Teen smoking cessation.

Interest in adolescent smoking cessation has increased dramatically over the past several years, as researchers and practitioners have acknowledged the high rates of adolescents who smoke regularly and the low probability that adolescents who are regular smokers will stop on their own. The evidence base behind smoking cessation interventions for adolescents is also now starting to grow, but unfortunately the studies to date have frequently been plagued by major methodological problems. This paper summarises research conducted on adolescent smoking cessation, notes some of the methodological limitations of prior work, highlights approaches that show promise, discusses some of the challenges involved in addressing adolescent smoking cessation, and makes recommendations for future work.

Responses to tobacco control policies among youth.

OBJECTIVE: Explore adolescents' response to current and potential tobacco control policy issues. DESIGN: The 13 site Tobacco Control Network (TCN), sponsored by the Centers for Disease Control and Prevention, conducted 129 sex and ethnic homogeneous focus groups. PARTICIPANTS: 785 white, African American, Asian American/Pacific Islander, American Indian, and Hispanic adolescents who were primarily smokers from rural, urban, and suburban locations across the USA. MAIN OUTCOME MEASURES: Awareness, knowledge, opinions, and behaviour regarding laws and rules, prices, cigarette ingredients, and warning labels. RESULTS: Teenagers were generally familiar with laws and rules about access and possession for minors, but believed them ineffective. They were knowledgeable about prices, and reported that a sharp and sudden increase could lead them to adjust their smoking patterns but could also have negative consequences. They found a list of chemical names of cigarette ingredients largely meaningless, but believed that disclosing and publicising their common uses could be an effective deterrent, especially for those who were not yet smoking. They were aware of current warning labels, but considered them uninformative and irrelevant. CONCLUSIONS: Understanding teenagers' attitudes and behaviours before implementing policies that will affect them will likely increase their effectiveness. Disclosing and publicising the chemical contents of cigarettes, and increasing prices quickly and sharply, are potentially effective areas for policy change to impact adolescent tobacco use.

Changes in self-efficacy and readiness for smoking cessation among women with high school or less education.

The most common theory of smoking cessation postulates that readiness to quit begins with changes in attitudes that move the smoker toward behavioral change and eventual cessation. However, trends in smoking indicate that many who currently smoke are not ready to quit. Hence, strategies that both enhance readiness and focus on quitting are likely to be most effective. We hypothesize that an intervention addressed to motivating behavior change will enhance readiness to change, which will in turn increase the smokers self-efficacy regarding further change. A smoking cessation intervention that combined a self-help booklet and televised segments was developed to address these issues in a population of women smokers with high school or less education. Readiness to quit was measured prior to the intervention, immediately following the intervention, and again at six and 12 months after intervention. The results indicate that the intervention had its effects on readiness to quit, which in turn affected self-efficacy, which further enhanced readiness to quit. These findings indicate that interventions aimed at this group of smokers may need to provide achievable objectives that focus on preparing the smoker to quit as well as promote cessation.

Profiling the trauma related symptoms of Bosnian refugees who have not sought mental health services.

The objective of this study was to profile trauma related psychiatric symptoms in a group of refugees not seeking mental health services and to consider the services implications. The study involved research assessments of two groups of Bosnian refugees: those who have not presented for mental health services and those who have. A total of 28 of 41 nonpresenters (70%) met symptom criteria for posttraumatic stress disorder (PTSD) diagnosis. All service presenters (N = 29) met symptom criteria for PTSD diagnosis. The group that did not present for services reported substantial but lower trauma exposure, PTSD symptom severity, and depression symptom severity. They had significant differences on all subscales of the MOS SF-36, indicating better health status. We concluded that those who do not seek services have substantial symptom levels, but their self-concept appears to be less oriented toward illness and help seeking. Innovative access, engagement, and preventive interventions are needed to address those who have symptoms but do not readily seek help for trauma mental health services.

Relapse and maintenance issues for smoking cessation.

This article reviews short-term (6 months) and longer term (12-24 months) maintenance of cessation and relapse in adult smokers and the factors and treatments that affect these outcomes. MedLine and PsycLIT searches were done for research published in English between 1988 and 1998 meeting a defined set of criteria. Intensive intervention, telephone counseling, and use of pharmacotherapy were found to improve outcomes; however, compared with public health approaches, they reach relatively few smokers. Brief interventions during medical visits are cost-effective and could potentially reach most smokers but are not consistently delivered. Predictors of relapse include slips, younger age, nicotine dependence, low self-efficacy, weight concerns, and previous quit attempts. Potential areas for research, recommendations for longer follow-up assessments, and standard definitions for slip, relapse, and long-term maintenance are discussed.

Analysis of longitudinal substance use outcomes using ordinal random-effects regression models.

In this paper we describe analysis of longitudinal substance use outcomes using random-effects regression models (RRM). Some of the advantages of this approach is that these models allow for incomplete data across time, time-invariant and time-varying covariates, and can estimate individual change across time. Because substance use outcomes are often measured in terms of dichotomous or ordinal categories, our presentation focuses on categorical versions of RRM. Specifically, we present and describe an ordinal RRM that includes the possibility that covariate effects vary across the cutpoints of the ordinal outcome. This latter feature is particularly useful because a treatment can have varying effects on full versus partial abstinence, for example. Data from a smoking cessation study are used to illustrate application of this model for analysis of longitudinal substance use data.

Ethnicity, gender and risk factors for smoking initiation: an overview.

Although the prevalence of cigarette smoking has increased dramatically among youth over the past several years, there are significant ethnic and gender differences in prevalence rates. This paper presents highlights of the research literature on ethnic and gender differences in risk factors for smoking. The effects of peer and family influences may vary by both ethnicity and gender. White youth, especially females, may be more susceptible to the negative influence of friends' smoking than are African-American youth. Although the evidence about the relative importance of parent smoking among ethnic groups is contradictory, recent data suggest that African-American parents provide stronger anti-smoking messages than do white parents. The subgroups also vary in their perceptions of the negative consequences of smoking, with Asian-American and African-American females perceiving stronger negative consequences. Cultural expectations may place white females at increased risk for smoking. The link between depressed mood and smoking also varies by subgroup. Finally, popular media figures may influence the appeal of smoking and be differentially relevant to youth subgroups. We need: (1) specific examinations of ethnic and gender effects with attention paid to identifying protective factors among certain ethnic/gender subgroups; (2) to know more about how family influences may vary by the ethnic/gender subgroups and over the developmental course of smoking; (3) to know more about how youth cope with negative moods and the role of smoking in coping; and (4) to investigate whether the factors that protect youth in some subgroups can be diffused to others.

Explanations of ethnic and gender differences in youth smoking: a multi-site, qualitative investigation. The Tobacco Control Network Writing Group.

Two of the most powerful predictors of adolescent smoking are ethnicity and gender, but little research has focused on understanding how these factors play a role in adolescent smoking. This paper reports results from a qualitative, multi-site investigation of explanations for ethnic and gender differences in cigarette smoking with five ethnic groups: whites, African-Americans, Hispanics, Native Americans, and Asian-American/Pacific Islanders. Across 11 states, we conducted 178 focus groups with a total of 1175 adolescents. The groups explored such major research themes as reasons for smoking and not smoking; images of smoking and smokers; messages youth receive about smoking and not smoking; and the social context of smoking. We synthesized data from the focus groups through multiple cross-site collaborations and discussions, with an emphasis on identifying consistent themes across a majority of groups and sites. Striking differences emerged across ethnic and gender sub-groups in reasons for not smoking. African-American females in particular viewed not smoking as a positive identity marker. Asian-American/Pacific Islander females similarly reported strong mandates not to smoke. Youth's perceptions of family messages about smoking also varied by ethnicity and gender, with African-American, Hispanic, and Asian-American/Pacific Islander youth consistently reporting strong, clear anti-smoking messages from family. These findings, notable in their consistency across geographic regions, may shed light on the discrepant prevalence of smoking across ethnic and gender groups.

The thresholds of change model: an approach to analyzing stages of change data.

Stage models are prominent in research describing health behavior change. Since stage models often propose that different factors have varying influences on membership in the different stage, statistical methods that can estimate the thresholds that separate the stages and the relative value of variables in influencing these thresholds are useful. This article describes use of a "thresholds of change" model for analyzing the thresholds separating stages and specifically for examining the effects of explanatory variables on these thresholds using a generalization of an ordinal logistic (or probit) regression model. Data from a skin cancer prevention study (N=3,185) in which participants were grouped into three stages for sunscreen use (precontemplation, contemplation, and action) are used to illustrate the Thresholds of Change Model. For this example, two thresholds exist: a contemplation (between precontemplation and contemplation) and an action threshold (between contemplation and action). Variables examined include gender, skin type, perceived susceptibility to sunburn, worry about skin cancer, and sun protection self-efficacy. We examine models that assume that the effects of these variables are the same across thresholds, and then allow the effects of these variables to vary across thresholds. Results indicate that perceived susceptibility has an equal effect on both thresholds, but that worry and self-efficacy have differential effects: worry exerts a greater influence on the contemplation threshold, whereas self-efficacy has a significantly stronger effect on the action threshold. Gender also has a stronger effect on the action threshold; males were less likely to be classified in the action stage than females. This analytic approach has broad applications to many types of stage data.

The role of weight concern and self-efficacy in smoking cessation and weight gain among smokers in a clinic-based cessation program.

Although the majority of smokers are concerned about postcessation weight gain, few studies have investigated the prospective relationship between weight concern and smoking and weight outcomes, or a mechanism by which concern is related to these outcomes. We investigated the prospective role of smoking-specific weight concern in smoking cessation and weight gain among participants in a smoking-cessation clinic, and we hypothesized that domain-specific self-efficacy would be a mediator of these relationships. While weight concern did not prospectively predict smoking status, increased weight concern predicted weight gain at the end of treatment and at 3-month follow-up. Self-efficacy for preventing postcessation weight gain mediated this relationship; lower levels were related to a greater likelihood of weight gain. Weight gain was found to be associated with subsequent relapse among abstainers. Implications and treatment recommendations are discussed.

Application of random-effects regression models in relapse research.

This article describes and illustrates use of random-effects regression models (RRM) in relapse research. RRM are useful in longitudinal analysis of relapse data since they allow for the presence of missing data, time-varying or invariant covariates, and subjects measured at different timepoints. Thus, RRM can deal with "unbalanced" longitudinal relapse data, where a sample of subjects are not all measured at each and every timepoint. Also, recent work has extended RRM to handle dichotomous and ordinal outcomes, which are common in relapse research. Two examples are presented from a smoking cessation study to illustrate analysis using RRM. The first illustrates use of a random-effects ordinal logistic regression model, examining longitudinal changes in smoking status, treating status as an ordinal outcome. The second example focuses on changes in motivation scores prior to and following a first relapse to smoking. This latter example illustrates how RRM can be used to examine predictors and consequences of relapse, where relapse can occur at any study timepoint.

Self-concept changes over time in cognitive-behavioral treatment for smoking cessation.

A smoker self-concept and an abstainer self-concept are individual difference variables that have been shown to predict smoking cessation. We examined whether these self-concept constructs changed as a function of participating in a clinic-based smoking cessation program and, specifically, whether these changes occurred differentially between posttreatment smokers and abstainers. Subjects completed the Smoker Self-concept scale and the Abstainer Self-concept scale at three time points: pretreatment, posttreatment, and 3 months' posttreatment. Smoking status was assessed and biochemically verified directly after quit day and 3 months' posttreatment. Results indicated that abstainers' smoker self-concept decreased more precipitously over time compared to smokers'. Abstainers showed consistent increases over time in their abstainer self-concept, and smokers showed increases followed by decreases to pretreatment levels. Clinical implications are discussed.

Individual differences in self-concept among smokers attempting to quit: Validation and predictive utility of measures of the smoker self-concept and abstainer self-concept.

We tested a theoretical model of individual differences in smoking cessation using a social-cognitive conception of the self-concept. We developed and validated measures of the smoker self-concept and the abstainer self-concept. Each scale was shown to have good internal reliability and construct validity and was distinct from other important predictive measures used in smoking research (e.g. Fagerstrom Tolerance Questionnaire, smoking rate, motivation, self-efficacy). Importantly, we demonstrated the predictive validity of the self-concept scales. The interaction of baseline measures of the smoker self-concept and abstainer self-concept predicted smoking status three months after treatment; subjects were most likely to be abstinent if they began treatment with a strong abstainer selfconcept and a weak smoker self-concept. This interaction held over and above baseline smoking rate, Fagerstrom Tolerance scores, and measures of motivation and self-efficacy to quit. The utility of social-cognitive individual difference models and potential patient-treatment matching interventions are discussed.

A cognitive-behavioral program to improve geriatric rehabilitation outcome.

A program of cognitive-behavioral interventions was applied on a hospital geriatric rehabilitation unit. Unique features were the tailoring of the program to the population and each participant, and the immediate application of the program with distressed patients in a proactive manner designed to maximize rehabilitation outcome. The program was successful in that initially distressed participants achieved rehabilitation goals to the same extent as the nondistressed comparison group, and participant scores on measures of distress and coping, except for anxiety, matched those of comparison patients at discharge.

Neoplastic lung lesions in rat after chronic exposure to crystalline silica.

Groups of 100 SPF Fischer-344 rats were exposed 6 h a day, 5 d a week for 24 months to crystalline silica (1 mg center dot m-3, DQ 12 quartz) or titanium dioxide (5 mg center dot m-3) or air only. The animals were kept without further exposure for an additional 1.5 months. In the group exposed to crystalline silica a significantly increased incidence of 20 primary lung tumors was observed among 19 animals. The distribution of tumor types consisted of 3 adenomas, 11 adenocarcinomas, 4 benign cystic keratinizing squamous-cell tumors, 1 adenosquamous carcinoma, and 1 squamous-cell carcinoma. There were also 13 nodular hyperplasia lesions, which were interpreted to be borderline cases of adenomas. Approximately half of the adenoid tumors and all of the nodular hyperplasia lesions were characterized by moderate central fibrosis. The principal nonneoplastic findings in the silica-exposed group were lipoproteinosis, inflammation, epithelial hyperplasia, and fibrosis. The results can be considered significant due to the increased lung tumor incidence at a relatively low exposure level.

Cigarette smoking under stress: the role of coping expectancies among smokers in a clinic-based smoking cessation program.

This study examined 2 expectancies to explain smoking under stress: smokers' expectations about their ability to cope with stress while remaining abstinent and their expectations about the stress-ameliorating and coping benefits of smoking under stress. The interaction of the expectancies concurrently predicted smoking urge under stress, which, in turn, predicted subsequent smoking. The interaction of posttreatment expectancies prospectively predicted smoking status 3 months after treatment, although the coping benefits of smoking expectancy effect was reversed. Expectations about coping ability increased and expectations about the coping benefits of smoking decreased as a function of participating in a smoking cessation program. The discrepant concurrent and prospective findings, reasons that coping expectancies are associated with smoking under stress, and treatment implications are discussed.

The effects and use of maintenance newsletters in a smoking cessation intervention.

This article evaluates the effects and use of adjuncts to a televised smoking cessation program, based on the American Lung Association's "Freedom From Smoking in 20 Days." Subjects were randomized to maintenance and control conditions. The maintenance condition received newsletters with information and support addressing different stages in the cessation process and information about a telephone hotline. The maintenance condition did not increase cessation at any wave of interviewing, assessed by multiple point or point prevalence of abstinence. Those abstinent at 6 months and those who had made an attempt to stop smoking by that time were more likely to have used the newsletters and were more likely to have used the sections relevant to their cessation stage. Rates of use of the telephone hotline were low. The newsletters appear to be useful to smokers who are predisposed to use written materials.

Effects of social support and relapse prevention training as adjuncts to a televised smoking-cessation intervention.

Smokers registering for a televised cessation program who also expressed interest in joining a support group and who had a nonsmoking buddy were randomly assigned to 3 conditions: no-contact control, discussion, and social support. All Ss received a self-help manual and were encouraged to watch the daily TV program. Ss in the discussion and social support conditions were scheduled to attend 3 group meetings (one with a buddy). Social support Ss and buddies received training in support and relapse prevention. A 4th analysis group was composed of Ss who failed to attend any of the scheduled meetings (no shows). There were strong group effects at the end of treatment. Abstinence rates were highest in the social support group, followed, in order, by the discussion group, no shows, and no-contact controls. The social support group improved outcome by increasing both the level of support and program material use (reading the manual and watching TV).