Telephone counseling showed improved quit rates among teens who smoke

Adolescent smokers were successfully recruited and retained in smoking cessation trial.

Proactive telephone counseling based on motivational interviewing and cognitive behavioral skills training demonstrated favorable quit rates among teen smokers.

Findings from previous studies have shown that although approximately half of adolescent smokers attempted to quit in any 12-month period, the rate of successful quitting is less than 5% per year. Researchers from the Fred Hutchinson Cancer Research Center in Seattle conducted the Hutchinson Study of High School Smoking trial to address conflicting findings due to methodological issues in prior studies.

Researchers enrolled 2,151 teenage smokers from 50 high schools in Washington into the trial. Twenty-five schools were assigned to a cessation intervention, 25 schools served as a comparison group and 745 nonsmoking teens were included to ensure contacting students for participation would not reveal their smoking status.

The design and implementation of the intervention was fundamental, as motivation and skills are critical for successfully changing behavior, the researchers said. Motivational interviewing and cognitive behavioral skills training were two important therapeutic modalities applied in the intervention.

“This study is remarkable for multiple reasons, not least because it is the first to show substantial quit rates in adolescent smokers at six months after quitting. Indeed, for those scientists not familiar with behavioral research, this study and the accompanying article on study design and implementation provide an outstanding example of how theory driven and methodologically sound behavioral research can be,” Scott J. Leischow, PhD, and Eva Matthews, MPH said in an accompanying editorial.

Leischow is professor in the department of family and community medicine, and Matthews is senior research specialist at the Arizona Cancer Center in Tucson.

Researchers attributed the success of the trial mainly to the proactive nature of the intervention, the counseling offered via telephone and the use of motivational interviewing techniques in all communication with teens.

“A proactive intervention can succeed in reaching and engaging teens, and an intervention delivered by telephone that is private, confidential and one-on-one, can be successful because it allows counselors to explore and focus on issues specific to the smoker,” said Arthur Peterson, PhD, professor of biostatistics at the Fred Hutchinson Cancer Research Center.

Researchers continually called potential participants in an effort to reach them.

“We used what I call ‘aggressive outreach’ and did not wait for participants to call us,” said Evette J. Ludman, PhD, senior research associate at Group Health Research Institute in Seattle. “Also, most teens have cellular phones and it is possible to reach them if we utilize our energy and do not give up.”

Intervention successfully implemented

In the experimental intervention group, researchers identified 1,058 junior-year adolescent smokers through classroom survey. Before the scheduled senior-year intervention, researchers mailed requests for written parental consent. Parents who did not respond were telephoned to provide or decline verbal consent.

Motivational interviewing was employed as the primary therapeutic modality in the intervention because of its emphasis on the adolescent and its minimally prescriptive style, which seemed appropriate for teens who value their own autonomy and independence, the researchers said. Cognitive behavioral skills training was chosen to assist adolescents who wanted to quit but lacked the skills to do so.

The telephone counseling employed in the intervention arm of the trial was based on the premise that smokers need to believe it is important to quit, have the confidence to quit and have the knowledge and skills needed to quit.

“Personalized telephone counseling can help one be successful with quitting smoking. Fortunately, telephone counseling is available nationwide through the state-run quit lines,” Peterson said.

Of the 1,058 identified smokers, 89.6% were eligible by parental consent, 80.4% were successfully contacted and invited to participate; 69.6% consented, 65.3% participated in at least one counseling call and 47.2% completed all planned counseling calls.

Counselors accurately assessed readiness to change in 92.9% of calls and administered the correct call type in 96.2% of calls, review of a random sample of calls showed.

Motivational Interviewing Treatment Integrity Code was used to evaluate counselor competence. Counselors achieved or exceeded the proficiency benchmark for empathy in 96.2% of calls and achieved or exceeded the proficiency benchmark for spirit in 99.1% of calls. Benchmarks were achieved or exceeded for ratio of reflections to questions in 97.2% of calls, and 85.7% of calls achieved or exceeded the benchmark for percent motivational interviewing adherence.

Counselor-initiated calls effective

Six-month prolonged smoking abstinence was achieved by 21.8% of teen smokers in the intervention group compared with 17.7% of those in the comparison group (95% CI, –0.2 to 8.1).

Among daily smokers, more teens in the intervention group (10.1%) than in the comparison group (5.9%) achieved quitting for six months (95% CI, 0.8-7.1). No evidence of intervention effect was observed for less-than-daily smokers (P=.19).

For all smokers, intervention affected smoking cessation with differences observed for duration since last cigarette (0.28; 95% CI, 0.04-0.51), seven-day smoking abstinence (7.5; 95% CI, 1.8-13.0), one-month smoking abstinence (6.8; 95% CI, 1.6-11.6) and three-month smoking abstinence (3.7; 95% CI, –0.6 to 7.8).

One-month and three-month smoking abstinence among teens assigned to telephone counseling were about three times higher than those from nearly 50 prior teen smoking cessation trials conducted during the past two decades, researchers said.

Compared with baseline, there was a decrease in the intervention group for reduction in smoking frequency (P=.054), number of days smoked in last month (P=.048) and number of cigarettes per day (P=.048).

“When a game-changing study provides new hope for how tobacco-using youth can be treated, the collective ‘ears’ of the public health community should perk to attention,” Leischow and Matthews said.

“This complex and elegant design brings together a rich variety of ‘ingredients’ that blend together into a scientific study that is very likely to set the standard for many years and will be a benchmark to which other similar studies will be compared,” they said. – by Christen Haigh

For more information:

• Kealey KA. J Natl Cancer Inst. 2009;101:1-13.
• Leischow SJ. J Natl Cancer Inst. 2009;doi:10.1093/jnci/djp333.
• Peterson AV. J Natl Cancer Inst. 2009;101:1-15.