| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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RESEARCH AND PRACTICE |
At the time of the study, Susan J. Curry, Sherry Emery, Amy K. Sporer, Robin Mermelstein, Brian R. Flay, Michael Berbaum, and Richard B. Warnecke were with the Institute for Health Research and Policy, University of Illinois, Chicago. Timothy Johnson, Jennifer Parsons, and Lori Harmon are with the Survey Research Laboratory, University of Illinois, Chicago. At the time of the study, Paul Mowery, Lisa Hund, and Henry Wells were with Research Triangle Institute, Research Triangle Park, NC.
Correspondence: Requests for reprints should be sent to Susan J. Curry, PhD, Institute for Health Research and Policy, University of Illinois at Chicago, 1747 West Roosevelt Road, Room 558, Chicago, IL 60608 (e-mail: suecurry{at}uic.edu).
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ABSTRACT |
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Objectives. We collected data on a national sample of existing community-based tobacco cessation programs for youths to understand their prevalence and overall characteristics.
Methods. We employed a 2-stage sampling design with US counties as the first-stage probability sampling units. We then used snowball sampling in selected counties to identify administrators of tobacco cessation programs for youths. We collected data on cessation programs when programs were identified.
Results. We profiled 591 programs in 408 counties. Programs were more numerous in urban counties; fewer programs were found in low-income counties. State-level measures of smoking prevalence and tobacco control expenditures were not associated with program availability. Most programs were multisession, school-based group programs serving 50 or fewer youths per year. Program content included cognitive-behavioral components found in adult programs along with content specific to adolescence. The median annual budget was $2000. Few programs (9%) reported only mandatory enrollment, 35% reported mixed mandatory and voluntary enrollment, and 56% reported only voluntary enrollment.
Conclusions. There is considerable homogeneity among community-based tobacco cessation programs for youths. Programs are least prevalent in the types of communities for which national data show increases in youths’ smoking prevalence.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The number of published studies of tobacco cessation treatments in youths remains small. To date, the most comprehensive description of cessation programs for youths is Sussman’s review of 66 program evaluation studies.9 All of the programs described were part of research studies, and the review concluded that data suggest a doubling of cessation rates with cessation interventions for adolescents; methodological limitations across studies precluded definitive estimates of program effectiveness. A recent evidence review panel identified only 20 studies from the Sussman review that were of sufficient rigor to inform recommendations.10 The panel concluded that programs with cognitive-behavioral components show the most promise for increased quit rates.10 Recent randomized trials report no significant differences among different types of treatment (e.g., self-help materials with and without telephone counseling11 or behavioral treatment and nicotine replacement with and without bupropion12); these studies generally do not include untreated control groups. There is evidence from controlled studies that young smokers receiving active treatment quit smoking or reduce their smoking at higher rates than untreated controls.13,14
In 2000, the Youth Tobacco Cessation Collaborative,15 a group of public and private organizations committed to increasing the availability of effective youth cessation programs, released its National Blueprint for Action: Youth and Young Adult Tobacco-Use Cessation, which outlines a series of strategic objectives to ensure that every tobacco user aged 12 to 24 years has access to effective cessation treatments by the year 2010.16
Prompted by the work of the Youth Tobacco Cessation Collaborative, The Robert Wood Johnson Foundation, with additional support from the National Cancer Institute and the Centers for Disease Control and Prevention, recruited the Institute for Health Research Policy at the University of Illinois at Chicago to launch Helping Young Smokers Quit, a national 3-phase initiative to identify best practices in tobacco cessation for youths.15 In phase 1 of Helping Young Smokers Quit, the purpose was to profile a national sample of existing tobacco cessation programs for youths to understand their prevalence and overall characteristics.
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METHODS |
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Operational Definition of a Tobacco Cessation Program for Youths
Youth tobacco cessation programs eligible for this study were those that had been established at least 6 months before we contacted them, provided direct tobacco cessation services for youths, had at least half of their participants aged 12 to 24 years, were not currently part of a research initiative, and did not focus on pregnant smokers.
County Sample
The overall sampling frame comprised 2453 counties (3142 counties in the United States excluding 689 with populations less than 10000, which were deemed unlikely to yield programs). We stratified counties by urbanization, socioeconomic status (SES), youth smoking prevalence, and per capita tobacco control expenditures. We defined urbanization and socioeconomic status at the county level and smoking prevalence and per capita tobacco control expenditures at the state level because county data were unavailable.
Urban counties were counties within a US Census Bureau metropolitan statistical area (MSA). Low-SES counties were those in which more than 20% of the population lived below the federal poverty threshold, on the basis of 2000 Census data. High-smoking-prevalence counties had 2000 Behavioral Risk Factor Surveillance System smoking prevalence rates above the national median (31%) for people aged 18 through 24 years.
We defined 3 levels of weighted per capita tobacco control expenditures on the basis of state-level data obtained by the consultant group RTI International.18 We used a 5-year (1997–2001) weighted average of these expenditures. The most recent years of data received the largest weights with a decay function derived from research measuring exposure to advertising.19 We ordered states by their weighted average expenditures and grouped them by tertiles.
The 4 stratification criteria produced 24 total strata. Some strata contained very few counties and were combined. We combined MSA and non-MSA counties within the low-SES strata and combined high- and medium-tobacco-control-expenditure counties in the collapsed MSA/non-MSA high-smoking-prevalence strata, for a final set of 17 strata. Because of cost limitations and using our expert judgment about the likely availability of programs, we set a target of 400 interviews with eligible tobacco cessation programs for youths and used that target as a guide for the number of counties to be surveyed. We sampled unequally across strata to identify 408 counties, presuming a greater likelihood of finding programs in states with higher per capita expenditures for tobacco control. We selected 18 counties from each of the 6 low-expenditure strata, 24 from each of the 5 medium-expenditure strata, and 30 from each of the 6 high-expenditure strata.
Within each stratum, we randomly selected counties, without replacement, in proportion to the size of the youth population (aged 10 to 24 years) in the county. Wyoming, with 15 eligible counties, was the only state for which we did not select counties.
Snowball Sampling
Our goal was to identify contacts at the local level who were knowledgeable about tobacco cessation programs for youths in their communities or who could lead us to such persons. Snowball sampling progressed through 2 tiers and ended with the identification of a program informant who administered a tobacco cessation program for youths in the community.
Tier 1 Key Informants. We followed replicable protocols to identify first-tier informants from county departments of health, county-based school districts, and the American Cancer Society, American Lung Association, or the American Heart Association. If we could not identify contacts through county-level domains, we contacted state-level organizations. We identified key informants through Web sites, telephone directories, and organizational lists of individuals likely to be knowledgeable about tobacco cessation treatment for youths.
Tier 2 Key Informants. We identified tier 2 informants by asking tier 1 informants for contact information for anyone in their county whom they believed to be knowledgeable about tobacco cessation for youths. We continued snowball sampling until no new key informants were identified in a given county.
Program Administrators. We asked all identified contacts, including tier 1 and tier 2 key informants, whether they administered a tobacco cessation program for youths. We asked those who answered yes a series of eligibility questions to determine whether their programs qualified for the program survey.
Program Survey
Our survey asked 153 questions in 11 domains: general community context, program history, program setting and mode of delivery, program components, enrollment criteria, program operation, client characteristics, program staffing, program funding, program evaluation, and program administrator characteristics.
The University of Illinois Survey Research Laboratory administered the program survey using CASES version 4.3 (Computer-Assisted Survey Methods Program; Berkeley, Calif). Interviewers scheduled 45-minute telephone appointments to complete the program survey. Program administrators received a paper copy of the survey in advance. (A copy of the survey can be obtained at http://helpingyoungsmokersquit.org/hysq-phase_1.)
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RESULTS |
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provides a summary of our snowball sampling results. We attempted to contact 10157 individuals across all tiers of key informants. We reached 99% of these individuals (10039). Tier 1 key informants named 7301 tier 2 informants, almost half of which (48%) were duplicate names, a result of continuing the snowball sampling until no new key informants were gathered.
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Respondents from 591 eligible programs (78%) completed surveys. Of the 165 eligible programs for which we did not obtain completed surveys, 113 had no respondent available to complete the survey, 29 actively refused the survey, and 23 had a respondent we could not reach during the study period despite multiple attempts. Surveyed and non-surveyed eligible programs did not differ on the 4 stratification variables.
Program Availability
Table 1 provides a summary of program availability overall and by each stratification variable. We found 3 or more programs in 26% of the counties, 2 programs in 13% of the counties, 1 program in 24% of the counties, and no programs in 38% of the counties. The number of programs in a county was unrelated to youth smoking prevalence or tobacco control expenditures. Significant differences in program availability emerged for MSA versus non-MSA counties and by county SES.
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provides a summary of characteristics of the surveyed programs.
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Organizational initiative (40%), health department or department of education requests (22%), and teacher initiative (11%) were most often reported as the primary impetus for offering a youth cessation program. Only 2% of programs reported youth demand, and less than 1% of programs reported parent demand as the primary motivation for offering cessation programs.
Program Format. Overall, 45% of the programs used materials that were purchased from an outside organization. Among those with externally developed programs, frequently cited reasons for program selection were research evidence that the selected program had worked for other groups (73%), ease of adoption (61%), recommendations from experts in tobacco cessation for youths (52%), and recommendations from colleagues (35%). Presentations from the program developers or marketers (41%) and previous relationships with the program’s sponsoring organization (41%) were not important factors for program selection.
Ninety-five percent of programs were delivered using in-person group meetings; more than three fourths of these programs also included an additional component (e.g., individual face-to-face counseling [61%], self-help manual [48%], telephone counseling [15%], or Internet-based programs [7%]). Primary locations for group programs included school classrooms (65%), school health clinics (23%), or another school-based setting (53%). Less commonly reported settings were community centers (20%), community-based health clinics (15%), hospitals (12%), and church or religious centers (7%). Also infrequently reported were cessation programs held in drug treatment centers (10%).
Treatment Providers. Most programs reported that the individuals who provided treatment were specifically trained in smoking cessation counseling (88%), and an outside organization had most often provided training (64%). Almost 90% of programs used written treatment guides. Treatment providers were most often teachers (42%), nurses (37%), school counselors (35%), social workers (27%), and sports coaches (15%). Youth peers were named as treatment providers by 18% of the program administrators.
Program Content. Virtually all programs provided information about the immediate and long-term consequences of smoking (99.8%) and about the strategies the tobacco industry used to market tobacco to youths (95%). A list of 17 program components was divided into 6 categories of cognitive-behavioral strategies (self-monitoring, disrupting smoking patterns, contingency control, coping skills training, general health and lifestyle balance, and social support). On average, programs included components from 5 out of 6 of these cognitive-behavioral categories. Nine youth-specific topics were coded into 3 categories (mood-related issues, life goals, and problem behavior). On average, programs included topics from 2 of these categories. Topics commonly reported were stress (94%), self-esteem (80%), other drug use (63%), alcohol (57%), depression (56%), and academic performance (55%). Fewer than half of the programs had a formal protocol for referrals to mental health professionals (43%). Of the 591 programs surveyed, only 43 (7%) included the use of medication. Of these, most reported use of the nicotine patch (98%).
Program Enrollment and Recruitment. Among the programs surveyed, 9% of respondents reported that all program enrollment was mandatory; 35% reported mixed voluntary and mandatory enrollment. Among programs with mixed enrollment, a slight majority of program participants were mandated to enroll (58%). More than 75% of the programs enrolled 50 or fewer youths annually (median = 20). In total, the surveyed programs provided treatment services to approximately 36600 youths during the previous year. On average, programs reported that 73% of youths who started treatment completed the entire program.
Among programs with voluntary enrollment, the most frequently cited methods of promoting program enrollment were adult encouragement (90%), referrals from an adult (e.g., physician, teacher, or school nurse; 90%), referrals from other participants (88%), and peer outreach (81%). Of these methods, peer outreach was endorsed as the most effective promotion method (27%), followed by referrals from other participants (19%). For programs with mandatory enrollment, the most common enrollment reason was as punishment for possession or use of tobacco (92%). For 37% of mandatory programs, youths could enroll in lieu of paying a fine. A minority of programs (22%) required parental permission to participate in the program; 34% notified parents of their child’s participation.
Follow-Up and Evaluation. Half of the respondents reported that their program maintained contact with participants after program completion without providing further treatment. The average number of follow-up contacts was 2.5. Mean (SD) time to follow-up for the first and last follow-ups were 1.8 (2.0) and 6.7 (4.5) months. The primary information collected during follow-up included current smoking status (98%); only 9% conducted any biochemical validation of having quit.
More than three fourths of programs (79%) included a formal evaluation component. Common aims of evaluation included obtaining feedback to improve outcomes and satisfaction (97%), monitoring cessation outcomes (87%), evaluating program materials (85%), and evaluating counselors (61%). Measures included attendance tracking (90%), participant satisfaction ratings (85%), and assessment of smoking status (82%). In the majority of programs, the same people that delivered treatment collected follow-up evaluation information (78%). Reported response rates ranged from an average of 67% (first follow-up) to 48% (last follow-up).
Program Challenges. The survey asked respondents to rate 13 challenges programs may encounter, such as staffing, recruitment, funding, and implementation problems. The majority of program administrators rated the following as "not too challenging": obtaining appropriate locations (68%), maintaining support of leadership (65%), and retaining hired staff (51%). Cited as "somewhat" or "very" challenging were enrolling a sufficient number of participants (71%), obtaining follow-up information from participants (65%), keeping participants in the program (64%), and obtaining sufficient operating funds (51%).
Community Context. When asked an open-ended question about the major community concern about youths, 12% said tobacco use and 6% said tobacco and drug use. The most commonly stated concern (47%) was drug use excluding tobacco. When asked directly what priority community leaders placed on tobacco cessation for youths, the majority of respondents (67%) indicated it was somewhat of a priority, and only 16% reported it was not a priority at all. Few administrators felt that the general population in their community was very aware of the program (8%). Among the 76% reporting at least some community awareness of their program, the majority felt that community residents were very supportive (58%) or somewhat supportive (41%) of the program.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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There appears to be an inverse association between the need for cessation programming on the basis of trends in smoking prevalence and program availability. Recent Monitoring the Future data show 2 groups for which smoking prevalence is rising: youths in non-MSA areas and youths with low parental education (an indicator of low SES).2 We found a clear lack of cessation programming for youths in non-MSA counties and in counties with low SES. Because of their small size, non-MSA counties likely have a smaller absolute number of smokers than MSA counties. Given the observed low demand for cessation programs among youths, perhaps there is a threshold number of young smokers needed as an impetus for creating and sustaining cessation services. Stratification measures of smoking prevalence among youths and per capita tobacco control expenditures, both defined at the state level, were not associated with the presence of any cessation programming for youths. Although this could mean that smoking prevalence and tobacco control expenditures are unrelated to the presence of cessation programs for youths in a county, it may also reflect the imprecision of applying state-level characteristics at the county level.
A striking result from this study is the considerable homogeneity among programs. The typical program was a multisession, school-based group program serving a modest number of youths per year. Most programs included the same cognitive-behavioral components found in evidenced-based adult programs along with content more specific to adolescence. Nearly all programs operated with modest budgets. Given that the median annual budget was $2000, it is not surprising that obtaining sufficient operating funds was a commonly cited challenge.
The similarity in content across programs is not because organizations are using the same program. Most programs used externally developed materials, which came from a variety of voluntary, governmental, and for-profit organizations. The American Lung Association’s Not On Tobacco program20–22 was the most commonly used packaged program and was reported as the source program by 30% of program administrators. The Substance Abuse and Mental Health Services Administration recently designated Not On Tobacco along with another evidence-based program (Project EX13) as model programs for tobacco cessation for youths.23
One impetus for youth cessation programs was the need to provide a consequence for students who violate local statutes or school rules against the purchase, possession, or use of tobacco. Although participation was mandated in only a small percentage of programs, more than one third of programs had some provision for mandatory participation. We were unable to ascertain the impact of mandated participation on group dynamics or on tobacco cessation. From the perspective of motivation theory, one concern is that mandated treatment participation undermines intrinsic motivation to quit and diminishes the likelihood of permanent cessation.24 This concern warrants further study.
There are some encouraging findings from this survey. First is the degree of organizational commitment to providing evidence-based treatment. Most programs reported that professionally trained adults delivered treatment from standardized written protocols. Research evidence that the program had worked for others was by far the most commonly cited reason for program selection. Also encouraging is the commitment of programs to conducting follow-up and program evaluations. Although only one fourth of programs that included an evaluation reported undergoing external evaluation, three fourths conducted internal evaluations aimed at program improvement and outcome monitoring. Given the modest operating budgets for the programs, it is not surprising that the methods used often do not meet recommended standards for program evaluation.25 For example, the people delivering treatment obtained follow-up information, the program did not validate self-reported cessation, and long-term follow-up rates were fairly low.
Less encouraging is the limited reach and perceived low demand for treatment among young smokers, even for programs offered in school settings. Although an impressive figure, the 36000 participants served by the 591 programs represent a minuscule proportion of young smokers in the 408 counties. Youth demand for cessation programs was rarely cited as an impetus for offering a program; the most commonly cited challenge was recruiting enough participants. This result mirrors the limited demand for multisession adult group cessation programs, which show relatively low reach into the population even when offered in convenient settings such as work sites, faith-based organizations, or health care facilities.26 Alternative formats have the potential to reach large numbers of young smokers while preserving anonymity. For example, our sample included a Web-based program that reported serving 2000 youths in the previous 12 months.
As with any cross-sectional survey, the profiled programs represent a slice of information at 1 particular point in time. Snowball sampling attempted to find all available programs, but there is no benchmark against which to gauge success in locating these programs. We obtained information directly from program administrators, who do not necessarily deliver treatment. Interpretation of the results is contingent upon the validity of the response data. For example, without detailed information on respondents’ interpretation of response options it is unclear which "experts" provided advice on program selection to 52% of the respondent organizations. Future surveys can explore these issues. We provided participants with advance copies of the survey so they could obtain information from coworkers before the interviews. However, we may have missed unique program aspects added by innovative treatment professionals. Although administrator reports were not independently validated, similarities to data reported elsewhere,10 including rates of program completion and follow-up response rates, are reassuring. Because our aim was simply to find and describe a national sample of available tobacco cessation programs for youths, we did not obtain data from program participants and cannot report on tobacco use outcomes.
Despite the inherent limitations of this survey, cooperation from the programs was excellent. The findings suggest that replicable programs exist in communities across the United States and that rigorous, simultaneous program evaluations could inform best practices for tobacco cessation in youths.
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Acknowledgments |
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We acknowledge the Youth Tobacco Cessation Collaborative for its visionary work to advance the evidence base for youth tobacco cessation treatment and C. Tracy Orleans of The Robert Wood Johnson Foundation for establishing the Helping Young Smokers Quit initiative.
Human Participant Protection
The survey protocol was reviewed and deemed exempt by the institutional review board at the University of Illinois at Chicago.
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Footnotes |
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Contributors
S. J. Curry provided overall scientific direction to the design and implementation of the study, including sampling design and survey development. As lead author, she drafted early versions of the article and made all revisions on the basis of comments from every coauthor. S. Emery, A. K. Sporer, R. Mermelstein, B. R. Flay, M. Berbaum, R.B. Warnecke, T. Johnson, and P. Mowery were coinvestigators who contributed to all aspects of study design, survey development, and interpretation of results. J. Parsons contributed to the development of the program survey and the development of snowball sampling tracking procedures and oversaw all data collection activities at the Survey Research Laboratory. L. Harmon helped conceptualize the snowball sampling methodology and coordinated its implementation. L. Hund played a major role in the development of the evaluation study methodology, including developing the methods for identifying Tier 1 key informants and the US county sampling frame. H. Wells contributed to the sampling design and wrote the SAS programs to draw the nationally representative sample of US counties.
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References |
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23. Substance Abuse and Mental Health Services Administration. SAMHSA model programs. Available at: http://modelprograms.samhsa.gov. Accessed July 25, 2005.
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26. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89:1322–1327.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
