Innovative approaches to prevention and cessation of youth tobacco use.

CS05-01

Smoking among youth remains a major public health concern. It is estimated that 3,000 adolescents begin using tobacco each day and, although many of these smokers express the desire to quit, many find it difficult to do so. Feasible and effective interventions to decrease smoking initiation and increase cessation among adolescents and young adults are an important public health challenge. Over the past several years, our group has designed smoking prevention and cessation programs utilizing state-of-the-art theoretical concepts and computer technologies which, we believe, hold considerable promise. Traditional smoking cessation interventions range from the individualized health care provider- or educator-delivered group counseling, to the broader, population-based pamphlets and public service campaigns. A major drawback to these methods is a lack of tailoring to the smoker's individual needs. Another problem is that the existing methods lack consistency in the intervention delivery. We believe that computer-assisted smoking prevention and cessation interventions can deliver the desired fidelity of implementation. The messages within such interventions can be tailored to developmental, psychosocial, behavioral, and cultural needs of the user. Here we present results from two federally funded studies, aimed at designing and testing interventions utilizing interactive computer technologies to identify effective and feasible approaches to prevent smoking and promote cessation among high-risk adolescents and young adults. The first study is a smoking prevention and cessation CD-ROM-based classroom curriculum for predominantly minority high-school students (Project ASPIRE). ASPIRE was evaluated in a group-randomized control trial of 16 Houston-area urban high schools compromising 1,608 mostly minority students (mean age is 15.7 ± .9 years; 58.8% female). The program consisted of five sessions and two booster sessions which provided eight educational "tracks" tailored to student characteristics. The extent to which the program decreased smoking initiation and increased cessation between intervention and control groups was estimated. Follow-up assessments were performed at 12 and 18 months to examine the program's impact on smoking behavior and progression through the stages of smoking acquisition or cessation, and to examine whether well-established predictors of smoking mediate or moderate the effect of the intervention on both acquisition and cessation. At 12-month follow-up, significant favorable changes in decisional balance and temptations to smoking in the intervention versus the control group were identified. At 18-month follow-up, the primary aim was to examine smoking initiation rates among baseline nonsmokers and smokers. As a secondary aim, the efficacy of the program with respect to changing the determinants of smoking and quitting behavior was also evaluated at 18 months and for baseline nonsmokers. The analyses were done with linear mixed model regression and mixed model ANCOVA, stratified by gender and ethnicity. A total of 1,160 participants completed the 18-month survey; 610 in the intervention and 550 in the control group. Among baseline nonsmokers (n= 1, 080), there were significantly fewer students who initiated smoking in the intervention group compared to the control (2% vs. 6%, p <0.05). Among those who initiated, only Hispanics initiated smoking in the intervention group and males had higher initiation rates than females in both intervention and control groups. Because of a high attrition of smokers in both the intervention and control groups (almost 50% of the 111 current smokers at baseline), it was not meaningful to compare cessation rates between the two groups at 18 months follow-up. These analyses were not conducted as originally planned. Significant differences were found between intervention and control in the Minnesota Smoking Index which reflects intensity of smoking (0.7 vs. 1.8, p < .05) and temptations to smoke (14.3 vs. 15.9%, p<.05). Differences were also found in decisional balance (T_cons minus T_pros) between the intervention and control (1% vs. 5%, p< .05) and among susceptible precontemplators (7% vs. 14%, p < .05). Self-efficacy also showed a more favorable trend in the ASPIRE group compared with standard care; however, this change did not reach statistical significance. Among not susceptible nonsmokers in precontemplation, there were significant differences in smoking initiation between the intervention and control (1% vs. 5%, p < .05). In a post hoc analysis at 18 months follow-up, smoking initiation rates were compared between the control and intervention groups over a risk index (to include student characteristics of depression, resistance to smoking, peer pressure to smoke, mother smoking and father smoking) using random effects linear regression modeling. The results show that as the level of risk increased, there was a dramatic increase in smoking initiation rates in the control group, ranging from 2.7% to 17.2%, p<.001, while smoking rates remained stable over the risk index in ASPIRE ( 1.9% to 1.2%, p=NS). Overall, the findings from Project ASPIRE indicate that the intervention appears to positively change determinants and smoking behavior and successfully prevent smoking initiation. In addition, these results demonstrate that for students who had a combination of known triggers of smoking behavior, Project ASPIRE substantially impeded smoking initiation. More studies of larger, more stable samples of adolescent smokers are necessary to prove the program's efficacy in smoking cessation. In the other study (Project Look at your Health [LAYH]), we evaluated the impact of a computer-assisted, counselor-delivered smoking cessation intervention on community college students. A group-randomized trial design was used to assess the intervention in a sample of 426 students from 14 Houston-area community colleges. The computer program was based on key constructs of the transtheoretical model of change and personal health risks. The program took into account the readiness to change smoking behavior. It also made use of the motivational intervention technique. Students in the standard care received brief counseling and a self-help manual. A total of 326 (168 in intervention and 158 in control) student smokers were followed for 10 months, 125 (mean age 22.6 ± 4.4 years; 62% females) of them were evaluated using spirometry and the American Thoracic Society Respiratory Symptoms Inventory at baseline and 10 month follow-up assessments. No significant differences in self-reported smoking cessation were found between the intervention and control groups at 10 months (28% vs. 24%; p>.05), and the cotinine validated quit rates (17% vs. 10%, two-sided p<.068). However, compared to the control group, the intervention group made significant progress through the stages of change and through psychological and physiological determinants of smoking. For students in the preparation stage at baseline, 48% of the intervention group progressed to action by 10 months, compared to 28% of the control group. Similar findings were noted for regressing through the stages of change. The intervention was successful in changing determinants of smoking cessation including decisional balance (2.1 for control vs. -2.2 for intervention, p<.05) and temptations to smoke (36.0 for intervention vs. 42.3 for control, p<.001). Also, noticeable improvements in respiratory symptoms and pulmonary function were observed in quitters versus continued smokers. Although the smoking cessation outcomes of Project LAYH did not achieve statistical significance, overall, the pronounced difference of 17% vs. 10% in quitting rates between the intervention and control indicates that our computer-assisted intervention holds considerable promise in reducing smoking among community college students. Additional studies with larger samples and longer follow-ups are warranted. In conclusion, these studies seem to emphasize the importance of technologically advanced, self-sustained and counselor-assisted interventions to prevent smoking initiation and increase cessation among adolescents and young adults. Our team has recently secured more federal funding to continue this line of high-tech interventions among rural and suburban high-school students aimed at smoking and spit tobacco prevention and cessation. We also have another ongoing similar technology-based study which attempts to reach school dropouts.