For Teen Smokers, Supportive vs. In-Your-Face Advice to Quit Yields Same Results
From 1997 through 1999, researchers at the Brown University Center for Alcohol and Addiction Studies, Providence, R.I., carried out a pilot study to examine the efficacy of a motivational interviewing intervention for adolescent smokers.
The investigators recruited 85 adolescents aged 12 to 19 who smoked daily and who were receiving medical treatment for other conditions at Rhode Island Hospital's Pediatric Emergency Department or outpatient adolescent clinic.
The adolescents were randomly assigned to either the motivational interviewing intervention or a brief advice intervention. The 45-minute motivational interviewing intervention used a no confrontational approach that gave the adolescents personalized feedback on the physical, social, and economic effects of their smoking.
Adolescents who received the five-minute brief advice intervention were given firm advice to quit smoking as soon as possible and provided self-help materials.
- Preliminary results found that teens that received the motivational interview were no more likely to quit than teens who received just brief advice.
- The investigators found that more motivated teens were more likely to try to quit regardless of the intervention they received, and that the motivational interview may encourage adolescents to be more honest about their smoking.
- The investigators suggested that the intervention may have failed to yield results because it only targeted daily smokers (rather than sporadic smokers), and there were not sufficient follow-up or resources in the community to support adolescents interested in quitting.
The Robert Wood Johnson Foundation (RWJF) supported the project with a grant of $196,085 between April 1997 and December 1999.
Few effective smoking cessation treatments exist for adolescents, especially for those who are unlikely to be reached through traditional school-based interventions, such as high school dropouts. Prior to the RWJF grant, in 1996, in an effort to develop a motivational interviewing intervention for adolescent smokers in hospital emergency departments, investigators at the Brown University Center for Alcohol and Addiction Studies conducted several focus groups and a small pretest study of 40 teenaged smokers.
Half of the teenagers received the motivational interviewing intervention and half received brief advice on quitting from a health care provider. The study found that 22 percent of teens receiving the motivational interviewing intervention quit smoking following the intervention compared with 10 percent of the teens that received the brief advice.
Researchers at the University of New Mexico originally developed the motivational intervention for adults with substance abuse problems who were not motivated to change their behavior. They found that the most effective approach for those adults was no confrontational and nonjudgmental. Similar research showed that effective brief interventions (one to four sessions) included personalized feedback, rather than citing general statistics of the effects of substance abuse on people.
The grant from RWJF enabled the Brown University investigators to conduct a larger-scale pilot study of the intervention with adolescents. The study was conducted at Rhode Island Hospital's Pediatric Emergency Department and its outpatient adolescent clinic. The hospital is a large regional referral center serving primarily Hispanic, Afro/Caribbean, and Southeast Asian patients.
The investigators recruited 85 teenagers aged 12 to 19 who were daily smokers and who were receiving medical treatment at the hospital or clinic for other conditions. After being screened for eligibility, patients completed a detailed assessment of their smoking history, patterns, and other measures. The adolescents were randomly assigned to either the motivational interviewing intervention or the brief advice intervention. In addition, 48 of the adolescents' parents completed questionnaires about their own smoking and demographics, and about their attitudes toward their child's smoking.
Of the adolescents who were enrolled, 54 percent resided with parents, 12 percent lived with other relatives or foster parents, 22 percent were in state custody, and 11 percent lived alone, with peers or offspring. Some 14 percent of the teens were parents, 51 percent used marijuana, and 60 percent used alcohol. They also reported high rates of tobacco use among parents (81 percent) and best friends (73 percent). About 50 percent of teens reported that their parents were neutral or approved of their smoking and 73 percent said that it was very easy to get cigarettes.
In addition, 26 percent of the teens had quit high school or had been expelled. At the time of recruitment for the study, most teens had no plans to quit smoking within the next six months, although 69 percent had made one or more serious quit attempts in the previous year.
The motivational interviewing intervention was individually tailored to each teen's stage of readiness to change his or her smoking behavior. During the 45-minute sessions, a counselor explored the pros and cons of the teen's smoking, showed videotaped vignettes related to smoking, and provided personalized feedback on the effects smoking was already having on the teen's health. For example, teens had the level of carbon monoxide in their lungs tested, and, if above normal, they were given that information. Counselors also asked them about any physical symptoms they were experiencing, such as difficulty breathing, current or past inability to participate in sports, coughing, wheezing, and respiratory infections.
Counselors also asked them what percentage of teenagers they believed smoked (which participants typically greatly overestimated) and told them the actual percentage. Based on the numbers of cigarettes the adolescents smoked, counselors calculated how much money the adolescents would save if they cut back smoking by 50 percent or quit all together. Then counselors asked the adolescents what they would do with that extra money.
After presenting all of this information, counselors asked the adolescents for their reactions. Counselors tried to motivate them to make changes in their smoking habits, even if that simply meant smoking fewer cigarettes or waiting until later in the day to smoke the first cigarette. Counselors also helped each participant set up goals for change, identified barriers and strategies to address those barriers, and provided self-help referral materials and a referral list to smoking cessation programs in the community.
Teens assigned to the motivational interviewing intervention also received a telephone booster session one week after the baseline session. This phone session focused on confirming goals established at the end of the session, checking on progress related to those goals, discussing any barriers to change that were encountered, and reviewing strategies and resources available.
Adolescents who received the five-minute brief advice intervention were given firm advice to quit smoking as soon as possible and provided with self-help materials and a referral list of smoking cessation programs in the community. Both groups were asked to return at one, three, and six months after the first intervention for in-person follow-up interviews. Some 76 teens (89 percent) completed one-and three-month follow-up interviews and 69 teens (81 percent) completed six-month follow-ups. Researchers obtained biochemical validation of smoking status at all interviews.
- Adolescents who received the motivational interview were no more likely to quit smoking than those who just received brief advice.
- More motivated teens were more likely to try to quit regardless of the intervention they received.
- The motivational interview may encourage adolescents to be more honest about their smoking. Teens who received brief advice reported at follow up visits smoking fewer cigarettes per day than they had before receiving the advice, but they showed an increase in biochemical markers that measure the actual amount they smoke. However, adolescents who received the motivational interview had biochemical data consistent with their self-report of smoking. It may be that giving firm, directive advice to quit smoking to a teen reduces accurate reporting at subsequent visits, while collaboratively setting goals with the teen at least keeps them honestly talking about their smoking.
- Despite low motivation to change smoking behavior at the start of the intervention, teens expressed concern about the negative physical, social, and financial effect of their smoking, particularly those teens with higher levels of cigarette use and nicotine dependence levels. These findings suggest that the motivational interviewing intervention was targeting appropriate content areas for teens.
- This study included only daily smokers while the pilot study, which had better outcomes, included teens who smoked less frequently. It may be that the motivational interview approach works better with more sporadic smokers, investigators postulated.
- Considering the social context in which teen smoking occurs, and reviewing the baseline characteristics of this adolescent sample (e.g., high rates of living outside the parental home, early parenthood, other substance abuse, depression), it may be that a more intensive intervention was needed.
- More resources are needed in the community, investigators stated. Few adolescent-focused community resources exist to which to refer adolescents.
The investigators made seven presentations on the study. See the Bibliography for details.
- Institutional Review Board rules on including adolescents in studies can make it difficult for projects to recruit sufficient subjects. The investigators ran into difficulties recruiting adolescents for the study, in part because of a new policy instituted by the Institutional Review Board (IRB) at Rhode Island Hospital. In the past, the IRB had granted permission to researchers to obtain parental consent by phone. That enabled investigators to recruit adolescents, call parents and request their verbal consent for their children to participate in the study, and conduct the assessments and interventions with adolescents before they left the clinical site. During this study, the IRB mandated that written parental consent be obtained prior to delivering assessments and interventions to teens. This policy made it more difficult to recruit and retain adolescents in the study, investigators said. Instead of being able to quickly gain permission from parents by phone, investigators had to reschedule adolescents for their baseline appointment days after their clinic visit so that parents could sign the consent form. Nearly 50 percent of the adolescents who initially had been recruited and scheduled for their baseline appointment did not return for the appointment.
AFTER THE GRANT
The RWJF grant helped the investigators secure funds for Phase III of the trial from the National Institute on Drug Abuse (NIDA).
The study examined the efficacy of a brief motivational interview to reduce smoking among adolescents. The research team recruited 162 adolescents aged 14 to 18 years from medical, community and school settings. The team compared a group of adolescents who received a brief, non-confrontational, motivational interviews with personalized feedback and a seven-day follow-up telephone booster with a group that received standardized brief advice to quit smoking.
Parents of adolescents receiving the motivational interview also participated in a brief telephone session that aimed to increase parental support for the adolescent's goals for changing smoking.
The researchers assessed the adolescents in the study one, three and six months later.
Project director Suzanne Colby reported preliminary findings to RWJF in April 2008:
"Findings indicate that brief interventions for adolescent smokers result in decreased smoking quantity and that MI [motivational interviews with a booster] can decrease the number of cigarettes per day relative to BA [standardized brief advice]. However the brief interventions resulted in little abstinence: about 3 percent were abstinent at each follow-up."
GRANT DETAILS & CONTACT INFORMATION
Motivational Interviewing for Adolescent Smokers in an Emergency Department
Brown University Center for Alcohol and Addiction Studies (Providence, RI)
Dates: April 1997 to December 1999
Suzanne Colby, Ph.D.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Stein LAR, Colby SM, O'Leary T, Monti PM, Rohsenow D, Spirito A, and Riggs S. Response Distortion in Adolescents Who Smoke. Under review.
Presentations and Testimony
Peter M. Monti, "Reaching Teens through Motivational Interviewing for Substance Abuse in Medical Settings," at the Second Annual Research Symposium on Mental Health Sciences, Brown University Department of Psychiatry and Human Behavior and the Brown University School of Medicine, November 19, 1997, Providence, R.I.
Suzanne M. Colby, "Motivational Interviewing to Reduce Smoking Among Adolescents: A Medical Setting Intervention" at the 1998 Update on Adolescent Health Care: Working Together to Strengthen Resiliency in Youth, a training initiative sponsored by Hasbro Children's Hospital, Division of Adolescent Medicine and the RI Department of Health, Division of Family Health, May 29, 1998, Providence, R.I.
Suzanne M. Colby, "Brief Interventions and Motivational Interviewing for Adolescent Substance Use Prevention and Early Intervention," at the Rhode Island Substance Abuse Prevention Task Force Association Prevention Planning Forum, RISAPTFA and Rhode Island Department of Health, June 18, 1998, Providence, R.I.
Suzanne Colby, TA O'Leary, PM Monti, K Hayes, A Spirito, R Woolard, S Riggs, and W Lewander, "Indices of Nicotine Dependence Among Adolescent Smokers in a Hospital Setting," poster presented at the Annual Meeting of the Society for Research on Nicotine and Tobacco, March 57 1999, San Diego, Calif.
TA O'Leary and L Ruffolo, "Motivational Interviewing for Teen Smoking," at the Adolescents, Alcohol, and Substance Abuse: Reaching Teens Through Brief Interventions conference, October 23, 1999, Newport, R.I.
K Hayes, S Colby, A Spirito, T O'Leary, P Monti, and S Riggs, "Smoking and Quitting Pros and Cons: Adolescents' Open-Ended Self-Reports," at the Annual Meeting of the Society for Research on Nicotine and Tobacco, February 2000, Arlington, Va.
TA O'Leary, SM Colby, DJ Rohsenow, A Spirito, CA Eaton, T Dusablon, S Riggs, and PM Monti, "Development and Validation of an Adolescent Smoking Effects Questionnaire," poster presented at the Annual Meeting of the Society for Research on Nicotine and Tobacco, February 2000, Arlington, Va.
CM Saleeba, TA O'Leary, SM Colby, PM Monti, A Spirito, DJ Rohsenow, and S Riggs, "The Relationship Between Stages of Change and Smoking Cessation Strategies Among Adolescent Smokers," poster presented at the Annual Meeting of the Society for Research on Nicotine and Tobacco, February 2000, Arlington, Va.
L Stein, S Colby, T O'Leary, P Monti, D Rohsenow, A Spirito, and S Riggs, "Reducing Response Distortion in Teens," poster presented at the Annual Meeting of the Society for Research on Nicotine and Tobacco, February 2000, Arlington, Va.
SM Colby, PM Monti, TA O'Leary, NP Barnett, A Spirito, and DJ Rohsenow, "Motivational Interviewing for Adolescent Smokers: A Randomized Clinical Trial of Brief Intervention in Medical Settings," at the 62nd Annual Scientific Meeting of the College on Problems of Drug Dependence (CPDD), June 2000, San Juan, Puerto Rico.
Report prepared by: Susan G. Parker
Reviewed by: Janet Heroux
Reviewed by: Robert Narus
Program Officer: C. Tracy Orleans