Cover Story

For decades, tobacco control researchers poured their efforts into helping adults quit and preventing teens from taking up the habit.

"The folk wisdom was that you're not going to get teen-agers to quit until they're a bit older, so why bother?" says Steve Sussman, PhD, a professor of preventive medicine and psychology at the University of Southern California.

As a result, there have historically been few randomly controlled studies examining what works and what doesn't in helping adolescents quit smoking.

Recently, however, tobacco control experts have reconsidered their focus on prevention, in part because adolescent smoking has increased since 1991, after having plateaued in the 1970s and declined slightly during the 1980s. That suggests that even the best prevention efforts, as they are currently deployed, aren't enough to stem the tide of teen-age smoking, many researchers believe.

Further, recent research has indicated that--contrary to what experts had long assumed--teen-agers can become dependent on tobacco even before they begin smoking on a daily basis, that most adolescent smokers continue smoking into adulthood and that many want to quit but are unable to do so. In 1999, 35 percent of high school seniors had smoked a cigarette in the past month, and 23 percent were daily smokers. About 40 percent of adolescent smokers report having unsuccessfully tried to quit in the past.

Responding to the increased need for a better understanding of how to help teen-agers quit smoking, in 1997 and 1998 the National Cancer Institute (NCI) issued requests for applications for research on the effectiveness of youth smoking-cessation programs. NCI now funds 16 major studies of smoking cessation in youth. Several other public and private organizations--including the National Institute on Drug Abuse, the National Institute of Child Health and Human Development, the National Institute of Dental and Craniofacial Research, and the Robert Wood Johnson Foundation--have followed suit.

Tobacco control experts hope the results of this new wave of research--expected to begin emerging in the coming months--will help clarify a wide range of questions about how best to treat adolescent smokers. For example:

  • How do parents and peers affect adolescents' efforts to quit smoking, and how can cessation programs capitalize on their influence?

  • What are the developmental factors that adolescent cessation programs must consider in order to be successful?

  • Are pharmacological treatments as effective for adolescent smokers as they are for adults?

  • What kinds of programs work for adolescent smokers who are very heavily dependent on nicotine or who have other substance abuse or psychiatric problems?

  • What's the best way to tailor cessation programs to smokeless tobacco users, whose tobacco addiction is unique?

Preliminary hints

Despite the scarcity, so far, of randomized studies on the subject, there are some clues to what kinds of programs best help young people stop smoking. In 1999, Sussman and colleagues reviewed 17 published tobacco cessation studies. Ten studies were single-group studies and seven were quasi-experimental or experimental studies that included control groups.

The review, published in the journal Substance Use and Misuse (Vol. 34, No. 1), indicated that on average, about 21 percent of teen-agers in cessation programs quit smoking--a number that dropped to 13 percent six months after smoking interventions. In comparison, the average naturally occurring quit rate, without intervention, appears to range from 0 to 11 percent. Of the six studies that reported smoking reduction among adolescents who didn't quit, four reported that study participants reduced their smoking by at least half.

More recently, at the request of a consortium of U.S. and Canadian health agencies, Sussman has completed an expanded review of 66 adolescent smoking-cessation studies, 37 of which included control groups and 29 of which did not. In most of the studies, most participants were white.

The studies encompassed a range of theoretical approaches, including cognitive behavioral and motivational programs, programs in which participants are rewarded for quitting smoking, supply reduction strategies such as tax increases on tobacco or restricting access to cigarettes, pharmacological therapies and "stages-of-change" approaches tailored to teen-agers' interest in quitting.

The review, not yet published, indicates that in studies that included control groups, about 7 percent of teen-agers in the control group quit smoking. In comparison, about 12 percent of young people in cessation programs quit smoking over an average of eight months.

That's encouraging, Sussman says, but he warns, "There's so much variation that everything has to be taken with a grain of salt." Indeed, he notes, programs' quit rates ranged from 0 percent to 41 percent at follow-up.

The programs that appear most effective are those that enhance adolescents' motivation to quit--by reducing their ambivalence and by providing extrinsic rewards for quitting--and hone their ability to resist pressures to smoke, as opposed to simply obstructing access to cigarettes or making superficial changes to programs designed for adults. In addition, classroom-based cessation programs tended to yield higher quit rates than clinic- or family-based programs or mass-media campaigns. Finally, programs that included more sessions showed higher quit rates.

"I suspect that there are four main elements that are likely to really help," concludes Sussman:

  • Building teens' intrinsic and extrinsic motivation to quit.

  • Tailoring programs to adolescents' developmental needs and making the programs fun to attend.

  • Providing social supports to help teen-agers persevere in their quit attempts.

  • Showing teens how to make use of community resources that are available.

"The bottom line," says Sussman, "is that no one is going to be able to do it for them, so you have to provide people with the motivation and ability to help themselves."

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NOTES: Lung cancer and other smoking deaths are estimates of deaths where smoking is an attributable factor, including cardiovascular and cerebrovascular diseases. Number of deaths are annual averages calculated from 1990-1994 estimates.
SOURCES: US Centers for Disease Control and Prevention, "Smoking Attributable Mortality and Years of Potential Life Lost--United States, 1984." Editorial Note--1997.
Morbidity and Mortality Weekly Report, 46(20): 444-451, 1997. www.ced.gov/tobacco/oshaag.htm.