.

RESULTS

Base case cost assumptions estimated that delivering Shamiri cost $15.17 (in 2021 U.S. dollars) per student. A sensitivity analysis, which varied cost and clinical change definitions, estimated it cost between $48.28 and $172.72 to help 1 student in Shamiri, relative to the control, achieve reliable and clinically significant change in depression and anxiety by 7-month follow-up.

CONCLUSIONS

Shamiri appears to be a low-cost intervention that can produce clinically meaningful reductions in depression and anxiety. Lay providers can deliver effective treatment for a fraction of the training time that is required to become a licensed mental health provider (10 days vs. multiple years), which is a strength from an economic perspective. Additionally, Shamiri produced reliable and clinically significant reductions in depression and anxiety after only four weekly sessions instead of the traditional 12-16 weekly sessions necessary for gold-standard cognitive behavioral therapy. The school setting, group format, and economic context of a LMIC influenced the cost per student; however, broader conclusions about the cost-effectiveness of Shamiri have yet to be determined due to limited economic evaluations of mental health programs in LMICs.

TRIAL REGISTRATION

This study was registered prior to participant enrollment in the Pan-African Clinical Trials Registry (PACTR201906525818462), registered 20 Jun 2019, https://pactr.samrc.ac.za/Search.aspx .

Economic Evaluations of Mental Health Programs for Children and Adolescents in the United States: A Systematic Review

The United States (US) spent 201 billion dollars on mental health-related concerns in 2016, ranking mental illness as the leading cause of disability and the single largest source of economic burden worldwide. With mental health-related treatment costs and economic burden only projected to rise, there is an increasing need for cost-inclusive evaluations of mental health interventions in the US. This systematic review evaluated the intervention characteristics and the quality of 9 economic evaluation studies (e.g., cost-effectiveness, cost-benefit) of youth mental health services conducted in the US from 2003 to 2019. Existing evaluations suggest that certain mental health interventions for youth, among the few that have been formally evaluated, may be cost-effective and cost-beneficial. However, intervention characteristics were generally homogenous, a majority of studies did not adhere to the standard of economic evaluations of the CHEERS checklist, and outcome measures were not consistently clinically useful, limiting the utility of such youth mental health economic evaluations to policymakers. By adhering to standards of economic evaluations and diversifying the characteristics of interventions subject to economic evaluations, intervention researchers can increase confidence in conclusions about which youth mental health interventions are cost-effective or cost-beneficial and more meaningfully inform evidence-based mental health policy.

Behavioural interventions for smoking cessation: an overview and network meta-analysis

BACKGROUND

Smoking is a leading cause of disease and death worldwide. In people who smoke, quitting smoking can reverse much of the damage. Many people use behavioural interventions to help them quit smoking; these interventions can vary substantially in their content and effectiveness.

OBJECTIVES

To summarise the evidence from Cochrane Reviews that assessed the effect of behavioural interventions designed to support smoking cessation attempts and to conduct a network meta-analysis to determine how modes of delivery; person delivering the intervention; and the nature, focus, and intensity of behavioural interventions for smoking cessation influence the likelihood of achieving abstinence six months after attempting to stop smoking; and whether the effects of behavioural interventions depend upon other characteristics, including population, setting, and the provision of pharmacotherapy. To summarise the availability and principal findings of economic evaluations of behavioural interventions for smoking cessation, in terms of comparative costs and cost-effectiveness, in the form of a brief economic commentary.

METHODS

This work comprises two main elements. 1. We conducted a Cochrane Overview of reviews following standard Cochrane methods. We identified Cochrane Reviews of behavioural interventions (including all non-pharmacological interventions, e.g. counselling, exercise, hypnotherapy, self-help materials) for smoking cessation by searching the Cochrane Library in July 2020. We evaluated the methodological quality of reviews using AMSTAR 2 and synthesised data from the reviews narratively. 2. We used the included reviews to identify randomised controlled trials of behavioural interventions for smoking cessation compared with other behavioural interventions or no intervention for smoking cessation. To be included, studies had to include adult smokers and measure smoking abstinence at six months or longer. Screening, data extraction, and risk of bias assessment followed standard Cochrane methods. We synthesised data using Bayesian component network meta-analysis (CNMA), examining the effects of 38 different components compared to minimal intervention. Components included behavioural and motivational elements, intervention providers, delivery modes, nature, focus, and intensity of the behavioural intervention. We used component network meta-regression (CNMR) to evaluate the influence of population characteristics, provision of pharmacotherapy, and intervention intensity on the component effects. We evaluated certainty of the evidence using GRADE domains. We assumed an additive effect for individual components.

MAIN RESULTS

We included 33 Cochrane Reviews, from which 312 randomised controlled trials, representing 250,563 participants and 845 distinct study arms, met the criteria for inclusion in our component network meta-analysis. This represented 437 different combinations of components. Of the 33 reviews, confidence in review findings was high in four reviews and moderate in nine reviews, as measured by the AMSTAR 2 critical appraisal tool. The remaining 20 reviews were low or critically low due to one or more critical weaknesses, most commonly inadequate investigation or discussion (or both) of the impact of publication bias. Of note, the critical weaknesses identified did not affect the searching, screening, or data extraction elements of the review process, which have direct bearing on our CNMA. Of the included studies, 125/312 were at low risk of bias overall, 50 were at high risk of bias, and the remainder were at unclear risk. Analyses from the contributing reviews and from our CNMA showed behavioural interventions for smoking cessation can increase quit rates, but effectiveness varies on characteristics of the support provided. There was high-certainty evidence of benefit for the provision of counselling (odds ratio (OR) 1.44, 95% credibility interval (CrI) 1.22 to 1.70, 194 studies, n = 72,273) and guaranteed financial incentives (OR 1.46, 95% CrI 1.15 to 1.85, 19 studies, n = 8877). Evidence of benefit remained when removing studies at high risk of bias. These findings were consistent with pair-wise meta-analyses from contributing reviews. There was moderate-certainty evidence of benefit for interventions delivered via text message (downgraded due to unexplained statistical heterogeneity in pair-wise comparison), and for the following components where point estimates suggested benefit but CrIs incorporated no clinically significant difference: individual tailoring; intervention content including motivational components; intervention content focused on how to quit. The remaining intervention components had low-to very low-certainty evidence, with the main issues being imprecision and risk of bias. There was no evidence to suggest an increase in harms in groups receiving behavioural support for smoking cessation. Intervention effects were not changed by adjusting for population characteristics, but data were limited. Increasing intensity of behavioural support, as measured through the number of contacts, duration of each contact, and programme length, had point estimates associated with modestly increased chances of quitting, but CrIs included no difference. The effect of behavioural support for smoking cessation appeared slightly less pronounced when people were already receiving smoking cessation pharmacotherapies.

AUTHORS' CONCLUSIONS

Behavioural support for smoking cessation can increase quit rates at six months or longer, with no evidence that support increases harms. This is the case whether or not smoking cessation pharmacotherapy is also provided, but the effect is slightly more pronounced in the absence of pharmacotherapy. Evidence of benefit is strongest for the provision of any form of counselling, and guaranteed financial incentives. Evidence suggested possible benefit but the need of further studies to evaluate: individual tailoring; delivery via text message, email, and audio recording; delivery by lay health advisor; and intervention content with motivational components and a focus on how to quit. We identified 23 economic evaluations; evidence did not consistently suggest one type of behavioural intervention for smoking cessation was more cost-effective than another. Future reviews should fully consider publication bias. Tools to investigate publication bias and to evaluate certainty in CNMA are needed.

Systematic review of economic evaluations of interventions for high risk young people

Background

The aim of this systematic literature review is to identify and critique full economic evaluations of interventions for high risk young people with the purpose of informing the design of future rigorous economic evaluations of such intervention programs.

Methods

A PRISMA compliant search of the literature between 2000 and April 2018 was conducted to identify full economic evaluations of youth focussed interventions for at risk young people. Duplicates were removed and two researchers independently screened the article titles and abstracts according to PICOS criteria for exclusion and inclusion. The remaining full text articles were assessed for eligibility and a quality assessment of the included articles was conducted using the Drummond checklist.

Results

The database, grey literature and hand searches located 488 studies of interventions for at risk young people. After preliminary screening of titles and abstracts, 104 studies remained for full text examination and 29 empirical studies containing 32 separate economic evaluations were judged eligible for inclusion in the review. These comprised 13 cost-benefit analyses (41%), 17 cost-effectiveness analyses (53%), one cost-utility analysis (3%) and a social return on investment (3%). Three main methodological challenges were identified: 1. attribution of effects; 2. measuring and valuing outcomes; and 3. identifying relevant costs and consequences.

Conclusions

A cost-benefit analysis would best capture the dynamic nature of a multi-component intervention for high risk young people, incorporating broader intersectoral outcomes and enabling measurement of more domains of risk. Prospective long-term data collection and a strong study design that incorporates a control group contribute to the quality of economic evaluation. Extrapolation of impact into the future is important for this population, in order to account for the time lag in effect of many impacts and benefits arising from youth interventions.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3450-x) contains supplementary material, which is available to authorized users.

Model-based economic evaluations in smoking cessation and their transferability to new contexts: a systematic review

AIMS

To identify different types of models used in economic evaluations of smoking cessation, analyse the quality of the included models examining their attributes and ascertain their transferability to a new context.

METHODS

A systematic review of the literature on the economic evaluation of smoking cessation interventions published between 1996 and April 2015, identified via Medline, EMBASE, National Health Service (NHS) Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA). The checklist-based quality of the included studies and transferability scores was based on the European Network of Health Economic Evaluation Databases (EURONHEED) criteria. Studies that were not in smoking cessation, not original research, not a model-based economic evaluation, that did not consider adult population and not from a high-income country were excluded.

FINDINGS

Among the 64 economic evaluations included in the review, the state-transition Markov model was the most frequently used method (n = 30/64), with quality adjusted life years (QALY) being the most frequently used outcome measure in a life-time horizon. A small number of the included studies (13 of 64) were eligible for EURONHEED transferability checklist. The overall transferability scores ranged from 0.50 to 0.97, with an average score of 0.75. The average score per section was 0.69 (range = 0.35-0.92). The relative transferability of the studies could not be established due to a limitation present in the EURONHEED method.

CONCLUSION

All existing economic evaluations in smoking cessation lack in one or more key study attributes necessary to be fully transferable to a new context.

Socioeconomic Disparities in Age of Initiation and Ever Tobacco Smoking: Findings from Romania

AIM

Smoking initiation is considered the fundamental behaviour that determines the future health burden of tobacco smoking in a society. The aim of the study was to evaluate the socio-demographic factors associated with initiation of regular smoking among adults.

METHODS

The data source was the 2011 Global Adult Tobacco Survey Romania (GATS), which is a cross-sectional, nationally representative study. Multivariate logistic regression model was applied for relevant analysis.

RESULTS

Among males, the regular smoking initiation rate was significantly higher compared to females (52.4% vs. 18.5%; p<0.001). Mean age of smoking initiation was lower in men compared to women (18.4±4.8 vs. 21.5±6.8; p<0.001). Age in men, awareness of environmental tobacco smoke consequences and place of living for women as well as educational attainment and employment status in both genders were associated with ever regular smoking. Moreover, cohabitation with a smoker was associated with greater odds for initiating smoking among both genders.

CONCLUSIONS

GATS revealed a significant but diverse role of socioeconomic factors in initiation of regular smoking among adult Romanians.

Pilot clinic study of Project EX for smoking cessation with Spanish adolescents

INTRODUCTION

Despite efforts to prevent smoking, the prevalence of smoking in Spanish adolescents remains high. So far, there are no evidence-based smoking cessation programs for adolescents in Spain.

METHODS

This study describes the evaluation of Project EX, an eight-session school-based clinic smoking cessation program, with Spanish cigarette smokers 13-19 years of age, from 9 schools (four program condition schools and five control condition schools). A group-randomized controlled trial was used. There were 211 smokers at baseline (112 program group, and 99 control group). Evaluation involved an immediate pretest and posttest survey (administered five-weeks later) and six-month follow-up (after the immediate posttest).

RESULTS

At immediate posttest, Project EX significantly reduced future nicotine dependence scores (mFTQ; p<.001), and increased intention to quit smoking (p<.001), and led to a higher previous day (prior to assessment) quit rate (p<.03). At the six-month follow-up, the percentage of quitters in the program group was 14.28%, whereas no smokers quit smoking in the control group (p<.04), and Project EX had a significant influence on future smoking expectation (p=.006) and overall level of 30-day smoking.

CONCLUSIONS

Results for the Project EX school-based clinic are promising for adolescent smokers in Spain, although difficulties in recruitment and high attrition are of concern. Findings and limitations are discussed and suggestions for future research are suggested.

Mathematical Modeling in Tobacco Control Research: Initial Results From a Systematic Review

OBJECTIVES

The US Food and Drug Administration has expressed interest in using mathematical models to evaluate potential tobacco policies. The goal of this systematic review was to synthesize data from tobacco control studies that employ mathematical models.

METHODS

We searched five electronic databases on July 1, 2013 to identify published studies that used a mathematical model to project a tobacco-related outcome and developed a data extraction form based on the ISPOR-SMDM Modeling Good Research Practices. We developed an organizational framework to categorize these studies and identify models employed across multiple papers. We synthesized results qualitatively, providing a descriptive synthesis of included studies.

RESULTS

The 263 studies in this review were heterogeneous with regard to their methodologies and aims. We used the organizational framework to categorize each study according to its objective and map the objective to a model outcome. We identified two types of study objectives (trend and policy/intervention) and three types of model outcomes (change in tobacco use behavior, change in tobacco-related morbidity or mortality, and economic impact). Eighteen models were used across 118 studies.

CONCLUSIONS

This paper extends conventional systematic review methods to characterize a body of literature on mathematical modeling in tobacco control. The findings of this synthesis can inform the development of new models and the improvement of existing models, strengthening the ability of researchers to accurately project future tobacco-related trends and evaluate potential tobacco control policies and interventions. These findings can also help decision-makers to identify and become oriented with models relevant to their work.

Immediate Effects of Project EX in Spain: A Classroom-Based Smoking Prevention and Cessation Intervention Program

Tobacco use is of high prevalence among Spanish adolescents. Programming to counteract tobacco use has been needed. There is a lack of knowledge on the efficacy of teen tobacco use cessation programming. The current study provides an immediate outcome evaluation of the Project EX tobacco use prevention and cessation program among Spanish adolescents. An eight-session, classroom-based curriculum was translated from English to Spanish and adapted to the Spanish culture. Next, it was tested using a randomized controlled trial with 1,546 Spanish students, involving three program and three control high schools. Participants at the program group provided moderately favorable process ratings of the program. Compared to the standard care control condition, the program condition revealed a greater reduction in smoking intentions and CO ppm levels.

Research priorities for economic analyses of prevention: current issues and future directions

In response to growing interest in economic analyses of prevention efforts, a diverse group of prevention researchers, economists, and policy analysts convened a scientific panel, on "Research Priorities in Economic Analysis of Prevention" at the 19th annual conference of the Society for Prevention Research. The panel articulated four priorities that, if followed in future research, would make economic analyses of prevention efforts easier to compare and more relevant to policymakers and community stakeholders. These priorities are: (1) increased standardization of evaluation methods, (2) improved economic valuation of common prevention outcomes, (3) expanded efforts to maximize evaluation generalizability and impact as well as (4) enhanced transparency and communicability of economic evaluations. In this paper, we define three types of economic analyses in prevention, provide context and rationale for these four priorities as well as related sub-priorities, and discuss the challenges inherent in meeting them.

The effectiveness of an integrated multicomponent program for adolescent smoking cessation in Taiwan

If adolescents do not receive appropriate assistance in quitting smoking, they are highly likely to become regular smokers when they enter adulthood. Thus, an effective smoking-cessation program is required. A program was designed based on both the smoking-cessation barriers reported by students and effective strategies derived from the literature. We assigned 143 student smokers from 6 vocational high schools to intervention (n=78) and comparison groups (n=65). Data were collected at the baseline, the end of the program, and 1- and 4-month follow-up time points. For the intervention group, the smoking-abstinence rates confirmed using the urine cotinine test were 22.73% at the end of the program and 20.75% at the 4-month follow-up point. Days smoked in the past month, number of cigarettes smoked per day, and the Fagerström Test for Nicotine Dependence score of the intervention group decreased at all of the time points. The group differences in these variables were statistically significant; the magnitude of effect sizes ranged from 0.44 to 0.95. Multicomponent programs addressing smoking-cessation barriers that students encounter can help adolescents quit smoking.

Developing a Dissemination Model to Improve Intervention Reach among West Virginia Youth Smokers

The not-on-tobacco program is an evidence-based teen smoking cessation program adopted by the American Lung Association (ALA). Although widely disseminated nationally via ALA Master Trainers, in recent years, adoption and implementation of the N-O-T program in West Virginia (WV) has slowed. WV, unfortunately, has one of the highest smoking rates in the US. Although it is a goal of public health science, dissemination of evidence-based interventions is woefully understudied. The present manuscript reviews a theoretical model of dissemination of the not-on-tobacco program in WV. Based on social marketing, diffusion of innovations, and social cognitive theories, the nine-phase model incorporates elements of infrastructure development, accountability, training, delivery, incentives, and communication. The model components as well as preliminary lessons learned from initial implementation are discussed.

Understanding physical activity outcomes as a function of teen smoking cessation

OBJECTIVE

Recent evidence suggests physical activity may be protective against smoking initiation and increased smoking among youth. The present study explored the effects of a teen smoking cessation intervention supplemented with a physical activity module on participants' physical activity outcomes. A secondary aim examined the relationship between participants' physical activity outcomes and postprogram smoking intensity.

DESIGN

The study reports primary data from a 3-arm randomized group trial consistent with CONSORT guidelines (Registry # NCT01242657).

SETTING

Public high schools (N = 19) in West Virginia.

PARTICIPANTS

Teens aged 14-19 years (N = 233) who reported current smoking, ≥1 cigarette in the past 30 days.

INTERVENTION

High schools were randomly selected, then randomly assigned to Brief Intervention (standard of care), Not-On-Tobacco (N-O-T, teen cessation program), or N-O-T plus a physical activity module (N-O-T+FIT).

OUTCOME MEASURES

Standardized instruments at baseline and end of treatment/3-months postbaseline measured physical activity outcomes. The study assessed smoking intensity using cigarettes smoked per day. We conducted ANCOVA controlling for school-level variance to measure physical activity changes. Multiple linear and logistic regression analyses explored favorable change influence of physical activity on smoking cessation outcomes, controlling for potential clustering.

RESULTS

Teens who increased the number of days on which they received at least 20 minutes of exercise were significantly more likely to reduce their daily cigarette use, with those in the N-O-T+FIT condition having the highest likelihood of reducing smoking. Teens in the N-O-T+FIT condition who increased the number of days on which they received at least 30 minutes of exercise were significantly more likely than those in other groups to quit smoking.

CONCLUSION

Findings suggest that it is possible to alter simultaneously more than one health behavior among teens-favorable changes in physical activity and smoking cessation may be particularly compatible targets for dual behavior change.

Economic evaluation of smoking-cessation therapies: a critical and systematic review of simulation models

BACKGROUND

Smoking is probably the most important among preventable health risks. Health economic evaluation of smoking-cessation interventions, applying a lifetime perspective, is made possible by available epidemiological knowledge. The well established method of performing cost-effectiveness analyses of smoking-cessation interventions involves mathematical modelling (both deterministic and stochastic) of future events important for cost effectiveness.

OBJECTIVES

This study surveys cost-effectiveness analyses of smoking cessation, with a particular focus on the mathematical modelling and simulation analyses performed.

DATA SOURCES

A systematic literature search was performed using the databases MEDLINE, Econlit and Academic Search Complete.

STUDY SELECTION

Health economic evaluations, published as full-length journal articles, were searched for.

RESULTS

423 studies were identified and 78 were finally included, of which 30 were assessed as being highly relevant, based on the application of simulation modelling.

CONCLUSIONS

In general, studies are well performed as regards modelling. Common weaknesses include reporting of modelling details; validation of used simulation models; and the handling of structural uncertainty and different types of heterogeneity.

The cost-effectiveness of a school-based smoking prevention program in India

Intervention programs aimed at preventing tobacco use among youth have been shown to be effective in curbing tobacco use onset and progression. However, the effects of even very successful tobacco prevention programs may not always impress policy-makers and lay audiences. Economic analysis potentially strengthens the case. In this paper, we evaluate the cost-effectiveness of a youth tobacco use prevention program which has been translated and implemented in India, a developing country. Although programs like these are inexpensive to implement in the USA, they are even less expensive in India due to low labor costs. Our results show that the costs per quality-adjusted life-year added, due to averted smoking, was $2057, even without including averted medical costs. If we ignore student time, cost-effectiveness improves by roughly 10%. To put the cost-effectiveness of this smoking prevention program into context, it is over 24 times more cost-effective than dialysis in the USA, which costs $50,000 for a life-year.

Economic evaluation of pharmaco- and behavioral therapies for smoking cessation: a critical and systematic review of empirical research

Economic evaluations are an important tool to improve our understanding of the costs and effects of health care services and to create sustainable health care systems. This article critically assesses empirical evidence from economic evaluations of pharmaco- and behavioral therapies for smoking cessation. A comprehensive literature review of PubMed and the British National Health Service Economic Evaluation Database was conducted. The search identified 15 articles on nicotine-based pharmacotherapies, 12 articles on nonnicotine based pharmacotherapies, no articles on selegiline, and 10 articles on brief counseling for smoking cessation treatment. Results show that both pharmaco- and behavioral therapies for smoking cessation are cost-effective or even cost-saving. The review highlights several shortcomings in methodology and a lack of standardization of current economic evaluations. Efforts to improve methodology will help make future studies more comparable and increase the evidence base so that such evaluations can be more useful to public health practitioners and policy makers.

Reducing smoking in adolescents: cost-effectiveness results from the cluster randomized ASSIST (A Stop Smoking In Schools Trial)

Introduction:

School-based smoking prevention programmes can be effective, but evidence on cost-effectiveness is lacking. We conducted a cost-effectiveness analysis of a school-based “peer-led” intervention.

Methods:

We evaluated the ASSIST (A Stop Smoking In Schools Trial) programme in a cluster randomized controlled trial. The ASSIST programme trained students to act as peer supporters during informal interactions to encourage their peers not to smoke. Fifty-nine secondary schools in England and Wales were randomized to receive the ASSIST programme or usual smoking education. Ten thousand seven hundred and thirty students aged 12–13 years attended participating schools. Previous work has demonstrated that the ASSIST programme achieved a 2.1% (95% CI = 0%–4.2%) reduction in smoking prevalence. We evaluated the public sector cost, prevalence of weekly smoking, and cost per additional student not smoking at 24 months.

Results:

The ASSIST programme cost of £32 (95% CI = £29.70–£33.80) per student. The incremental cost per student not smoking at 2 years was £1,500 (95% CI = £669–£9,947). Students in intervention schools were less likely to believe that they would be a smoker at age 16 years (odds ratio [OR] = 0.80; 95% CI = 0.66–0.96).

Conclusions:

A peer-led intervention reduced smoking among adolescents at a modest cost. The intervention is cost-effective under realistic assumptions regarding the extent to which reductions in adolescent smoking lead to lower smoking prevalence and/or earlier smoking cessation in adulthood. The annual cost of extending the intervention to Year 8 students in all U.K. schools would be in the region of £38 million and could result in 20,400 fewer adolescent smokers.

Effects of physical activity on teen smoking cessation

OBJECTIVE

To understand the influence of physical activity on teen smoking-cessation outcomes.

METHODS

Teens (N = 233; 14-19 years of age) from West Virginia high schools who smoked >1 cigarette in the previous 30 days were included. High schools with >300 students were selected randomly and assigned to brief intervention (BI), Not on Tobacco (N-O-T) (a proven teen cessation program), or N-O-T plus a physical activity module (N-O-T+FIT). Quit rates were determined 3 and 6 months after baseline by using self-classified and 7-day point prevalence quit rates, and carbon monoxide validation was obtained at the 3-month follow-up evaluation.

RESULTS

Trends for observed and imputed self-classified and 7-day point prevalence rates indicated that teens in the N-O-T+FIT group had significantly higher cessation rates compared with those in the N-O-T and BI groups. Effect sizes were large. Overall, girls quit more successfully with N-O-T compared with BI (relative risk [RR]: >∞) 3 months after baseline, and boys responded better to N-O-T+FIT than to BI (RR: 2-3) or to N-O-T (RR: 1-2). Youths in the N-O-T+FIT group, compared with those in the N-O-T group, had greater likelihood of cessation (RR: 1.48) at 6 months. The control group included an unusually large proportion of participants in the precontemplation stage at enrollment, but there were no significant differences in outcomes between BI and N-O-T (z = 0.94; P = .17) or N-O-T+FIT (z = 1.12; P = .13) participants in the precontemplation stage.

CONCLUSIONS

Adding physical activity to N-O-T may enhance cessation success, particularly among boys.

Beyond reach and effectiveness: evaluating the not-on-tobacco (N-o-T) program in West Virginia from 2000 to 2005

Despite most teenage smokers wanting to quit, their likelihood of success resembles that of flipping a coin. Evidence-based cessation programs, like the American Lung Association's Not-On-Tobacco (N-O-T) program, are effective. Evaluation of program dissemination is critical. This study uses the RE-AIM framework to evaluate the N-O-T program in West Virginia from 2000 to 2005. RE-AIM components consisted of four measures. Regional dissemination was measured using comparative differences between Regional Educational Service Agency regions (RESAs). Significant associations were found between RESAs for numerous characteristics. Among the RE-AIM components, two measures of Implementation were significantly different between RESAs. Variability between RESAs provided valuable descriptive evidence of N-O-T program dissemination in West Virginia. Therefore, geographical tailoring grounded in community-based participatory research could increase the N-O-T program's overall dissemination.

Evaluation of school-based smoking-cessation interventions for self-described adolescent smokers

OBJECTIVE

The goal was to compare the efficacy of school-based, multisession, group smoking-cessation interventions versus a single group session in increasing quit rates among adolescent smokers.

METHODS

Eight schools were assigned randomly to use 1 of 2 group smoking-cessation programs previously shown to increase quit rates among adolescents (Not on Tobacco [NOT] or Kickin' Butts). We reformatted the programs to twice-weekly 25- to 30-minute sessions delivered during lunch periods. Smoking status was assessed at end of program (EOP) and 1, 3, 6, and 12 months later. Self-reported quit status was confirmed with salivary cotinine levels.

RESULTS

A total of 407 students (56% black and 52% female; mean age: 16 years) participated. Kickin' Butts participants were no more likely to quit than control subjects. In the conservative analysis (students with missing follow-up data classified as smokers), NOT participants were 1.92 times (95% confidence interval [CI]: 1.09-3.40 times) more likely to self-report quitting at 1 month. In the Bayesian analysis (missing follow-up data imputed by using all available data), NOT participants were significantly more likely than control subjects to self-report quitting at EOP (relative risk [RR]: 1.26 [95% CI: 1.10-1.43]), 1 month (RR: 2.07 [95% CI: 1.68-2.56]), and 12 months (RR: 1.58 [95% CI: 1.22-2.04]). Cotinine-confirmed quit rates were significantly greater among NOT participants, compared with control subjects, at EOP and 1 month.

CONCLUSIONS

The reformatted NOT program had a modest effect on adolescents interested in quitting. Kickin' Butts, as reformatted for this project, did not have any effect on quit rates.

Teen perceptions of facilitator characteristics in a school-based smoking cessation program

BACKGROUND

Facilitators are often responsible for the implementation of public health programs, yet little is known about how they influence outcomes. Not-On-Tobacco (N-O-T) is a youth smoking-cessation program implemented by trained facilitators. The purpose of this study was to investigate teens' perceptions of facilitator characteristics and the relationship between those perceptions and program outcomes.

METHODS

Data were collected from N-O-T participants aged 14 to 19 who completed a survey about perceptions of facilitator characteristics that were linked to program outcomes 3 months post-baseline (n = 769). Eight facilitator characteristics were ordered, based on importance to participants. Chi-square tests measured differences in perceptions of facilitator characteristics according to race and sex, and an aggregate facilitator favorability score was created and analyzed in relation to program outcomes (smoking reduction or cessation vs increase/no change). Logistic regression was used to analyze facilitator characteristics' relationship to outcomes, controlling for race and sex.

RESULTS

Participants rated facilitator characteristics of trustworthy, cares about students, and confidential as most important. Girls consistently ranked facilitator characteristics as more important than did boys. There were few significant differences based on race, except that white students rated nonjudgmental to be more important than did nonwhite students. There were no significant findings from the logistic regression, but there was a significant relationship between the aggregate facilitator favorability score and favorable changes in smoking outcomes (reduction or cessation).

CONCLUSIONS

This study provides insights into the facilitator characteristics that are important to teen participants. It demonstrates that teens' overall perceptions of facilitators contribute to their perception of how the program contributes to their success and program outcomes.

Beyond quitting: predictors of teen smoking cessation, reduction and acceleration following a school-based intervention

There remains a great need for effective, cost-efficient, and acceptable youth smoking cessation interventions. Unfortunately, only a few interventions have been demonstrated to increase quit rates among youth smokers, and little is known about how elements of cessation interventions and participants' psychosocial characteristics and smoking histories interact to influence program outcomes. Additionally, few studies have examined how these variables lead to complete smoking abstinence, reduction or acceleration over the course of a structured cessation intervention. Data for the present investigation were drawn from a sample of teen smokers (n=5892) who voluntarily participated in either a controlled study or field study (i.e., no control group) of the American Lung Association's Not On Tobacco (N-O-T) program between 1998 and 2006 in five states. Results suggest that those who reduce smoking (but do not achieve full abstinence) are similar to those who quit on most measures except stage of change. Furthermore, it was found that those who increased smoking were heavier smokers at baseline, more addicted, were more likely to have parents, siblings, and significant others who smoked and reported less confidence in and less motivation for quitting than did those who quit or reduced smoking. Finally, a path model demonstrated how peers, siblings and romantic partners affected tobacco use and cessation outcomes differently for males and females. Implications for interventions are discussed.

A randomized trial of nicotine nasal spray in adolescent smokers

OBJECTIVES

Nicotine nasal spray has been 1 of the most successful forms of nicotine-replacement therapy in adult populations. The nasal sprayer has not been studied in adolescent smokers. The objective of this pilot study was to determine the feasibility and utility of using nicotine nasal spray for adolescent smokers who wanted to quit smoking.

METHODS

Forty adolescent smokers who were between 15 and 18 years of age and smoked >/=5 cigarettes daily for at least 6 months were recruited from several San Francisco Bay area schools from 2005 to 2007. Using a randomized, open-label, 12-week trial, adolescent smokers were assigned to receive either weekly counseling alone (control) for 8 weeks or 8 weeks of counseling along with 6 weeks of nicotine nasal spray. Self-reported smoking abstinence was verified by both expired-air carbon monoxide and salivary cotinine.

RESULTS

There was no difference in cessation rates, the numbers of cigarettes smoked per day, or cotinine levels at 12 weeks. Fifty-seven percent of participants stopped using their spray after only 1 week. The most commonly reported adverse effect was nasal irritation and burning (34.8%) followed by complaints about the taste and smell (13%).

CONCLUSIONS

The unpleasant adverse effects, poor adherence, and consequent lack of efficacy observed in our pilot study do not support the use of nicotine nasal spray as an adjunct to counseling for adolescent smokers who wish to quit.

A profile of teen smokers who volunteered to participate in school-based smoking intervention

OBJECTIVES

Although a number of population-based studies have examined the characteristics of teens who attempt to quit smoking, few have identified the characteristics of youth who participate in structured cessation interventions, particularly those with demonstrated effectiveness. The purpose of the present study is to describe the sociodemographic and smoking-related characteristics of teen smokers who participated in the American Lung Association's Not On Tobacco (N-O-T) program, spanning eight years. N-O-T is the most widely used teen smoking cessation program in the nation.

METHODS

Drawn from multiple statewide N-O-T studies, this investigation examined data from 5,892 teen smokers ages 14-19 who enrolled in N-O-T between 1998-2006. We demonstrate similarities and differences between N-O-T findings and existing data from representative samples of US teen smokers where available and relevant.

RESULTS

N-O-T teens started smoking earlier, were more likely to be poly-tobacco users, were more dependent on nicotine, had made more previous attempts to quit, and were more deeply embedded in smoking contexts than comparative samples of teen smokers. Additionally, N-O-T teens were moderately ready to quit smoking, believed important people in their lives would support their quit efforts, yet had deficits in their confidence with quitting.

CONCLUSION

This profile of N-O-T teens can guide efforts for targeted recruitment strategies to enhance intervention reach for teen smoking cessation. Findings provide guidance for marketing and recruitment efforts of intensive, school-based cessation interventions among established teen smokers, particularly those who want to quit. Study results may shed light upon who is and is not enrolling in N-O-T.