West Virginia led the nation in teenage smoking during the mid–1990s, and as a result, the West Virginia University PRC partnered with West Virginia's Bureau for Public Health, Department of Education, and other members of the state's public health community to strengthen school-based tobacco control initiatives. West Virginia needed an effective, user–friendly teenage smoking cessation program that could be adopted statewide and that would support a newly developed state tobacco-free school policy emphasizing prevention and cessation support rather than punitive action (25
Later inclusion of the American Lung Association (ALA) into the partnership brought a national scope to the West Virginia teenage smoking cessation efforts. The partnership identified local and national needs and took on the shared goal of developing a theoretically based, scientifically tested teenage smoking cessation intervention (26
). With funding from CDC and other organizations, the West Virginia University PRC launched a smoking cessation project that was committed to community-based participatory research methods and included the following contributions: 1) teachers, students, and school health professionals provided input for program development; 2) the ALA provided program expertise, funding, and a means for disseminating programs; and 3) PRC researchers provided a scientific framework to evaluate the effectiveness of programs and a commitment to program dissemination.
The partnership decided the intervention should be initially developed for use in schools because schools can promote tobacco-free environments through policy, can offer services for students and staff who want to quit smoking, and can reach youth efficiently (27
). Program goals were to create a smoking cessation program that could 1) enhance adolescent health, 2) fulfill the needs of students who want to quit smoking, 3) reduce school tobacco policy violations, and 4) provide an educational alternative to punitive measures for violating school tobacco policy.
Through an iterative, collaborative process, the partnership developed a smoking cessation program designed for 14- to 19-year–old daily smokers (27
). The program was given the youth-approved name, Not-On-Tobacco. In addition to smoking cessation, other N-O-T goals include reducing smoking; increasing healthy lifestyle behaviors (e.g., physical activity, healthy eating); and improving stress management, decision making, coping ability, and social support skills. Students participate in the program on a voluntary basis, and the program includes 10 hour-long weekly sessions and 4 booster sessions in same-sex groups with same-sex facilitators (e.g., teachers, school nurses, counselors, volunteers).
Facilitators are trained by the ALA and may lead sessions in both schools and other community settings. They assist participants with 1) identifying reasons for smoking and excuses for not quitting, beliefs and behaviors that reinforce smoking and self-defeating behaviors, triggers for smoking, and other barriers to the quitting process; 2) recognizing and understanding the process of nicotine addiction, advertising ploys to encourage youth smoking, and situations that may spark relapse; and 3) developing skills in cognitive restructuring, coping with stress and peer pressure, identifying and maintaining social supports, goal setting, and assertiveness and other behavior changes (27
After the N-O-T program was developed, partners collaborated to implement the program and assess its efficacy and acceptability in school settings (29
). Because the need for a youth smoking cessation program was so great, ALA field workers were anxious to use N-O-T even before effectiveness studies were complete. As a result, while the N-O-T demonstration studies in West Virginia and several other states were under way, other local uses of the program were allowed if results were carefully monitored (26
Over a 7–year period the N-O-T program went through several iterations, testing, refinement, and retesting. Demonstration studies were conducted in West Virginia, North Carolina, Florida, New Jersey, Illinois, Wisconsin, and Washington by the West Virginia team and independent investigators. Studies have consistently shown that adolescents enrolled in N-O-T programs have significantly greater quit and reduction rates than adolescents in more conventional smoking cessation programs. A recent review of N-O-T program outcomes in different locations included more than 6000 youths in 489 schools and showed that after 3 months, adolescents enrolled in N-O-T programs were twice as likely to have quit smoking than adolescents in conventional smoking cessation programs (33
). The N-O-T program has been designated a model program by the federal Substance Abuse and Mental Health Services Administration and the federal Office of Juvenile Justice and Delinquency Prevention and is considered a research tested intervention program by the National Cancer Institute.
PRC researchers and the ALA developed a national training prototype by using the tested curriculum and scientific study results and initiated a N-O-T media campaign in 2000. The ultimate success of an evidence-based program is reflected in its widespread dissemination and adoption (34
), and as of 2005, N-O-T trainings have occurred in 47 states and in Europe and Canada. It is estimated that since 1998, at least 100,000 adolescents have participated in N-O-T programs in the United States (American Lung Association, 2005). N-O-T program leaders estimate conservatively that one in five participants quits smoking (33
); this rate suggests that N-O-T programs have helped up to 20,000 U.S. adolescents quit smoking. In West Virginia, there are trained N-O-T facilitators in 75% of high schools, and program dissemination is supported by the Bureau for Public Health, the Department of Education, and the American Lung Association's West Virginia chapter.
N–O–T programs are supported in Canada and a number of U.S. states. Some states, including Virginia, Vermont, Wisconsin, Delaware, and Rhode Island, incorporate the N-O-T program into their state tobacco control plans.
Lessons learned from the N-O-T program
- Involvement of multiple stakeholders, including school personnel and students, in the N-O-T program design resulted in a program that is feasible and effective and that attracts local champions to spearhead implementation in multiple locales.
- Dissemination of the N-O-T program was a goal from its beginning, and this aim was a valuable guide to keep the program practitioner-friendly, consistent with local policies, and appealing to local funding agencies.
- Having a partner with experience in national dissemination (the ALA) provided the capacity for widespread diffusion and adoption of the N-O-T program.