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Smoking remains the most preventable cause of prematur


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Title: Smoking remains the most preventable cause of prematur

Reducing the Burden of Youth Smoking Lessons in
Behavioral Approaches Teen Smoking Cessation
  • The 2009 Virginia Forum on Tobacco Use
    Translating Research into Policy and Practice
  • Geri Dino, PhD, Professor, Department of
    Community Medicine
  • Director, WV Prevention Research Center
  • Mary Babb Randolph Cancer Center
  • West Virginia University

The Need for Teen Smoking Cessation
  • Smoking remains the most preventable cause of
    premature morbidity and mortality in the US.
    Monitoring the Future data indicate past month
    smoking prevalence of 21.6 among 12th graders
    (Johnson et al., 2007).
  • In 2007, 26 of 9th 12th graders in the US
    reported smoking cigarettes (YRBS, 2007).
  • If current tobacco use patterns persist, an
    estimated 6.4 million youth who smoke will
    eventually die prematurely from a smoking-related
    disease (OSH, 2006).

The Need for Teen Smoking Cessation
  • Adolescence is the critical period for smoking
    initiation and tobacco dependence. About 90 of
    adult smokers begin at this time (Curry,
    Mermelstein, Sporer (2009).
  • Without effective intervention, most youth who
    smoke will continue smoking into adulthood. This
    will elevate their lifetime risk for
    cardiovascular disease several types of cancer,
    especially lung cancer and other debilitating
  • Fortunately, research shows that 65 of daily
    teen smokers want to quit (Lamkin, 1998).

The Need for Teen Smoking Cessation
  • Until recently, there were few available and
    effective youth smoking cessation options
    (Sussman, 2002).
  • As the previous lowering of youth smoking rates
    began to level off, there has been an increased
    emphasis on youth smoking cessation
  • Recently, experts have concluded that there is
    sufficient evidence to recommend youth cessation
    programs (e.g., Curry, Mermelstein, Sporer,
    2009 Grimshaw Stanton, 2006 Sussman, Sun,
    Dent, 2006).

The Evidence for Teen Smoking Cessation
  • There have been two meta-analytic studies of
    high-quality teen smoking cessation studies.
  • The Cochrane Collaboration used stringent
    criteria to identify 15 studies for review
    (Grimshaw Stanton, 2006).
  • In the aggregate, tobacco cessation treatment
    significantly increased the likelihood of
    cessation over controls.
  • This review identified the ALAs Not On Tobacco
    (N-O-T) program (Dino et al., 2001 Horn et al.,
    2005) as the only program of promise based on the
    number and outcome of evaluation studies.

The Evidence for Teen Smoking Cessation
  • Sussman, Sun, Dent (2006) meta-analysis
    conducted searches of electronic databases and
    unpublished manuscripts from 1970 to 2003.
  • Their review of 48 studies found that program
    conditions offered smokers a 2.9 absolute
    advantage in quitting over control conditions,
    and an increased the likelihood of quitting by
  • In general, group-based cessation programs,
    showed the greatest success.
  • The review identified only two federally-recognize
    d, evidence-based behavioral programs Project
    EX (Sun et al., 2007) and N-O-T.

Characteristics of Effective TreatmentsSussman,
Sun, Dent, 2006
  • Theoretical orientations include
    cognitive-behavioral, motivation-enhancing,
    social influence, stages of change/transtheoretica
    l model
  • Intensity Behavioral programs consisting of at
    last five sessions were found effective
  • Behavioral programs found effective. Insufficient
    evidence to recommend pharmacotherapy
  • Comparison with adult treatment similar for
    cognitive-behavioral and multisession. Different
    for pharmacotherapy (Curry et al., 2009).

Influence of Treatment Setting
  • Most interventions done in school settings in
    either classrooms or school clinics.
  • Other tested settings include medical clinics,
    shopping malls, marks, worksites, and grocery
  • Sussman, Sun, Dent (2006) examined the
    influence of treatment setting. They found
    significant effects for school classrooms and
    clinics, but not for medical clinics.

Beyond Effectiveness Getting Evidence-based
Interventions into the Field
  • Achieving national health protection and
    promotion goals requires the research and
    development of effective, adoptable interventions
    that enhance population health and reduce disease
  • Currently, there is a major translation gap
    between research and practice, delaying the speed
    and efficiency at which interventions translate
    into public health practice, especially among
    populations with the greatest disparities
    (McKenna, Taylor, Marks, Koplan, 1998).

Getting Evidence-based Interventions into the
  • The research to practice translation gap is a
    critical problem youth smoking cessation. Only a
    handful of empirically-based interventions exist.
    Even fewer are widely available to teens who want
    to quit smoking.
  • This deficiency leaves the majority of teen
    smokers without access to effective
    interventions, many of whom can be characterized
    as high-risk or hard-to-serve populations
    (Chassin, 2007).

Getting Evidence-based Interventions into the
  • An interventions efficacy is a necessary but not
    sufficient condition to determine its suitability
    for widespread dissemination and adoption
    (Glasgow, Lichtenstein, Marcus, 2003).
  • An interventions potential for dissemination
    (e.g., translatability) also includes factors
    such as relevance, feasibility, acceptability to
    the target population, adaptability, and economic
  • One evidence-based intervention, N-O-T, was
    developed and evaluation research conducted with
    national dissemination in mind.

Not On Tobacco
  • A voluntary smoking cessation program for 14-19
    year-old adolescents who are regular smokers
    (average gt 5 cigarettes a day) and who want to
    quit smoking.
  • Grounded in Social Cognitive Theory.
  • Also utilized Diffusion of Innovations, RE-AIM,
    and Social Marketing
  • Includes 10 weekly sessions
  • Uses a prescribed facilitator curriculum and a
    standard training protocol

Not On Tobacco N-O-T
  • Gender-Sensitive
  • Utilizes selected, trained facilitators national
    ALA training protocol
  • Promotes a total health approach. Program Goals
  • quit smoking
  • reduce the number of cigarettes by non-quitters
  • increase healthy behaviors in nutrition and
    physical activity
  • improve life skills such as stress management,
    coping, decision-making, communication, and
    interpersonal skills

Curriculum Topics
  • Reasons for smoking and reasons for quitting
  • Smoking history
  • Nicotine addiction
  • Physical, psychological, and social effects of
  • Preparing to quit
  • Physical, psychological, and social aspects of
    quitting and withdrawal
  • Managing the quitting process
  • Stress management
  • Dealing with family and peer pressure
  • Volunteerism
  • Recognizing social and media ploys
  • Accessing and maintaining social support

N-O-T Development and Evaluation
  • Based on CBPR Approaches
  • Partners with shared vision and values
  • American Lung Association
  • West Virginia Prevention Research Center
  • WV Bureau for Public Health
  • WV Department of Education
  • Coalition for a Tobacco Free WV
  • Used multiple evaluation strategies
  • Designed for Dissemination
  • Pilot tested
  • Florida and West Virginia
  • Additional research and evaluation
  • FL, NC, OH, NJ, WI, IL, VA
  • American Indian adaptation
  • Ongoing evaluations allow for continual revision
  • Developed and tested a physical activity module.

Scientific Evidence for N-O-T
  • More than ten years of efficacy and effectiveness
    research by the developers and others.
  • Scientifically controlled efficacy studies showed
    end-of-program quit rates between 15 and 19.
  • Real-world effectiveness studies showed
    end-of-program quit rates between 27 and 31.

Horn, K., Dino, G., Goldcamp, J., Kalsekar, I.,
Mody, R. (2005). The impact of Not On Tobacco on
teen smoking cessation End-of-program
evaluation results, 1998-2003. Journal of
Adolescent Research, 20 (6), 640-661.
Scientific Evidence for N-O-T
  • Teens who received N-O-T were twice as likely to
    quit smoking than teens who received a brief
  • Approximately 1 in 5 teens quit with N-O-T
  • Teens who quit smoking continued to not smoke 18
    months after the program
  • Evidence suggests that many teens who do not
    initially quit will do so over time.

Horn, K., Dino, G., Goldcamp, J., Kalsekar, I.,
Mody, R. (2005). The impact of Not On Tobacco on
teen smoking cessation End-of-program
evaluation results, 1998-2003. Journal of
Adolescent Research, 20 (6), 640-661.
N-O-T Cost-Effectiveness
  • Compared the cost effectiveness of N-O-T to that
    of a brief intervention (in school settings).
  • Teens who completed the N-O-T program were
    predicted to have an increased life expectancy of
    about 7 years more than teens who completed the
    brief intervention.
  • Financial cost for each additional year of life
    expectancy for those completing N-O-T rather than
    the brief intervention was 442.65.
  • As cost effective as school-based primary tobacco
  • Potentially more cost-effective than adult
    tobacco use cessation

Dino, G., Horn, K., Abdulkadri, A., Kalsekar, I,
Branstetter, S. (2008). Cost-effectiveness of
the Not On Tobacco program for adolescent smoking
cessation. Prevention Science. Mar9(1)38-46.
Epub 2008 Feb 20.
National Dissemination of N-O-T
  • N-O-T has been designed for dissemination.
  • Dissemination has been theory driven
  • Rogers Diffusion of Innovations
  • RE-AIM Framework
  • Stakeholder collaboration critical to the
    national dissemination effort
  • ALA oversees training
  • WVU oversees evaluation

Current Dissemination of N-O-TReaching More
Teens in More Places
  • Current
  • Providing grants to ethnically diverse
    populations and settings in the United States
  • Has reached between 150,000 and 200,000 US teens
  • New
  • Developing and Testing a centralized
    dissemination model in WV
  • Testing a Web-based dissemination and technical
    assistance tool
  • Developing
  • Online version

N-O-T Statistics for Virginia
  • 2007-2008
  • 37 of teens stopped smoking
  • 63 of teens reduced or stopped smoking
  • 2006-2007
  • 285 (44) teens stopped smoking
  • 562 (86) teens reduced or stopped smoking
  • 2005-2006
  • 267 (47) teens stopped smoking
  • 475 (80) teens reduced or stopped smoking
  • 2004-2005
  • 403 (57) teens stopped smoking
  • 506 (85) teens reduced or stopped smoking on
  • 507 (80) teens reduced or stopped smoking on

American Lung Association of Virginia Not On
Tobacco Virginia Summary Report (2004-2008).
Prepared in partnership with Virginia
Commonwealth University.
Profile of N-O-T Teens
  • Profile of teen smokers that have participated in
    N-O-T compared to teen smokers that have
    attempted to quit without a structured cessation
  • Not experimental smokers
  • Started smoking at an earlier age
  • More likely to be poly-tobacco users
  • Smoke with greater intensity and frequency
  • More dependent on nicotine
  • Smoke daily
  • More deeply embedded in smoking context
  • Moderately ready to quit smoking
  • Made more previous quit attempts
  • Felt support with quitting efforts
  • Lack of confidence to quit

Horn, K., Dino, G., Branstetter, S., Zhang, J.,
Kelley, G., Noerachmanto, N., Tworek, C.
(2008). A profile of teen smokers who volunteered
to participate in school-based smoking
intervention. Tobacco Induced Diseases, 4 (1) 6.
The RE-AIM Framework and N-O-TDesigning for
  • Reach
  • Effectiveness
  • Implementation
  • Adoption
  • Maintenance
  • Glasgow, R. E., Lichenstein, E., Marcus, A.
    C. (2003). Why dont we see more translation of
    health promotion research to practice? Rethinking
    the efficacy-effectiveness transition. American
    Journal of Public Health, 93(8), 1261-1267.

  • Conducted formative research with potential
    adopters, implementers, and recipients inform
    program content, promotion, and recruitment
  • Used evidence-based approaches to identify common
    intervention components needed for different
    sub-populations and multiple settings, and
    incorporated them into the intervention
  • Piloted the intervention in multiple states and
    in multiple settings.
  • Included program promotion and participant
    recruitment in training. Considered diversity of
    sites and target populations.
  • Conducted discussions with potential facilitators
    and teens to inform recruitment strategies,
    including identification of barriers and
    strategies to address them.
  • Tracked the effectiveness of different
    recruitment strategies.
  • Monitored participant characteristics across
    sites and states. Assessed reasons for dropout.
    Used this information to inform national and
    local training by the ALA.

  • Developed N-O-T content and implementation
    strategies to maximize relevance, feasibility,
    and cost-effectiveness for implementers and
  • Developed training protocol designed to balance
    implementation fidelity with flexibility for use
    with diverse populations and in multiple
    settings. Used ancillary materials, such as
    modules for different sub-populations, and
    curriculum options.
  • Incorporated social and environmental strategies
    and individual behavior change strategies, e.g.,
    integrating N-O-T with comprehensive school-based
    tobacco control policy encouraging participants
    to serve as role models for others and in
  • Developed nationally standardized protocols for
    training, program delivery, and evaluation
  • Considered intended and unintended consequences
    of the intervention when developing program
    materials training protocols.

  • Measured participant retention.
  • Process data collected at each session.
  • Utilized multiple outcome measures in research
    studies (e.g., smoking quit and reduction,
    attitude change, nicotine dependence, changes in
    physical activity, eating habits, academic
    performance, mental health variables).
  • Utilized multiple evaluation strategies
    (matched-design, RCT, and field studies) to
    address multiple stakeholder concerns.

  • Provided training materials and a program format
    that is straightforward, low-cost, easy to use,
    and provides guidance in potential areas of
  • Incorporated social marketing principles and
    techniques in program and training materials to
    promote dissemination and adoption.
  • Conducted formative research to ensure that
    program addresses consumer needs at multiple
    levels of the adoption process.
  • Technical assistance provided by the ALA and WV
  • Assessed facilitators and barriers to program
  • Used evaluative feedback to enhance training and
    technical assistance.

  • Conducted formative research to ensure a program
    that can be easily implemented in a variety of
  • Identified stakeholders during the program
    development phase who have important roles in
    program diffusion, adoption, and maintenance.
  • Training is standardized and provides clear
    guidance on implementation and evaluation. Plan
    for consider program and protocol revisions as
    needed to incorporated needed changes based on
    evaluation data and consumer feedback.
  • Conducted cost effectiveness analysis.
  • Collected process data.

  • Developed booster sessions.
  • Curriculum includes self-monitoring techniques
    and provides feedback to participants.
  • Program incorporates techniques to help
    participants incorporate healthy behavior choices
    into daily lives, manage relapse, and obtain
    social support for continued cessation.
  • Developed procedures for ongoing feedback from
    implementers and recipients so issues of
    sustainability can be incorporated into program
    promotion and training.
  • Curriculum provides options so that facilitators
    can make choices based on their participants.
  • Monitored program maintenance by state and site.

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Who are the Target Audiences?
  • Potential and current adopters of the program
  • Public health professionals
  • Public health advocates

Web site Development Process
  • Established a development group
  • Chose a Web site design company
  • Reviewed N-O-T materials nationally
  • Conducted card sorts
  • Developed site map
  • Wrote content
  • Chose a Web site template
  • Reviewed Web site

  • Guided by
  • Research-Based Web Design Usability Guidelines
  • RE-AIM
  • Diffusion of Innovations
  • Elaboration Likelihood Model
  • Social Marketing
  • Stages of Change/Transtheoretical Model

  • Web site development team included
    representatives from academia and the public,
    private, and non-profit sectors.
  • CDCs PRC Program Office (funded the development
    of the Web site)
  • WV PRC and its Community Partnership Board
  • ALA
  • NeboWeb, Inc.
  • Lay and professional community members

  • The Web site has two components.
  • The public area describes the benefits and
    history of the program, the evidence behind it,
    how to start the program, and enables users to
    share success stories.
  • The password-protected area, for certified N-O-T
    facilitators, provides access to technical
    assistance tools, implementation tips, program
    evaluation forms, and a message board for

  • Users to the site can be classified according to
    Stages of Change (Prochaska DiClemente, 1992)
  • Precontemplation - Doesnt know anything about
    N-O-T (e.g., just heard about it briefly or saw a
    link to the site)
  • Contemplation - Knows about N-O-T and needs a
    little more information to decide if it is the
    right fit for constituents
  • Preparation - Wants to use N-O-T needs to know
    next steps
  • Action - Is already trained to implement N-O-T
    but needs more guidance to implement for the
    first time
  • Maintenance Is already trained, has implemented
    N-O-T at least once, and is seeking supplemental
    information and guidance
  • The public area is designed for those users in
    Contemplation and Preparation. The
    password-protected area is geared toward those in
    Action and Maintenance

  • Web site was informed by the RE-AIM framework.
  • Long-term goal is to apply research-based
    modifications to the Web site to enhance
  • program reach (e.g., consumer awareness)
  • effectiveness (e.g., through implementation
    guidance and facilitator networking)
  • adoption (e.g., by providing the type of
    information that demonstrates the advantages of
    N-O-T over alternative strategies),
  • and implementation and maintenance (e.g.,
    providing guidance on and reinforcement for
    program use).

Next Steps
  • Disseminate Web site
  • Monitor site usage
  • Conduct Usability Testing
  • Keep site dynamic

  • Prevention Research Center Program Office at CDC
  • American Lung Association-National Office
  • Local Lung Associations, especially in FL, ME,
    NC, NJ, VA, WV, WI
  • ALA N-O-T Master Trainers
  • WV Division of Tobacco Prevention
  • WV Office of Healthy Schools
  • WV PRC Community Partnership Board
  • Thousands of N-O-T Facilitators across the US who
    make N-O-T happen
  • Schools and community sites across the country
    that have welcomed N-O-T
  • The teens who are the reason for N-O-T

  • The Staff of the
  • WV Prevention Research Center
  • and the
  • Translational Tobacco Research Reduction Program
  • Mary Babb Randolph Cancer Center
  • n partnership with the WV PRC