Journal of Pediatric Psychology Advance Access published online on December 3, 2007
Journal of Pediatric Psychology, doi:10.1093/jpepsy/jsm112
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Developing Smoking Cessation Programs for Chronically Ill Teens: Lessons Learned from Research with Healthy Adolescent Smokers*
1Department of Psychology, The University of Memphis, 2Dana-Farber Cancer Institute and Harvard School of Public Health, 3National Institutes of Health, National Institute on Drug Abuse, Intramural Research Program, and 4Department of Psychiatry & Behavioral Sciences, Memorial Sloan-Kettering Cancer Center
All correspondence concerning this article should be addressed to Leslie A. Robinson, PhD, Department of Psychology, 202 Psychology, The University of Memphis, Memphis, TN 38152, USA. E-mail: L.Robinson{at}mail.psyc.memphis.edu
 |
Abstract |
|---|
 Top Abstract Unaided Quitting Among Healthy...The Outcomes of Cessation...Special Considerations for...Lessons LearnedConclusionsAcknowledgmentsReferences |
|---|
Objective Medically fragile teens who smoke need access to smoking cessation programs, because they are at even higher risk than their healthy peers for smoking-related complications. Methods To date, no studies on the outcome of smoking cessation programs for medically ill teens have been conducted. To suggest directions for future research, we turn to the literature on smoking cessation in the general population of teens and occasionally to the literature on adult smokers. Results Four areas are explored: (a) the prevalence of unaided cessation in healthy teens; (b) the outcomes of various treatments for smoking cessation in healthy adolescents; (c) special issues that should be considered when designing programs for medically ill teens; and (d) lessons learned from previous research. Conclusions Medically ill teens face a number of medical, emotional, social, and developmental challenges that can affect the quitting process. Research is sorely needed to address the unique needs of this population.
Key words: adolescents; chronic illness; pediatric; smoking cessation; tobacco use.
Clinicians and researchers are just beginning to grapple with the realization that medically fragile children (i.e., those with serious illnesses) use tobacco at substantial rates. For example, teens with asthma have been found to be nearly 1.5 times more likely to smoke than their healthy peers (Zbikowski, Klesges, Robinson, & Alfano, 2002
). Similarly, high rates of tobacco use have been found in other medically compromised adolescents, such as those with sickle cell disease, cystic fibrosis, and diabetes (Britto, 2005).
With the focus still on establishing how many youths with chronic illnesses smoke and what predicts tobacco use in this population, little attention has been directed toward understanding when medically compromised teens attempt to quit smoking and whether they are successful. Further, there are no randomized trials aimed at determining whether treatment can increase smoking cessation among chronically ill adolescents. Nonetheless, it is clear that these teens cannot afford additional harm from tobacco (Myers & Brown, 1994; Wiencke et al., 1999). Thus, programs for medically fragile youths are sorely needed.
Given the lack of data in this population, we must use other literatures to help inform initial research on cessation with medically ill adolescents. Fortunately, there are two large bodies of research that are relevant. First, research on cessation methods is extensive for adults, and in some cases this literature may offer guidance. Second, the literature on smoking cessation in the general population of adolescents has grown rapidly in recent years. Multiple studies have established rates of unaided cessation among young smokers, predictors of quit attempts, and strategies teens use when they try to stop smoking. In addition, a number of randomized studies have been conducted to determine the effectiveness of interventions to promote smoking cessation among adolescents unselected for illness.
The purpose of this article is to present an overview of issues that should be considered as research on smoking cessation among medically ill adolescents grows. First, we summarize what is known about unaided smoking cessation with healthy teens, including rates and predictors of quit attempts. Second, the efficacy of smoking cessation programs with the general population of teens is reviewed. Intrinsic to this discussion are the concepts of reach and efficacy as determinants of program impact. Third, we summarize the special issues to be considered when designing programs for health impaired youth. Finally, we point out methodological issues to be resolved if research is to move forward in this area.
|
Unaided Quitting Among Healthy Teens |
|---|
|
TopAbstractUnaided Quitting Among Healthy...The Outcomes of Cessation...Special Considerations for...Lessons LearnedConclusionsAcknowledgmentsReferences |
|---|
As this research on the general population of adolescents has progressed, it has become clear that quit attempts are quite common among young smokers. For example, Reidel, Robinson, Klesges, and McLain-Allen (2002a) found that 70% of a sample of high school smokers reported trying to quit within the past year, and 44% reported two or more quit attempts within the past year. Stanton, Lowe, and Gillespie (1996
) found that an even higher proportion of 18-year-old smokers (81%) had tried quitting within the past year.
Predictors of Quit Attempts
What variables prompt students to attempt quitting so soon after initiating tobacco use? The motivation for quitting most often reported by teens unselected for health status involves concerns about their health (Dozois, Farrow, & Miser, 1995; Stone & Kristeller, 1992). For example, when adolescents were queried about why they entered a smoking cessation program, health concerns were the most popular reason for participation (Hurt et al., 2000; Lotecka & MacWhinney, 1983). In fact, Reidel, Robinson, Klesges, & McLean-Allen (2002b) found that future health and current health were the top 2 reasons for quitting endorsed by high school students trying to quit smoking. These findings are surprising, given that emphasis on the negative health effects of smoking has generally been found to be ineffective in reducing smoking initiation rates (Bruvold, 1993). Apparently, knowledge of the harmful nature of tobacco in and of itself may not prevent teens from starting to smoke, but such knowledge may help students who do smoke make the decision to quit.
Success Rate for Quit Attempts
Although it is encouraging that a large number of teen smokers try to quit on their own, the odds of their success are unfortunately low. Longitudinal studies have indicated that only 37% (Laoye, Creswell, & Stone, 1972) to 3% (McNeill, 1991) of young smokers quit in a 2-year period. Relapse rates among those who do quit are even more sobering: Burt and Peterson (1998) found that 79% of adolescents who had quit relapsed within a year.
Strategies for Quitting
Such poor success rates are perhaps understandable when one considers the developmental characteristics of adolescents, such as their limited ability to plan ahead and anticipate consequences. These characteristics are reflected in their rather disorganized strategies for quitting unaided. For example, Reidel et al. (2002a) found that only 19% of teens who had tried to quit made an effort to avoid the company of smokers during the cessation effort. In addition, only 44% removed smoking paraphernalia (e.g., ashtrays) from their environment. Thus, part of the difficulty teens experience when they attempt cessation may arise from their lack of organized planning and inability to marshal their resources.
|
The Outcomes of Cessation Programs with Teens |
|---|
|
TopAbstractUnaided Quitting Among Healthy...The Outcomes of Cessation...Special Considerations for...Lessons LearnedConclusionsAcknowledgmentsReferences |
|---|
Measuring Impact: Efficacy versus Reach
For both adults and teens, a wide variety of smoking cessation interventions have been developed to teach the skills needed for quitting. Some programs are quite intensive, whereas others are brief. Overall, the outcomes of these programs tend to be better when intensity (i.e., time spent in the intervention) is greater.
This effect has been well documented among adults, who have been the subject of more study. A number of investigations have shown that when a clinician provides very brief advice to stop smoking (i.e., 3 min), an additional 2% of adult smokers above the base rate quit for 6 months or longer. If the advice lasts up to 10 min, the cessation rate increases by 3%, and if a smoking intervention program plus pharmacotherapy is offered, the cessation rate increases by 8% (Fiore et al., 1996; Silagy & Ketteridge, 1998; Silagy et al., 1998). Thus, efficacy tends to increase with intensity.
In evaluating smoking cessation strategies at the population level, not only efficacy, but also the reach of the intervention must be considered. Low intensity programs such as self-help manuals can be widely distributed with little professional involvement. More intensive programs are usually more effective at the individual level, but they have higher costs and are likely to be used by a smaller portion of the individuals who could benefit from them. The relationship between reach and efficacy, sometimes described as "impact," is depicted in Fig. 1. When smoking cessation intervention strategies are designed, particularly for special populations, it is important to consider the ultimate impact of different approaches.
|
Low Efficacy/High Reach Programs
An example of a smoking cessation approach with relatively low efficacy but high reach is provided in the Agency for Health Care Policy and Research (AHCPR) Smoking Cessation Clinical Practice Guideline (Fiore et al., 1997
). These guidelines recommend that all providers give brief smoking cessation advice, utilizing the five As (ask about tobacco use, advise to quit, assess willingness to make a quit attempt, assist in the quit attempt, and arrange follow-up). Although cessation rates produced by physician advice are quite modest for adults, given the extensive reach of physicians, the total public health impact is impressive (Fiore et al., 1996; Silagy & Ketteridge, 1998; Silagy et al., 1998).
By comparison, there has been much less emphasis on high reach/low intensity strategies such as physician advice in pediatric settings. A recent large-scale study of youth unselected for illness found that only 16.4% of young smokers were advised to quit by their doctors (Shelley et al., 2005). Rates of counseling for medically fragile children are more difficult to estimate because they have rarely been reported. One study of childhood cancer survivorship programs found that only 3% followed AHCPR recommendations to assess smoking status at every visit (De Moor, Puleo, Butterfield, Li, & Emmons, manuscript under review).
Medical providers’ failure to monitor tobacco use is disappointing, because even a modest benefit could have high impact, through the extensive reach of primary care settings. For example, Shelley et al. (2005) found that teen smokers who had been advised to quit by their doctor were 90% more likely to make a quit attempt than those not advised. Thus, if physician advice to quit were instituted consistently, considerable benefits could accrue for adolescents with chronic illness, in terms of added health and reduced costs for health care.
A more complex, but potentially more successful model is to encourage the delivery of smoking cessation messages from a wide range of interventionists, including nurses, respiratory therapists, psychologists, and dentists. In this way, young smokers could be exposed to repeated cessation messages. The AHCPR Smoking Cessation Guidelines encourage this systems approach, recognizing the limitations of relying on physicians alone. The guidelines emphasize that it is essential that clinicians and health care delivery systems (including administrators, insurers, and purchasers) institutionalize the consistent identification, documentation, and treatment of every tobacco user. Further research could explore which of these messengers is effective, and whether a combination of sources is more effective in prompting cessation than individual interventionists.
Few data on the quit rates produced by health care provider advice are available for teens. However, consider the modest effects of brief physician advice upon adults, with about 5% of counseled smokers quitting, and apply these findings to the pediatric setting. There are 40 million adolescents in the United States between the ages of 10–19 (National Center for Health Statistics [NCHS], 2000). As many as 31.5% of adolescents of United States have one or more chronic health conditions (Newacheck, McManus, & Fox, 1991). A more conservative 20% illness rate would suggest that 8 million adolescents have a chronic health condition. There are currently no clear estimates available regarding the number of adolescents with chronic conditions that smoke, but tobacco use rates among high school students in general are about 23% (CDC, 2005). Assume for a moment that 15% of chronically ill teens smoke, a conservative estimate which allows for the possibility that adolescents with chronic conditions may be less likely to smoke. These assumptions suggest that over 1.2 million adolescent smokers with chronic illnesses are routinely seen in the health care system. In this case, as many as 72,000 medically fragile adolescents might quit smoking if even low intensity smoking interventions were instituted in their health care facilities. If more intensive interventions with quit rates of closer to 20% were put in place, almost a quarter of a million chronically ill adolescents would quit smoking.
We recognize that these estimates are based on assumptions in lieu of data, including the assumption that the quit rate from brief advice for adults would also apply to adolescents. These figures are presented not to document likely quit rates, but rather to illustrate the potential that might result from systems-based approaches. Youth with chronic illnesses are likely to be more vulnerable to tobacco-related health effects than healthy teens; thus, if they can be helped to quit smoking, the potential to avert disease and death is enormous.
High Efficacy/Low Reach Programs
A variety of more intensive cessation programs have now been developed for use with healthy teens. In fact, a recent Cochrane Review noted that 13 of the 15 controlled trials of smoking interventions for teens have been published within the past 8 years, indicating a remarkable surge of interest in helping teens quit (Grimshaw & Stanton, 2006). The methods under examination in these studies have been quite varied, but most of these trials have evaluated programs offering a combination of motivational enhancement for quitting and training in coping skills. Often, motivational interviewing has served as the framework for approaching treatment, with specific skill building exercises including stimulus control techniques, methods for seeking social support, skills training for resisting cigarette offers, yoga, and meditation. The intensity of these programs has been widely variable, ranging from a single session to programs lasting 3 months.
Along with variations in treatment, a number of participant variables have differed across studies. One such variable is smoking rate. Grimshaw and Stanton (2006) restricted their review to studies using weekly smokers, but some investigations have used participants who smoked less. Samples have also varied in gender, ethnicity, and other participant characteristics. In most studies, participants have been recruited from schools (Grimshaw & Stanton, 2006), but other sites have sometimes been used, such as healthcare settings.
As is often the case in an emerging field of research, the methodology in these studies has been as diverse as the program components and participant characteristics. For example, studies have used varying approaches to group assignment (random vs. use of intact convenience samples), and comparison groups have included wait list controls, other treatments, and placebo interventions. Attrition from groups in intervention trials has only occasionally been reported, and recruitment reach is rarely mentioned. Methods for calculating outcomes have been unstandardized. For example, some studies have reported the point prevalence of smoking (i.e., the percent of treated participants still smoking at posttest or follow-up), whereas others have required continuous abstinence as the criterion for quitting. Biochemical verification of smoking status has rarely been attempted, and when it has, the evidence suggests that such verification is crucial to obtaining valid estimates of treatment effects (Robinson, Vander Weg, Riedel, Klesges, & McLain-Allen, 2003).
Summarizing research findings across such disparate studies can be difficult. In this case, the results of controlled evaluations of smoking cessation programs for teens are, with few exceptions, discouraging. The Cochrane Review (Grimshaw & Stanton, 2006) identified statistically significant benefits in only two of 15 controlled trials of cessation programs for teen smokers (Aveyard et al., 2001; Hollis et al., 2005), and for one of these studies, the benefits were inconsistent across time. Given the well-established success of smoking cessation interventions with adults, the negative outcomes with teens are startling. However, there are multiple differences between adolescents and adults that could contribute to teens’ greater resistance to cessation programming. Clearly, we can no longer assume that what works for adults will benefit youth, and research aimed at the unique needs of teen smokers is needed.
Pharmacologic Treatment
Although pharmacological treatment, including nicotine replacement therapy (NRT) and bupropion, is effective for enhancing cessation among adults, pharmacotherapy for adolescent smokers remains at the discretion of practitioners and should be considered according to the Clinical Practice Guideline (Fiore, 2000). In the few trials to date, medications found to be successful for adults have demonstrated lower efficacy for adolescent smokers (Hanson, Allen, Jensen, & Hatsukami, 2003; Killen et al., 2004). However, one recent trial found that the transdermal nicotine patch significantly enhanced successful cessation for young smokers (Moolchan et al., 2005). The more positive outcomes obtained in this trial may be partly due to the stringent criteria used to select teen participants: Only youths smoking more than 10 cigarettes per day were enrolled and 75% of them had at least one psychiatric diagnosis. Moolchan and colleagues (2005) concluded that their positive results may apply to highly addicted young smokers with substantial comorbidity. Experimental use of bupropion is being investigated in several trials but no controlled data have been reported.
Practitioners who treat medical ill teens face special challenges when approaching cessation, because few data are available on how various drugs and medical conditions might affect the safety of NRT for adolescents. Within the general population, if used as instructed, NRT has few contraindications, the most prominent of which are allergy and hypersensitivity (Hughes, 1993). Although NRT is not approved for individuals younger than 18 years, practitioners might consider several risks and benefits within various disease contexts, depending on their familiarity with NRT and the developmental stage of the adolescent patient.
On the risk side, potential toxicity from NRT should be considered, although no serious adverse effects and good general tolerability have been observed in most trials to date. Common side effects from use of the gum include jaw soreness, gastrointestinal symptoms, and nausea, and mild skin reactions can result from the patch (AMA, 1994; Moolchan et al., 2005). Studies with adults suggest the abuse liability of NRT does not seem to constitute a major deterring factor (Hughes et al., 1991), although no long-term studies of tolerance to nicotine have been conducted among adolescents treated with NRT.
Buproprion is contraindicated among adolescents with certain health conditions. Because buproprion lowers the seizure threshold, use of this medication for smoking cessation would not be appropriate for adolescents with epilepsy, a history of brain tumor, and psychiatric conditions like anorexia or bulimia.
On the benefit side, effective treatment with medication could reduce tobacco-related premature mortality in 50% of regular smokers, as well as provide immediate health benefits for teens (Moolchan, 2007). Even during adolescence, smoking increases the frequency and severity of respiratory infections (Myers & Brown, 1994), has unfavorable effects on the lipid profile, decreases overall fitness, and seems to increase cancer risk compared to later onset smoking (Wiencke et al., 1999). Further, medication reduces the acute withdrawal symptoms that adolescent smokers experience (Sargent, Mott, & Stevens, 1998), including depressive symptomatology (Rojas, Killen, Haydel, & Robinson, 1998). This improvement in clinical status can allow coping skills for long-term abstinence to be acquired more easily. Successful cessation at any age, but especially early in the addictive cycle adds years to the lifespan (Anthoniesen et al., 2005; Samet, 1991).
|
Special Considerations for Medical Populations |
|---|
|
TopAbstractUnaided Quitting Among Healthy...The Outcomes of Cessation...Special Considerations for...Lessons LearnedConclusionsAcknowledgmentsReferences |
|---|
This review of cessation methods illustrates both the potential rewards of developing quit programs for teens, as well as some of the difficulties that may be encountered when programs are targeted to adolescents with medical illnesses. We focus next on issues that are specific to medically fragile teens, with the knowledge that addressing these issues may be the key to designing effective tobacco cessation programs for this special population.
Medical Complications
Medically ill teens may be especially prone to the harms of smoking because of their chronic disease and its treatment-related complications. For instance, smoking among adolescents with asthma exacerbates their shortness of breath, wheezing, and coughing, and teens with diabetes who smoke are at increased risk for micro- and macro-vascular disease (Haire-Joshu, Glasgow, & Tibbs, 1999). Further, survivors of childhood cancer have a significant increase in cardiovascular risk factors compared to controls (Link et al., 2004), suggesting that they may be especially vulnerable to cardiovascular damage from tobacco.
Historically, youth cessation programs have not emphasized the health consequences of smoking, given that most teens discount the risk of distant health consequences (Reppucci, Revenson, Aber, & Reppucci, 1991). However, even adolescents with significant illnesses can be unaware that they are more vulnerable to the health hazards of smoking because of their disease, and when this misunderstanding occurs, adolescents and young adults are more likely to intend to smoke (Tyc, Hadley, & Crockett, 2001). On the other hand, medically ill teens may have more concerns about their present and future health, and these health concerns could provide motivation for quitting. In either case, personalized health education may motivate teens to make active quit attempts.
As an example of integrating health concerns into treatment, Tyc and colleagues (2003) developed a multi-component tobacco risk intervention for cancer survivors 10–18 years of age. Brief counseling about the late effects of cancer treatment, an educational video, behavioral goal setting, physician feedback, and follow-up telephone counseling produced increased awareness of tobacco risks, greater perceived vulnerability to tobacco-related disease, and lower intentions to smoke 12 months after the intervention. Hollen, Hobbie, and Finley (1999) tested a 1-day program designed to reduce risk behaviors among adolescent cancer survivors, but the results were disappointing: They found no changes in smoking or motivation for quitting. Nonetheless, pioneering programs such as these are needed to determine what interventions are most effective for medically ill adolescents.
One potential advantage to working with medically compromised teens is that these adolescents may be more receptive to discussing tobacco with health care providers than their peers. Even healthy adolescents tend to trust health care providers and are willing to talk with them about sensitive topics, particularly if confidentiality is assured (Cheng, Savageau, & Sattler, 1993; Steiner, & Gest, 1996). For medically ill adolescents, physician advice may be even more significant; these youth have become accustomed to relying on their physicians. Clearly, studies of the effects of health care provider advice need to be conducted with medically fragile teens to determine whether such interventions have a particularly positive effect. It may also be worthwhile to explore whether biomarker monitoring (e.g., carbon monoxide measurement) could be used to provide positive feedback about the health benefits of cessation for those who have recently quit.
At the same time, it must be recognized that medically fragile teens may find it difficult to acknowledge tobacco use to the same medical team that has been providing life-sustaining treatment. Although self-reports of tobacco use are generally considered valid for adolescents in large-scale studies with strong assurances of confidentiality, teens tend to underreport smoking when privacy is not assured and when there is social pressure to report nonsmoking status, such as in treatment outcome trials (Patrick et al., 1994; Robinson et al., 2003). In addition, teens differ in how much tobacco they believe must be consumed in order to be considered a smoker. Inquiring about the specific amount of tobacco used may help avoid such definitional ambiguities. Privacy concerns may be reduced by providing adolescents with straightforward information on who has access to their smoking status. Equally important is the attitude of the professional collecting the smoking status information. It is critical that teens be questioned in an accepting, non-threatening manner. In this regard, the principals of motivational interviewing have been helpful in establishing guidelines for the sensitive assessment of problem behaviors (Miller & Rollnick, 2002).
Psychological Issues
The psychological impact of having a chronic medical condition should also be considered when smoking cessation programs are developed. Previous research has shown that posttraumatic stress disorder is more common among cancer survivors than their healthy peers (Schwartz & Drotar, 2006). In response to the stress of cancer, individuals engage in coping responses, with varying levels of success. In comparison with healthy peers, cancer survivors show greater reliance on repressive avoidant coping (Elkin, Phipps, Mulhern, & Fairclough, 1997; Fritz, Spirito, & Yeung, 1994; Phipps, Steele, Hall, & Leigh, 2001). Such avoidant coping has also been associated with increased risk for tobacco dependence.
In contrast, engagement coping (i.e., prosocial and proactive coping) has been linked with more positive outcomes. For example, proactive coping (i.e., information seeking, decision making, and direct action) has been linked with positive emotional adjustment (Aspinwall & Taylor, 1997) and lower levels of tobacco use among adolescents (Wills & Cleary, 1995; Wills & Hirky, 1996). Thus, those designing cessation programs for medically ill teens should consider providing training in prosocial and proactive skills for coping with illness-related stress, along with the more typical lessons on coping with smoking urges.
Social Support for Quitting
To date, cessation programs have rarely taken into account the social context of teen smoking. Instead, most research on social interactions has focused on the role of peer pressure in smoking initiation (Robinson et al., 2006). However, both smoking and nonsmoking friends might discourage tobacco use for medically ill adolescents. In this case, close friends could be engaged to provide support for a friend's quit attempt. Alternatively, peer counselors, particularly those who have first-hand experience with both medical illness and smoking cessation, could be used to assist with program delivery. For instance, Emmons and colleagues (2002) found that the Partnership for Health Intervention doubled smoking quit rates among a large national cohort of young adult survivors of childhood cancer. Given the significance of peer relations in the life of an adolescent, the addition of peer support through programs such as this constitutes a promising approach to adolescent smoking cessation intervention.
Parents are another potential source of support or interference in a teen's quit attempt. Surprisingly, adolescent cessation programs have rarely addressed the problems that may ensue when teens quit in the midst of tobacco-addicted relatives. Household smokers may provide access to cigarettes, behavioral modeling, and positive reinforcement of tobacco use. Further, the stress of coping with medical concerns and care-giving responsibilities may make it more difficult for family members to quit. On the other hand, a child's illness may raise family-wide motivation for smoking cessation. Clearly, research is needed to determine whether families provide support or interfere when teens quit. Further, studies exploring family-focused smoking intervention would be an interesting addition to this literature.
The emotional reactions teens experience when their smoking becomes public constitute another complex psychosocial issue. Adolescents with chronic medical conditions are often acutely aware of their family's sacrifices and medical efforts to control their illness. As such, medically fragile teens may be more likely than their healthy peers to experience shame and fear of condemnation for their smoking. It may be particularly important to help teens diffuse feelings of shame, so that energy can be redirected toward the quitting process itself. Moreover, cessation programs could guide concerned family members in the best ways to provide support for teens’ efforts to quit. For instance, parents may learn to acknowledge the difficulty of quitting, provide assistance in coping with smoking urges, and praise efforts for smoking cessation.
Developmental Losses
Adolescence is a period characterized by separation–individuation with a move toward autonomy (Eiser, 1993; Jessor, 1984; Maggs, Schulenberg, & Hurrelmann, 1997). Medical illness interferes with these tasks, so that teens can become isolated from their peer networks. In such a situation, tobacco use may serve a functional role, by providing teens with a means of reconnecting with friends, establishing independence, and declaring personal identity (Maggs, Almeida, & Galambos, 1995). Cessation programs that emphasize methods for restoring peer connections may be especially effective for adolescents who experience social disruption because of their illness.
In summary, our current understanding of how to promote cessation among adolescents with chronic medical conditions is limited. Despite the health consequences of smoking, there are no controlled studies evaluating interventions to promote smoking cessation in chronically ill teens. Without evidence-based guidelines for tobacco counseling, it is important for health care providers to deliver at minimum personalized cessation advice and counseling to adolescents receiving primary and specialty medical care (Tyc & Throckmorton-Belzer, 2006). However, further research aimed at developing and evaluating cessation interventions tailored for this special population is sorely needed. Such interventions should address the specific health risks of smoking, provide proactive coping skills, rebuild a sense of age-appropriate autonomy, restore peer connections, diffuse smoking-related shame, and increase social support for quitting.
|
Lessons Learned |
|---|
|
TopAbstractUnaided Quitting Among Healthy...The Outcomes of Cessation...Special Considerations for...Lessons LearnedConclusionsAcknowledgmentsReferences |
|---|
Cessation research with the general population of adolescent smokers has yielded a number of important methodological lessons (Mermelstein et al., 2002
). Researchers interested in developing cessation programs for teens with serious illnesses could avoid many a pitfall by noting the difficulties that investigators have already encountered in studies using healthy adolescent smokers. In the following section, we highlight some of the issues from this broader literature that should influence future studies.
The Importance of Biochemical Verification of Quitting
Biochemical validation of smoking cessation has been the subject of considerable debate. Although not indispensable in large-scale studies in which it might be impractical, biochemical validation of smoking status does appear important in treatment studies (Society for Research on Nicotine and Tobacco [SRNT] Subcommittee on Bioverification, 2002). Previous treatment research has indicated that adolescent smokers tend to inflate cessation success (Robinson et al., 2003). This need to exaggerate success might be more likely among adolescents who have frequent involvement with health care professionals. Given the demand characteristics inherent in treating teens with medical illnesses, biochemical verification of smoking status would be advisable for both clinical and scientific reasons.
The method of determining biochemical validation is also an important consideration. Cotinine obtained via saliva or blood might be the most sensitive marker for smoking (SRNT Subcommittee on Bioverification, 2002); however, when NRT is used in treatment, a non-nicotine marker such as expired air carbon monoxide (CO) is more appropriate. Treatment trials have used CO cut-offs ranging from 5 parts per million (p.p.m.) (Hanson et al., 2003) to 9 p.p.m. (Killen et al., 2004). Lower CO concentrations appear among teens relative to adults because teens have higher metabolic rates and levels of activity (Mermelstein et al., 2002; Thompson, 1996). It should be remembered that marijuana smoking (which is more frequent among tobacco smokers than nonsmokers) has also been shown to increase CO concentrations and might falsely indicate cigarette smoking (Moolchan et al., 2004).
Study Design
In studies with teens, researchers sometimes lack the resources to randomize participants to treatment and control groups. As an alternative, investigators may use intact groups. For example, one clinic of teens may be randomized to one treatment, whereas another clinic may be assigned to a control condition. In this situation, matching is often used in an attempt to render the intact groups as equivalent as possible. However, even when matching is accomplished on a wide range of variables, it is still possible that groups are not equivalent on some critical variable that has not been identified. For example, the participants in the control group may be less motivated to quit, therefore obtaining worse outcomes. In this scenario, the intervention may appear effective simply because its participants started off more likely to quit. The only way to insure that spurious relationships do not underlie group differences is to randomize participants at the beginning of a study.
Participant Characteristics
Participant characteristics such as age and amount smoked have important effects on outcome. Comorbid psychiatric illness has frequently been associated with reduced treatment response, and psychopathology may be more common among teens with chronic medical conditions (Moolchan, Frazier, Franken, & Ernst, 2007). Further, the eligibility criteria used to obtain study participants are critical to the interpretation of outcomes. For example, adolescent smoking rates vary widely, and it seems reasonable to expect that studies using very light smokers might obtain systematically different results from those using heavy smokers. Thus, clinical trials should evaluate the relation between these characteristics and outcome, and literature reviews that compare investigations should be attentive to differences in participant characteristics.
Intervention Timing
The timing of intervention may also be important. Should teens be approached for enrollment in a cessation program soon after diagnosis with a serious illness, while they are in treatment, or after treatment is complete? Clinical practice has suggested that it is important to use "teachable moments" in which individuals are particularly receptive to information about behavior change. However, it is not clear exactly what moments are most teachable. This issue can only be solved by empirical research, sensitively conducted with an eye toward achieving the best health and well-being of teens in the midst of medical crisis.
Choosing Outcomes
Currently, the gold standard for treatment outcome studies with healthy teens is smoking cessation. Even that is not consistently reported, because some investigations use the point prevalence of smoking, whereas others require continuous abstinence. Nonetheless, this standard for successful outcome may be too high. In fact, changes in knowledge about tobacco and attitudes toward it usually precede behavioral changes, and many more studies have demonstrated knowledge and attitudinal shifts before behavioral changes (Robinson, Klesges, Levy, & Zbikowski, 1999). Perhaps these less dramatic changes are the precursors of quitting, and cessation programs that fail to produce quitting do in fact "prime" teens for future success. In that case, it would be important to follow recipients of a quit program long term to determine whether increased cessation occurs over the long haul.
|
Conclusions |
|---|
|
TopAbstractUnaided Quitting Among Healthy...The Outcomes of Cessation...Special Considerations for...Lessons LearnedConclusionsAcknowledgmentsReferences |
|---|
Rarely has a research area been so clinically important and so in need of further work. The fact that initial evaluations of quit programs with the general population of adolescents yielded rather disappointing results should not be discouraging. To help teen smokers stop using tobacco requires a sensitive understanding of the forces that maintain smoking and the social and biological costs of quitting. Research on these preliminary topics is still emerging.
Nevertheless, teens with medical problems need help to stop smoking now. Given our limited research to date, what guidelines can be given to clinicians? Our goal has been to provide a core of recommendations from which treatment plans can be developed, along with an outline of novel research that could push this evolving field forward.
At the most fundamental level, chronically ill teens who smoke need advice to quit, sensitively delivered, with consistency not only across time, but also across social groups. Every medical visit is an opportunity for a conversation about smoking, and everyone who cares about a teen has an obligation to support that adolescent in quitting. Systemic organization needs to be improved until all aspects of a teen's medical team and social network can collaborate effectively together.
This coordination may require a family-based or peer-network approach, in order to teach the important people in a teen's life how to offer support. It is not always clear what social behaviors encourage cessation, and further research is needed to clarify how attempted smoking cessation affects family and social relationships, especially in the context of illness. Given the high rate of smoking in the families of teens who smoke, it is recommended that clinicians ensure that families are aware of the effects of their own smoking and have the tools and support they need to quit themselves.
In addition, it is recommended that attention be directed to the unique difficulties medically ill teens face when quitting. Under these conditions, pharmacotherapy must be carefully considered, and weighed against the risks of continued tobacco consumption. Teens with chronic illnesses face developmental pressures and health-related anxieties that are unique. In the final analysis, intervention programs will need to address these difficulties in order to offer these adolescents effective assistance.
Finally, it is critical to remember that the vast majority of teens who smoke try to quit repeatedly, and that those with illnesses have added incentive fueled by their fears for their health and concerns about disappointing their medical teams. These youth deserve our best efforts to develop intervention programs that give them a fighting chance at life, tobacco-free.
|
Acknowledgments |
|---|
|
TopAbstractUnaided Quitting Among Healthy...The Outcomes of Cessation...Special Considerations for...Lessons LearnedConclusionsAcknowledgmentsReferences |
|---|
This study is supported by a grant from the National Cancer Institute, National Institute of Child Health and Human Development, and the National Heart, Lung, and Blood Institute (CA117417).
Conflicts of interest: None declared.
|
Footnotes |
|---|
*This article is based on the proceedings from the conference, "Tobacco Control Strategies for Medically At-Risk Youth" held at St Jude Children's Research Hospital in Memphis, TN on October 6–8, 2005.
Received December 15, 2006; revision received July 26, 2007; accepted October 17, 2007
|
References |
|---|
|
TopAbstractUnaided Quitting Among Healthy...The Outcomes of Cessation...Special Considerations for...Lessons LearnedConclusionsAcknowledgmentsReferences |
|---|
American Medical Association. Drug Evaluations, Annual (1994) Chicago, IL: American Medical Association.
Anthonisen NR, Skeans MA, Wise RA, Manfreda J, Kanner RE, Connett JE. Lung Health Study Research Group. The effects of a smoking cessation intervention on 14.5-year mortality: A randomized clinical trial. Annals of Internal Medicine (2005) 142:233–239.
Aspinwall LG, Taylor SE. A stitch in time: Self-regulation and proactive coping. Psychological Bulletin (1997) 121:417–436.[CrossRef][Web of Science][Medline]
Aveyard P, Sherratt E, Almond J, Lawrence T, Lancashire R, Griffin C, et al. The change-in-stage and updated smoking status results from a cluster-randomized trial of smoking prevention and cessation using the transtheoretical model among British adolescents. Preventive Medicine (2001) 33:313–324.[CrossRef][Web of Science][Medline]
Britto M. Tobacco use and detection in specialty pediatrics. (2005) October. Presentation at NCI-sponsored conference "Tobacco Control Strategies for Medically At-Risk Youth," St. Jude's Children's Medical Center: Memphis, TN.
Bruvold WH. A meta-analysis of adolescent smoking prevention programs. American Journal of Public Health (1993) 83:872–880.
Burt RD, Peterson V. Smoking cessation among high school seniors. Preventive Medicine (1998) 27:319–327.[CrossRef][Web of Science][Medline]
Centers for Disease Control. Cigarette use among high school students—United States, 1991–2005. In: Morbidity and Mortality Weekly Report, 55, No MM26, 724 (2005).
Cheng TL, Savageau JA, Sattler AL. Confidentiality in health care: A survey of knowledge, perceptions and attitudes among high school students. Journal of the American Medical Association (1993) 269:1404–1407.
De Moor JS, Puleo E, Butterfield RM, Li FP, Emmons KM. Availability of smoking prevention and cessation services for childhood cancer survivors. (manuscript under review).
Dozois DN, Farrow JA, Miser A. Smoking patterns and cessation motivations during adolescence. The International Journal of the Addictions (1995) 30:1485–1498.[Web of Science][Medline]
Eiser C. Growing up with a chronic disease: The impact on children and their families (1993) London: Jessica Kingsley Publishers.
Elkin TD, Phipps S, Mulhern RK, Fairclough D. Psychological functioning of adolescent and young adult survivors of pediatric malignancy. Medical and Pediatric Oncology (1997) 29:582–588.[CrossRef][Web of Science][Medline]
Emmons K, Li FP, Whitton J, Mertens AC, Hutchinson R, Diller L, et al. Predictors of smoking initiation and cessation among childhood cancer survivors: A report from the childhood cancer survivor study. Journal of Clinical Oncology (2002) 20:1608–1616.
Fiore MC, Bailey WC, Cohen S, et al. Smoking cessation. Clinical Practice Guideline No 18. (1996) Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, April, 1996. (AHCPR Publication No 96-0692.)
Fiore MC, Bailey WC, Cohen S, et al. Smoking cessation, a systems approach. (1997) Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, April, 1997. (AHCPR Publication No 97-0698).
Fiore MC. US public health service clinical practice guideline: treating tobacco use and dependence. Respiratory Care (2000) 45:1200–1262.[Medline]
Fritz GK, Spirito A, Yeung A. Utility of the repressive defense style construct in childhood. Journal of Clinical Child Psychology (1994) 23:306–313.[CrossRef][Web of Science]
Grimshaw GM. Tobacco cessation interventions for young people. Cochrane Database of Systematic Reviews, Issue 4. (2006) Art. No.: CD003289, doi: 10.1002/14651858.CD003289.pub4 [Epub ahead of print].
Haire-Joshu D, Glasgow, R. E., Tibbs TL. Smoking and diabetes. Diabetes Care (1999) 22:1887–1898.
Hanson K, Allen S, Jensen S, Hatsukami D. Treatment of adolescent smokers with the nicotine patch. Nicotine and Tobacco Research (2003) 5:515–526.[CrossRef]
Hollen PJ, Hobbie WL, Finley SM. Testing the effects of a decision-making and risk-reduction program for cancer-surviving adolescents. Oncology Nursing Forum (1999) 26:1475–1486.[Medline]
Hollis JF, Polen MR, Whitlock EP, Lichtenstein E, Mullooly JP, Velicer WF, et al. Teen reach: outcomes from a randomized, controlled trial of a tobacco reduction program for teens seen in primary medical care. Pediatrics (2005) 115:981–989.
Hughes JR. Risk-benefit assessment of nicotine preparations in smoking cessation. Drug Safety (1993) 8:49–56.[Web of Science][Medline]
Hughes JR, Gust SW, Keenan R, Fenwick JW, Skoog K, Higgins ST. Long-term use of nicotine vs. placebo gum. Archives of Internal Medicine (1991) 151:1993–1998.
Hurt RD, Croghan GA, Beede SD, Wolter TD, Croghan IT, Patten CA. Nicotine patch therapy in 101 adolescent smokers: Efficacy, withdrawal symptom relief, and carbon monoxide and plasma cotinine levels. Archives of Pediatrics and Adolescent Medicine (2000) 154:31–37.
Jessor R. Adolescent development and behavioral health. In: Behavioral health: A handbook of health enhancement and disease prevention—Matarazzo JD, Weiss SM, Herd JA, Miller NE, Weiss SM, eds. (1984) . New York: Wiley.
Killen JD, Robinson TN, Ammerman S, Hayward C, Rogers J, Stone C, et al. Randomized clinical trial of the efficacy of bupropion combined with nicotine patch in the treatment of adolescent smokers. Journal of Consulting and Clinical Psychology (2004) 72:729–735.[CrossRef][Web of Science][Medline]
Laoye JK, Creswell WH, Stone DB. A cohort study of 1,205 secondary school smokers. The Journal of School Health (1972) 17:47–52.
Link K, Moell C, Garwicz S, Cavallin-Stahl E, Bjork J, Thilen U, et al. Growth hormone deficiency predicts cardiovascular risk in young adults treated for acute lymphoblastic leukemia in childhood. The Journal of Clinical Endocrinology and Metabolism (2004) 89:5003–5012.
Lotecka L, MacWhinney M. Enhancing decision behavior in high school "smokers." The International Journal of the Addictions (1983) 18:479–490.[Web of Science][Medline]
Maggs JL, Almeida DM, Galambos NL. Risky business: The paradoxical meaning of problem behavior for young adolescents. Journal of Early Adolescence (1995) 15:344–362.[Abstract]
Maggs JL, Schulenberg J, Hurrelmann K. Developmental transitions during adolescence: Health promotion implications. In: Health risks and developmental transitions during adolescence—Schulenberg J, Maggs HL, Hurrelmann K, eds. (1997) . New York: Cambridge University Press.
McNeill AD. The development of dependence on smoking in children. British Journal of Addition (1991) 86:589–592.[CrossRef]
Mermelstein R, Colby SM, Patten C, Prokhorov A, Brown R, Myers M, et al. Methodological issues in measuring treatment outcome in adolescent smoking cessation studies. Nicotine and Tobacco Research (2002) 4:395–403.[CrossRef]
Miller WR. Motivational interviewing: Preparing people for change. (2002) (2nd ed.). New York: Guilford Press.
Moolchan ET. Perspectives on the risk-benefit ratio of pharmacological treatment for adolescent chemical addiction. In: Drug Addiction Treatment in the 21st Century—Hinningfield JE, Santora PB, Bickel WK, eds. (2007) . Johns Hopkins Press.
Moolchan ET, Frazier M, Franken FH, Ernst M. Adolescents seeking smoking cessation treatment: Relationship between externalizing symptoms, smoking history, and outcome. Psychiatry Research (2007) 16(1):62–66.
Moolchan ET, Robinson ML, Ernst M, Cadet JL, Pickworth WB, Heishman SJ, et al. Safety and efficacy of the nicotine patch and gum for the treatment of adolescent tobacco addiction. Pediatrics (2005) 115:407–414.[CrossRef]
Moolchan ET, Zimmerman D, Sehnert SS, Zimmerman D, Huestis MA, Epstein DH. Recent marijuana blunt smoking impacts carbon monoxide as a measure of adolescent tobacco abstinence. Substance Use and Misuse (2004) 40:231–240.[CrossRef]
Myers MG, Brown SA. Smoking and health in substance-abusing adolescents: A two-year follow-up. Pediatrics (1994) 93:561–566.
National Center for Health Statistics, Health, United States. with Adolescent Chartbook. (2000) Hyattsville, MD.
Newacheck PW, McManus MA, Fox HB. Prevalence and impact of chronic illness among adolescents. American Journal of Diseases of Children (1991) 145:1367–1373.[Web of Science][Medline]
Patrick DL, Cheadle A, Thompson DC, Diehr P, Koepsell T. The validity of self-reported smoking: A review and meta-analysis. American Journal of Public Health (1994) 84:1086–1093.
Phipps S, Steele RG, Hall K, Leigh L. Repressive adaptation in children with cancer: A replication and extension. Health Psychology (2001) 20:445–451.[CrossRef][Web of Science][Medline]
Reppucci JD, Revenson TA, Aber M, Reppucci ND. Unrealistic optimism among adolescent smokers and nonsmokers. Journal of Primary Prevention (1991) 11:227–236.[CrossRef]
Riedel BW, Robinson LA, Klesges RC, McLain-Allen B. Characteristics of adolescents caught with cigarettes at school: Implications for developing smoking cessation programs. Nicotine and Tobacco Research (2002a) 4:351–354.[CrossRef]
Riedel BW, Robinson LA, Klesges RC, McLain-Allen B. What motivates adolescent smokers to make a quit attempt? Drug and Alcohol Dependence (2002b) 68:167–174.[CrossRef][Web of Science][Medline]
Robinson LA, Klesges RC, Levy MC, Zbikowski SM. Preventing cigarette use in a bi-ethnic population: Results of the Memphis Smoking Prevention Program. Cognitive and Behavioral Practice (1999) 6:136–143.[CrossRef][Web of Science]
Robinson LA, Murray DM, Alfano CM, Zbikowski SM, Blitstein JL, Klesges RC. Ethnic differences in predictors of adolescent smoking onset and escalation: A longitudinal study from seventh to twelfth grade. Nicotine and Tobacco Research (2006) 8:297–307.[CrossRef]
Robinson LA, Vander Weg MW, Riedel BW, Klesges RC, McLain-Allen B. "Start to Stop:" Results of a randomized controlled trial of a smoking cessation program for teens. Tobacco Control (2003) 12(Suppl 4):iv26–iv33.
Rojas NL, Killen, J. D., Haydel KF, Robinson, T. N. Nicotine dependence among adolescent smokers. Archives of Pediatrics and Adolescent Medicine (1998) 152:151–156.
Samet JM. Health benefits of smoking cessation. Clinical Chest Medicine (1991) 12:669–679.
Sargent JD, Mott LA, Stevens M. Predictors of smoking cessation in adolescents. Archives of Pediatrics and Adolescent Medicine (1998) 152:388–393.
Schwartz L, Drotar D. Posttraumatic stress and related impairment in survivors of childhood cancer in early adulthood compared to healthy peers. Journal of Pediatric Psychology (2006) 31:356–366.
Shelley D, Cantrell J, Faulkner, D., Haviland L, Healton, C., Messeri P. Physician and dentist tobacco use counseling and adolescent smoking behavior: Results from the 2000 National Youth Tobacco Survey. Pediatrics (2005) 115:719–725.
Silagy C, Ketteridge S. The effectiveness of physician advice to aid smoking cessation (Cochrane review). In: The Cochrane Library Issue 2 (1998) Oxford: Update Software.
Silagy C, Mant D, Fowler G, et al. Nicotine replacement therapy for smoking cessation (Cochrane review). In: The Cochrane Library Issue 2 (1998) Oxford: Update Software.
SRNT Subcommittee on Biochemical Verification. Biochemical verification of tobacco use and cessation. Nicotine and Tobacco Research (2002) 4:149–159.[CrossRef]
Stanton WR, Lowe JB, Gillespie AM. Adolescents’ experiences of cessation. Drug and Alcohol Dependence (1996) 43:63–70.[CrossRef][Web of Science][Medline]
Steiner BD, Gest KL. Do adolescents want to hear preventive counseling messages in outpatient settings? Journal of Family Practice (1996) 43:376–381.
Stone SL, Kristeller JL. Attitudes of adolescents toward smoking cessation. American Journal of Preventive Medicine (1992) 8:221–225.[Web of Science][Medline]
Thompson AE. Environmental emergencies. In: Synopsis of pediatric emergency medicine—Fleisher GR, Ludwig S, eds. (1996) . Baltimore, MD: Williams and Wilkins.
Tyc VL, Hadley W, Crockett G. Brief report: Predictors of intentions to use tobacco among adolescent survivors of cancer. Journal of Pediatric Psychology (2001) 26:117–121.
Tyc VL, Rai SN, Lensing S, Klosky JL, Stewart DB, Gattuso J. Intervention to reduce intentions to use tobacco among pediatric cancer survivors. Journal of Clinical Oncology (2003) 21:1366–1372.
Tyc VL, Throckmorton-Belzer L. Smoking rates and the state of smoking interventions for children and adolescents with chronic illness. Pediatrics (2006) 118:471–487.[CrossRef]
Wiencke JK, Thurston SW, Kelsey KT, Varkonyi A, Wain JC, Mark EJ, et al. Early age at smoking initiation and tobacco carcinogen DNA damage in the lung. Journal of the National Cancer Institute (1999) 91:614–619.
Wills TA, Cleary SD. Stress-coping model for alcohol/tobacco interactions in adolescence. In: Alcohol and tobacco: From basic science to policy—Fertig J, Allen J, eds. (1995) . Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.
Wills TA, Hirky E. Coping and substance abuse: A theoretical model and review of the evidence. In: Handbook of coping: Theory, research, applications—Zeidner M, Endler NS, eds. (1996) . New York: John Wiley & Sons.
Zbikowski SM, Klesges RC, Robinson LA, Alfano CM. Risk factors for smoking among adolescents with asthma. Journal of Adolescent Health (2002) 30:279–287.[CrossRef][Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||