The problem is getting us to stop

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Preventive Medicine 37 (2003) 209 –218

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The problem is getting us to stop What teens say about smoking cessation Nancy Vuckovic, Ph.D.,* Michael R. Polen, M.A., and Jack F. Hollis, Ph.D. Kaiser Permanente Center for Health Research, Portland, OR, USA

Abstract Background. Low participation and high dropout in many teen cessation programs may be due to lack of fit between teens’ needs and the way programs are delivered. Qualitative studies, designed to identify and understand preferences of intervention participants and barriers to participation, offer opportunities to customize programs and improve their reach and effectiveness. Methods. Two sets of focus groups with high school students were held in the Portland, OR, metropolitan area to elicit reactions to two smoking cessation programs and discuss motivations for and experiences with quitting. Thirty-three students (15 girls, 18 boys) participated in the first set of four focus groups; 40 students (21 girls, 19 boys) in the five focus groups for the second. Results. Participants preferred programs that respect the challenges that teens face in quitting, and acknowledge their choice in making the decision to quit. Teens wanted nonjudgmental and confidential support from cessation counselors, and preferred counselors who are ex-smokers, give useful quit tips, and can provide support for quit attempts. Private, computer-based programs and personalized telephone services were options for delivering cessation information and support. Conclusion. Teen smokers can supply valuable information to improve youth cessation programs to fit teen lifestyles, respect the challenges teens face, and acknowledge their choice in making the decision to quit. © 2003 American Health Foundation and Elsevier Inc. All rights reserved. Keywords: Teens; Smoking; Cessation; Focus groups

You try to encourage them not to smoke, but for those who already smoke it’s like it’s too late. It’s all I hear about when people are talking about smoking cigarettes is trying to find out why teenagers, why we do it. They just need to stop wasting money trying to figure out why teenagers smoke. That’s not the problem, about why we do it. It’s to get us to stop it. That’s what they need to concentrate on rather than why we do it. (Teen REACH participant)

Introduction A considerable amount of research is available on the prevention of smoking among teens in school settings

* Corresponding author. Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave., Portland, OR 97227, USA. Fax: ⫹1-503335-2424. E-mail address: [email protected] (N. Vuckovic).

[1–10] and community-based settings [11–16]. This focus on prevention in schools and through the media has certainly been important, but long-term outcomes have been disappointing [17]. Given this fact, it is more important than ever that we find ways to intervene with the large and growing population of newer teen smokers before they become fully addicted and firmly entrenched in the tobacco subculture. In contrast to prevention programs, few teen cessation programs have been tested [18], and most have produced disappointing results [16]. School-based cessation programs, for example, typically recruit relatively few adolescent smokers, experience high attrition rates, and yield low cessation rates in those who do participate [19]. Sussman et al. [20] worked with 16 rural and suburban high schools in two states. Students volunteering to participate were randomized to a cessation clinic or a wait-list control group. Assigned students were further randomized to either an addiction model or a psycho-social dependency model

0091-7435/03/$ – see front matter © 2003 American Health Foundation and Elsevier Inc. All rights reserved. doi:10.1016/S0091-7435(03)00115-4

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clinic. Recruitment was modest and attrition was high; 48% of students were lost from session 1 to session 5, and an additional 61% of session 5 attendees failed to attend the 3-month follow-up where outcome data were obtained. Based on the 3-month follow-up, and assuming students lost to follow-up were smokers, 8.4% of clinic participants were abstinent compared to 10.5% of controls, and these figures dropped slightly when corrected for biochemical verification. Similar findings were reported by Digiusto [21], who recruited students from Australian schools with similar problems in recruitment, attrition, and outcome. Pallonen et al. [22] used an interactive computer program for teens in a school setting and found quit rates of about 20%, though maintenance at a 6-month follow-up was poor. In another study, Hollis and colleagues [23] recruited 486 adolescent tobacco users between 14 and 17 years of age by means of a mailed screening questionnaire and an in-home assessment/recruitment procedure. The participation rate for identified smokers was reasonably good; about 40% of smoking respondents agreed to participate in the randomized trial of a cessation program. The program focused on a 1-hour visit with a trained nurse counselor who discussed teen health issues with smoking cessation as a priority and made a follow-up call. The intervention also included a teen cessation video, a cessation kit, and a series of newsletters. Despite these efforts, 1-year cessation outcomes for intervention and usual care participants were similar (36% versus 30%). The poor results of many teen cessation programs may be due to the lack of fit between the needs of teens and the setting and manner in which these programs are typically delivered. This mismatch leads to low participation and high dropout rates, especially in a school setting [1,4,5]. Qualitative studies, which are designed to identify and understand the preferences of intervention participants and their barriers to participation, offer opportunities for investigating why existing programs are not attractive to teens and identifying program features that could contribute to relevant, successful interventions. Balch [24] conducted nine focus groups with high school smokers to assist development of tobacco cessation program for teens. He found that teens were unfamiliar with the idea of smoking cessation programs and had difficulty conceptualizing the content or utility of such programs. When asked to imagine what school-based cessation programs would be like, teens said they would not trust school personnel and locations, and anticipated that counselors would be lecturing, nagging, and preaching. Teens were highly sensitive about confidentiality and wanted caring counselors they could trust and to whom they could relate. Recommendations for program development include incorporating information about other substance use, positioning smoking cessation as “preparation for adulthood,” and building in stress management and strategies for helping teen smokers deal with smoking peers. Other qualitative studies of adolescent smoking also con-

tribute to our understanding of teens’ motivations to continue smoking, and offer suggestions for areas to emphasize in interventions. For example, in an ethnographic study of teenage girls, Nichter et al. [25] found that stress reduction and relaxation were important reasons for smoking among adolescent girls, and need to be addressed in smoking prevention and cessation programs. Other studies have examined how teens develop an individual identity as “a smoker” that includes engaging socially with other smokers [26]. Stromberg and King, in an unpublished theoretical overview of culture and cigarette smoking, discuss concerns that a smoker’s personal identity and group membership must be renegotiated after cessation. Hines [28] used qualitative methods to identify important attributes of a teen cessation program. These included cost, convenience, and the ability to be in charge and quit on one’s own. About 50% of teens said they would use a free program, whereas only 20% would use a program costing $25. These studies underscore the need for cessation programs that address teens’ needs for convenient, confidential, and respectful cessation support and address concerns that are specific to teens’ developmental stage and lifestyle. These qualitative studies provide important indications of how cessation programs aimed at teens can be improved, but lack connection to specific programs. In this report, we describe the use of focus groups to elicit teens’ opinions and ideas about two smoking cessation programs for adolescents. We also examine how these data provide information on adolescent concerns and values that speak more globally to their needs and preferences, and thus generalize beyond specific programs. We report on nine focus groups conducted as formative research for two cessation programs at the Kaiser Permanente Center for Health Research. Participants in the two sets of focus groups were asked to talk about their experiences trying to quit smoking and to suggest ways to improve the smoking cessation programs.

Methods We conducted focus groups with Portland-area teens as part of our developmental work for two teen smoking studies implemented by the authors at the Center for Health Research in Portland, OR—Teen REACH and the Teen Quitline. Teen REACH tested the long-term efficacy of brief clinician advice, the Pathways to Change (PTC) expert-system interactive computer program developed at the University of Rhode Island [22], and brief motivational support for reducing the prevalence of smoking among teens being seen for routine primary care. The Teen Quitline project developed a multisession telephone cessation intervention for youth between the ages of 15 and 18. “Phone coaches” worked with teen smokers to prepare them to set a quit date, and to offer support after cessation. Teens enrolled in the program also received written materials and

N. Vuckovic et al. / Preventive Medicine 37 (2003) 209 –218 Table 1 Characteristics of focus group participants

Gender Female Male Age (years) Race Caucasian African American Asian American Hispanic Smoking status

Teen REACH (n ⫽ 33)

Teen Quitline (n ⫽ 40)

15 18 14–16

21 19 14–16

27 4 1 1 Nonsmokers, current smokers, ex-smokers

36 1 1 2 Current smokers, ex-smokers

a “Quit Kit” that included chewing gum, straws, and objects like worry stones and puzzles. During program development (Teen Quitline) and usability testing (Teen REACH), we conducted focus groups with area teens to discuss smoking habits, motivations to quit, and experience with cessation, as well as to review materials or program features specific to the individual projects. We recruited students from selected inner city and suburban high schools for focus groups to achieve a distribution of socioeconomic and ethnic groups. Teens were recruited through teachers, counselors, and student health clinic nurses, using information and flyers provided by the studies. All volunteers who met study criteria were included in the focus groups. The study protocols for each set of focus groups were approved by the Institutional Review Board of the Kaiser Permanente Center for Health Research. We obtained informed consent from all participants. Parental consent was not required because Oregon law permits adolescents 15 and older to provide consent. Nonsmokers were recruited for Teen REACH, because materials discussed both tobacco use prevention and cessation. While smokers clearly had different experiences about smoking, both smokers and nonsmokers were able to speak to our questions about reasons teens smoke and motivations to quit, and to respond to our questions about program elements (e.g., characteristics of narrator). We found that differences in smoking status did not create a combative dynamic. Only self-identified smokers and ex-smokers (quit in last year) were recruited for Teen Quitline focus groups. As an incentive to participate in the groups, we served pizza and gave students who participated passes to local movie theaters. A total of 33 students (smokers and nonsmokers) participated in the four groups for Teen REACH. Forty students (smokers and ex-smokers) participated in the five Teen Quitline focus groups. Teen REACH focus groups were mixed gender. For Teen Quitline, we conducted two groups with boys, two groups with girls, and one mixedgender group. Table 1 contains descriptors of focus group participants for each study.

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Using established methods [29 –32], focus groups were led by trained facilitators, including one of the authors (N.V.), who is an anthropologist with extensive experience in qualitative research methods. An assistant was present at each focus group to take notes and to provide logistical support. All focus groups were observed by another member of the research team, and were audiotaped for analysis and review by other project members. The focus groups took place at the high schools, and lasted 1 hour to accommodate students’ schedules. Each project had its own interview guide, which provided direction for the facilitator and ensured that the same topics were covered at each focus group. The order in which these questions were asked and the probes used to encourage discussion and clarify responses varied from group to group, in response to the flow of the conversation and group dynamics. Each set of focus groups began with questions about the benefits and drawbacks of smoking, motivations for quitting, experiences quitting, and quit strategies. Participants were then asked to react to elements of the program under development. In Teen REACH, focus group participants completed the Pathways to Change computer program prior to the discussion and were asked to comment on specific features of the program, including ease of use, phrasing of messages, and preferences of narrator and music. Focus groups for the Teen Quitline project were held during the formative phase of the project, prior to material development. The facilitator described program elements to participants in these focus groups and asked for comment on these features. Each set of focus group data had been independently coded and content analyzed for the benefit of the sponsoring project. Analysis consisted of identifying and summarizing answers to specific questions (e.g., preference for type of narrator) and examining thematic elements found throughout the text (e.g., social aspects of smoking). After data from the two sets of groups had been analyzed, the authors noted the similarity in findings and reevaluated the transcripts as a single body of data. This analysis examined common questions (e.g., motivations to smoke) and common thematic elements (e.g., need for autonomy). In this report we describe reactions to program-specific features as well as themes common to both sets of focus groups. The source of quotes used to illustrate reactions and themes is indicated.

Results and discussion Who is a smoker? As noted above, the Teen REACH focus groups included teens who self-identified as smokers, nonsmokers, or exsmokers. The Teen Quitline focus groups were limited to self-identified smokers and ex-smokers. In each set of focus groups, we asked smokers and ex-smokers to talk about their smoking history. Smoking histories were recorded for

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36 of the 40 Teen Quitline participants. Of the 33 current smokers, most (21 of 33) had extended histories of smoking that began in junior high school or earlier. A smaller number said they had started in the past year or two (n ⫽ 6), or had smoked for less than 1 year (n ⫽ 6). Overall, long-term smokers indicated that they smoked more regularly or “seriously” than smokers who began in the last year or two, although there was considerable differences in self-description of smoking patterns, even among participants with long histories of smoking. Motivations for smoking Teens in both sets of focus groups reported the following motivations for smoking that were consistent with other studies: stress, boredom, to look older, to fit in, because friends smoke, because parents smoke, to decrease appetite, and to increase the high from alcohol and drugs [19,33]. Smoking also served as a social marker that the smoker was “not a baby.” At parties, smoking was “kind of a ritual”: “If you’re drinking, then you’ve got to be smoking.” Smoking cigarettes was something to share with friends and do when having fun. Teens acknowledged that being around people who smoke provides strong cues and incentives for smoking. Yet at the same time, they were adamant that peer pressure did not cause smoking: “It’s not like people are forcing you or saying ’here, have a cigarette.’ It’s still your decision” (Teen REACH participant). Motivations to quit We asked motivation to quit in the course of focus group discussions, but did not assess participants’ readiness to quit or degree of motivation. When asked generally about interest in quitting, most smokers participating in our focus groups said they wanted to quit—if not immediately, at least some time in the near future. Many of these teens said they had attempted to do so though only a few had been successful. When asked what might prompt them to quit smoking— or prompted them in the past to attempt to quit—teens cited factors such as being sick of the smell of cigarettes, family members who were sick or died as a result of smoking, the cost of cigarettes, decline in athletic or artistic performance, and requests to stop from a boyfriend or girlfriend. Teens in both studies agreed that quitting is a personal decision that cannot be forced by adults or even peers: “You can give them all of the information in the world, ride them as hard as you want, it’s not going to make them change their mind. They’ve got to do it themself [sic]” (Teen Quitline participant). Experience with cessation Teens who had never tried to quit could only draw on what they had heard or witnessed about the quitting expe-

riences of friends and family members. Their impressions from what they saw were that quitting is difficult, that it might make you gain weight or increase your stress, and that you might have to change your friends or social habits to be successful. A couple of people have actually succeeded. They just stopped hanging out with the same crowds. You know, and I don’t want to just stop being friends with all the friends that I have, ⬘cause I think my friends are awesome and I’m not about ready just to stop hanging out with them’ cause they smoke and I want to quit. (Teen Quitline participant)

Teens who had tried to quit could relate examples of methods they used in their attempts, but did not feel they were successful strategies. Strategies they tried included quitting cold turkey, cutting down, keeping busy (with work, vacation, or sports), using nicotine replacement patches or gum, not buying cigarettes, chewing gum or straws, and staying away from people who smoke. Some had gotten assistance from programs in their school-based clinics. Participants with cessation experience acknowledged that quitting was difficult and relapse easy, especially in times of stress. Because quitting was so difficult, being motivated to quit was essential. As one participant said “You can’t just say ‘I’m gonna quit’ and not really want to.” Social consequences of quitting Being a smoker was associated with having particular friends, going to particular places, and engaging in smoking as part of social interaction. As noted above, some teens felt that quitting would be “a big lifestyle choice” because “people that don’t smoke don’t normally hang out with people that do smoke. . . . I don’t have a lot of friends that don’t smoke” (Teen Quitline participant). Several teens reported that friends— both those who smoke and those who do not— do not take a smoker’s quit attempt seriously and would not be supportive of their attempts to quit. Friends’ lack of confidence in the smoker’s ability to quit undermines their resolve to quit and makes the attempt seem futile. It also made the concept of receiving cessation support seem unrealistic to some. When friends say ‘you’re not going to quit, you’re not going to quit,’ then you just start smoking again. Well if they don’t believe, then shoot, I don’t care. I don’t really care anymore. Nobody cares if I smoke or not. I’m going to smoke. . . . I just think if you want to quit, just do it on your own. (Teen REACH participant)

What would help teens quit? We asked teens to suggest ways to help them and other teens quit smoking. Their responses included suggestions about the content of programs as well as recommendations about the way in which such programs should be delivered.

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Information The responses of teens in our focus groups suggested that they lacked practical knowledge about how to go about quitting. Like my best friend is a smoker. She’s been smoking since she was 14. She knows she shouldn’t [smoke]. And she’s tried to quit. She just doesn’t know how to quit. And I think it’s more important to like focus on the kids who want to quit but don’t know how. (Teen Quitline participant)

Teens wanted information on what to expect physically and emotionally during cessation, and how long such effects would last. They also asked for suggestions about what to do instead of smoking that fit into their life. A participant in the Teen REACH focus groups liked the project’s computer program because it offered specific strategies for quitting: “It gave me a strategy to not smoke 30 minutes after I wake up in the morning, because that’s the first thing I do. I go in my garage and smoke, because that’s like my morning coffee.” Several teens claimed to know all about the effects of tobacco use because of exposure to school-based tobacco prevention programs: “There isn’t any 17 year old out there that hasn’t heard all this before. Who’s going to listen to it? I mean, we’ve been getting it since [grammar school]” (Teen Quitline participant). Others, however, felt that reinforcing information about health effects of smoking in a way that was proximal and tangible to teens might encourage them to quit. I think that like if you target kids who sing and say ‘if you smoke, you’re not going to be able to sing any more.’ Or you target kids with basketball and say ‘you’re not going to be able to breathe as well.’ And you see it in kids who smoke. It affects them. And they can’t do what they used to do as well. (Teen Quitline participant)

Still other participants felt that graphic pictures of health effects, such as blackened lungs, would be a powerful influence on teens’ motivation to quit. Support Even though the decision to quit had to be made by the smoker alone, teens felt that having someone support them in the quit attempt would be important. A friend— or at least another teen—was the most agreeable source of support. However, teens did not expect to get much support from friends. I’m sick of smoking. I need to quit. And you’re gonna need people to help you. You’re not gonna be able to do it by yourself. At least I’m not. I’ll start pulling my hair out. (Teen Quitline participant)

When we introduced the concept of telephone cessation support in Teen Quitline focus groups, participants were initially skeptical that such a program would work. Teens had trouble conceptualizing how a stranger (the program counselor or “coach”) could provide the type of commiser-

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ation and support they expected to need during a quit attempt. We asked to teens to put aside misgivings and consider components of the program— e.g., characteristics of counselors, content of program—and found they were able to provide concrete, constructive suggestions. They then stressed the importance of staffing cessation programs with people who take the time to learn about teens’ lives and stressors, and aren’t “the smoking police.” In the words of one participant, “Care about my life, not just that I smoke.” Teens felt it was important that counselors take an interest in the teen as a person, not just a smoker: “First you have to understand what’s going on in a person’s head before you start to solve the problem. First you have to know what the problem is.” Teens wanted counselors’ who have themselves quit smoking, because they would understand what it was like to quit and could provide strategies that worked for them. I think it’s irritating when people who don’t smoke, and have never really been addicted to cigarettes, try to tell you stop smoking. ‘It’s not good for you.’ I think that irritates me more than anything, because I’d just like to ask them “Have you ever been addicted to cigarettes?” (Teen Quitline participant)

The age of the counselor did not matter to most participants, as long at the counselor could be empathetic and “connect” with teens: “Someone who knows what they’re talking about. . . . You know, like someone that knows about kids and their problems” (Teen Quitline participant). Some participants, however, felt that someone close to them in age would be best because someone older (the age of parents or teachers) would make teens “feel pressured in a way. . . . Like you have to do what the older person says” (Teen Quitline participant). Respect As noted previously, teens felt it was their decision to smoke or to quit smoking, not something that could be forced upon them. Participants in the Teen REACH focus groups were asked to evaluate text for the computer program’s narration, and given examples of alternate wording for statements that recommended qutting. Teens consistently preferred text that explicitly acknowledged teens’ independence and autonomy. Participants liked that these messages made quitting “our personal decision” and that “It’s giving you ideas, not telling you that you have to do something.” Teens in all focus groups repeatedly said they did not want “people on our back” about smoking, and noted “you have to have the willingness to do it yourself instead of someone else yelling at you all day.” They wanted to be able to “choose your own way” to first decide to quit and then to decide on a quit strategy they thought would work for them. Teens also said they did not want to be stereotyped as bad students, drug users, or “losers” just because they smoked. Whether commenting on program content or delivery,

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participants wanted counselors and materials to communicate a respectful and nonjudgmental attitude about quitting. Teens did not want to feel pressured to quit, or be made to feel guilty if they relapsed. “Don’t be preachy” summarizes the thoughts of several participants. Teen REACH participants, commenting on alternate versions of program text, preferred versions written to be noncritical. They rejected text that “sounds like it’s criticizing you, like you’re not trying hard enough. ‘If you’re serious, you need to try harder’ and stuff like that.” Delivering cessation programs to teens One aim of our focus groups was to explore which methods of contact would be most appealing to teens, and which would work best with their lifestyles. The Teen REACH study proposed to offer a computer-based program at medical clinic visits, coupled with brief messages from the teen’s clinician (in person) and an interventionist (by phone). Teens generally liked the confidentiality of working with a computer program because it was more private than “sharing your problems with the whole world.” Most participants felt that having the program in the medical office was acceptable, providing it was “totally confidential” and they were assured “we’re not going to tell your parents.” A few participants felt that completing a private, computer-based program was fine, though they already received a lot of anti-smoking information from their health care provider and did not want to receive additional advice. When you go to the doctor you see a lot of like warnings and stuff and you’re like, OK, they’re going to hassle me some more about this. But if you could get it as your own little thing, and go through it and get your own advice, I think that would be better.

Others’ reactions to talking to a health care provider about smoking centered on the approach taken by the clinician, saying “It all depends on the person” and their style of delivery. Participants thought it was acceptable to talk about health effects but “if he says ‘smoking’s going to kill you and you’re going to die because you smoke’ then I’d be like ‘well I don’t want to talk to you.’” The Teen Quitline study proposed to offer telephonebased cessation support to teens. We explained to participants that teens themselves would initiate contact with the Teen Quitline, establish a quit date, and then receive calls from a “coach” to support them as they were quitting. We addressed the issue of confidentiality with Teen Quitline focus group participants, particularly as it related to receiving support calls at home. Some teens noted that receiving calls like this could create problems for teens that had kept their smoking a secret from family members. Arranging to call in to the Teen Quitline was

offered as a suggestion for those who did not want to receive incoming calls. For the majority of teens, however, receiving calls at home would not create family conflicts. These teens did note, however, that reaching them at home could be a problem because they were often not at home due to school, work, and social activities. Scheduling a time would help, but not guarantee that the teen would be at home. We asked if pagers or loaned cell phones would help ensure that teens kept in contact with the Quitline coaches. Although the idea of receiving free equipment (if only for the duration of their participation) was appealing to teens, they said that in all honesty they probably would not answer pages or take cell phone calls from the Quitline unless they were alone and it was a convenient time to do so. Confidentiality was also an issue when considering mailing cessation materials to teens’ homes. Although most teens in our focus groups said their parents knew they smoked, they acknowledged that this was not true for all teen smokers. They pointed out that for teens whose parents were unaware that they smoked, receiving information at home would create problems. Alternative suggestions offered were to mail information to a friend’s house, and to make materials available for pick up at a central location (e.g., a health clinic or school). As noted above, Teen Quitline participants were initially skeptical that a stranger could provide support to them during a quit attempt. They stressed the need for counselors to reduce the anonymity and distance by learning something about the teen’s life and being concerned about more than just the teens’ smoking status. This desire for personal attention fueled teens’ rejection of an idea to incorporate automatic voice messaging (AVR) support as part of the Quitline.

Implications and suggestions for teen cessation programs Findings from the two studies described in this report reveal remarkably consistent messages about what teens need and want from tobacco cessation programs (Table 2). We specifically sampled in each set of focus groups to examine distinctions based on socio-economic status (SES) and gender. Although groups displayed some differences in the ways ideas were articulated and in their preferences for elements of program materials (e.g., music and graphics), their discussions about why they smoke, motivations for quitting, and experience with quit attempts did not display major differences based on either gender or SES. Our findings are also consistent with data from other research with teens [24,25], and strengthen our conclusion that these findings have relevance beyond our projects and population. We summarize these findings, along with their implications for youth cessation programs.

N. Vuckovic et al. / Preventive Medicine 37 (2003) 209 –218 Table 2 Principal findings from focus groups Motivations for smoking: Stress, boredom, to look older, to fit in, because friends do, because parents smoke, to decrease appetite, and to increase the high from alcohol and drugs, as a social ritual. Motivations to quit: Being sick of the smell, family members who were sick or died as a result of smoking, the expense, decline in athletic or artistic performance, or a boyfriend or girlfriend who requests that they stop. Expectations of quitting: Quitting is difficult, might cause gain weight or increased stress, requires change in social circle, change of lifestyle. Ways to help teens quit smoking: Provide information about smoking effects, what to expect during cessation. Offer support by taking interest in the teen as a person, not just a smoker. Use counselors that are ex-smokers so they can understand quit experience and provide useful quit tips. Treat teens with respect. Respect their autonomy and independence, be nonjudgmental. Respect teens’ confidentiality. Social impact of quitting: Teens fear that quitting will mean an end to current friendships.

Who is a smoker? The smoking behavior described by teens is variable. Some committed smokers in our focus groups described behavior that was consistent with the smoking habits of adult, long-term smokers. Others described an ability to mold their smoking behavior to circumstances—smoking less or not at all on family vacations, smoking more when they were hanging out with friends. These findings are consistent with previous research on teen smokers [24,25]. The variability in smoking behavior and labeling reported by teens has implications for counseling. A teen’s response to the question “Are you a smoker?” may reveal little useful information for counseling. Finding face valid ways to ask teens about smoking behavior is a useful step in understanding what type of information and assistance could support cessation. Nichter et al. [25] provide examples of questions derived from ethnographic research with teenage girls. Those who defined themselves as “smokers” included girls who smoked a few or many cigarettes in a week. Other girls who did not define themselves as smokers engaged in social smoking— having a few cigarettes on weekends in the company of friends. Surveys about smoking status conducted for the Teen Lifestyle Project offered response categories that included “I’m not a smoker, but I’ll have a cigarette every once in a while” and “I only smoke at parties” [25]. These questions acknowledged that some teens do not identify as smokers, but are situational smokers. Similar questions that focus on behavior and the context of smoking, rather than asking teens to label themselves as “a smoker,” may help counselors and clinicians to identify

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experimenters and occasional users of tobacco as well as more regular users, and elicit information that can be used to tailor cessation support. Motivations to quit Many of the teens we interviewed who considered themselves regular smokers expressed an interest in quitting. As noted previously, several of these teens had tried unsuccessfully to quit at least once. This suggests that teens are trying to quit, but are failing because they lack the knowledge and skills to quit and support for their quit attempts. Findings from the intervention phase of the Teen REACH program (n ⫽ 2526) support these qualitative findings [34]. Among study participants who self-identified as current, regular smokers (n ⫽ 348), 67.5% indicated that they were serious about quitting in the next 6 months, and 33.6% indicated that they were planning to quit in the next 30 days. Seventynine percent of respondents who smoked in the last year (n ⫽ 532) reported that they had made at least one quit attempt; 52% had made two or more attempts to quit. Similarly, a literature review by Sussman and colleagues [3] found that most regular teen smokers want to quit and 55– 65% have tried. Surveillance data also suggest that many adolescent smokers are motivated to quit and have tried to quit smoking, but that success rates are low [35,36]. National surveys of teens in high school also indicate that the majority of teen smokers want to quit and most have tried in the past year. In 2000, for example, 61.0% of current smokers reported they want to stop smoking and 59.3% had tried to quit in the past year [37]. These findings argue against the notion that teen smokers do not want to quit smoking, and strongly suggest that many teen smokers’ desire to quit are legitimate and require support to make them effective. Social influence vs. social pressure While teens say they do not feel pressured to smoke, they acknowledged powerful social influences to smoke. Study findings from the intervention phase of the Teen REACH study likewise identified the influence of friends. In that study, participants who reported that more than half of their friends smoked were 17 times more likely to smoke than respondents with few or no friends who smoked [34]. Despite teens’ claims that peer influences do not explicitly “cause” them to smoke or hinder them from quitting, the importance of peer influence was noted prominently in discussion of both onset and cessation processes. Cessation programs directed at teens need to adopt a similarly subtle tone, allowing teens to examine the subtle influences on their behavior. If we highlight the apparent discrepancy between statements that say “It’s my decision” and those that describe friends’ influence, we are likely to antagonize, rather than engage, teens. Teens also may be unaware of the subtle influences tobacco advertising has on their decisions

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to smoke. Recent evidence suggests that teens view the images used in tobacco advertising more favorably than the images used in antismoking ads [38]. Materials and counseling that enables teens to neutrally examine the subtle social influences on their smoking can help them develop strategies for dealing with these influences. Lifestyle change Cessation programs should take into account the role of smoking in teens’ lives and the social implications of quitting. Even the 15- and 16-year-olds we interviewed acknowledged that smoking was an ingrained habit. Giving suggestions for ways to delay the first cigarette of the day, or how to combat urges associated with other triggers, is as critical for teens as it is for adult smokers. The need to change social networks, or at least to temporarily avoid smoking friends, is a significant cost that is unacceptable to many teens. We need to help teen smokers realize that quitting does not necessarily mean giving up their good friends forever— even though they may need to stay away from them during their quit attempt. Because friends are such a significant part of a teen’s life, suggestions about how to deal with smoking friends is crucial. What helps teens quit Suggestions and information that fit teen lifestyles are a critical part of effective cessation programs aimed at youth. Triggers and suggestions to deal with them should also be customized for teens. Instead of stress from problems with spouse, children, and jobs that are barriers to quitting and triggers of relapse in adults, teens are more likely to find stress-related triggers in problems with parents, boyfriends/ girlfriends, and classes [39]. Information must be presented in ways that inform teen smokers about the effects of smoking, but avoid manipulative or coercive language. As previous programs have demonstrated, emphasizing immediate risks (e.g., yellow teeth and bad breath) speak more to teens than the message that smoking can kill them or creates health problems later in life [18,40]. Respect and confidentiality Teens are at a developmental stage in which they strive for independence and an ability to decide their own fate. Messages that emphasize the teen smoker’s choice and support his or her ability to make a decision to quit are more likely to be received favorably and empower teens; teens will turn away from critical messages. An approach that invites participants to explore their own reasons for behavior changes and work through barriers to change, such as motivational interviewing [41], shows indications of being very effective with teens who are striving for autonomy and control over decisions [42,43].

The need for nonjudgmental and confidential support was a strong message from teens who participated in the two projects reported on in this study. In light of these findings, teens’ negative response to school-based cessation programs become more understandable. School-based programs may seem less than confidential to students, and teens may be concerned that attending special programs or visiting school health centers may provoke unwelcome questions or comments from their peers. The school setting may also cause students to anticipate lectures and demands from the counselors or teachers who provide cessation services [24]. Schools need to work on overcoming these perceptions and obstacles. Some options include using counselors who are not associated with the school system to deliver the program, or looking for other places to offer cessation programs that are not loaded with the sociological baggage of school. The health care system provides a feasible option because adolescents view physicians as credible sources of medical information [44], and attend to their advice more often than their parents or other adults [19], and report their physician’s advice is influential in their health practices [45] and would motivate them to try to stop smoking [39]. The attributes of counselors have important implications for the success of teen cessation programs. Counselors who have been through the experience of quitting can be positive and honest role models, give teens useful quit tips, and can provide much needed support for a teen’s quit attempt. Counselors who relate to teens and tap into the realities of the teen quitter’s life can enhance support and diminish teens’ concerns that counselors are the “smoking police.” Health care providers, who can play important roles in teens’ decisions to quit, should bear in mind teens’ desires for confidentiality and their expectation that they will be “hassled” about quitting. Additionally, the recommendations for nonjudgmental, interested, and trustworthy support persons received from Teen Quitline participants are relevant characteristics for clinicians as well as counselors intervening with teens about tobacco use. Modes of program delivery Offering teens options about the ways they receive cessation information and support allows teens to select the method that suits their personality and lifestyle. Regardless of the method of delivery, it is important to keep in mind that teens need options that are confidential as well as convenient. For teens who want and need personal attention, telephone cessation programs can be an effective and costefficient way to provide support to a large geographic area (e.g., statewide programs) and to large numbers of teens. Telephone cessation programs are an effective and costefficient way to provide personalized support to a large number of teens in a wide geographic area (e.g., statewide programs). Teens’ reports that they are seldom home and their concerns about privacy should be taken into account

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when designing telephone services, although increasing use of mobile phones by this population may make these issues easier to overcome. Computer- or Web-based programs offer teens options that are private and do not require interaction with others, and are not limited in terms of the times of service provision. Increasing access to computers and the Internet through libraries and schools may reduce barriers to use of these services by teens. Summary and conclusion Listening to teens yields valuable information to improve the design and appropriateness of youth cessation programs. Methods such as focus groups are useful to create and test specific components of individual programs (e.g., materials and promotion). In addition, examining common thematic components across qualitative data sets, as we have done in this report, can provide insights into the values and beliefs underlying teen preferences that are useful beyond the confines of a single program. Our data suggest that above all, programs—whether delivered in person, on the phone, by computer, or through written documents—should always respect the challenges that teens face in quitting, acknowledge the teen’s choice in making the decision to quit, and provide confidential, nonjudgmental support.

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