Review of the Efficacy of a Variety of Smoking Cessation Methods in Adolescents
by Michelle Rybak
Cigarette smoking is currently the number one cause of morbidity and mortality in the United States. Teenage smoking prevalence is around 15% in developing countries and around 26% in the United Kingdom and the United States. Recent studies provide data on the efficacy of many different smoking cessation methods, but controversy persists over what method of adolescent smoking cessation should be employed. This review article seeks to evaluate the efficacy and validity of nicotine replacement therapy and counseling-based therapies in affecting adolescent smoking behavior.
Cigarette smoking is currently the number one cause of morbidity and mortality in the United States.1 Smoking-related ailments include such conditions as cardiovascular disease; cancers of the lung, cervix, kidney, pancreas, and stomach; emphysema; and chronic bronchitis. In the United States as well as the United Kingdom, up to one in four teenagers smoke, and worldwide between 80,000 and 100,000 young people start smoking every day.1 Most adolescents with established smoking habits continue to smoke as adults and incur both short-term and long-term health consequences, including premature death.2 Adolescents should therefore be the targets of any effective method of smoking cessation.
For every year that passes, more than one million youth in the United States start smoking, adding 9 to 10 billion dollars to the national health care bill throughout their lifetimes.
For every year that passes, more than one million youth in the United States start smoking, adding 9 to 10 billion dollars to the national health care bill throughout their lifetimes.3 According to one study by Barendregt, Bonneax and van der Maas, health care costs for smokers at a certain age are as much as 40% higher than those for nonsmokers.4 Additionally, smoking is said to take an average of 13 to 14 years off a person's life.3
Many recent studies on smoking cessation have focused on adolescents. People who do not smoke before the age of twenty are significantly less likely to start as adults, so the most effective way to prevent smoking is to help adolescents quit.3
At this point in time, there is no widely agreed upon method of smoking cessation in adolescents. Many studies have been done on smoking cessation in adults; however, smoking cessation studies in adolescents are still developing. A majority of studies published in the field use groups of adolescents who volunteer, indicating that participants already identify as interested in quitting. Although these samples are not representative of the entire population of adolescent smokers (considering that most rebellious teens will probably be resistant to cessation programs), a cooperative sample allows experimentalists to determine what methods of smoking cessation are most effective.
Motivational Interviewing (MI) is a typical interviewing method employed in smoking cessation studies. MI emphasizes independence and respect for participants' choices, making it particularly appropriate for adolescents.5 MI is defined as a method of encouraging intrinsic motivation to change through exploring an individual's ambivalence. Some MI strategies include reflective listening, open-ended questioning, and summarizing. These strategies support optimism and allow adolescents to explore smoking concerns while minimizing interviewee resistance. MI does this by discussing the importance of quitting, including strategic reflection on morals and beliefs, and promoting self-initiated rewards for quitting.
A second method used in smoking cessation studies, Cognitive Behavioral Skills Training (CBST), is a skill-building training method for adolescents who have decided to quit but need some guidance.5 CBST is geared towards helping build skills for quitting and preventing relapses. The training attempts to accomplish this by offering strategies for resisting smoking triggers and collaborating to create a quitting plan. Like MI, CBST attempts to be empathic, respectful, and caring, in the hopes of sustaining long-term abstinence.
Smoking cessation can be measured in a variety of qualitative and quantitative ways. To obtain quantitative results, many studies use "The Fagerstrom Test for Nicotine Dependence" (FTND), a questionnaire concerning smoking behavior.6 Participants provide answers about usage, quitting, and addiction, and then receive scores on a scale of 1-10, with 10 indicating the highest level of nicotine dependence. Studies also measure cigarettes per day (CPD), as reported by participants.7 Some studies just use participant feedback; however, this may be unreliable.
Saliva can also be tested for signs of addiction. Levels of nicotine, cotinine, and thiocyanate in saliva are all indicators of smoking activity.
To guarantee more accurate and objective results, some studies measure carbon monoxide (CO) concentrations in exhaled air. Specifically, a participant is characterized as abstinent if the concentration of CO measures less than 6 parts per million. Saliva can also be tested for signs of addiction. Levels of nicotine, cotinine, and thiocyanate in saliva are all indicators of smoking activity.7
Recent studies have addressed the problem of adolescent smoking in a number of different ways. Some studies exclusively use behavioral therapies, but choose to communicate these therapies through different media such as telephones, text messaging, or classroom group sessions. Other therapies pair counseling with nicotine replacement therapy, using the nicotine patch, nicotine gum, or nicotine nasal spray. These methods will be discussed, in order of increasing efficacy.
Nicotine Replacement Therapy
Nicotine Replacement Therapy (NRT) is widely known as an effective method of treating nicotine addiction in adults. However, the efficacy of NRT in young adults has yet to be established.8 NRT works by stimulating the nicotinic receptors in the brain. This stimulation causes the release of dopamine, which serves to relieve nicotine withdrawal symptoms.10 The different types of NRT discussed here are nicotine nasal spray therapy, nicotine gum therapy, and nicotine patch therapy.
Nicotine nasal spray has many bonuses for adolescents. It works by quickly delivering nicotine to provide quick relief from withdrawal symptoms and cravings.11 Furthermore, self-administration of the nasal spray, in contrast to the transdermal delivery of the nicotine patch, provides the user with greater control, which adolescents tend to value.
A pilot study of adolescent smokers in San Francisco, CA showed that participants who attended 8 weeks of counseling while using nasal spray showed no significant difference in cessation rates from those who received counseling alone, despite the appealing aspects of nicotine nasal spray.11 In fact, of the 17 adolescents who solely received counseling, 2 quit smoking after 8 weeks, while of the 23 participants who received counseling and nasal spray, none quit smoking after eight weeks.
The poor success of the nasal spray can be correlated with participant noncompliance. During the first week of spray use, only 6 (23%) of the 23 participants used the spray daily as instructed.11 Furthermore, only 10 of the original 23 participants were still using their nasal spray by the end of the treatment; 38.9% of the nasal spray users reported that the spray had negative side effects, specifically nasal irritation and burning, and foul taste and smell.
Nicotine gum therapy, again more successful in treatment of smoking addiction in adults, also produced largely unsuccessful results for teenagers. According to a study done on over 120 adolescents ages 13-17 who smoked on average more than 10 CPD for more than 6 months with a minimal score of 5 on the FTND, 6 of 34 participants (17.7%) were abstinent by the end of the trial.7 The trial used two randomized groups, one given nicotine gum and the other provided a placebo. Data analysis on the placebo and gum groups indicated that the differences in cessation rates between the two groups were not statistically significant. Compliance rates were relatively high in this study, specifically 82.8%, although some participants complained about the taste of the gum.
Nicotine patch therapy has produced some similarly disappointing results. This therapy provides nicotine transdermally, but the nicotine serves the same effect as in the nasal spray. In a pilot study of 101 adolescents from two cities in Wisconsin, a comparatively large sample size, only 5% of the participants were abstinent at the end of the trial.10 Many subjects reported adverse effects, including upper respiratory tract infections (44%), headache (43%), nausea and/or vomiting (13%), skin reaction at patch site (12%), and sleep disturbance.
However, there is a discrepancy among nicotine patch studies. In a separate study of adolescent smokers, statistically significant results indicated that nicotine patch therapy can be successful for adolescents.7 Specifically, participants in this study were randomly assigned either to receive the patch along with counseling or a placebo with counseling. The proportion of participants who achieved prolonged abstinence in the active patch group was 6 of 34 (17.7%) versus 1 of 40 (2.5%) in the placebo group.
The difference in the ways the nicotine patch experiments were controlled may indicate which study produced more trustworthy results. The nicotine patch therapy study that reported positive results was placebo-controlled.7 Specifically, the study was double-blind, meaning that neither participants nor physicians knew who received the placebo, and all patients were given either active doses or placebo doses to ensure no special treatment of those receiving the active form of the patch. The study also had a very high compliance rate (78.4%), increasing its reliability. On the other hand, the unsuccessful study was nonrandomized with no control group, leaving ample room for bias and error.10 However, the sample size of the unsuccessful study was significantly larger (101 versus ~70), indicating that the larger sample size results may be more trustworthy.7 The conflicting results of these two studies suggest that more experimentation needs to be done to determine the efficacy of nicotine patch therapy among adolescents.7,10
Classroom-Based Behavioral Therapy
In the studies previously mentioned, behavioral therapy was used in conjunction with various nicotine therapies. Other studies emphasize behavioral counseling as a means of encouraging smoking cessation. A convenient and successful method of approaching smoking addiction in high school students is a classroom-based therapy.12
A study of students in a large public high school in Baltimore has produced significant data on this method.12 The study enrolled 74 students randomly assigned either to Group 1 (the smoking cessation curriculum) or Group 2 (educational pamphlet on how to quit smoking). The therapy session took place in a classroom during the school day. Students learned how to identify their own smoking habits as well as perceived barriers to quitting, such as lack of self-confidence or desire. After learning problem solving strategies related to quitting smoking, dealing with withdrawal, and mental preparation for stopping smoking, participants who received the classroom-based therapy were significantly more likely to quit smoking after the intervention. Specifically, 59% of Group 1 were smoke-free at the end of the study, while 17% of Group 2 were smoke-free, creating an extremely small P-value of .001. A significant difference in mean cotinine levels of quitters compared to non-quitters indicated that the participants really had stopped smoking; 82% of Group 1 versus 54% of Group 2 made quit attempts, and Group 1 reduced their mean CPD by 7 cigarettes while Group 2 reduced their mean CPD by just 1. The large difference in success rates in Group 1 versus Group 2 reported in this study suggests that classroom-based therapy is a convincing method for adolescent smoking cessation.12
Similar successful results were obtained in a classroom-based smoking cessation study called ACTION conducted on 269 adolescent smokers from 14 schools in Kentucky, North Carolina, and Ohio.13 Smoking abstinence was reported by the students and saliva cotinine levels were measured, one week before, 3 days after, and 7 days after the cessation program. 11.1% of students who received the counseling versus 4% in the control classroom were abstinent 1 week after the program, indicating a significant increase in smoking cessation rates among students enrolled in the classroom program.
Telephone Counseling Intervention
While some smoking cessation therapy is conducted in the classroom, there has also been data indicating that proactive, personalized telephone counseling intervention for adolescent smoking cessation can also be successful.14 This method gives the participants a considerable amount of privacy by allowing their smoking status to remain confidential from their peers.
The Hutchinson Study (HS) of High School Smoking, conducted in 50 public high schools throughout the state of Washington, has provided results indicating that telephone counseling can be effective.14 Of the 50 participating high schools, 25 were assigned to the experimental condition (HS cessation intervention) and 25 were assigned to the control condition (no intervention). This study used a combination of Motivational Interviewing (MI) and Cognitive Behavioral Skills Training (CBST) through the telephone with a sample size of 2,151 adolescents. The status of the participants was assessed initially and current smokers unprepared to quit received specific therapy designed to build confidence and motivation. Those motivated to quit received support calls concerned with strengthening commitment, building skills and preventing relapse. According to analysis of the callers, counseling intervention was done with greater than 90% adherence to protocol of MI and CBST.5 The calls were 15 minutes in duration, and the numbers of calls a participant received were personalized to their preparedness to quit.14 Overall, the intervention increased the percentage of participants who achieved 6-month prolonged abstinence (21.8% in experimental group versus 17.7% in the control condition).
A larger sample size means a more accurate picture of the population of adolescent smokers and more credible results.
The larger sample size and adherence to protocol featured in the HS study strengthen its successful results.14 The sample size was 2,151 high school students, a very large number compared to the other studies mentioned. A larger sample size means a more accurate picture of the population of adolescent smokers and more credible results. The reviewing of the adherence to protocol also gives the experiment strength, indicating that the callers were doing their jobs and contributing to the adolescents' pursuit of smoking cessation. Further, the personalized telephone calls gave participants a specialized intervention, contributing to the overall success rate.
Unlike the other studies mentioned, in the Hutchinson Study, the smoking status of participants was never revealed.14 A cohort of nonsmokers was included, meaning that a phone call did not necessarily mean the participant was a smoker. The cohort consisted of adolescents who were willing to help friends stop smoking and to learn more about how to help others quit. Overall, this adds to the strength of the study because the status of the participants was not revealed, indicating that people would be more likely to be honest, and the smokers were likely to have friends learning about how to help the peers quit, increasing the likelihood of abstinence. The lack of more telephone-based smoking cessation studies indicates more experimentation should be done, but the Hutchinson Study is a convincing study with significant, positive results.
A review of adolescent smoking cessation studies identifies telephone and classroom-based counseling as the most successful methods of combating teen smoking, although more research should be done regarding nicotine patch therapy.
When reviewing the data, it is important to assess the validity of the separate samples used. The adolescents in these studies do not represent adolescent smokers as a whole because there are a number of ulterior motives for joining these studies. Primarily, in nearly all of the studies, participants received monetary compensation. In the ACTION study, several schools offered students participation in the study as an alternative to suspension for smoking violations.13 If the experiment had been designed for adolescents trying to quit smoking, compensation would have been a confounding variable that could reflect in the success rate. Some experiments cited that decreases in CPD were not associated with cotinine levels, indicating that the participants had continued smoking but lied about their usage.7,8 In the ACTION study, many participants falsely reported abstinence (61% 3 days after and 38% 1 week after).13 In some cases, it's possible that the participants were never interested in quitting, decreasing the number of abstinent subjects and making a method of smoking cessation seem ineffective.
A sample composed of adolescents who genuinely wanted to quit smoking would still not represent all teenage smokers. Many adolescents are not at all interested in quitting, and will therefore not be affected by any cessation methods. Similarly, many adolescents smoke, but hide their habit from their parents, and since parental consent was mandatory in a majority of these studies, the samples used inaccurately represent the adolescent smoking population. Lack of samples representative of the population can greatly skew the results. Therefore, more studies should be done to ensure that methods that seem ineffective actually are ineffective. Experiments that allow confidentiality for the subject or force a smoker to follow a specific regimen may be extremely hard to design and implement, but they would be helpful in analyzing adolescent smoking cessation.
Noncompliance is encountered in all of the studies mentioned, and can greatly skew the results. Specifically in the NRT studies, many adolescents did not complete the required steps, such as daily nasal spray or patch use, because of adverse side effects.7,8,9 Therefore, lower abstinence rates at the end of studies could possibly be attributed to unwillingness to deal with unexpected side effects, such as nasal burning or irritation, rather than ineffective methods. A method of smoking cessation that leads to noncompliance would probably not be promoted or advised, but noncompliance occurs in all studies. A method which has previously produced a low compliance rate should not immediately be discarded, but rather more experimentation should be done. In the classroom-based therapy session, many students stopped attending after the first session, and the attendance rate decreases exponentially.12 Similarly, many participants in the telephone-based counseling study stopped answering the phone calls and were inserted into the data pool as smokers, although the people conducting the experiment had no idea whether this was actually the case. Although the telephone and classroom-based counseling seemed effective, the data may be unreliable, considering that assumptions are made about participants who do not complete the study, and non-compliant participants create samples that may be too small to show any correlations relating to methods and smoking cessation.12,14 Therefore more studies need to be conducted.
Ideally, experiments would have 100% compliance from a perfectly randomized sample of adolescent smokers. However, this is impossible, and we need to do the best we can with the available data, and continue studying different approaches to adolescent smoking cessation. To promote health in adolescence and to decrease the burden put on the population by adolescent smokers, personalized counseling methods should be employed, and more data should be gathered on the efficacy of nicotine replacement therapies.
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