Statewide Teen Smoking-Cessation Trial Is the First to Achieve Significant Increase in Prolonged Quit Rates: Largest Randomized Trial of Teen Smoking Cessation Ever Conducted

By Arthur V. Peterson, Department of Biostatistics

Arthur V. Peterson

In 2000, colleagues and I at the Fred Hutchinson Cancer Research Center and the Group Health Research Institute in Seattle launched a large study to develop and test a new, proactive approach for reaching out to teen smokers and helping them to quit. When this study started, despite decades of research and dozens of intervention trials, there were no proven ways to reach large numbers of teen smokers from the general population, recruit them into smoking cessation programs, or help them to quit smoking.

The importance of finding an effective way to help teen smokers is profound: an estimated 26.5% of high school seniors smoke at least monthly, and 16% smoke daily. Young adults ages 18 to 24 have the highest smoking rates in the U.S. Teens who are regular smokers are at increased risk for serious health problems, and this risk increases the longer they smoke. Unless we can find a way to reach teen smokers and help them quit, smoking for them will become a long-term addiction. Without effective help, an estimated 5 million of today’s youth will die prematurely from smoking-related illnesses. Overall in the U.S., cigarette smoking remains the number-one cause of preventable, premature death, killing more than 440,000 Americans annually.

Most teens who smoke wish they could quit. And fully half of all teen smokers try to quit at least once in any 12-month period. But very few—only about 4%—succeed on their own. Few teens seek help with quitting, and it has been difficult to recruit teens to teen smoking cessation programs.

Our study, the Hutchinson Study of High School Smoking, was the largest randomized trial of teen smoking cessation ever conducted. (A liberal definition of smoking was used, which included all students who gave any evidence of having smoked at least once in the preceding month at the time of the baseline survey.) Funded by the National Cancer Institute, the trial involved 2,151 teenage smokers from 50 high schools in Washington. Half of the schools were randomly assigned to the experimental intervention; teen smokers in these schools, identified via a baseline classroom survey, were proactively contacted and invited to take part in personalized, confidential telephone counseling designed to help motivate them to want to quit and provide the skills needed to succeed with quitting. 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 study would not reveal a participant’s smoking 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 (MI), which emphasizes building motivation and confidence for quitting, and Cognitive Behavioral Skills Training (CBST), which gives smokers the tools they need to learn how to quit.
The results were positive for both reach and effectiveness. With regard to reach, 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.

With regard to effectiveness, the study found that proactive delivery of the MI plus CBST intervention by trained telephone counselors effectively helped many of them to kick the habit. At the completion of the study, the percentages for 6-month prolonged abstinence among smokers in the experimental high schools were significantly higher than in the control high schools [10.1% vs. 5.9% (p=.02) for daily smokers, and 21.8% vs. 17.7% (p=.060) for all smokers], demonstrating that the intervention was in fact successful in helping them to quit.

The intervention also affected three-month, one-month and seven-day smoking abstinence, with differences between the counseling group and the comparison group of 3.3%, 6.8% and 7.5%, 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 studies of a variety of interventions conducted over the past two decades.

This is the first time that a smoking intervention has been found to be effective for increasing smoking cessation in a general, non-medical population of teen smokers. An editorial¹ in the Oct 21, 2009 issue of the Journal of the National Cancer Institute (JNCI), in which this study’s results²,³ appeared, called for implementing this new method of telephone counseling in the nation’s telephone quitlines for smoking cessation.

Why did it turn out that this new strategy for teen smoking cessation was effective? We hypothesize that the reason is fourfold:

• 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.
  
• Non-smokers were also included in the study population: Including nonsmokers helped to keep confidential the smoking/non-smoking status of each participant and avoided stigmatization of smokers.
  
• The counseling was offered by telephone: Using the telephone allowed for private, confidential, one-to-one counseling and allowed the counselors to explore and focus on issues specific to the individual smoker. 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: Motivational Interviewing, first described in the early ‘80s by William R. Miller, Ph.D., as a way to help treat problem drinkers, is designed to enhance a person’s motivation to change by focusing on the person’s attitudes and situation in a deferential, caring, nonjudgmental, and respectful manner. In this study, MI was used to explore and resolve the teen smoker’s ambivalence about smoking and quitting, and to mobilize the teen’s inner resources to trigger a decision to quit. MI is respectful of the client, placing the decision to quit in the client’s hands. Such a strategy seemed quite appropriate for use with teen smokers because teens, in particular, don’t want to be told what to do. A counseling goal was to put them in the driver’s seat. In the end, it was the smoker’s own reasons and desire to quit that motivated the quit attempt.
  

So we were able to demonstrate, for the first time, 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, to significantly affect rates of six-month prolonged abstinence.

There is more to do. First, following Leischow’s exhortations in the JNCI editorial, we need to facilitate and study adapting this intervention to the nation’s tobacco quit lines. Second, we need to follow-up this study’s teens into adulthood, to see to what extent the quitters have maintained their smoking abstinence, and to see to what extent the ‘almost-quitters’ have continued on their path toward abstinence. Third, we need to continue to make interventions better in order to help more teen smokers. By continuing these efforts, help may be at hand for our nation’s teen smokers.