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The HYP program—Targeted motivational interviewing for adolescent violations of school tobacco policy
Preventive Medicine 43 (2006) 466 – 471 www.elsevier.com/locate/ypmed
The HYP program—Targeted motivational interviewing for adolescent violations of school tobacco policy Adrian B. Kelly a,⁎, Kely Lapworth b a
School of Social Science, The University of Queensland, Michie Building, St Lucia 4072, Australia b Griffith University Psychological Health Research Centre, Australia Available online 21 August 2006
Abstract Objective. To evaluate the efficacy of a short-term tobacco-focused intervention for high school students referred by school administrators because of tobacco use. Method. A sample of 56 adolescents (66% male, mean age 15 years) was recruited through referrals from three state high schools. Participants were randomly assigned to a one-hour motivational interview (MI) session or to standard care (advice/education). The two groups were followed up at one, three, and six-month intervals. Results. The MI intervention resulted in significant short-term reductions in quantity and frequency of smoking relative to standard care, however, effects were not maintained at 3- and 6-month follow-up. Improvements in refusal self-efficacy were significant relative to standard care. Conclusion. For adolescents who are established smokers and at high risk of other problems, motivational interviewing was associated with modest short-term gains relative to standard care. © 2006 Elsevier Inc. All rights reserved. Keywords: High school students; Tobacco; Indicated prevention; Motivational interviewing; Efficacy
Introduction By the age of 19, the majority of adolescents in Western countries have smoked tobacco. In the United States, 64% of high school students have tried tobacco (Centres for Disease Control and Prevention, 2000). In Australia, about 57% of Australians under 19 have smoked a cigarette (Kelly et al., 2006). Furthermore, 20% and 33% of Australian and American high school students report smoking in the last month, with half of Australian adolescents who smoke reporting signs of nicotine dependence (Kelly et al.). The prevalence and well-established health consequences of tobacco use by teenagers provide a strong argument for identifying those who are at the early stages of their smoking career and intervening to stop smoking before the behavior becomes more firmly entrenched. High schools commonly have a policy of enforced smoking bans on school grounds (Wold et al., 2004). While disciplinary policies (typically involving suspension/expulsion) have numer⁎ Corresponding author. Fax: +61 7 33651544. E-mail address: [email protected] (A.B. Kelly). 0091-7435/$ - see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2006.06.018
ous benefits (e.g., promoting a health culture), the effectiveness of such responses for established smokers is unclear (Hamilton et al.). Suspension/expulsion may serve to strengthen deviant peer networks and involvement in other drugs. A less common high school policy is the provision of counseling to students who are caught smoking. Indeed, there is a poverty of empirical trials to guide education/health practitioners on what works for adolescent caught smoking (Garrison et al., 2003). The most systematically evaluated program, Project EX (Sussman et al., 2001), involves an eight-session group program delivered to adolescent volunteers from continuation high schools. The program resulted in 19% reporting greater than 30-day abstinence relative to a standard care control (10%). A strength of Project EX was its heavy focus on enhancing motivation to quit. However, pathways to participation in Project EX (e.g., voluntary response to flyers and brief public announcements) may have resulted in recruitment of students already motivated to quit. Project EX may generalize less well to students less motivated to attend such clinics. Given that adolescents commonly report strong attractions to drug use and they are sensitive and resistant to adult attempts
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to control or direct their behavior (Marlatt and Witkiewitz, 2002; Masterman and Kelly, 2003), motivational interviewing (MI) would seem well suited to adolescents caught smoking (Masterman and Kelly, 2003). MI is a client-centered approach that emphasizes rolling with resistance and the enhancement of both intra-personal conflict about risky behaviors and confidence about overcoming risky behavior patterns (Project MATCH Research Group, 1997, 1998). There is limited support for the utility of MI in reducing smoking at 3-month follow-up among further education college students in the UK (McCambridge and Strang, 2004). Furthermore, university students respond well to brief motivational enhancement for alcohol-related problems (Baer et al., 2001; Monti et al., 1999; Roberts et al., 2000), though one study found MI did not add significantly to a personalized feedback session (Murphy et al., 2004). The primary goal of this study was to evaluate the effectiveness of an individually delivered brief MI intervention for middle high school students caught smoking in the school context. It was hypothesized that participants receiving the MI intervention would report significant and meaningful reductions in tobacco use and increased refusal self-efficacy relative to those in a standard care (SC; education/advice) intervention. Method Participants Participants were 56 students (34% female) aged 14–16 years from three state high schools in Brisbane (Queensland, Australia). Participants were included if the drug of concern was tobacco and if parent/guardian active informed consent was obtained. The mean age was 15 years, average scholastic grade was ‘sound achievement’, and participants were from lower SES families (skilled workers). Participants reported smoking an average of 51 cigarettes/week and smoked on about 6 days of the week. Nicotine dependence levels were generally low [MTFQ mean score 3.6 (SD = 1.4, see Measures)].
Measures To assess smoking behavior, participants completed a quantity/frequency measure. Items included typical days in the last month where smoking occurred (tick boxes for days of the week), the number of cigarettes smoked on days where smoking occurred (completed for each typical smoking day), peak consumption on any day in the last month (Likert Scale from 0 ‘no cigarettes’ to 10 ‘31 cigarettes or more’), and frequency of this peak consumption (Likert Scale from 0 ‘none’ to 7 ‘12 or more times’). Clinical significance of change was based on 30-day abstinence rates prior to follow-up assessment. The Smoking Refusal Self Efficacy Questionnaire (SRSEQ) was used to measure confidence about refusing cigarettes across a range of situational and affective cues. The SRSEQ is based on the 29-item Drink Refusal Self Efficacy Questionnaire (DRSEQ: Young and Oei, 1996), with the instructional set modified to refer to smoking. The measure consisted of situational and affective precursors and used a 5-point Likert scale rating of smoking refusal likelihood (e.g., “How sure are you that you could resist smoking when you feel nervous?”). The 7-item MFTQ (Prokhorov et al., 1998) was used to measure nicotine dependence. The MFTQ has established test–retest reliability with adolescent samples and is sensitive to changes in smoking status over time (Prokhorov et al., 1998). Academic performance was measured by averaging grades reported by the student in the previous term (for math, literature, science, and arts) (1 ‘very low achievement, 3 ‘sound’, 5 ‘very high achievement’). Socioeconomic status
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was measured using Congalton and Daniel's (1976) seven-point Likert scale, which ranges from ‘1’ unemployed to ‘7’ professional. Design We used a two-group within-subjects MANOVA, with intervention as the between-groups IV (MI/SC) and time as the within-groups variable (preintervention, 1-, 3-, and 6-month follow-up). The key-dependent measures were tobacco use (days/week of smoking, quantity consumed on smoking days) and refusal self-efficacy. Students were randomly assigned to either the MI or SC conditions.
Procedure The referral procedure When a student was detected smoking by school administrators or teachers, they were referred to the Deputy Principal. As part of school policy, parents were contacted regarding their dependent's tobacco use, and participation in the HYP program was offered. Interventions were delivered once informed consent was received from a parent and the student.
Interventions The two interventions were delivered by the second author (KL), a PhD candidate and registered psychologist, with 4 years experience in adolescent psychotherapy. The therapist received 6 weeks of individual training in MI, viewed a professional training videotape series by the founding theorists/ researchers of MI (Miller et al., 1998), attended an advanced workshop on MI, and received ongoing supervision from the first author. A therapy manual was used to define and differentiate the content and process of the MI intervention and the SC condition. Both interventions were of one-hour duration. The two interventions reflected two different philosophies about health-related behavior change. The MI philosophy is that health-risk behaviors are commonly characterized by ambivalence or indifference, and an effective way of facilitating change is to resolve ambivalence/indifference through a nonconfrontational Rogerian style built on principles of selfresponsibility, empathy, empowerment, and rolling with resistance. The SC intervention was built on a widely used psychoeducation model, where knowledge dissemination/attainment is assumed to result in change. The interventions differed in content and focus. The MI intervention primarily explored the meaning of smoking in their lives, the positives and negatives of smoking/quitting, the impact of smoking on self-concept, health goals, and identification of obstacles to goal attainment (Miller and Rollnick, 1991). Ambivalence/indifference was a focus of the MI intervention but was not a focus of the SC condition. Reading materials were provided in both interventions, but in the MI, these were not reviewed in the session, whereas they were reviewed in the SC condition. The SC condition consisted of going through published reading materials on the effects of smoking (and other drugs) and a “Quit kit” on smoking. The MI intervention included information only where it related to the participant's direct experiences (e.g., effects of smoking on respiration if breathlessness in sport was reported), whereas the SC condition consisted of education about the broad effects of smoking regardless of the participant's experience. The therapy manual documented a number of behavioral indices that would normally characterize close adherence to the two interventions. Relative to the SC condition, the MI intervention would normally be characterized by: more talking by the participant than the therapist, open probes, summary statements aimed to develop discrepancy, asking permission of the student to extend/expand the content focus, and reflexive delivery of intervention components. The therapist regularly completed a behavioral checklist for each session to reduce content drift/contamination and promote discussion during supervision.
Results Recruitment and attrition are presented in Fig. 1. Participants were included in the study on an intention-to-treat
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Fig. 1. Participant selection and recruitment flowchart for Australian high school students caught smoking in the school context.
basis (i.e., informed consent conditions met, otherwise participants were excluded). In summary, a total of 130 participants were referred to the program. Of these, 68 parents/ guardians did not return their consent forms. Of the remaining 62, four adolescents did not attend the first session, and two that did attend the first session did not give informed consent. The remainder (n = 56) were randomly assigned to one of the two conditions. Six of these participants did not attend the one-month follow-up and were considered treatment failures. A further seven participants did not attend the three-month follow-up and were considered treatment failures at this time point. At six-month follow-up, a further two participants did not participate. One participant who completed the six-month follow-up did not complete the three-month follow-up. This participant had relapsed, and three-month follow-up data were assumed to reflect six-month follow-up data. All attritors were considered treatment failures, and Time 1 data on smoking were entered for all later time points. The overall attrition was 14 of 56 (25%).
To test for attrition bias, differences between attritors and nonattritors were tested using one-way ANOVAs on all demographic, psychological health, smoking, and drinking measures. There were no significant differences on any variables except mother's occupational status. Completers were more likely to have mothers who were unemployed or working in the home than attritors, F(1,50) = 4.4, p < .05. To test for differences between groups at Time 1, a series of oneway ANOVAs were conducted (see Table 1). Across all measures, there were two significant differences. In the SC condition, participants had higher average academic performance (high pass grade versus low pass grade) and a trend towards fewer smoking days per week (mean difference of about 1 day). Correlations between key-dependent measures at Time 1 were moderate in size (absolute r ranged from .44 to .52, p < .01). Changes in smoking quantity/day, number of smoking days/ week, and tobacco refusal self-efficacy were evaluated using a mixed model MANOVA, with condition (MI/SC) as the
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between-group independent variable and time (pre-intervention, one-, three- and six-month follow-up) as the within-subjects independent variable (see Fig. 2). Cell means, standard deviations, and F ratios are presented in Table 2. For number of smoking days/week, the overall model showed a significant effect for time, F(3,52) = 4.9, p < .01, a nonsignificant group effect, and a significant group by time interaction, F(3,52) = 6.43, p < .05. Relative to the SC group, MI was associated with significantly reduced number of smoking days at 1-month follow-up, but at 3- and 6-month follow-up, the two conditions were not significantly different. The SC condition did not show significant variation in smoking days/week over time. The observed power and partial eta squared for the significant interaction were 0.72 and 0.16, respectively, indicating an acceptable risk of Type II error and a small effect using Cohen's (1992) criteria. For quantity of cigarettes per smoking day, the overall model showed nonsignificant effects for time and group, and a significant group by time interaction, F(3,52) = 4.08, p < .01. Relative to the SC group, MI was associated with significantly reduced smoking quantity (on days when smoking occurred) at one-month follow-up, but at 3- and 6-month follow-up, the two conditions were not significantly different. The SC condition did not show significant variation in smoking quantity. There was an acceptable risk of Type II error (observed power = 0.79) and a small effect size for the interaction (0.18) (Cohen, 1992). For refusal self-efficacy, the overall model showed significant effects for time, F(3,52) = 5.92, p < .01, group, F(3,52) = 3.58, p < .05, and a trend towards a significant group by time interaction, F(3,52) = 2.73, p = .053. MI was associated with
Table 1 Demographic means (and standard deviation in parentheses) across groups for adolescents referred for smoking intervention Demographic variable
MI (n = 30)
SC (n = 26)
Overall mean/proportion
Age (years) Number of females Average grade*,1 SES of father SES of mother Global severity index (SCL-90R) Hostility (SCL-90R)
15.0 (1.0) 9 2.79 (0.75) 1.9 (1.7) 1.6 (1.3) 0.77 (0.63)
15.1 (1.0) 10 3.21 (0.63) 2.4 (1.4) 1.6 (1.8) 0.70 (0.73)
15.0 (1.0) 34% 3.0 (0.6) 2.1 (1.6) 1.6 (1.5) 0.74 (0.67)
1.23 (1.04)
1.24 (1.07)
1.24 (1.05)
52 (40) 6.6 (1.4) 3.6 (1.3)
49 (43) 5.7 (2.3) 3.6 (1.6)
51 (41) 6.2 (1.9) 3.6 (1.4)
9.6 (10.3) 1.3 (1.0) 4.1 (6.2)
10.9 (14.0) 1.6 (1.50) 3.1 (6.0)
10.2 (12.0) 1.4 (1.2) 3.6 (6.1)
Smoking and alcohol use Smoking (av/week) Smoking days/week2 Nicotine dependence (MTFQ) Alcohol (SDs/week) Drinking days/week Alcohol problems (RAPI)
Notes. MI = motivational interviewing. SC = standard care. Except where superscripted, one-way ANOVAs (by group) for dependent variables revealed no statistically significant differences at p < .05. 1F(1,54) = 4.66, p < .05. 2SC group showed a trend towards fewer days of smoking, F(1,54) = 2.95, p = .09. * 1 ‘very low achievement, 3 ‘sound’, 5 ‘very high achievement’.
Fig. 2. Australian students caught smoking in the school context: intervention effects on quantity of smoking/week, smoking days/week, and refusal self-efficacy.
significantly increased refusal self-efficacy at 1-month followup, and this improvement was maintained at 3- and 6-month follow-up. The SC condition also showed a significant improvement at 1-month follow-up, but this effect was not maintained at 3- or 6-month follow-up. Relative to the SC condition, there was higher refusal self-efficacy in the MI group at 3-month follow-up and a trend towards higher refusal self-efficacy at 6-month follow-up (p = .08). The risk of Type II error appeared elevated for this dependent variable relative to the previous ones (observed power = 0.63), and the effect size for the interaction was small (0.14). The rates of abstinence at each follow-up were compared across interventions. At one- and three-month follow-up, 6 (20%) of those receiving MI and 4 (15%) receiving SC reported abstinence. At six-month follow-up, 7 (23%) of those receiving MI and 4 (12%) receiving SC reported
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Table 2 Changes in primary dependent measures for Australian high school students caught smoking in the school context MI group
Smoking days Number smoked per week Refusal self-efficacy
SC group
F Ratio (3, 52)
Initial
F/U 1 month
F/U 3 months
F/U 6 months
Initial
F/U 1 month
F/U 3 months
F/U 6 months
Group
Time
Interaction
6.6 (1.4)a 52 (40)a 89 (24)a
4.6 (3.0)b 28 (34)bc 99 (29)ace
4.7 (3.0)b 42 (47)ac 108 (32)c
4.6 (3.1)b 42 (45)ac 109 (37)bcd
5.7 (2.3)ab 49 (43)a 84 (36)a
5.5 (2.7)ab 57 (52)a 99 (36)be
5.2 (2.8)ab 51 (46)a 89 (40)ab
5.8 (2.3)ab 57 (46)a 91 (40)ad
<1 1.5 1.79
4.9⁎⁎ 1.5 5.1⁎⁎
3.3⁎ 3.8⁎ 2.7a
Notes. F/U = follow-up. MI = motivational interviewing. SC = standard care. Means on the same line with the same superscripts are not significantly different from each other using simple t tests and the modified Bonferroni correction. Standard deviations are in parentheses. Trends are noted in the manuscript. ⁎ p < 0.05. ⁎⁎ p < 0.01.
abstinence. Chi-square tests of frequency differences were not significant. Discussion There were some modest short-term gains for the MI group relative to the SC group. Participants in the MI condition significantly reduced their smoking days/week and smoking quantity at one-month follow-up, and this improvement was significant relative to the SC group. The MI condition showed statistically significant improvements in refusal self-efficacy, and the SC group showed no statistically significant change. These results were partially consistent with prior research that MI produces short-term changes in smoking (McCambridge and Strang, 2004) and improvements in refusal self-efficacy (Brown et al., 2003). Despite the brevity of the interventions, the overall rates of 30-day abstinence at six-month follow-up (17%) compared favorably with longer tobacco cessation programs (17% for Project EX; Sussman et al., 2001). Using conservative criteria for movement from one distribution to another (Compas et al., 1998; Jacobson and Truax, 1991), evidence for clinically significant differences between the two interventions was low. However, the sample as a whole may have been at high risk of an upward and snowballing trajectory of tobacco use and other problems. Consistent with the high-risk nature of the sample, there was early onset of smoking (mean 10.5 years), disciplinary problems, poor academic performance, and relatively high rates of depression, anxiety, and hostility (see Dierker et al., 2004). If the sample was on an upward trajectory of smoking and other problems, stable/downward movement in smoking behavior in response to either intervention may have extra clinical significance. While our clinical impressions were that this sample was on an upward trajectory without intervention, this issue could only have been addressed with a wait list control group or possibly some form of retrospective baseline smoking measure. One of the anticipated challenges of HYP program implementation was the integration of a Rogerian-oriented intervention with a directive and disciplinary school process. Qualitatively, disciplined students often noted that the MI intervention was a more positive, non-judgmental, and helpful process than what they were expecting. While beyond the available data, it is possible that the parallel policies of disciplinary action and MI are more effective than discipline alone and that the combination lowers adolescent disengagement from
school. In partial support of this, other research has found that health-oriented interventions and disciplinary processes can interact to improve smoking-related outcomes. Hamilton et al. (2003) found evidence that a combination of discipline, education, and counseling was associated with better smoking outcomes than discipline only. It seems likely that a comprehensive intervention policy that includes MI is greater than the sum of its parts in arresting the high prevalence of smoking. Of concern was the number of participants that were excluded because active parental consent was not obtained (about half of referrals). We used a number of strategies to maximize the return rates, including follow-up phone calls, resending consent materials, sending prepaid envelopes, and asking the schools to follow-up the parents of referred adolescents. The results of the study may therefore not generalize to adolescents whose parents did not return consent forms. Consistent with this possibility, Langinrichsen-Rohling et al. (2004) found that adolescents whose parents did not provide active consent had more significant problems than those whose parents did return their forms. To ensure unrestricted access to substance abuse treatment for adolescents who may not otherwise seek assistance, the United States has federal legislation according minors the legal right to consent to treatment without the need for parental consent and guidelines specifically link the right for minors to consent to both treatment and related research (Brody and Waldron, 2001). Passive parental consent would go a long way towards resolving the selection biases inherent in active parental consent mechanisms (Frissell et al., 2004; Kelly and Halford, in press). It would also protect the rights of parents who receive the information, preserve potential parent–child discussion of sensitive issues, and keep communication lines between researchers and the community open. The study is limited by its sample size, reliance on selfreport data, and participant attrition (25%). It is possible that dropouts had escalated their smoking from Time 1 levels. While the design successfully detected modest intervention effects for smoking quantity/frequency, there was insufficient power to detect differences in follow-up abstinence rates. We had confidence in the reliability of self-report data given assurances of confidentiality and data independence, good rapport, and that parents were already aware of adolescents' smoking status. In conclusion, MI resulted in modest short-term reductions in smoking and improved cigarette refusal self-efficacy, relative to the SC condition. Both interventions resulted in good short-term abstinence rates, particularly given the brevity
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of the interventions, and the high-risk nature of the sample. Brief interventions like the ones in the present study may complement universal prevention and disciplinary strategies commonly used in Australian high schools. Acknowledgments The manuscript was completed during an NHMRC Career Development Award to the first author. The study was funded by NHMRC Project 189414 awarded to the first author. The authors thank the Principals and Deputy Principals of the high schools for their support of the program. References Baer, J.S., Kivlahan, D.R., Blume, A.W., McNight, P., Marlatt, G.A., 2001. Brief intervention for heavy drinking college students: four-year follow up and natural history. Am. J. Public Health 91, 1–8. Brody, J.L., Waldron, H.B., 2001. Ethical issues in research on the treatment of adolescent substance abuse disorders. Addict. Behav. 25, 217–228. Brown, R.A., Ramsey, W.E., Strong, D.R., et al., 2003. Effects of motivational interviewing on smoking cessation in adolescents with psychiatric disorders. Tob. Control 12, 1–11. Centres for Disease Control and Prevention, 2000. Youth tobacco surveillance—United States. Morb. Mort. Wkly. Rep. 2001 50, 1–84. Cohen, J., 1992. A power primer. Psychol. Bull. 112, 155–159. Compas, B.E., Haaga, D.A., Keefe, F., Leitenberg, F.J., Williams, H., 1998. Sampling of empirically supported psychological treatments from health psychology: smoking, chronic pain, cancer, and bulimia nervosa. J. Consult. Clin. Psychol. 66, 89–112. Dierker, L.C., Avenevoli, S., Goldberg, A., Glantz, M., 2004. Defining subgroups of adolescents at risk for experimental and regular smoking. Prev. Sci. 5, 169–183. Frissell, K.C., McCarthy, D.M., D'Amico, E.J., Metrik, J., Ellingstad, T.P., Brown, S.A., 2004. Impact of onset procedures on reported levels of adolescent alcohol use. Psychol. Addict. Behav. 18, 307–315. Garrison, M.M., Christakis, D.A., Ebel, B.E., Wiehe, S.E., Rivara, F.P., 2003. Smoking cessation interventions for adolescents: a systematic review. Am. J. Prev. Med. 25, 363–367. Hamilton, G., Cross, D., Resnicow, K., Williams, P., 2003. School policy: What helps to reduce teenage smoking? Nicotine Tob. Res. 5, 507–513. Jacobson, N.S., Truax, P., 1991. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J. Consult. Clin. Psychol. 59, 12–19. Kelly, A.B., Halford, W.K., in press. Responses to ethical challenges in conducting research with Australian adolescents. Australian Journal of Psychology.
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Kelly, A.B., Masterman, P.M., Marlatt, G.A., 2006. Tobacco-related associative strength in adolescents: A cross-sectional and contextual analysis. Nicotine Tob. Res. 8, 49–55. Langinrichsen-Rohling, Arata, Bowers, O'Brien, Klibert, 2004. Sensitive research with adolescents: Just how upsetting are self-report surveys anyway? Paper presented at the 38th Annual AABT Convention, Nov 18– 21. LA: New Orleans. Marlatt, G.A., Witkiewitz, K., 2002. Harm reduction approaches to alcohol use: health promotion, prevention, and treatment. Addict. Behav. 27, 867–886. Masterman, P.W., Kelly, A.B., 2003. Reaching adolescents who drink harmfully: fitting intervention to developmental reality. J. Subst. Abuse Treat. 24, 347–355. McCambridge, J., Strang, J., 2004. The efficacy of single-session motivational interviewing in reducing drug consumption and perceptions of drug-related risk and harm among young people: results from a multi-site cluster randomized trial. Addiction 99, 39–52. Miller, W.R., Rollnick, S., 1991. Motivational interviewing: preparing people to change addictive behaviour. Guilford Press, New York. Miller, W.R., Rollnick, S., Moyers, T.B., 1998. Motivational interviewing: Professional training series. CASAA: University of New Mexico. Monti, P.M., Colby, S.M., Barnett, N.P., Spirito, A., Rohsenow, D.J., 1999. Brief intervention for harm reduction with alcohol positive older adolescents in a hospital emergency department. J. Consult. Clin. Psychol. 67, 989–994. Murphy, J.G., Benson, T.A., Vuchinich, R.F., Deskins, M.M., Eakin, D., Flood, A.M., McDevitt-Murphy, M.E., Torrealday, O., 2004. A comparison of personalized feedback for college student drinkers delivered with and without a motivational interview. J. Stud. Alcohol 65, 200–203. Project MATCH, Research Group, 1997. Matching alcoholism treatments to client heterogeneity: project MATCH posttreatment drinking outcomes. J. Stud. Alcohol 58, 7–29. Project MATCH, Research Group, 1998. Therapist effects in three treatments for alcohol problems. Psychother. Res. 8, 455–474. Prokhorov, A.V., Koehly, L.M., Pallonen, U.E., Hudmon, K.S., 1998. Adolescent nicotine dependence measured by the Modified Fagerstroem Tolerance Questionnaire at two time points. J. Child Adolesc. Subst. Abuse 7, 35–47. Roberts, L.J., Neal, D.J., Baer, J.S., Marlatt, G.A., 2000. Individual drinking changes following a brief intervention among college students: Clinical significance in an indicated preventive context. J. Consult. Clin. Psychol. 68, 500–505. Sussman, S., Dent, C.W., Lichtman, K.L., 2001. Outcomes of a teen smoking cessation program. Addict. Behav. 26, 425–438. Wold, B., Torsheim, T., Currie, C., Roberts, C., 2004. National and school policies on restrictions of teacher smoking in seven European countries. Health Educ. Res. 19, 217–226. Young, R. McD., Oei, T.P.S., 1996. Manual for the drinking expectancy profile. Behaviour Research and Therapy Centre, University of Queensland, Brisbane, Queensland.
The HYP program—Targeted motivational interviewing for adolescent violations of school tobacco policy Adrian B. Kelly a,⁎, Kely Lapworth b a
School of Social Science, The University of Queensland, Michie Building, St Lucia 4072, Australia b Griffith University Psychological Health Research Centre, Australia Available online 21 August 2006
Abstract Objective. To evaluate the efficacy of a short-term tobacco-focused intervention for high school students referred by school administrators because of tobacco use. Method. A sample of 56 adolescents (66% male, mean age 15 years) was recruited through referrals from three state high schools. Participants were randomly assigned to a one-hour motivational interview (MI) session or to standard care (advice/education). The two groups were followed up at one, three, and six-month intervals. Results. The MI intervention resulted in significant short-term reductions in quantity and frequency of smoking relative to standard care, however, effects were not maintained at 3- and 6-month follow-up. Improvements in refusal self-efficacy were significant relative to standard care. Conclusion. For adolescents who are established smokers and at high risk of other problems, motivational interviewing was associated with modest short-term gains relative to standard care. © 2006 Elsevier Inc. All rights reserved. Keywords: High school students; Tobacco; Indicated prevention; Motivational interviewing; Efficacy
Introduction By the age of 19, the majority of adolescents in Western countries have smoked tobacco. In the United States, 64% of high school students have tried tobacco (Centres for Disease Control and Prevention, 2000). In Australia, about 57% of Australians under 19 have smoked a cigarette (Kelly et al., 2006). Furthermore, 20% and 33% of Australian and American high school students report smoking in the last month, with half of Australian adolescents who smoke reporting signs of nicotine dependence (Kelly et al.). The prevalence and well-established health consequences of tobacco use by teenagers provide a strong argument for identifying those who are at the early stages of their smoking career and intervening to stop smoking before the behavior becomes more firmly entrenched. High schools commonly have a policy of enforced smoking bans on school grounds (Wold et al., 2004). While disciplinary policies (typically involving suspension/expulsion) have numer⁎ Corresponding author. Fax: +61 7 33651544. E-mail address: [email protected] (A.B. Kelly). 0091-7435/$ - see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2006.06.018
ous benefits (e.g., promoting a health culture), the effectiveness of such responses for established smokers is unclear (Hamilton et al.). Suspension/expulsion may serve to strengthen deviant peer networks and involvement in other drugs. A less common high school policy is the provision of counseling to students who are caught smoking. Indeed, there is a poverty of empirical trials to guide education/health practitioners on what works for adolescent caught smoking (Garrison et al., 2003). The most systematically evaluated program, Project EX (Sussman et al., 2001), involves an eight-session group program delivered to adolescent volunteers from continuation high schools. The program resulted in 19% reporting greater than 30-day abstinence relative to a standard care control (10%). A strength of Project EX was its heavy focus on enhancing motivation to quit. However, pathways to participation in Project EX (e.g., voluntary response to flyers and brief public announcements) may have resulted in recruitment of students already motivated to quit. Project EX may generalize less well to students less motivated to attend such clinics. Given that adolescents commonly report strong attractions to drug use and they are sensitive and resistant to adult attempts
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to control or direct their behavior (Marlatt and Witkiewitz, 2002; Masterman and Kelly, 2003), motivational interviewing (MI) would seem well suited to adolescents caught smoking (Masterman and Kelly, 2003). MI is a client-centered approach that emphasizes rolling with resistance and the enhancement of both intra-personal conflict about risky behaviors and confidence about overcoming risky behavior patterns (Project MATCH Research Group, 1997, 1998). There is limited support for the utility of MI in reducing smoking at 3-month follow-up among further education college students in the UK (McCambridge and Strang, 2004). Furthermore, university students respond well to brief motivational enhancement for alcohol-related problems (Baer et al., 2001; Monti et al., 1999; Roberts et al., 2000), though one study found MI did not add significantly to a personalized feedback session (Murphy et al., 2004). The primary goal of this study was to evaluate the effectiveness of an individually delivered brief MI intervention for middle high school students caught smoking in the school context. It was hypothesized that participants receiving the MI intervention would report significant and meaningful reductions in tobacco use and increased refusal self-efficacy relative to those in a standard care (SC; education/advice) intervention. Method Participants Participants were 56 students (34% female) aged 14–16 years from three state high schools in Brisbane (Queensland, Australia). Participants were included if the drug of concern was tobacco and if parent/guardian active informed consent was obtained. The mean age was 15 years, average scholastic grade was ‘sound achievement’, and participants were from lower SES families (skilled workers). Participants reported smoking an average of 51 cigarettes/week and smoked on about 6 days of the week. Nicotine dependence levels were generally low [MTFQ mean score 3.6 (SD = 1.4, see Measures)].
Measures To assess smoking behavior, participants completed a quantity/frequency measure. Items included typical days in the last month where smoking occurred (tick boxes for days of the week), the number of cigarettes smoked on days where smoking occurred (completed for each typical smoking day), peak consumption on any day in the last month (Likert Scale from 0 ‘no cigarettes’ to 10 ‘31 cigarettes or more’), and frequency of this peak consumption (Likert Scale from 0 ‘none’ to 7 ‘12 or more times’). Clinical significance of change was based on 30-day abstinence rates prior to follow-up assessment. The Smoking Refusal Self Efficacy Questionnaire (SRSEQ) was used to measure confidence about refusing cigarettes across a range of situational and affective cues. The SRSEQ is based on the 29-item Drink Refusal Self Efficacy Questionnaire (DRSEQ: Young and Oei, 1996), with the instructional set modified to refer to smoking. The measure consisted of situational and affective precursors and used a 5-point Likert scale rating of smoking refusal likelihood (e.g., “How sure are you that you could resist smoking when you feel nervous?”). The 7-item MFTQ (Prokhorov et al., 1998) was used to measure nicotine dependence. The MFTQ has established test–retest reliability with adolescent samples and is sensitive to changes in smoking status over time (Prokhorov et al., 1998). Academic performance was measured by averaging grades reported by the student in the previous term (for math, literature, science, and arts) (1 ‘very low achievement, 3 ‘sound’, 5 ‘very high achievement’). Socioeconomic status
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was measured using Congalton and Daniel's (1976) seven-point Likert scale, which ranges from ‘1’ unemployed to ‘7’ professional. Design We used a two-group within-subjects MANOVA, with intervention as the between-groups IV (MI/SC) and time as the within-groups variable (preintervention, 1-, 3-, and 6-month follow-up). The key-dependent measures were tobacco use (days/week of smoking, quantity consumed on smoking days) and refusal self-efficacy. Students were randomly assigned to either the MI or SC conditions.
Procedure The referral procedure When a student was detected smoking by school administrators or teachers, they were referred to the Deputy Principal. As part of school policy, parents were contacted regarding their dependent's tobacco use, and participation in the HYP program was offered. Interventions were delivered once informed consent was received from a parent and the student.
Interventions The two interventions were delivered by the second author (KL), a PhD candidate and registered psychologist, with 4 years experience in adolescent psychotherapy. The therapist received 6 weeks of individual training in MI, viewed a professional training videotape series by the founding theorists/ researchers of MI (Miller et al., 1998), attended an advanced workshop on MI, and received ongoing supervision from the first author. A therapy manual was used to define and differentiate the content and process of the MI intervention and the SC condition. Both interventions were of one-hour duration. The two interventions reflected two different philosophies about health-related behavior change. The MI philosophy is that health-risk behaviors are commonly characterized by ambivalence or indifference, and an effective way of facilitating change is to resolve ambivalence/indifference through a nonconfrontational Rogerian style built on principles of selfresponsibility, empathy, empowerment, and rolling with resistance. The SC intervention was built on a widely used psychoeducation model, where knowledge dissemination/attainment is assumed to result in change. The interventions differed in content and focus. The MI intervention primarily explored the meaning of smoking in their lives, the positives and negatives of smoking/quitting, the impact of smoking on self-concept, health goals, and identification of obstacles to goal attainment (Miller and Rollnick, 1991). Ambivalence/indifference was a focus of the MI intervention but was not a focus of the SC condition. Reading materials were provided in both interventions, but in the MI, these were not reviewed in the session, whereas they were reviewed in the SC condition. The SC condition consisted of going through published reading materials on the effects of smoking (and other drugs) and a “Quit kit” on smoking. The MI intervention included information only where it related to the participant's direct experiences (e.g., effects of smoking on respiration if breathlessness in sport was reported), whereas the SC condition consisted of education about the broad effects of smoking regardless of the participant's experience. The therapy manual documented a number of behavioral indices that would normally characterize close adherence to the two interventions. Relative to the SC condition, the MI intervention would normally be characterized by: more talking by the participant than the therapist, open probes, summary statements aimed to develop discrepancy, asking permission of the student to extend/expand the content focus, and reflexive delivery of intervention components. The therapist regularly completed a behavioral checklist for each session to reduce content drift/contamination and promote discussion during supervision.
Results Recruitment and attrition are presented in Fig. 1. Participants were included in the study on an intention-to-treat
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Fig. 1. Participant selection and recruitment flowchart for Australian high school students caught smoking in the school context.
basis (i.e., informed consent conditions met, otherwise participants were excluded). In summary, a total of 130 participants were referred to the program. Of these, 68 parents/ guardians did not return their consent forms. Of the remaining 62, four adolescents did not attend the first session, and two that did attend the first session did not give informed consent. The remainder (n = 56) were randomly assigned to one of the two conditions. Six of these participants did not attend the one-month follow-up and were considered treatment failures. A further seven participants did not attend the three-month follow-up and were considered treatment failures at this time point. At six-month follow-up, a further two participants did not participate. One participant who completed the six-month follow-up did not complete the three-month follow-up. This participant had relapsed, and three-month follow-up data were assumed to reflect six-month follow-up data. All attritors were considered treatment failures, and Time 1 data on smoking were entered for all later time points. The overall attrition was 14 of 56 (25%).
To test for attrition bias, differences between attritors and nonattritors were tested using one-way ANOVAs on all demographic, psychological health, smoking, and drinking measures. There were no significant differences on any variables except mother's occupational status. Completers were more likely to have mothers who were unemployed or working in the home than attritors, F(1,50) = 4.4, p < .05. To test for differences between groups at Time 1, a series of oneway ANOVAs were conducted (see Table 1). Across all measures, there were two significant differences. In the SC condition, participants had higher average academic performance (high pass grade versus low pass grade) and a trend towards fewer smoking days per week (mean difference of about 1 day). Correlations between key-dependent measures at Time 1 were moderate in size (absolute r ranged from .44 to .52, p < .01). Changes in smoking quantity/day, number of smoking days/ week, and tobacco refusal self-efficacy were evaluated using a mixed model MANOVA, with condition (MI/SC) as the
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between-group independent variable and time (pre-intervention, one-, three- and six-month follow-up) as the within-subjects independent variable (see Fig. 2). Cell means, standard deviations, and F ratios are presented in Table 2. For number of smoking days/week, the overall model showed a significant effect for time, F(3,52) = 4.9, p < .01, a nonsignificant group effect, and a significant group by time interaction, F(3,52) = 6.43, p < .05. Relative to the SC group, MI was associated with significantly reduced number of smoking days at 1-month follow-up, but at 3- and 6-month follow-up, the two conditions were not significantly different. The SC condition did not show significant variation in smoking days/week over time. The observed power and partial eta squared for the significant interaction were 0.72 and 0.16, respectively, indicating an acceptable risk of Type II error and a small effect using Cohen's (1992) criteria. For quantity of cigarettes per smoking day, the overall model showed nonsignificant effects for time and group, and a significant group by time interaction, F(3,52) = 4.08, p < .01. Relative to the SC group, MI was associated with significantly reduced smoking quantity (on days when smoking occurred) at one-month follow-up, but at 3- and 6-month follow-up, the two conditions were not significantly different. The SC condition did not show significant variation in smoking quantity. There was an acceptable risk of Type II error (observed power = 0.79) and a small effect size for the interaction (0.18) (Cohen, 1992). For refusal self-efficacy, the overall model showed significant effects for time, F(3,52) = 5.92, p < .01, group, F(3,52) = 3.58, p < .05, and a trend towards a significant group by time interaction, F(3,52) = 2.73, p = .053. MI was associated with
Table 1 Demographic means (and standard deviation in parentheses) across groups for adolescents referred for smoking intervention Demographic variable
MI (n = 30)
SC (n = 26)
Overall mean/proportion
Age (years) Number of females Average grade*,1 SES of father SES of mother Global severity index (SCL-90R) Hostility (SCL-90R)
15.0 (1.0) 9 2.79 (0.75) 1.9 (1.7) 1.6 (1.3) 0.77 (0.63)
15.1 (1.0) 10 3.21 (0.63) 2.4 (1.4) 1.6 (1.8) 0.70 (0.73)
15.0 (1.0) 34% 3.0 (0.6) 2.1 (1.6) 1.6 (1.5) 0.74 (0.67)
1.23 (1.04)
1.24 (1.07)
1.24 (1.05)
52 (40) 6.6 (1.4) 3.6 (1.3)
49 (43) 5.7 (2.3) 3.6 (1.6)
51 (41) 6.2 (1.9) 3.6 (1.4)
9.6 (10.3) 1.3 (1.0) 4.1 (6.2)
10.9 (14.0) 1.6 (1.50) 3.1 (6.0)
10.2 (12.0) 1.4 (1.2) 3.6 (6.1)
Smoking and alcohol use Smoking (av/week) Smoking days/week2 Nicotine dependence (MTFQ) Alcohol (SDs/week) Drinking days/week Alcohol problems (RAPI)
Notes. MI = motivational interviewing. SC = standard care. Except where superscripted, one-way ANOVAs (by group) for dependent variables revealed no statistically significant differences at p < .05. 1F(1,54) = 4.66, p < .05. 2SC group showed a trend towards fewer days of smoking, F(1,54) = 2.95, p = .09. * 1 ‘very low achievement, 3 ‘sound’, 5 ‘very high achievement’.
Fig. 2. Australian students caught smoking in the school context: intervention effects on quantity of smoking/week, smoking days/week, and refusal self-efficacy.
significantly increased refusal self-efficacy at 1-month followup, and this improvement was maintained at 3- and 6-month follow-up. The SC condition also showed a significant improvement at 1-month follow-up, but this effect was not maintained at 3- or 6-month follow-up. Relative to the SC condition, there was higher refusal self-efficacy in the MI group at 3-month follow-up and a trend towards higher refusal self-efficacy at 6-month follow-up (p = .08). The risk of Type II error appeared elevated for this dependent variable relative to the previous ones (observed power = 0.63), and the effect size for the interaction was small (0.14). The rates of abstinence at each follow-up were compared across interventions. At one- and three-month follow-up, 6 (20%) of those receiving MI and 4 (15%) receiving SC reported abstinence. At six-month follow-up, 7 (23%) of those receiving MI and 4 (12%) receiving SC reported
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Table 2 Changes in primary dependent measures for Australian high school students caught smoking in the school context MI group
Smoking days Number smoked per week Refusal self-efficacy
SC group
F Ratio (3, 52)
Initial
F/U 1 month
F/U 3 months
F/U 6 months
Initial
F/U 1 month
F/U 3 months
F/U 6 months
Group
Time
Interaction
6.6 (1.4)a 52 (40)a 89 (24)a
4.6 (3.0)b 28 (34)bc 99 (29)ace
4.7 (3.0)b 42 (47)ac 108 (32)c
4.6 (3.1)b 42 (45)ac 109 (37)bcd
5.7 (2.3)ab 49 (43)a 84 (36)a
5.5 (2.7)ab 57 (52)a 99 (36)be
5.2 (2.8)ab 51 (46)a 89 (40)ab
5.8 (2.3)ab 57 (46)a 91 (40)ad
<1 1.5 1.79
4.9⁎⁎ 1.5 5.1⁎⁎
3.3⁎ 3.8⁎ 2.7a
Notes. F/U = follow-up. MI = motivational interviewing. SC = standard care. Means on the same line with the same superscripts are not significantly different from each other using simple t tests and the modified Bonferroni correction. Standard deviations are in parentheses. Trends are noted in the manuscript. ⁎ p < 0.05. ⁎⁎ p < 0.01.
abstinence. Chi-square tests of frequency differences were not significant. Discussion There were some modest short-term gains for the MI group relative to the SC group. Participants in the MI condition significantly reduced their smoking days/week and smoking quantity at one-month follow-up, and this improvement was significant relative to the SC group. The MI condition showed statistically significant improvements in refusal self-efficacy, and the SC group showed no statistically significant change. These results were partially consistent with prior research that MI produces short-term changes in smoking (McCambridge and Strang, 2004) and improvements in refusal self-efficacy (Brown et al., 2003). Despite the brevity of the interventions, the overall rates of 30-day abstinence at six-month follow-up (17%) compared favorably with longer tobacco cessation programs (17% for Project EX; Sussman et al., 2001). Using conservative criteria for movement from one distribution to another (Compas et al., 1998; Jacobson and Truax, 1991), evidence for clinically significant differences between the two interventions was low. However, the sample as a whole may have been at high risk of an upward and snowballing trajectory of tobacco use and other problems. Consistent with the high-risk nature of the sample, there was early onset of smoking (mean 10.5 years), disciplinary problems, poor academic performance, and relatively high rates of depression, anxiety, and hostility (see Dierker et al., 2004). If the sample was on an upward trajectory of smoking and other problems, stable/downward movement in smoking behavior in response to either intervention may have extra clinical significance. While our clinical impressions were that this sample was on an upward trajectory without intervention, this issue could only have been addressed with a wait list control group or possibly some form of retrospective baseline smoking measure. One of the anticipated challenges of HYP program implementation was the integration of a Rogerian-oriented intervention with a directive and disciplinary school process. Qualitatively, disciplined students often noted that the MI intervention was a more positive, non-judgmental, and helpful process than what they were expecting. While beyond the available data, it is possible that the parallel policies of disciplinary action and MI are more effective than discipline alone and that the combination lowers adolescent disengagement from
school. In partial support of this, other research has found that health-oriented interventions and disciplinary processes can interact to improve smoking-related outcomes. Hamilton et al. (2003) found evidence that a combination of discipline, education, and counseling was associated with better smoking outcomes than discipline only. It seems likely that a comprehensive intervention policy that includes MI is greater than the sum of its parts in arresting the high prevalence of smoking. Of concern was the number of participants that were excluded because active parental consent was not obtained (about half of referrals). We used a number of strategies to maximize the return rates, including follow-up phone calls, resending consent materials, sending prepaid envelopes, and asking the schools to follow-up the parents of referred adolescents. The results of the study may therefore not generalize to adolescents whose parents did not return consent forms. Consistent with this possibility, Langinrichsen-Rohling et al. (2004) found that adolescents whose parents did not provide active consent had more significant problems than those whose parents did return their forms. To ensure unrestricted access to substance abuse treatment for adolescents who may not otherwise seek assistance, the United States has federal legislation according minors the legal right to consent to treatment without the need for parental consent and guidelines specifically link the right for minors to consent to both treatment and related research (Brody and Waldron, 2001). Passive parental consent would go a long way towards resolving the selection biases inherent in active parental consent mechanisms (Frissell et al., 2004; Kelly and Halford, in press). It would also protect the rights of parents who receive the information, preserve potential parent–child discussion of sensitive issues, and keep communication lines between researchers and the community open. The study is limited by its sample size, reliance on selfreport data, and participant attrition (25%). It is possible that dropouts had escalated their smoking from Time 1 levels. While the design successfully detected modest intervention effects for smoking quantity/frequency, there was insufficient power to detect differences in follow-up abstinence rates. We had confidence in the reliability of self-report data given assurances of confidentiality and data independence, good rapport, and that parents were already aware of adolescents' smoking status. In conclusion, MI resulted in modest short-term reductions in smoking and improved cigarette refusal self-efficacy, relative to the SC condition. Both interventions resulted in good short-term abstinence rates, particularly given the brevity
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