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Kimberly A. Horn, EdD, MSW, Geri A. Dino, PhD, Iftekhar D. Kalsekar, BS and Ancilla W. Fernandes, MS

The authors are with the Office of Drug Abuse Intervention Studies, West Virginia University, Morgantown, WVa. Kimberly A. Horn and Geri A. Dino are also with the Department of Community Medicine and the Prevention Research Center, West Virginia University, Morgantown, WVa.

Correspondence: Requests for reprints should be sent to Kimberly A. Horn, EdD, Office of Drug Abuse Intervention Studies, West Virginia University, PO Box 9190, Morgantown, WV 26505 (e-mail: khorn{at}hsc.wvu.edu).

	ABSTRACT

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High school smokers from 2 central Appalachian states received the American Lung Association’s 10-session Not On Tobacco (N-O-T) program or a 15-minute brief self-help intervention. Our study compared the efficacy of N-O-T with that of the brief intervention by examining group differences in the 15-month-postbaseline (12-month-postprogram) smoking quit rates.

N-O-T youths had higher overall quit rates. Review of end-of-program (3-month-postbaseline) and 3-month-postprogram (6-month-postbaseline) follow-up data showed state-level differences and positive cessation trends over time, regardless of treatment intensity. Quit rates were lower than rates found in other N-O-T studies of nonrural youths, suggesting that Appalachian youths are a recalcitrant smoking sample. Findings suggest that N-O-T is one option for long-term smoking cessation among rural teens.

	INTRODUCTION

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IN AN OUTSTANDING REVIEW of the current adolescent tobacco cessation research, Sussman¹ concludes that there is ample evidence to recommend the use of teen smoking cessation programs rather than providing little or no intervention. In spite of this encouraging conclusion, there is much more that we need to learn about teen smoking cessation, especially among disparate or high-risk subgroups.^1,2 One notable high-risk group is youths from less-educated, impoverished, rural areas.³ Rural youths start smoking earlier, have higher smoking rates, and have higher risk for developing smoking-related mortality and morbidity later in life than their nonrural counterparts.³ Intervention is particularly important because it is a way to address current disparities in risky behavior as well as health disparities in future tobacco-related chronic disease.

Little is known about smoking cessation in this vulnerable subpopulation, especially regarding cessation maintenance over time. To address this gap, this report provides long-term follow-up data for 14- to 19-year-olds who participated in the American Lung Association’s Not On Tobacco (N-O-T) program. High school smokers from 2 central Appalachian states, West Virginia and North Carolina, received either the 10-session N-O-T program or a 15-minute brief self-help intervention (BI). The investigation’s aim was to compare the efficacy of N-O-T with that of the BI by examining group differences in the 15-month-postbaseline (12-month-postprogram) smoking quit rates.

	PROGRAM DESCRIPTION

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Intervention Approaches
N-O-T consisted of 10 hour-long sessions that occurred on average once a week. The program was delivered in same-sex groups of 4 to 12 teens, led by a same-sex facilitator. The program was delivered in accordance with the American Lung Association’s N-O-T curriculum requirements. During the BI, mixed-sex groups were gathered for a single, 15-minute classroom session, where they received study-scripted quit smoking advice and self-help brochures widely available to the general public.⁴ The BI approximated what teen smokers might typically receive in a school setting. (The N-O-T curriculum and training are provided nationally by the American Lung Association; refer to its Web site at http: //www.lungusa.org for information about program implementation. Detailed descriptions of N-O-T research protocols are reported elsewhere.^4–6)

West Virginia and North Carolina school selection factors included (1) type of community in the school locale (e.g., rural or rural/suburban), (2) student population size, (3) student–teacher ratio, (4) geographic location, (5) economic status of the community or county of the school locale (e.g., above or below poverty levels, percentage of students receiving free or reduced school lunches), and (6) racial/ethnic composition. Additionally, all schools were located within the federally identified central Appalachian region. In sum, 20 West Virginia and North Carolina public schools were selected for recruiting and enrolling youths in the study. The youth recruitment period was between 3 and 6 weeks.^7–10

The total recruited baseline sample included 258 youths. The West Virginia program had 136 youths: 63 in the 5 N-O-T schools and 73 in 5 BI schools. There were 122 youths in the North Carolina program: 61 in the 5 N-O-T schools and 61 in 5 BI schools. Most youths were White (93.4%). The mean age was 16 years; 56% were females. Participants had been smoking for about 5 years. Mean daily cigarette use was over a half a pack on weekdays (mean = 13.32) and a pack a day on weekends (mean = 19.38). The youths were also highly addicted to nicotine as measured by the Fagerstrom Tolerance Questionnaire (modified).^10,11

N-O-T PROGRAM HIGHLIGHTS Includes 10 sessions that last about 50 minutes each. Is offered in private small-group settings by facilitators trained by the American Lung Association. Is voluntary rather than punitive. Covers all aspects of the quitting process (from preparation to relapse). Is delivered to girls and boys separately by same-gender facilitators, and gender issues are emphasized in facilitator training. Provides the option of extending the program with 4 booster modules. Covers issues relevant to teens and uses teen-friendly language. Uses peer group discussion, journals, and experiential activities. Integrates nutrition and physical activity. Is linked to the training and ongoing information resources of the American Lung Association. Is based on social cognitive theory.

 

Measurement
At the 3- and 6-month measurements (i.e., at the end of the program and 3 months after the program), participants who responded no to the question "Are you currently smoking?" and had carbon monoxide readings of less than 9 ppm were considered quitters.^5,7 Quitting assumed at least 24-hour abstinence. At the 3- and 6-month observations, however, data documenting days of continuous abstinence also were collected. Importantly, across the 3-month and 6-month observations, there was high agreement between self-report and carbon monoxide–validated quit rates (3-month observation: = 1, P = .000; 6-month observation: = 1, P = .000). Therefore, there was a 15-month follow-up conducted via telephone interviews in which carbon monoxide readings were not collected.

	DISCUSSION AND EVALUATION

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Design
A matched rather than a randomized design allowed the selection of N-O-T schools that were already trained to administer N-O-T and of BI schools that did not have the N-O-T program already in place, thus reducing the possibility of contamination. N-O-T and BI programs did not operate simultaneously in any study school. Baseline data from N-O-T and BI participants, such as age, grade, age of smoking onset, number of cigarettes smoked per day, motivation and confidence to quit, and nicotine dependence, were compared to determine the similarity of the 2 samples prior to intervention. Independent 2-tailed t tests showed that participants were similar upon enrollment.

Determination of Quit Rates
Approximately 50% (n = 129) of the youths were available at the 15-month follow-up. Using the intent-to-treat sample (number of youths who quit/total sample), ² was used to compare the quit rates for N-O-T and BI participants⁸ (Table 1). Intent-to-treat analysis assumed that all youths who were unavailable for contact had relapsed or never quit. Among quitters, the number of days since last cigarette was strikingly different for the 2 groups at the end of the program: 1.33 (SD = 0.58) for the BI group and 16.8 (SD = 23.66) for the N-O-T group. Three months later, the mean number of days since last cigarette was 39.20 (SD = 81.56) and 33.30 (SD = 66.71) for the BI and N-O-T groups, respectively.

Conservatively, intent-to-treat analyses showed that 11% of N-O-T youths had quit at the 15-month follow-up—assuming that all youths who were unavailable for contact had relapsed or never quit. Interestingly, compliant sample analyses (i.e., number of youths who quit/total sample available at follow-up) showed that 22% of N-O-T youths reported quitting. As has been argued in previous research, intent-to-treat analyses may not be as appropriate for teen smoking cessation as it is for adult clinical trials.^4,5,8 The reasons that youths are unavailable for follow-up (e.g., relocation or graduation) may be beyond their control and unrelated to smoking or relapse. Sussman¹ reports that the mean end-of-program quit rate for school-based programs is 12%, and roughly 14% across all types of cessation programs.

	NEXT STEPS

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N-O-T appears to be one option for reducing smoking among the Appalachian sample. Although quit rates were satisfactory, other N-O-T studies revealed higher quit rates (at 3- and 6-month follow-up) than found in this study, especially among urban samples of youths.⁷ Recent surveillance data show that rural youths (e.g., those in the Appalachian states of Kentucky, West Virginia, North Carolina, and Mississippi) have higher smoking rates and smoke more heavily than youths in nonrural states.³

Given high smoking rates and possibly greater difficulty with cessation, it may be necessary to tailor programs such as N-O-T to make them more consistent with the unique life experiences of rural youths. Cessation programs tailored for rural youths may need to consider topics such as tobacco-growing economies, favorable tobacco environments, favorable norms about use, geographic isolation and lack of access to services, cultural and traditional values and customs, poverty, and stress and coping. Future research should examine the consequences of simultaneously operating tobacco prevention or cessation programs at school, county, and state levels. In addition, tobacco-related economic and political climates should be assessed, especially in rural tobacco growing areas.¹³

	KEY FINDINGS

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• Half of all participants were still involved in the Not On Tobacco (N-O-T) program 15 months after it began, and they attended 70% of the program.
  
• N-O-T youths demonstrated higher quit rates overall than did the brief intervention (BI) youths; the 15-month quit rate for the N-O-T program is estimated at between 11% and 22%.
  
• While the gap between the rates for the N-O-T program and the BI appeared to narrow over time, overall, the analyses by state showed a different trend—North Carolina, in particular, showed a widening of the gap between N-O-T and BI quit rates over time.
  
• The study results, which are particularly striking given that youths were addicted, daily smokers, may be most generalizable to a rural, heavy-smoking youth population.
  
• We project that a valid 15-month quit rate for the N-O-T program is somewhere between 11% and 22%.
  

	Acknowledgments

 
This study was funded through the West Virginia University Prevention Research Center from a Cooperative Agreement (U48/CCU310821) with the Centers for Disease Control and Prevention.

Appreciation is extended to Dr Steve Sussman, University of Southern California, for his preliminary review of this report. Acknowledgment also is given to Tim McGloin of the University of North Carolina–Chapel Hill, who facilitated study implementation in North Carolina.

Human Participant Protection
All participants provided signed parental consent and participant assent forms prior to study enrollment.

	Footnotes

 
Contributors
K. A. Horn, the principal investigator of the study, supervised all aspects of the study and its implementation and led the writing of the report. G. A. Dino, the co-investigator of the study, assisted with the study and in writing and reviewing all parts of the study. A. W. Fernandes completed the analyses and assisted in writing the results and analyses sections. I. D. Kalsekar assisted with the analyses and reviewed and edited the manuscript. All authors helped in interpreting findings and reviewing the report.

Peer Reviewed

Accepted for publication October 10, 2003.

	References

TOP ABSTRACT INTRODUCTION PROGRAM DESCRIPTION DISCUSSION AND EVALUATION NEXT STEPS KEY FINDINGS References

 
1. Sussman S. Effects of sixty-six adolescent tobacco use cessation trials and seventeen prospective studies of self-initiated quitting. Tob Induced Dis. 2002; 1:35–81.

2. Mayhew KP, Flay BR, Mott JA. Stages in the development of adolescent smoking. Drug Alcohol Depend. 2000; 59:S61–S81.

3. Centers for Disease Control and Prevention. Youth risk behavior surveillance summaries—United States, 1999. MMWR Morb Mortal Wkly Rep. 2000; 49(SS-5):1–96.[Medline]

4. Horn K, Dino G, Gao X, Momani A. Feasibility evaluation of Not On Tobacco: The American Lung Association’s new stop smoking programme for adolescents. Health Educ. 1999;99: 192–206.

5. Dino GA, Horn KA, Goldcamp J, Kemp-Rye L, Westrate S, Monaco K. Teen smoking cessation: making it work through school and community partnerships. J Public Health Manag Pract. 2001;7:71–80.[Medline]

6. Dino G, Horn K, Zedosky L, Monaco K. A positive response to teen smoking: why N-O-T? Natl Assoc Secondary Sch Principals Bull. 1998; 82:46–58.

7. Dino GA, Horn KA, Goldcamp J, Maniar SD, Fernandes AW, Massey CJ. A gender sensitive teen smoking cessation program. J Sch Nurs. 2001;17:90–97.[Medline]

8. Dino G, Horn K, Goldcamp J, Fernandes A, Kalsekar I, Massey CJ. A 2-year efficacy study of Not On Tobacco in Florida: an overview of program successes in changing teen smoking behavior. Prev Med. 2001;33:600–605.[Medline]

9. Massey C, Dino G, Horn K, Lacey-McCracken A, Goldcamp J, Kalsekar I. (2003). School-based teen smoking cessation programs: recruitment issues in research. J Sch Health. 2003;73:58–63.[Medline]

10. Horn K, Dino G, Kalsekar I, Massey CJ, Manzo-Tennant K, McGloin T. Exploring the relationship between mental health and smoking cessation: a study of rural teens. Prev Sci. In press.

11. Horn K, Fernandes A, Dino G, Kalsekar I, Massey C. Adolescent nicotine dependence and smoking cessation outcomes. Addict Behav. 2003;28:769–776.[Medline]

12. National Association of Attorney Generals. NAAG Projects: Tobacco. Master Settlement Agreement and Amendments. Available at http://www.naag.org/issues/tobacco/index.php?sdpid=919. Accessed January 8, 2003.

13. Noland MP. Tobacco prevention in tobacco-raising areas: lessons from the lion’s den. J Sch Health. 1996;66:266– 269.[Medline]

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