A National Survey of Tobacco Cessation Programs for Youths

A National Survey of Tobacco Cessation Programs for Youths
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  Objectives. We collected data on a national sample of existing community-based tobacco cessation programs for youths to understand their prevalenceand overall characteristics. Methods. We employed a 2-stage sampling design with US counties as thefirst-stage probability sampling units. We then used snowball sampling in se-lected counties to identify administrators of tobacco cessation programs foryouths. We collected data on cessation programs when programs were identified. Results. We profiled 591 programs in 408 counties. Programs were more nu-merous in urban counties; fewer programs were found in low-income counties.State-level measures of smoking prevalence and tobacco control expenditureswere not associated with program availability. Most programs were multisession,school-based group programs serving 50 or fewer youths per year. Program con-tent included cognitive-behavioral components found in adult programs alongwith content specific to adolescence. The median annual budget was $2000. Fewprograms (9%) reported only mandatory enrollment, 35% reported mixed manda-tory and voluntary enrollment, and 56% reported only voluntary enrollment. Conclusions. There is considerable homogeneity among community-based to-bacco cessation programs for youths. Programs are least prevalent in the typesof communities for which national data show increases in youths’ smoking prev-alence.( Am J Public Health. 2007;97:XXX–XXX. doi:10.2105/AJPH.2005.065268) A National Survey of Tobacco Cessation Programs for Youths | Susan J. Curry,PhD,Sherry Emery,PhD,Amy K. Sporer,MS,Robin Mermelstein,PhD,Brian R. Flay,DPhil,Michael Berbaum,PhD,Richard B. Warnecke,PhD,Timothy Johnson,PhD,Paul Mowery,PhD,Jennifer Parsons,MA,Lori Harmon,MA,Lisa Hund,MPH,and Henry Wells,MS ment with and without bupropion 12  ); thesestudies generally do not include untreatedcontrol groups. There is evidence from con-trolled studies that young smokers receivingactive treatment quit smoking or reducetheir smoking at higher rates than un-treated controls. 13,14 In 2000, the Youth Tobacco CessationCollaborative, 15 a group of public and pri-vate organizations committed to increasingthe availability of effective youth cessation programs, released its National Blueprint  forAction: Youth and Young Adult Tobacco- Use Cessation, which outlines a series of strategic objectives to ensure that everytobacco user aged 12 to 24 years has ac-cess to effective cessation treatments by the year 2010. 16 Prompted by the work of the Youth To- bacco Cessation Collaborative, The Robert Wood Johnson Foundation, with additionalsupport from the National Cancer Instituteand the Centers for Disease Control andPrevention, recruited the Institute for Health Research Policy at the University of Illinois at Chicago to launch Helping YoungSmokers Quit, a national 3-phase initiativeto identify best practices in tobacco cessa-tion for youths. 15 In phase 1 of HelpingYoung Smokers Quit, the purpose wastoprofile a national sample of existingtobacco cessation programs for youths tounderstand their prevalence and overallcharacteristics. METHODS Overview We faced the challenge of identifying a na-tional sample of existing tobacco cessation programs for youths without the aid of anycentralized directories or estimates of the prevalence of such programs. We selected a 2-stage sampling design, with US counties asthe first-stage probability sampling units. Weused snowball sampling at the second stage toidentify individual administrators of tobaccocessation programs for youths. 17 We collecteddata on cessation programs as the programswere identified. January 2007,Vol 97,No. 1|American Journal of Public Health Curry et al. |Peer Reviewed|Research and Practice|1  RESEARCH AND PRACTICE   Cigarette smoking remains the leadingcause of premature morbidity and mortalityin the United States. 1 Recent data fromMonitoring the Future, a national survey of secondary school students, show an overallsmoking prevalence of 24% among 12th-grade students; among students who do not  plan to attend a 4-year college, the preva-lence is 36%. 2 Because students often initi-ate smoking between grades 6 and 7 (be-tween ages 11–13), many high school-agedsmokers have well-established addictions totobacco. 2 Although young smokers are mo-tivated to quit, quit rates among youths arelow. 3–5 In the 2003 Youth Risk Behavior Surveillance Survey, 54% of current youngsmokers reported an unsuccessful quit at-tempt in the previous year. 6  Unfortunately,the vast majority of these quit attempts oc-curred without the support of evidence- based tobacco cessation treatments, such asgroup programs, telephone quit lines, or  pharmacotherapy. 7,8 The number of published studies of to- bacco cessation treatments in youths re-mains small. To date, the most comprehen-sive description of cessation programs for  youths is Sussman’s review of 66 programevaluation studies. 9 All of the programs de-scribed were part of research studies, andthe review concluded that data suggest a doubling of cessation rates with cessationinterventions for adolescents; methodolog-ical limitations across studies precluded de-finitive estimates of program effectiveness.A recent evidence review panel identifiedonly 20 studies from the Sussman reviewthat were of sufficient rigor to inform rec-ommendations. 10 The panel concluded that  programs with cognitive-behavioral compo-nents show the most promise for increasedquit rates. 10 Recent randomized trials report no significant differences among different types of treatment (e.g., self-help materialswith and without telephone counseling 11 or  behavioral treatment and nicotine replace- latest version is at Published Ahead of Print on November 30, 2006, as 10.2105/AJPH.2005.065268  American Journal of Public Health|January 2007,Vol 97,No. 12|Research and Practice|Peer Reviewed| Curry et al.  RESEARCH AND PRACTICE   Operational Definition of a TobaccoCessation Program for Youths Youth tobacco cessation programs eligiblefor this study were those that had been estab-lished at least 6 months before we contactedthem, provided direct tobacco cessation ser-vices for youths,had at least half of their par-ticipants aged 12 to 24 years, were not cur-rently part of a research initiative, and did not focus on pregnant smokers. County Sample Theoverallsamplingframecomprised2453counties(3142countiesintheUnitedStatesexcluding689withpopulationslessthan10000,whichweredeemedunlikelyto yieldprograms).Westratifiedcountiesbyur- banization,socioeconomicstatus(SES),youthsmokingprevalence,andpercapitatobaccocontrolexpenditures.Wedefinedurbaniza-tionandsocioeconomicstatusatthecountylevelandsmokingprevalenceandpercapita tobaccocontrolexpendituresatthestatelevelbecausecountydatawereunavailable. Urban counties were counties within a USCensus Bureau metropolitan statistical area (MSA). Low-SES counties were those in whichmore than 20% of the population lived belowthe federal poverty threshold, on the basis of 2000 Census data. High-smoking-prevalencecounties had 2000 Behavioral Risk Factor Surveillance System smoking prevalence ratesabove the national median (31%) for peopleaged 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 ex- penditures. The most recent years of data re-ceived the largest weights with a decay func-tion derived from research measuringexposure to advertising. 19 We ordered states by their weighted average expenditures andgrouped them by tertiles.The 4 stratification criteria produced 24total strata. Some strata contained very fewcounties and were combined. We combinedMSA and non-MSA counties within the low-SES strata and combined high- and medium-tobacco-control-expenditure counties in thecollapsedMSA/non-MSA high-smoking- prevalence strata, for a final set of 17 strata.Because of cost limitations and using our ex- pert judgment about the likely availability of  programs, we set a target of 400 interviewswith eligible tobacco cessation programs for  youths and used that target as a guide for thenumber of counties to be surveyed. We sam- pled unequally across strata to identify 408counties, presuming a greater likelihood of finding programs in states with higher per capita expenditures for tobacco control. Weselected 18 counties from each of the 6 low-expenditure strata, 24 from each of the 5medium-expenditure strata, and 30 fromeach of the 6 high-expenditure strata.Within each stratum, we randomly selectedcounties, without replacement, in proportionto the size of the youth population (aged 10to 24 years) in the county. Wyoming, with 15eligible counties, was the only state for whichwe did not select counties. Snowball Sampling Our goal was to identify contacts at thelocal level who were knowledgeable about to- bacco cessation programs for youths in their communities or who could lead us to such persons. Snowball sampling progressedthrough 2 tiers and ended with the identifica-tion of a program informant who adminis-tered a tobacco cessation program for youthsin the community. Tier 1 Key Informants  . We followed replica- ble protocols to identify first-tier informantsfrom county departments of health, county- based school districts, and the American Can-cer Society, American Lung Association, or the American Heart Association. If we couldnot identify contacts through county-level do-mains, we contacted state-level organizations.We identified key informants through Websites, telephone directories, and organizationallists of individuals likely to be knowledgeableabout tobacco cessation treatment for youths. Tier 2 Key Informants  . We identified tier 2informants by asking tier 1 informants for contact information for anyone in their countywhom they believed to be knowledgeableabout tobacco cessation for youths. We contin-ued snowball sampling until no new key in-formants were identified in a given county. Program Administrators  . We asked allidentified contacts, including tier 1 and tier 2key informants, whether they administered a tobacco cessation program for youths. Weasked those who answered yes a series of eli-gibility questions to determine whether their  programs qualified for the program survey. Program Survey Oursurveyasked153questionsin11do-mains:generalcommunitycontext,program history,programsettingandmodeofdelivery, programcomponents,enrollmentcriteria,pro-gramoperation,clientcharacteristics,programstaffing,programfunding,programevaluation,andprogramadministratorcharacteristics.TheUniversityofIllinoisSurveyResearchLaboratoryadministeredtheprogramsur-veyusingCASESversion4.3(Computer-AssistedSurveyMethodsProgram;Berkeley,Calif).Interviewersscheduled45-minutetelephoneappointmentstocompletethe programsurvey.Programadministratorsreceivedapapercopyofthesurveyinad-vance.(Acopyofthesurveycanbeob-tainedat RESULTS Snowball Sampling Figure1 provides a summary of our snow- ball sampling results. We attempted to contact 10157 individuals across all tiers of key in-formants. We reached 99% of these individu-als (10039). Tier 1 key informants named7301 tier 2 informants, almost half of which(48%) were duplicate names, a result of con-tinuing the snowball sampling until no newkey informants were gathered.We identified 1347 possible program ad-ministrators. We completed screening inter-views for 1275 administrators (95%), andwe identified 756 eligible programs (59% of those screened). Common reasons for pro-gram ineligibility were not enough partici- pants aged 12 to 24 years (32% of ineligi- bles), current participation in a researchinitiative (21% of ineligibles), and having been in operation for less than 6 months(24% of ineligibles). Because program ad-ministrators responded to all eligibilityquestions, the percentages were notmutu-ally exclusive.Respondents from 591 eligible programs(78%) completed surveys. Of the 165 eligible  January 2007,Vol 97,No. 1|American Journal of Public Health Curry et al. |Peer Reviewed|Research and Practice|3  RESEARCH AND PRACTICE   FIGURE1—Snowball sampling results for the Helping Young Smokers Quit initiative.  programs for which we did not obtain com- pleted surveys, 113 had no respondent avail-able to complete the survey, 29 actively re-fused the survey, and 23 had a respondent we could not reach during the study perioddespite multiple attempts. Surveyed and non-surveyed eligible programs did not differ onthe 4 stratification variables. Program Availability Table1 provides a summary of programavailability overall and by each stratificationvariable. We found 3 or more programs in26% of the counties, 2 programs in 13% of the counties, 1 program in 24% of the coun-ties, and no programs in 38% of the coun-ties. The number of programs in a countywas unrelated to youth smoking prevalenceor tobacco control expenditures. Significant differences in program availability emergedfor MSA versus non-MSA counties and bycounty SES. Program Characteristics Table2 provides a summary of characteris-tics of the surveyed programs. Organizational Characteristics  . Most pro-grams took place in school-based settingswith modest annual budgets (median an-nual budget=$2000) and multiple fundingsources. The 3 most commonly mentionedsources for the program’s funding werestate government, 53%; local government,49%; and community-based not-for-profit organizations, 24%. Programs reported anaverage of 1 paid treatment provider andless than 1 full-time equivalent in volunteer  providers.Organizational initiative (40%), health de- partment or department of education re-quests (22%), and teacher initiative (11%)were most often reported as the primary im- petus for offering a youth cessation program.Only 2% of programs reported youth de-mand, and less than 1% of programs reported parent demand as the primary motivation for offering cessation programs. Program Format  . Overall, 45% of the pro-grams used materials that were purchasedfrom an outside organization. Among thosewith externally developed programs, fre-quently cited reasons for program selectionwere research evidence that the selected pro-gram had worked for other groups (73%),ease of adoption (61%), recommendationsfrom experts in tobacco cessation for youths(52%), and recommendations from colleagues(35%). Presentations from the program devel-opers or marketers (41%) and previous rela-tionships with the program’s sponsoring or-ganization (41%) were not important factorsfor program selection.Ninety-five percent of programs were deliv-ered using in-person group meetings; morethan three fourths of these programs also in-cluded an additional component (e.g., individualface-to-face counseling [61%], self-help manual[48%],telephone counseling [15%], or Inter-net-based programs [7%]). Primary locationsfor group programs included school class-rooms (65%), school health clinics (23%), or another school-based setting (53%). Lesscommonly reported settings were communitycenters (20%), community-based health clin-ics (15%), hospitals (12%), and church or re-ligious centers (7%). Also infrequently re- ported were cessation programs held indrug treatment centers (10%). Treatment Providers  . Most programs re- ported that the individuals who providedtreatment were specifically trained in smokingcessation counseling (88%), and an outsideorganization had most often provided training(64%). Almost 90% of programs used writtentreatment guides. Treatment providers weremost often teachers (42%), nurses (37%),school counselors (35%), social workers(27%), and coaches (15%). Youth peers werenamed as treatment providers by 18% of the program administrators. Program Content  . Virtually all programs pro-vided information about the immediate andlong-term consequences of smoking (99.8%)and about the strategies the tobacco industryused to market tobacco to youths (95%). Alist of 17 program components was dividedinto 6 categories of cognitive-behavioral strat-egies (self-monitoring, disrupting smoking  American Journal of Public Health|January 2007,Vol 97,No. 14|Research and Practice|Peer Reviewed| Curry et al.  RESEARCH AND PRACTICE    TABLE 2—Characteristics of TobaccoCessation Programs for Youths: Helping  Young Smokers Quit Initiative Program OrganizationSchool-based setting,%89.8Primary funding source,%State39.7Federal1.6Other58.7 Annual budget of cessation $2000,$21003 program,median,($0–$600000)mean (range)Full-time employees,mean (range)1.07 (0–23)Program administrator has other 89.9 job responsibilities,% Program Format and Content Prepackaged program,%63.4Format,%Group only21.4Group plus adjunct73.6Other5Sessions,mean (range)8.7 (1–100)Duration of session in min,mean64 (4–360)(range) ≤ 15,% 0.516–60,%79.261–90,%8.5>90,%11.7Number of cognitive-behavioral 5.0 (0–6)components, a mean (range)Number of youth-specific topics, b 2.2 (0–3)mean (range) Enrollment and Participants  Average participant age group,% c 12–14 y17.415–18 y76.219–24 y5.6Participants required to enroll,% All8.9Some35.1None56.0No.of participants treated in the 20,61.57 past 12 mo,median,mean (0–2000)(range)<10,%19.210–25,%36.426–50,%19.751–100,%11.8>100,%12.9Parental notification required,%33.7Parental consent required,%22.2 Continued   TABLE 1—Demographic Characteristics of Tobacco Cessation Programs for Youths,by Number of Programs Deemed Eligible: Helping Young Smokers Quit Initiative Eligible Number of Programs per County Stratum0,no.(%)1,no.(%)2,no.(%)3 or more,no.(%)  χ 2 P   All counties (n = 408)153 (37.5)99 (24.3)51 (12.5)105 (25.7)Urban vs rural90.02<.01MSA (n = 166)28 (16.9)31 (18.7)29 (17.5)78 (47.0)Non-MSA (n = 242)125 (51.7)68 (28.1)22 (9.1)27 (11.2)Smoking prevalence1.15.77 ≥ 31% (n = 192)67 (34.9)48 (25.0)26 (13.5)51 (26.6)<31% (n = 216)86 (39.8)51 (23.6)25 (11.6)54 (25.0)Socioeconomic status25.10<.01Low (n = 120)64 (53.3)31 (25.8)9 (7.5)16 (13.3)Not low (n = 288)89 (30.9)68 (23.6)42 (14.6)89 (30.9) Tobacco control expenditures7.73.26Upper tertile (n = 178)60 (33.7)49 (27.5)19 (10.7)50 (28.1)Middle tertile (n = 122)43 (35.2)27 (22.1)18 (14.8)34 (27.9)Bottom tertile (n = 108)50 (46.3)23 (21.3)14 (13.0)21 (19.4) Note .MSA=metropolitan statistical area.Percentages may not total 100% because of rounding.  patterns, contingency control, coping skillstraining, general health and lifestyle balance,and social support). On average, programs in-cluded components from 5 out of 6 of thesecognitive-behavioral categories. Nine youth-specific topics were coded into 3 categories(mood-related issues, life goals, and problem behavior). On average, programs includedtopics from 2 of these categories. Topics com-monly 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 sur-veyed, only 43 (7%) included the use of med-ication. Of these, most reported use of thenicotine patch (98%). Program Enrollment and Recruitment  .Among the programs surveyed, 9% of re-spondents reported that all program enroll-ment was mandatory; 35% reported mixedvoluntary and mandatory enrollment. Among programs with mixed enrollment, a slight ma- jority of program participants were mandatedto enroll (58%). More than 75% of the pro-grams enrolled 50 or fewer youths annually(median=20). In total, the surveyed pro-grams provided treatment services to approxi-mately 36600 youths during the previous year. On average, programs reported that 73% of youths who started treatment com- pleted the entire program.Among programs with voluntary enroll-ment, the most frequently cited methods of  promoting program enrollment were adult en-couragement (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 ef-fective promotion method (27%), followed byreferrals from other participants (19%). For  programs with mandatory enrollment, themost common enrollment reason was as pun-ishment for possession or use of tobacco (92%).For 37% of mandatory programs, youthscould enroll in lieu of paying a fine. A minor-ity of programs (22%) required parental per-mission to participate in the program; 34% notified parents of their child’s participation. Follow-Up and Evaluation  . Half of the re-spondents reported that their program main-tained contact with participants after programcompletion without providing further treat-ment. The average number of follow-up con-tacts was 2.5. Mean (SD) time to follow-up for the first and last follow-ups were 1.8 (2.0) and6.7 (4.5) months. The primary informationcollected during follow-up included current   January 2007,Vol 97,No. 1|American Journal of Public Health Curry et al. |Peer Reviewed|Research and Practice|5  RESEARCH AND PRACTICE    TABLE 2— Continued  Follow-Up Number of follow-ups,mean 2.5 (1–40)(range)Biochemical confirmation of 8.7smoking status,% Formal Program Evaluation Program includes an evaluation 78.6component,%Evaluated programs that have 24.3undergone an external evaluation,% Community Support for Program Leaders somewhat or very aware,%83.8Leaders somewhat or very 99.0supportive,%Residents somewhat or very 76.0aware,%Residents somewhat or very 98.7supportive,% a  The 6 cognitive-behavioral components wereself-monitoring,disrupting smoking patterns,contingency control,coping skills training,generalhealth and lifestyle balance,and social support. b  The 3 youth-specific topics were mood-relatedissues,life goals,and problem behavior. c  The percentages for each age group are averagedpercentages and therefore do not total 100%. smoking status (98%); only 9% conductedany biochemical validation of having quit.More than three fourths of programs(79%) included a formal evaluation compo-nent. Common aims of evaluation includedobtaining feedback to improve outcomes andsatisfaction (97%), monitoring cessation out-comes (87%), evaluating program materials(85%), and evaluating counselors (61%).Measures included attendance tracking(90%), participant satisfaction ratings (85%),and assessment of smoking status (82%). Inthe majority of programs, the same peoplethat delivered treatment collected follow-upevaluation information (78%). Reported re-sponse rates ranged from an average of 67% (first follow-up) to 48% (last follow-up). Program Challenges  . The survey asked re-spondents to rate 13 challenges programs mayencounter, such as staffing, recruitment, fund-ing, and implementation problems. The major-ity of program administrators rated the follow-ing as “not too challenging”: obtainingappropriate locations (68%), maintainingsupport of leadership (65%), and retaining hired staff (51%). Cited as “somewhat” or “very” challenging were enrolling a sufficient number of participants (71%), obtainingfollow-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 communityconcern about youths, 12% said tobacco useand 6% said tobacco and drug use. The most commonly stated concern (47%) was druguse excluding tobacco. When asked directlywhat priority community leaders placed ontobacco cessation for youths, the majority of respondents (67%) indicated it was somewhat of a priority, and only 16% reported it wasnot a priority at all. Few administrators felt that the general population in their commu-nity was very aware of the program (8%).Among the 76% reporting at least somecommunity awareness of their program, themajority felt that community residents werevery supportive (58%) or somewhat support-ive (41%) of the program. DISCUSSION We used a key informant interview snow- ball sampling method in a stratified randomsample of 408 US counties to locate and profile a national sample of community-basedtobacco cessation programs for youths.Through contact with more than 10000 indi-viduals, we profiled 591 programs that had provided treatment in the previous year to a combined total of more than 36000 youths. Unassisted by program directories or other estimates of the prevalence of cessation pro-grams for youths, the snowball samplingmethod identified programs in nearly twothirds of the counties studied.There appears to be an inverse association between the need for cessation programmingon the basis of trends in smoking prevalenceand program availability. Recent Monitoringthe Future data show 2 groups for whichsmoking prevalence is rising: youths in non-MSA areas and youths with low parental edu-cation (an indicator of low SES). 2 We founda clear lack of cessation programming for  youths in non-MSA counties and in countieswith low SES. Because of their small size,non-MSA counties likely have a smaller ab-solute number of smokers thanMSA coun-ties. Given the observed low demand for ces-sation programs among youths, perhaps thereis a threshold number of young smokersneeded as an impetus for creating and sus-taining cessation services. Stratification mea-sures of smoking prevalence among youthsand per capita tobacco control expenditures, both defined at the state level, were not asso-ciated with the presence of any cessation programming for youths. Although this couldmean that smoking prevalence and tobaccocontrol expenditures are unrelated to the presence of cessation programs for youth ina county, it may also reflect the imprecisionof applying state-level characteristics at thecounty level.A striking result from this study is theconsiderable homogeneity among programs.The typical program was a multisession,school-based group program serving a modest number of youths per year. Most programsincluded the same cognitive-behavioral com- ponents found in evidenced-based adult pro-grams along with content more specific toadolescence. Nearly all programs operatedwith modest budgets. Given that the medianannual budget was $2000, it is not surprisingthat obtaining sufficient operating funds wasa commonly cited challenge.The similarity in content across programs isnot because organizations are using the same program. Most programs used externally de-veloped materials, which came from a varietyof voluntary, governmental, and for-profit or-ganizations. The American Lung Association’sNot On Tobacco program 20–22 was the most commonly used packaged program and wasreported as the source program by 30% of  program administrators. The SubstanceAbuse and Mental Health Services Adminis-tration recently designated Not On Tobaccoalong with another evidence-based program(Project EX 13  ) as model programs for tobaccocessation for youths. 23 One impetus for youth cessation programswas the need to provide a consequence for students who violate local statutes or schoolrules against the purchase, possession, or useof tobacco. Although participation was man-dated in only a small percentage of programs,more than one third of programs had some
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