This paper provides the most comprehensive review to date of teen tobacco use cessation; 66 programs and 17 prospective self-initiated cessation studies were included. Detailed information from any program that provided a quit session and some data collection was included among the program studies. Also, a time lag as brief as three months was permitted for inclusion in the survey studies. Sufficient data were collected to provide at least a reasonable descriptive presentation of variables relevant to teen tobacco use cessation. For the program studies, which included heavier tobacco users than the self-initiated cessation studies, the overall control-group mean quit-rate was approximately 7% and the overall program cessation mean was 12%. Based on these data, and available studies that provided direct program-control group comparisons, there is strong evidence that teen cessation programs are more effective than doing nothing or little among those tobacco users who might attend such programs. Regarding percentage consumption reduction findings, however, there are too few studies to make any strong inferences, although it would appear that there is sufficient evidence to state that cessation programs do increase percentage reduction relative to no or little programming.
Above the grand program cessation mean of 12% are the motivation enhancement and contingency-based reinforcement theory-based programs (among eight theories). Programs that involve manipulation of intrinsic or extrinsic motivation do the best at changing behavior over a three to 12 month follow-up period.
Regarding modalities of cessation, classroom programs do the best (17% quit-rate). Three expert system (computer-type) programs showed promise (13% quit-rate). Finally, school-based clinics showed promise (12%, n = 18). In addition, it appears that program material applied more intensely (i.e., number of sessions) produces higher cessation rates. Cessation rates did not differ as a function of available data on gender, ethnicity, age, or baseline tobacco use.
It is surprising that supply reduction theory studies failed to find quit rate effects examined over multiple studies. In theory, such programs could be applied to very large numbers of youth, and even if effects were small could elicit cessation in large absolute numbers of youth. Yet, the mean quit rate was 0%. Possibly, new state-wide supply reduction efforts will indicate other findings than those shown here. One can't argue that supply reduction cessation efforts should not continue. However, exactly how these efforts can achieve cessation effects needs further investigation. Perhaps, monopolization of life contexts is needed to remove youth from opportunities for continued use [74
]. On the other hand, one may argue that different types of approaches are needed to examine supply reduction effects on tobacco consumption. For example, Tauras & Chaloupka [110
] used sequential longitudinal data from the Monitoring the Future Surveys, augmented with cigarette price and policy related measures to estimate smoking cessation equations among young adults (mean age = 23 years). They found that a 10% increase in prices are likely to lead to an 11–12% increase in quit rates among young male and female adults. Possibly, use of this type of methodology will reveal similar price elasticity effects on regular teen smokers, though such work is yet to be completed.
Regarding the self-initiated quit studies, behavior that seems directed away from smoking (living in a social milieu that is composed of fewer smokers, intending not to smoke in the future) is one key to cessation. Less nicotine or psychological dependence on smoking seems to be another key to youth cessation (lower pretest smoking and less experience with smoking). Anti-tobacco beliefs (e.g., that society should step in to place controls on smoking, perceiving smoking as negative behavior) also are keys to quitting. Finally, having the fortitude to maintain a quit-attempt is important (e.g., feeling relatively hopeful about life). Motivation enhancement, social skills provision, combating dependence, and achieving social support from nonsmokers are important theoretical variables that might be considered for programming. Programs that include these aspects do appear to work relatively well.
Key variables relevant to the quitting process may include gaining access and support of a context, structuring the context of programming for youth, motivating quit attempts and reducing ambivalence about quitting, making programming as enjoyable as possible, and helping youth to sustain a quit attempt (e.g., providing ongoing support during the acute withdrawal period). First, to be able to bring in the best programming possible and to facilitate access to participants, a context needs to support cessation efforts. Relevant gatekeepers can provide material support and encourage support of other staff in the same context. Certainly, inclusion of extrinsic motivators (e.g., release time) can be managed best by gatekeepers. Second, one may conjecture that programming should be tailored to the development and the lifestyles of teens. Adults are relatively likely to structure their own lives (e.g., keep careful records of their behaviors, make meeting appointments), and engage in higher-order thinking tasks (e.g., determining what "type" of smoker one is) [111
]. Placed into quit-programs, the efficacy of these strategies among teens in not clear. Also, tobacco use among adults generally is at a more consistent and heavier level than teens. While use of pharmacological adjuncts are recommended for adults [3
], so little work in this arena has been completed with youth that not much confidence can be placed into suggestions of the usefulness or uselessness of alternative nicotine delivery products for them. It is clear that while highly addicted youth can benefit from programming, they are less likely to quit tobacco use than are less physically addicted youth [112
], and may therefore require more intensive interventions (as was recently shown in the data of Sussman, Dent, & Lichtman [57
]). Some means of assisting more physically dependent youth still needs to be developed. Potentially, inpatient stays to quit tobacco might be helpful for youth, as has been completed among adults at the Mayo Clinic (the current work of R. Hurt and colleagues).
Third, programming needs to motivate quitting now rather than waiting until the future. All tobacco users should be welcome in a program, no matter what their initial stage of change is. Motivational material is likely to be helpful for most tobacco-using youth. Awareness of the changes that gradually occur as a function of smoking (e.g., increased stress, decreased mood) and quitting (e.g., decreased stress, improved mood) need instruction, along with means to help youth overcome ambivalence toward quitting [57
Fourth, programming should be a fun as possible, involving games, dramatizations, and use of alternative medicine concepts. Youth will want to remain in a program that is interesting. Finally, means to support sustained quit-efforts is needed. Youth need the support of adults in multiple contexts to give them some flexibility during early quitting. Possibly, youth need to learn new social life skills so that they can reach out for the assistance they need (e.g., general conversation skills, how to use the yellow pages, knowledge of community organizations). If one was to try to coin a new theory with these steps, perhaps a "motivation, developmental tailoring, resource acquisition follow-through" model of cessation would be a possible name.
There are many limitations with the presentation of these data. First, several statistical means are presented without sufficient consideration of the distribution around those means. Thus, some apparent differences may not be significantly different. Provision of descriptive distributions (e.g., of control group quit-rates) does provide an indication that some differences (e.g., between program cessation and control group cessation) is clinically significant, and would be statistically significant if such methods were applied. However, it would be preferable to employ more sophisticated methods in continued work with these data. For example, use of critical values could indicate which of the theories or modalities are significantly better than the others. Also, use of multivariate methods may be able to provide some insight into the maximal combination of theory with modality for highest quit-rates.
Second, the value of the analysis is limited by the quality of the data. Numerous aggregated estimates across studies needed to be calculated to make comparisons within studies. It is much wiser to pool comparisons first made within studies. For example, an effect size, comparing the difference of a program condition to a control condition within one study should be standardized and pooled across studies to create an average effect size [e.g.[91
]]. This approach is not possible with so many single-subject design studies and so many missing data points. In other words, it is difficult to conduct a meta-analysis on these cessation programs, though it could potentially provide more statistical information about precisely what works and what does not work. Only 12 and 24 studies, respectively, provided direct program-control comparisons. Thus, an absolute reduction in risk statistic also was not calculated. The use of single group designs and comparison to an overall quit rate statistic is speculative, and this important limitation needs correction through future studies that provide control groups measured concurrently with program groups.
There are many scattered areas of missing data. Ethnicity is not described in many of the studies. In studies that do describe ethnicity, a majority white sample is described. Thus, collection of ethnicity data should become a regular process in these studies, and research needs to be completed in areas with higher racial minority concentrations to assess generalizability of programming to different ethnic groups. Percentage reduction statistics are not commonly used. Thus, it is not possible to assess the totality of impact a program may have on teen tobacco use. A standard definition of baseline smoking and quitting is not used, and in several studies quitting is not measured over at least a one-week duration. Thus, it is difficult to compare studies, and the meaningfulness of cessation in several studies is suspect.
There are also several types of data that are not collected in most or all of these studies. These include the measurement of different types of tobacco use, effects of programming on other drug use, level of nicotine dependence and cessation (aside from level of pretest tobacco use), duration of smoking and cessation, and patterns of smoking and quitting among youth (i.e., across days). These other types of missing data also include provider characteristics and cessation, or matching of provider characteristics with different types of tobacco users, and issues related to cost and feasibility of implementation. Also included should be assessment of the effects of different social contexts on effectiveness of programming, measurement of mediation of program effects, and measurement of many psychosocial moderators of program effects. These additional pieces of information are needed to better understand teen tobacco use cessation.
Very recently, this review was re-examined by a team of 35 teen tobacco use cessation researchers and practitioners, sponsored by the American Legacy Foundation, Canadian Tobacco Control Research Initiative, Centers for Disease Control and Prevention, and National Cancer Institute ("Youth Tobacco Cessation Collaborative Best Practices Workshop"). The results will be presented in a guide entitled "Youth tobacco use cessation: A guide for making decision to help youth quit." These reviewers decided not to examine percentage reduction information, and made some different theoretical distinctions. In general, however, this re-analysis led to the same conclusions. There are some promising approaches as summarized herein. However, new research is needed including use of more rigorous designs.
In 1982, Cheryl Perry wrote on the importance of developing teen cessation programming [11
]. Anecdotally, many researchers and practitioners may have assumed that youth would not quit smoking until they became adults and had more reasons to quit. Many researchers were surprised to learn that youth became readily addicted to tobacco and had made several previous attempts to quit. Still, skepticism about youth cessation was based on early unsuccessful experiences.
In some of these experiences, a treatment provider acquired a quit-manual, placed a simple notice in a school or other setting, and then was surprised that only three youth showed up to the program and only one quit. There are probably numerous efforts "out there" that are not contained in this report, which relate such experiences. After more rigorous recruitment strategies were employed, more youth showed up for programming. Still, quit-rates were considered relatively low. Indeed, they are much lower than adult clinic programs, but are as high as adult minimal intervention programs [92
Once the realization was made that youth prevention programs did not work for everyone, or that effects tended to decay, a renewed interest was gained in the promise of teen cessation programming [6
]. The numbers of programs being researched and implemented has increased dramatically over the last 10 years. However, the technology for measuring older teen's smoking and dependence, defining cessation, and exploring various avenues of cessation assistance (e.g., use of alternative nicotine products) is brand new territory. This review is only able to summarize studies that have been completed thus far. There are many more studies currently in development or in progress (e.g., there currently are 19 teen tobacco use cessation projects underway that are being funded by the National Cancer Institute). Much more information will be learned over the next 10 years. In this time, more complete data will be collected, replication studies will be conducted, better summary analyses will be completed, and a much better understanding of teen cessation will be gained.