For the first time, researchers at Fred Hutchinson Cancer Research Center have demonstrated that it is possible to successfully recruit and retain a large number of adolescent smokers from the general population into a smoking intervention study and, through personalized, proactive telephone counseling, significantly impact rates of six-month continuous quitting. These findings, by Arthur V. Peterson Jr., Ph.D., Kathleen A. Kealey and colleagues, are reported in a pair of papers in the Oct. 12 Advance Access online edition of the Journal of the National Cancer Institute.
"When this study started, despite decades of research and dozens of intervention trials, there was no proven way to reach teens from the general population and recruit them into smoking cessation programs, and there was no proven way to help these teens quit," said Peterson, a member of the Hutchinson Center's Public Health Sciences Division and lead author of the paper that reported the results of the Hutchinson Study of High School Smoking, the largest randomized trial of teen smoking cessation ever conducted.
The trial, funded by the National Institutes of Health, involved 2,151 teenage smokers from 50 high schools in Washington. Half of the schools were randomly assigned to the experimental intervention; teens in these schools were invited to take part in confidential, personalized telephone counseling designed to help motivate them to quit. The remaining 25 schools served as a comparison group; teen smokers from these schools did not participate in the telephone intervention. The study also included 745 nonsmokers to ensure that contacting students for participation in the trial would not reveal a participant's smoking status.
Study recruitment was robust; in the experimental group 65.3 percent of the smokers were eligible and participated in the telephone intervention. Recruitment took place in their junior year and the counseling intervention took place during their senior year. "The literature says it is very difficult to recruit kids to teen smoking programs. People have tried. The field has encountered great obstacles in recruiting teens to smoking cessation programs. And so we took that as a challenge," Peterson said.
The study found that a proactive strategy of reaching out to teens and offering them the opportunity to receive up to nine personalized, confidential telephone counseling sessions effectively helped many of them to kick the habit. In addition, by proactively identifying and recruiting teen smokers (with parental consent for those under age 18), two-thirds of all identified smokers participated in the telephone counseling and nearly half completed all of their scheduled counseling calls.
At the completion of the study, 21.8 percent of all smokers (daily and less than daily) in the counseling group had achieved continuous quitting for six months, as compared to 17.7 percent of those in the comparison group, a difference of 4 percent.
The intervention also impacted three-month, one-month and seven-day smoking abstinence, with differences between the counseling group and the comparison group of 3.3 percent, 6.8 percent and 7.5 percent, respectively. Notably, the one-month and seven-day quit rates among the smokers who received telephone counseling were roughly three times higher than those reported in nearly 50 previous adolescent smoking-cessation trials of a variety of interventions conducted over the past two decades.
"These results are critically important for supporting and stimulating our nation's search to find successful ways to help reduce smoking by teens and young adults," Peterson said.
An estimated 26.5 percent of high school seniors smoke monthly, and 13.6 percent smoke 10 or more cigarettes daily. Although nearly half of all current adolescent smokers report having tried to quit smoking in the past year, only about 4 percent per year succeed on their own. In addition, young adults ages 18 to 24 have the highest smoking rates in the U.S., ranging between 27 percent and 40 percent, depending on geographic region and socioeconomic status.
The telephone counseling intervention was based on the premise that smokers need to believe it is important to quit, have confidence they can quit and have the knowledge and skills needed to be successful with quitting. Therefore, the intervention integrated two types of counseling: motivational interviewing, which emphasizes building motivation and confidence for quitting, and cognitive behavioral skills training, which gives smokers the tools they need to learn how to quit.
Motivational interviewing, first described in the early '80s by William R. Miller, Ph.D., as a way to help treat problem drinkers, enhances a person's motivation to change by exploring and resolving one's ambivalence about change. In this study, the technique was used to explore and resolve the participants' ambivalence about smoking and quitting, and to mobilize their inner resources to trigger a decision to quit.
"Motivational interviewing is very caring, nonjudgmental and respectful. It is non-confrontational. A counselor would never say, 'I want you to quit smoking.' Instead the counselor would ask what the behavior means to the participant. What do they like about it? What don't they like about it?" explained Kealey, first author of the companion paper, which describes in detail the design and implementation of the telephone counseling intervention.
In motivational interviewing, the counselor would use reflective statements to repeat the participant's own words back to him or her. For example: "So, it sounds to me like you smoke because it helps you to relax when you're under stress. But on the other hand, you said that you really don't like the way it smells, and that it's really expensive. So what do you make of that?"
"In the end, it is the smoker's own reasons and desire to quit that motivate the quit attempt," said Kealey, project manager for the study.
Cognitive behavioral skills training seeks to help people build skills for quitting and preventing relapse through counseling strategies that emphasize practical tools, such as self-talk strategies, ways to cope with stress and smoking triggers, and collaborating on a plan for quitting. "While motivational interviewing increases a person's motivation to quit, cognitive behavioral skills training gives them the resources and the confidence they need to be successful," Kealey said.
Adolescent smoking cessation studies conducted in the past 20 years have been largely unsuccessful in getting teens to quit. These studies have identified significant challenges. To date, only two other randomized controlled trials – with smaller numbers of teen smokers than the Hutchinson Study and conducted in medical settings – have shown promise in achieving significant teen quit rates.
So what makes the Hutchinson Study so effective? The researchers hypothesize that the reason is threefold:
The intervention was proactive, reaching out and engaging teens – "Past research has shown that, for a multitude of reasons, many teen smokers do not seek out help with quitting. However, our study demonstrates that if we reach out to teens, without pressuring them to quit, many will talk to counselors about their smoking and some of those teens will decide to quit," Peterson said.
The counseling was offered by telephone – "This allowed for private, confidential, one-to-one counseling and allowed the counselors to explore and focus on issues specific to the individual smoker," he said. Telephone counseling also gave teens control over the timing and length of the counseling sessions.
The counselors used motivational interviewing techniques in all communications with the teens – "It seemed quite appropriate for us to test this deferential strategy in youth because teens, in particular, don't want to be told what to do," Peterson said. "Our goal was to put them in the driver's seat."
So even though teens tend not to seek help for quitting smoking, this study indicates that they are more likely to succeed with quitting if they have help. "An important message from this study for teens and young adult smokers – really for all smokers – is that personalized telephone counseling can help one be successful with quitting smoking," Peterson said. Such help is available through the nation's network of quit lines, such as 1-800-QUIT-NOW offered through the Washington State Department of Health.
The National Cancer Institute funded the study, which also involved investigators at Group Health Research Institute in Seattle.
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