Motivation to quit as a mediator of tobacco cessation among at-risk youth

Tobacco Cessation Intervention for Young People

Most adolescent tobacco control programs focus on preventing consumption, but teen smoking persists. It is uncertain whether adult-specific therapies can assist adolescents in quitting smoking. The rising incidence of smoking in low and middle-socioeconomic countries and the challenges of conducting tobacco cessation programs in these settings (due to increasing population, poor lifestyle, lack of awareness and education, professional stress, and non-compliance) need an emphasis on the scope of trials to conduct tobacco cessation in these settings. In the 11th Five Year Plan, the Indian government introduced a new National Tobacco Control Program, which currently spans 108 districts in 31 states across the country. The objective is to review the randomized control trials of selected individuals held in India and assess and evaluate the effectiveness of the steps taken by the government to help people quit tobacco consumption. These programs are important because of the hazards and impact they have on the public health indices of the nation. The government has taken steps like prohibiting smoking in public areas and banning sources. Several programs, particularly those that employed group counselling, included a range of approaches that proved beneficial in helping young people quit smoking. The RCTs mentioned are psychosocially followed by behavioral and pharmacological therapies. The challenges faced are not having participatory health care, motivating tobacco users to quit even in the short-term, adequate coverage; barriers at a different level of implementation (at a regional, state, or national level); and interference by the tobacco industry should be eliminated. The currently functioning programs in India are the National Tobacco Control Program, the National and three Regional Quitlines and mCessation.

Smoking prevalence among tuberculosis patients: A crosssectional study in Bangladesh and Pakistan

INTRODUCTION

Smoking has a negative impact on TB outcomes. We estimated the proportion of TB patients who smoke and are willing to quit in two high TB burden countries, Bangladesh and Pakistan.

METHODS

A cross-sectional survey was conducted among TB patients to assess their eligibility and recruit them to a smoking cessation randomized controlled trial. Adults diagnosed with TB were recruited from 32 health facilities in Bangladesh and Pakistan. Data on smoking behaviour and willingness to quit were collected and analysed.

RESULTS

In total, 13934 TB patients completed the survey between June 2017 and April 2018. The prevalence of smoking in these TB patients was estimated to be 22.5% (95% CI: 21.8, 23.2). Moreover, the prevalence of smoking in TB patient population was 8% (RR=1.49; 95% CI: 7.1–8.9; p<0.01) and 8.3% (RR=1.24; 95% CI: 7.3–9.4; p<0.01) higher than smoking prevalence in the general population in Bangladesh and Pakistan, respectively. Among TB patients who smoke, 97.7% (95% CI: 97.2–98.2) were willing to quit.

CONCLUSIONS

The estimated prevalence of smoking was higher in TB patients than the general population; however, a vast majority of TB patients who smoke were willing to quit.

Nicotine Use Disorders in Adolescents

Rates of certain tobacco products have decreased over the past decade, but nicotine use disorder is still prevalent among adolescents. New trends in tobacco use, such as in the use of electronic cigarettes, are creating alarm. This article reviews nicotine addiction and measurement in adolescents, along with potential health risks and comorbidities. Various psychosocial and pharmacologic interventions are reviewed along with novel interventions that show promise for reducing tobacco use in this vulnerable population.

A randomized controlled trial to test the effectiveness of a peer-based social mobile game intervention to reduce smoking in youth

Smoking is a major cause of worldwide morbidity and mortality. Almost no evidence-based intervention programs are available to help youth quit smoking. We argue that ineffective targeting of peer influence and engagement difficulties are significant barriers to successful youth smoking cessation. To address these barriers, we developed the mobile game intervention HitnRun. A two-armed randomized controlled trial (RCT; n = 144) was conducted and young smokers (Mage = 19.39; SDage = 2.52) were randomly assigned to either play HitnRun or read a psychoeducational brochure. Prior to, directly following the intervention period, and after three-month follow-up, weekly smoking behavior, abstinence rates, intervention dose, and peer- and engagement-related factors were assessed. Results indicated similar reductions in weekly smoking levels and similar abstinence rates for both groups. Yet, we found a dose effect with HitnRun only: The longer participants played HitnRun, the lower their weekly smoking levels were. In the brochure group, a higher dose was related to higher weekly smoking levels at all measurement moments. Exploratory analyses showed the most powerful effects of HitnRun for participants who connected with and were engaged by the intervention. Future work should build on the promising potential of HitnRun by increasing personalization efforts and strengthening peer influence components.

Three-month effects of Project EX: A smoking intervention pilot program with Korean adolescents

Despite current prevention and cessation efforts, adolescent smoking remains a pressing issue worldwide, including in Korea. The current study evaluates Project EX-Korea, a teen tobacco use cessation program, three months after baseline. The quasi-experimental trial intervention involved 160 smokers in 10th to 12th grade, 85 from the program condition schools and 75 from the control. At three-month follow-up, the intent-to-treat (ITT) quit rate in the program group (30.2%) was 3.6 times that of the rate in the standard care control group (9.2%; p < 0.05). Among those who did not quit, those in the program group smoked less on average than those in the control group, but there was no difference in follow-up mFTQ scores between the two non-quitter groups. As teen tobacco use cessation programming is much needed in Korea, Project EX is a plausible program to implement among Korean adolescents.

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Teen tobacco use cessation programming is still much needed in Korea and worldwide.

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Project EX is a credible tobacco cessation program to help Korean adolescents quit.

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The program group's quit rate was 3.6 times that of the control group's quit rate.

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Non-quitters in the program group smoked less than those in the control group.

Role of smoking intention in tobacco use reduction: A mediation analysis of an effective classroom-based prevention/cessation intervention for adolescents

INTRODUCTION

Although some school-based tobacco cessation and prevention programs have been proven to be effective, there remains a lack of understanding of how these programs succeed.

METHODS

This longitudinal study aimed to test smoking intention as a mediator of Project EX's intervention efficacy to reduce tobacco use. Using a computerized random number generator, six high schools located in the Mediterranean coast were randomly selected to participate in the program condition (Spanish version of Project EX) or the waiting-list control group with baseline, immediate-posttest, and 12-month follow-up assessments. At baseline, 685 adolescents aged 14-20 years (mean age: 14.87; SD = 0.92; 47.4% were females) were evaluated using self-administered tests of tobacco, and smoking intention. A biomarker of smoke inhalation, a measurement of exhaled carbon monoxide (ECM), was used. Mediation analyses were conducted using the PROCESS v2.12 macro for Windows.

RESULTS

Project EX had a significant effect on smoking intention. Indirect effects indicated that Project EX reduced the ECM level, and number of cigarettes used.

CONCLUSIONS

This is the first Spanish study that explored intention as a mediator of the long-term efficacy of Project EX to reduce tobacco use in adolescents. Results suggested that interventions that reduce consumption intention at short-term are more likely to be successful in decreasing tobacco use in the long-term.

Smoking behavior of males attending the quit tobacco clinics in Bahrain and their knowledge on tobacco smoking health hazards

Background

One third of Bahraini adult (20–64 years) males and 7.0% of females use some form of tobacco. The corresponding rates for cigarette and waterpipe tobacco smoking (WTS) are 11.0% and 6.0%, respectively. The objective of the study was to determine the knowledge on tobacco smoking and past smoking related behavior of male patients attending the Quit Tobacco Clinics (QTC) in Bahrain.

Methods

A sample of 339 male clinic attendees was taken proportional to the population distribution in the three QTC at Al Hoora Health Center, Hamad Kanoo Health Center, and Bank of Bahrain and Kuwait Health Center. Data collection was performed until the sample size was completed (September 2015 to December 2016). Knowledge on the health effects of cigarette and WTS was examined based on 10 statements on cigarette and similar ones on WTS. Respondents “agreeing” with the statements were considered knowledgeable and those “disagreeing” or responding “don’t know”, not knowledgeable. All the “agree” responses for cigarette/WTS were summed across the 10 health effects and average health knowledge scores for cigarette/WTS were computed.

Results

Most of the study participants were Bahraini nationals, ever married and educated with at least secondary level. The majority (65.8%) of participants smoked a single type of tobacco product, and the rest, two (28.0%) or three or more (6.2%). Age of starting cigarette and WTS was 16.2 ± 4.0 and 19.3 ± 6.7 years, respectively. The majority (81%) smoked in the presence of other family members and 26.3% in the presence of a child. 76.2% smoked in the presence of others in their cars. 18.9% of the attendees had quit smoking at the time of interview. 81% of the participants knew about the hazards of both cigarette and WTS with a significantly higher (p = 0.0001) mean knowledge score for cigarette (93.3 ± 3.0%) than WTS (85.2 ± 2.1%).

Conclusion

The relative lack of knowledge on the hazards of WTS in a sample of Arab country population with an increasing trend of WTS warrants the attention of health policy makers in the country and region.

Tobacco cessation interventions for young people

BACKGROUND

Most tobacco control programmes for adolescents are based around prevention of uptake, but teenage smoking is still common. It is unclear if interventions that are effective for adults can also help adolescents to quit. This is the update of a Cochrane Review first published in 2006.

OBJECTIVES

To evaluate the effectiveness of strategies that help young people to stop smoking tobacco.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register in June 2017. This includes reports for trials identified in CENTRAL, MEDLINE, Embase and PsyclNFO.

SELECTION CRITERIA

We included individually and cluster-randomized controlled trials recruiting young people, aged under 20 years, who were regular tobacco smokers. We included any interventions for smoking cessation; these could include pharmacotherapy, psycho-social interventions and complex programmes targeting families, schools or communities. We excluded programmes primarily aimed at prevention of uptake. The primary outcome was smoking status after at least six months' follow-up among those who smoked at baseline.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of candidate trials and extracted data. We evaluated included studies for risk of bias using standard Cochrane methodology and grouped them by intervention type and by the theoretical basis of the intervention. Where meta-analysis was appropriate, we estimated pooled risk ratios using a Mantel-Haenszel fixed-effect method, based on the quit rates at six months' follow-up.

MAIN RESULTS

Forty-one trials involving more than 13,000 young people met our inclusion criteria (26 individually randomized controlled trials and 15 cluster-randomized trials). We judged the majority of studies to be at high or unclear risk of bias in at least one domain. Interventions were varied, with the majority adopting forms of individual or group counselling, with or without additional self-help materials to form complex interventions. Eight studies used primarily computer or messaging interventions, and four small studies used pharmacological interventions (nicotine patch or gum, or bupropion). There was evidence of an intervention effect for group counselling (9 studies, risk ratio (RR) 1.35, 95% confidence interval (CI) 1.03 to 1.77), but not for individual counselling (7 studies, RR 1.07, 95% CI 0.83 to 1.39), mixed delivery methods (8 studies, RR 1.26, 95% CI 0.95 to 1.66) or the computer or messaging interventions (pooled RRs between 0.79 and 1.18, 9 studies in total). There was no clear evidence for the effectiveness of pharmacological interventions, although confidence intervals were wide (nicotine replacement therapy 3 studies, RR 1.11, 95% CI 0.48 to 2.58; bupropion 1 study RR 1.49, 95% CI 0.55 to 4.02). No subgroup precluded the possibility of a clinically important effect. Studies of pharmacotherapies reported some adverse events considered related to study treatment, though most were mild, whereas no adverse events were reported in studies of behavioural interventions. Our certainty in the findings for all comparisons is low or very low, mainly because of the clinical heterogeneity of the interventions, imprecision in the effect size estimates, and issues with risk of bias.

AUTHORS' CONCLUSIONS

There is limited evidence that either behavioural support or smoking cessation medication increases the proportion of young people that stop smoking in the long-term. Findings are most promising for group-based behavioural interventions, but evidence remains limited for all intervention types. There continues to be a need for well-designed, adequately powered, randomized controlled trials of interventions for this population of smokers.

Nicotine Dependence as a Mediator of Project EX's Effects to Reduce Tobacco Use in Scholars

In Spain, 44% of 14-18-year-olds have smoked, and 12.5% have smoked cigarettes in the last 30 days. Nicotine is one of the most addictive substances, and can lead to serious addiction in adulthood with adverse consequences to one's health. School plays a relevant role in health promotion and preventing risk behaviors such as tobacco consumption. Despite the fact that some school-based tobacco cessation and prevention interventions prove to be effective for their purposes, there is a lack of understanding as to why these programs succeed or fail. This longitudinal study aims to test the nicotine dependence (ND) as a mediator of Project EX's effect - a tobacco-use cessation program developed for high school youth to reduce tobacco consumption in scholars. Six high schools located in the Mediterranean coast were randomized for the participation of the program (Spanish version of Project EX) or a waiting-list group with baseline, immediate-posttest, and 12-month follow-up assessments. At baseline, 1,546 adolescents aged 14-21 years old (mean age: 15.28; SD = 1.20; 46% were women) were evaluated by self-administered tests on tobacco consumption and ND. A biomarker of smoke inhalation - a measurement of exhaled carbon monoxide (ECM) - was used. Participants who were smokers (N = 501; 32%) were selected for this study. Mediation analyses were conducted using the PROCESS v2.12 macro for Windows. The significant criterion was p ≤ 0.05, and 5,000 samples were used for bias-corrected bootstrap confidence intervals. Results indicated that Project EX indirectly decreased the number of cigarettes smoked in the last month, the number of cigarettes smoked within the last 7 days, the number of daily cigarettes, and ECM level at 12-month follow up through decreasing the level of ND in the short-term. This is the first Spanish study that explores ND as a mediator of the long-term efficacy of Project EX to reduce tobacco consumption in adolescents. Results suggest that interventions that reduce ND at short-term are more likely to be successful to decrease tobacco use at long-term.

Youth motivation as a predictor of treatment outcomes in a community mental health system

OBJECTIVE

The purpose of this study was to examine the relationship between youth motivation and psychotherapy outcomes in routine community mental health settings.

METHOD

One hundred fifty youth, ages 12-17, from three community mental health clinics completed the Youth Outcome Questionnaire and Treatment Support Measure at frequent intervals over the course of treatment.

RESULTS

Increases in motivation followed a curvilinear trajectory. On average, youth motivation significantly increased over the course of therapy according to both self- and parent reports (p < .001). The slope for youth motivation over the course of therapy was negatively associated with the slope for mental health symptoms (p < .001). Initial youth motivation did not predict overall change or the rate of change in symptoms. However, there was significant individual variability in patterns of youth motivation.

CONCLUSIONS

Our findings demonstrate that youth show increases in motivation over the course of therapy with most gains occurring in the first few sessions. Because increases in motivation over the course of therapy were related to decreases in mental health symptoms, further research is needed to examine how treatment interventions or other factors such as parent motivation may moderate this relationship. Additional research examining the likely complex relationship between initial youth motivation and treatment outcomes in community mental health settings is needed.

Predictors of adolescent smoking cessation and smoking reduction

OBJECTIVE

To investigate the processes of change, demographic, health- and smoking-related predictors of both smoking cessation and smoking reduction in adolescents.

METHODS

Data were drawn from a sample of 755 adolescent smokers who participated in a study testing the efficacy of a text messaging-based intervention for smoking cessation. Demographic, health- and smoking-related variables were assessed at baseline. Five processes of smoking cessation, derived from the Transtheoretical Model and the Social Cognitive Theory, as well as outcome measures were assessed at 6-month follow up. Univariate and multivariate regression analyses were conducted to identify baseline and process variables to predict smoking abstinence and smoking reduction.

RESULTS

Male gender (OR=0.43, p<.01), lower alcohol consumption (OR=0.90, p=.05) and a lower number of cigarettes smoked per day at baseline (OR=0.87, p<.01) predicted smoking abstinence. Baseline physical activity predicted smoking reduction (OR=1.04, p=.03). None of the examined process variables significantly predicted smoking abstinence. The process variable "counter-conditioning" predicted smoking reduction (OR=1.46, p=.03).

CONCLUSIONS

Baseline predictors of smoking cessation differ from predictors of smoking reduction. Dynamic or modifiable variables play an important role in predicting adolescent smoking cessation.

PRACTICE IMPLICATIONS

Counter-conditioning might be an important element in adolescent smoking cessation interventions.

The impact of mindfulness education on elementary school students: Evaluation of the Master Mind Program

Children need to be equipped with the skills to respond effectively to stress and prevent poor decision-making surrounding alcohol and tobacco use. Training and practice in mindfulness is one possible avenue for building children's skills. Recent research has revealed that mindfulness education in the classroom may play a role in enhancing children's self-regulatory abilities. Thus, the goal of the current study was to extend existing research in mindfulness education in classrooms and conduct an assessment of the feasibility and effectiveness of a new mindfulness education, substance abuse prevention program for 4^th and 5^th grade children (Master Mind). Two elementary schools were randomly assigned to be an intervention group (N = 71) or waitlist control group (N = 40). Students in the intervention group were taught the four-week Master Mind program by their regular classroom teachers. At pre- and post-intervention time points, students completed self-reports of their intentions to use substances and an executive functioning performance task. Teachers rated students on their behavior in the classroom. Findings revealed that students who participated in the Master Mind program, as compared to those in the wait-list control condition, showed significant improvements in executive functioning skills (girls and boys), as well as a marginally significant increase in self-control abilities (boys only). In addition, significant reductions were found in aggression and social problems (girls and boys), as well as anxiety (girls only). No significant differences across groups were found for intentions to use alcohol or tobacco. Teachers implemented the program with fidelity; both teachers and students positively rated the structure and content of the Master Mind program, providing evidence of program satisfaction and feasibility. Although generalization may be limited by the small sample size, the findings suggest that mindfulness education may be beneficial in increasing self-regulatory abilities, which is important for substance abuse prevention.

Factors associated with intent to quit tobacco use in Cyprus adolescents

OBJECTIVES

To identify factors associated with adolescent smokers' desire to quit based on the 2006 Cyprus Global Youth Tobacco Survey.

METHODS

A cluster sample design was used to select a representative sample of students from all registered middle and high schools in Cyprus with >40 students in academic year 2005-2006. Multivariable logistic regression was used taking into account the weight associated with each of the respondents.

RESULTS

Out of the total sample with available information (N=12,629), 1591 students were current smokers (weighted frequency=14%) and were included in the analysis, with 734 (46.1%) of them reporting that they want to quit smoking. In both males and females, strong predictors of intention to quit smoking include past quit attempts and physical activity. Intention to quit is also associated with the belief that smoking is harmful to them and inversely associated with having peers who smoke, in boys, and the belief that smoking is harmful to others and perceiving smokers as less attractive, and inversely associated with pocket money, in girls.

CONCLUSIONS

The present study has identified factors that appear to influence youth's intention to quit tobacco, which is of major importance in developing successful tobacco cessation programs targeting adolescents.

Tobacco cessation interventions for young people

BACKGROUND

Most tobacco control programmes for adolescents are based around prevention of uptake, but teenage smoking is still common. It is unclear if interventions that are effective for adults can also help adolescents to quit. This is the second update of a Cochrane review first published in 2006.

OBJECTIVES

To evaluate the effectiveness of strategies that help young people to stop smoking tobacco.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register in February 2013. This includes reports for trials identified in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and PsyclNFO.

SELECTION CRITERIA

We included randomized controlled trials, cluster-randomized controlled trials and other controlled trials recruiting young people, aged less than 20, who were regular tobacco smokers. We included any interventions; these could include pharmacotherapy, psycho-social interventions and complex programmes targeting families, schools or communities. We excluded programmes primarily aimed at prevention of uptake. The primary outcome was smoking status after at least six months follow-up among those who smoked at baseline.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed the eligibility of candidate trials and extracted data. Included studies were evaluated for risk of bias using standard Cochrane methodology. Where meta-analysis was appropriate, we estimated pooled risk ratios using a Mantel-Haenszel fixed-effect method, based on the quit rates at longest follow-up.

MAIN RESULTS

Twenty-eight trials involving approximately 6000 young people met our inclusion criteria (12 cluster-randomized controlled trials, 14 randomized controlled trials and 2 controlled trials). The majority of studies were judged to be at high or unclear risk of bias in at least one domain. Many studies combined components from various theoretical backgrounds to form complex interventions.The majority used some form of motivational enhancement combined with psychological support such as cognitive behavioural therapy (CBT) and some were tailored to stage of change using the transtheoretical model (TTM). Three trials based mainly on TTM interventions achieved moderate long-term success, with a pooled risk ratio (RR) of 1.56 at one year (95% confidence interval (CI) 1.21 to 2.01). The 12 trials that included some form of motivational enhancement gave an estimated RR of 1.60 (95% CI 1.28 to 2.01). None of the 13 individual trials of complex interventions that included cognitive behavioural therapy achieved statistically significant results, and results were not pooled due to clinical heterogeneity. There was a marginally significant effect of pooling six studies of the Not on Tobacco programme (RR of 1.31, 95% CI 1.01 to 1.71), although three of the trials used abstinence for as little as 24 hours at six months as the cessation outcome. A small trial testing nicotine replacement therapy did not detect a statistically significant effect. Two trials of bupropion, one testing two doses and one testing it as an adjunct to NRT, did not detect significant effects. Studies of pharmacotherapies reported some adverse events considered related to study treatment, though most were mild, whereas no adverse events were reported in studies of behavioural interventions.

AUTHORS' CONCLUSIONS

Complex approaches show promise, with some persistence of abstinence (30 days point prevalence abstinence or continuous abstinence at six months), especially those incorporating elements sensitive to stage of change and using motivational enhancement and CBT. Given the episodic nature of adolescent smoking, more data is needed on sustained quitting. There were few trials with evidence about pharmacological interventions (nicotine replacement and bupropion), and none demonstrated effectiveness for adolescent smokers. There is not yet sufficient evidence to recommend widespread implementation of any one model. There continues to be a need for well-designed adequately powered randomized controlled trials of interventions for this population of smokers.

Immediate and six-month effects of Project EX Russia: a smoking cessation intervention pilot program

This study evaluates the performance of the Project EX tobacco use cessation program in Russian summer recreational camps. An eight-session clinic-based tobacco use cessation program for adolescents was tested during the summer of 2011 in an experimental pilot trial that involved different youth that rotated through camps. Conditions were nested within camps. Two rotations of unique subject groups of smokers (program and standard care control) through each of five camps provided the means of controlling for campsite by condition. Assignment of condition by rotation was random (by a flip of a coin), achieving reasonable baseline comparability (total n=164 smokers at baseline, 76 program group, 88 standard care control group). Evaluation involved an immediate pretest and posttest and a six-month telephone follow-up. At immediate posttest, Project EX was moderately well-received, significantly reduced future smoking expectation (46% reduction in EX program condition versus 8% in control, p<.0001), decreased intention to not quit smoking (-5.2% in EX versus +1.4% in control, p<.05), and increased motivation to quit smoking (0.72 versus -0.04, p<.0001). At the six-month follow-up, program subjects reported a higher intent-to-treat quit rate during the last 30days (7.5% versus 0.1%, p<.05). For the subjects who remained monthly smokers at the six-month follow-up, Project EX reduced subjects' level of nicotine dependence (-0.53 versus +0.15, p<.001). The results were quite promising for this program, which included motivation enhancement, coping skill, and alternative medicine material. However, further research on teen tobacco use cessation programming in Russia with larger sample sizes, involving other locations of the country, and with stronger research designs is needed.

International Translation of Project EX: A Teen Tobacco Use Cessation Program

AIMS

There are relatively few documented teen tobacco use cessation efforts outside the United States (U.S.). Project EX is an evidence-based program that consists of eight sessions, as a school-based clinic tobacco cessation-only version and a classroom-based prevention and cessation version. This paper provides a 'snapshot' of progress on international translation of ProjectEXpilot study work in eight countries that have been approached thus far. The program was implemented in Wuhan, China; Israel and partners; Bashkortostan, Russia; and Elche, Spain. Implementation is planned for Vienna, Austria; Mumbai, India; and Bangkok, Thailand. This work will lead eventually to a greater understanding regarding preference for type of programming (e.g., clinic versus classroom modality), challenges in recruitment and retention, program receptivity, and short-term (approximately 3-month post-program) quit rates.

PROTOCOL AND INTERIM RESULTS OF INTERNATIONAL TRANSLATION OF PROJECT EX

Convenience samples are being recruited based on previous contacts with each location. A protocol was sent to each location, proposing a controlled design, in which subjects enter cessation groups or become a wait-list control, with an immediate pretest, posttest, and 3-month follow-up. Language translation of program materials was completed in seven of the eight locations. Several variations in design and implementation were demanded though. For example, youth fear of reporting tobacco publicly mandated to researchers that the prevention/cessation classroom version be implemented in some locations (Israel and partners, and India). Program effects are suggested across countries.

CONCLUSIONS

Ongoing partnerships with parties actively involved in tobacco control facilitate pilot testing of teen tobacco use cessation programming. The Project EX curriculum appears quite translatable, though having flexibility in implementation modality eased being able to pilot test the program. Research on this cognitive-behavioral, motivation enhancement approach continues.

Standardization Study of the Korean Version of the Stages of Change Readiness and Treatment Eagerness Scale for Smoking Cessation (K-SOCRATES-S) and Its Predictive Validity

OBJECTIVE

The purpose of the study was to develop the Korean version of the Stage of Change Readiness and Treatment Eagerness Scale for Smoking Cessation (K-SOCRATES-S) based on the Korean version of the Stages of Readiness for Change and Eagerness for Treatment scale (K-SOCRATES). This paper also demonstrates its reliability and validity among patients with nicotine dependence in South Korea.

METHODS

At seven healthcare promotion centers in Gyeonggi-do, 333 male smokers aged 20 to 70 who visited smoking cessation clinic were recruited for this study and the K-SOCRATES-S was administered. After three months, the number of respondents who successfully stopped smoking was assessed by testing their urine cotinine level. Subsequently, exploratory factor analysis was performed to verify the reliability and validity of the K-SOCRATES-S. Also, a logistic regression analysis was performed to examine the variables that can predict the successful cessation of smoking on subscales of the K-SOCRATES-S.

RESULTS

Exploratory factor analysis of the K-SOCRATES-S showed that the scale consisted of three factors: Taking Steps, Recognition, and Ambivalence. The scales measuring Taking Steps and Recognition in this scale had a significantly positive correlation with the scores observed on Kim's smoking cessation motivation scale. The scales measuring Taking Steps and Recognition had a significantly negative correlation with Ambivalence. Overall, the results indicate that the K-SOCRATES-K scale showed high validity.

CONCLUSION

The K-SOCRATES-S developed in the present study is highly reliable and valid for predicting a patient's likelihood of success in quitting smoking among patients who want to cease smoking.

Smoking cessation with teenagers: the relationship between impulsivity, emotional problems, program retention and effectiveness

AIMS

This study examines whether individual differences in impulsivity and emotional problems in adolescent smokers are related to initial smoking characteristics of participants, acceptance, retention and outcome of a school-based smoking cessation program.

DESIGN

The data was obtained from a feasibility study of a youth-specific, cognitive-behavioral and motivation enhancing program at 22 schools with 139 participating teenage smokers in Germany. A one-group-pre-posttest design was realized.

MEASUREMENT

Impulsivity levels were assessed by use of the impulsivity scale of the IVE ("Inventar zur Erfassung von Impulsivität, Risikoverhalten und Empathie", Stadler, Janke, & Schmeck, 2004). To evaluate the extent of emotional problems, the corresponding 5-items scale of the SDQ-Deu ("Strength and difficulties questionnaire", Klasen et al., 2000) was applied. Smoking behavior and acceptance of the program were assessed by students' self-reports.

FINDINGS

Acceptance and retention did not differ with regard to impulsivity and emotional problems, but initial smoking status did. Cessation rates varied with level of impulsivity: compared to non-impulsive participants, impulsive adolescents succeeded in quitting smoking less often. Emotional problems were not related to the rate of quitting.

CONCLUSIONS

Impulsive adolescents were similarly compliant to the offered cessation intervention as less impulsive smokers. In spite of their general positive evaluation, impulsive adolescents seem to benefit less from a smoking cessation program than their non-impulsive counterparts. Specific elements supporting impulsive teenage smokers in their goal to quit should be incorporated into youth-specific cessation programs.

Rekrutierung, Implementation und Aufhörrate eines Rauchstopp-Kurses für Jugendliche

Fragestellung: Es besteht ein Bedarf nach effektiven, jugendspezifischen Rauchstopp-Angeboten. Inwiefern kann das schulbasierte Rauchstopp-Programm losgelöst die Zielgruppe erreichen und bundesweit umgesetzt werden? Methodik: Die Studie hat ein Ein-Gruppen-Prä-Post-Design und wertet Daten von 2 754 Jugendlichen aus 24 meist Haupt- und Realschulen sowie von 22 Kursleitungen und 139 Kursteilnehmenden aus. Rekrutierungsrate, Teilnehmermerkmale, Bewertung und Aufhörrate werden nach Schultyp und Geschlecht verglichen. Ergebnisse: An 73,3 % der anvisierten 30 Schulen (n = 22) fand mindestens ein Kurs statt, 18,9 % der rauchenden bzw. 48,8 % der aufhörwilligen rauchenden Jugendlichen wurden erreicht (n = 139). Losgelöst wurde von Teilnehmenden und Kursleitungen sehr positiv beurteilt, eine Haltequote von 72 % wurde erreicht (n = 101). Während des Kurses hören 30,2 % der Jugendlichen (n = 42) mit dem Rauchen auf (intention-to-treat-Analyse), weitere 37,7 % (n = 51) reduzierten die Konsummenge um die Hälfte. Am Ende der Nachbetreuungsphase von vier Wochen waren 24,4 % (n = 34) rauchfrei. Akzeptanz und Aufhörrate differierten nicht zwischen Schultyp oder Geschlecht. Schlussfolgerungen: Die Studie erbrachte Hinweise darauf, dass mit losgelöst ein Rauchstopp-Programm zur Verfügung steht, das gut implementierbar ist, rauchende Jugendliche erreicht und sowohl von ihnen als auch von den durchführenden Fachkräften akzeptiert wird.

An evaluation of immediate outcomes and fidelity of a drug abuse prevention program in continuation high schools: project towards no drug abuse (TND)

The present study provides an implementation fidelity, process, and immediate outcomes evaluation of Project Towards No Drug Abuse (TND), a drug prevention program targeting continuation high school youth (n=1426) at risk for drug abuse. A total of 24 schools participated in three randomized conditions: TND Only, TND and motivational interviewing follow-up, and no treatment control. Fidelity was high: across program schools the curriculum was implemented as intended and was received favorably by students. Relative to controls, intervention conditions produced effects on hypothesized mediators, including greater gains in program related knowledge, greater reductions in drug use intentions, and positive changes in motivation. However, few generalizations to attitudes and intentions regarding risky sexual behavior were found. The pattern of results suggests that the experimental manipulations worked as intended.

Prospective predictors of quitting behaviours among adult smokers in six cities in China: findings from the International Tobacco Control (ITC) China Survey

AIMS

To examine predictors of quitting behaviours among adult smokers in China, in light of existing knowledge from previous research in four western countries and two southeast Asian countries.

DESIGN

Face-to-face interviews were carried out with smokers in 2006 using the International Tobacco Control (ITC) China Survey, with follow-up about 16 months later. A stratified multi-stage cluster sampling design was employed.

SETTING

Beijing and five other cities in China.

PARTICIPANTS

A total of 4732 smokers were first surveyed in 2006. Of these, 3863 were re-contacted in 2007, with a retention rate of 81.6%.

MEASUREMENTS

Baseline measures of socio-demographics, dependence and interest in quitting were used prospectively to predict both making quit attempts and staying quit among those who attempted.

FINDINGS

Overall, 25.3% Chinese smokers reported having made at least one quit attempt between waves 1 and 2; of these, 21.7% were still stopped at wave 2. Independent predictors of making quit attempts included having higher quitting self-efficacy, previous quit attempts, more immediate intentions to quit, longer time to first cigarette upon waking, negative opinion of smoking and having smoking restrictions at home. Independent predictors of staying quit were being older, having longer previous abstinence from smoking and having more immediate quitting intentions.

CONCLUSIONS

Predictors of Chinese smokers' quitting behaviours are somewhat different to those found in previous research from other countries. Nicotine dependence and self-efficacy seem to be more important for attempts than for staying quit in China, and quitting intentions are related to both attempts and staying quit.

Tobacco use in youth with mental illnesses

Despite an abundance of literature documenting the prevalence and dangers of youth tobacco use, there is a relative dearth of literature in the area of effective cessation treatments for youth (Fiore et al. in Clinical tobacco guideline: treating tobacco use and dependence, 2008). Additionally, although it has been widely accepted that mental illness is highly correlated with tobacco use and dependence, little research has been done to support prevention and cessation efforts for youth with mental illnesses. This paper summarizes the literature on tobacco use and cessation in youth, with a focus on describing the existing knowledge base for youth with mental illnesses.

Factors associated with Taiwanese junior high school personnel advising students to quit smoking

BACKGROUND

Most smokers in developing countries begin smoking before age 18, and smoking prevalence is rising among adolescents. School personnel represent a target group for tobacco-control efforts because they interact daily with students, are role models for students, teach about tobacco-use prevention in school curricula, and implement school tobacco-control policies. The prevalence of teenage smoking has been examined in numerous studies, but few have focused on the influence of school personnel and the characteristics of school personnel who enforce school nonsmoking policy. The purpose of this study was to determine the factors associated with junior high school personnel advising students to quit smoking.

METHODS

School personnel (N = 7129) were recruited by cluster sampling from 60 junior high schools in Taiwan; of these, 5280 voluntarily returned self-administered, anonymous questionnaires (response rate = 74.06%) in 2004.

RESULTS

Most personnel (70%) had advised students to quit smoking. School personnel who were older, male, responsible for teaching health, smokers, with positive attitude against tobacco, or with more knowledge of tobacco hazards were more likely to advise students to quit smoking. Personnel with more interest in and access to tobacco-related materials were more likely to advise students to quit smoking. Personnel who had received tobacco-prevention training were 2.41 times more likely to persuade students to quit smoking after adjusting for other factors. However, only half of the participants had ever had access to educational materials about tobacco use, and 8% had ever received training to prevent tobacco use.

CONCLUSIONS

To reduce youth smoking prevalence, school tobacco-control programs should support tobacco-prevention training for school personnel.

Social cognitive mediators of adolescent smoking cessation: results from a large randomized intervention trial

Only one prior study has examined why adolescent smoking cessation interventions are effective. To address this understudied and important issue, we examined whether a large adolescent smoking cessation intervention trial's outcomes were mediated by social cognitive theory processes. In a randomized trial (N = 2,151), counselors proactively delivered a telephone intervention to senior year high school smokers. Mediators and smoking status were self-reported at 12-months postintervention eligibility (88.8% retention). At least 6-months abstinence was the outcome. Among all enrolled smokers, increased self-efficacy to resist smoking in (a) social and (b) stressful situations together statistically mediated 55.6% of the intervention's effect on smoking cessation (p < .001). Among baseline daily smokers, increased self-efficacy to resist smoking in stressful situations statistically mediated 56.9% of the intervention's effect (p < .001). Self-efficacy to resist smoking is a possible mediator of the intervention's effect on smoking cessation.

Smoking cessation for adolescents: a review of pharmacological and psychosocial treatments

Unlike the vast literature on smoking cessation in adults, research in adolescents has gained significant attention only within the last decade. Even with this increase in focus, research into pharmacological aids for smoking cessation in adolescents (e.g., nicotine replacement therapy, bupropion) is a more recent phenomenon and has produced only modest results. While more extensive, much of the research on behaviorally- or psychosocially-based adolescent smoking cessation interventions has been limited by a lack of control for contact time, biochemical verification of self-reported abstinence, and/or a theoretical focus for the interventions. The MEDLINE, PubMed, PSYCInfo, EMBASE, ERIC, CINHAL, Cochrane CENTRAL and Systematic Review databases were searched for articles relevant to adolescent smoking cessation treatment. After briefly examining the adolescent smoking cessation research prior to 2000, more recent developments in pharmacological aids and psychological treatment will be reviewed. Investigations have made progress in elucidating efficacious treatments for adolescent smokers, but much work remains to be done in both pharmacological and non-pharmacological areas of treatment. With the current state of the literature as a guide, future directions for research into smoking cessation for adolescents will be proposed.

Concurrent predictors of cigarette and alcohol use among U.S. and Russian adolescents

In the present study, we describe correlates of 30-day cigarette and alcohol use among two samples of high school students, one in the Russian Federation (n = 365), and one in the United States (n = 965). The correlates used in the analyses are based on the theory of triadic influence, which organizes predictors of adolescent substance use into three distinct types of influence. Overall, correlates from each of the types of influence were significant predictors of substance use in both samples. The most consistent positive predictors of cigarette and alcohol use across countries were friends' substance use and sensation seeking behavior. Perceived harmfulness of drug use was negatively associated with cigarette and alcohol use in both samples. Having a substance abuser in one's family was negatively associated with alcohol use in the Russian sample, but positively associated with alcohol use in the U.S. sample. In general, similar patterns of relationships between predictors and substance use were seen across both countries.

Tobacco cessation interventions for young people

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 psycho-social 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.

Project EX: A Program of Empirical Research on Adolescent Tobacco Use Cessation

This paper presents the Project EX research program. The historical background for Project EX is presented, including a brief summary of reasons youth fail to quit tobacco use, the disappointing status of previous cessation research, and the teen cessation trial that provided the template for the current project (Project TNT). Next, program development studies for Project EX are described. Through use of focus groups, a theme study (concept evaluation of written activity descriptions), a component study, and pilot studies, an eight-session program was developed. This program involves novel activities (e.g., "talk show enactments," games, and alternative medicine-type activities such as yoga and meditation) in combination with motivation enhancement and cognitive-behavioral strategies to motivate and instruct in cessation initiation and maintenance efforts. The outcomes of the first experimental trial of Project EX, a school-based clinic program, are described, followed by a posthoc analysis of its effects mediation. A second EX study, a multiple baseline single group pilot study design in Wuhan, China, is described next. Description of a second experimental trial follows, which tested EX with nicotine gum versus a natural herb. A third experimental trial that tests a classroom prevention/cessation version of EX is then introduced. Finally, the implications of this work are discussed. The intent-to-treat quit rate for Project EX is approximately 15% across studies, double that of a standard care comparison. Effects last up to a six-month post-program at regular and alternative high schools. Through a systematic protocol of empirical program development and field trials, an effective and replicable model teen tobacco use cessation program is established. Future cessation work might expand on this work.