Harvard Mental Health Letter

Helping teens stop smoking

A number of options exist, but many challenges remain.

Despite widespread efforts at education and prevention, roughly one-quarter of U.S. teenagers are smoking cigarettes at least occasionally by the time they graduate from high school. Sadly, about three-fourths of those who smoke on a regular basis will continue smoking into adulthood.

In part, this is because adolescents are more vulnerable than adults to becoming hooked on cigarettes. When researchers compared people of different ages who smoked the same number of cigarettes per day, they found that young people ages 12 to 17 demonstrated higher levels of nicotine dependence than any other age group. Adolescents are also more likely to become addicted after smoking fewer cigarettes per day than adults.

It is well known by now that smoking is the leading behavioral cause of premature death in the United States. Cigarettes are implicated in one in five deaths in Americans each year, including approximately one-third of deaths due to cancer. Smoking can also cause disabling health problems, including heart disease, stroke, and chronic obstructive pulmonary disease.

Although there are plenty of evidence-based guidelines for adults who want to quit smoking, until recently there's been a dearth of research about how to help adolescents quit. Initially, the advice was simply to adapt adult stop-smoking strategies for teens. But more recent analyses have concluded that teens are not just "little adults" when it comes to quitting, so different approaches may be in order.

A number of options are available — in medical clinics, at schools, and on the Internet — to help teens quit smoking. A meta-analysis found that such stop-smoking programs aimed at teens increased the probability of quitting: Roughly 9% of teens participating in a stop-smoking program quit, compared to about 6% of controls. However, another review, which analyzed only studies that followed teens longer than six months, found there is no evidence as yet that any program improves abstinence rates for a prolonged period.

Even so, some guidance is emerging about which approaches work best for teens and which are not effective.

Progress and challenges

Several public health initiatives are aimed at preventing teens from smoking. These include raising taxes on cigarettes, which makes them more expensive; passing laws to restrict exposure to secondhand smoke and tobacco advertising and to prevent young people from purchasing cigarettes; and launching mass media campaigns to encourage prevention. In addition, a number of school-based prevention programs are offered nationwide.

These efforts seem to be having an impact. Data collected by the Centers for Disease Control and Prevention indicate that the proportion of teens who smoked in any given month fell from a high of 36% in 1997 to 23% in 2005. But that still means nearly one in four teens are smoking cigarettes.

Teens may begin smoking for any number of reasons. Many are copying behavior modeled by parents or peers. Girls in particular may hope that smoking cigarettes will help them lose weight. Some evidence indicates that media exposure to smoking may also influence teens. Although cigarette advertising on television is prohibited, ads continue to appear in print, on billboards, and on the Internet. And an analysis of top box office hits in the United States found that three in four movies contained some depiction of people smoking.

Once hooked, many teens do try to quit. Anywhere from 55% to 65% of smokers ages 12 to 18 have attempted to stop smoking, according to surveys. But most teens (like most adults) need help to kick the habit.

Clinical approaches

The most current clinical practice guideline encourages physicians, nurses, and other clinicians to ask teens about smoking behavior during office visits, and then use age-appropriate methods to help teens to quit. The guideline recommends that clinicians do the following:

  • Regularly screen adolescents and their parents to determine whether they smoke and, if so, provide encouragement and suggest interventions to stop smoking.

  • Use behavioral and counseling interventions. (For some tips, see discussion below.)

  • If an adolescent has become dependent on nicotine and expresses a desire to quit smoking, consider prescriptions for bupropion (Zyban) or nicotine replacement therapy. (Be aware, however, that a review published since this recommendation was published indicates bupropion may not be effective for teens.)

Although more specific advice is hard to come by, case reports provide the following practical tips, which may help make a clinical intervention more effective.

Ask specific questions. Adolescents may not consider themselves smokers even if they use cigarettes on a regular basis. Concrete questions may better elicit smoking status. Ask, for example, if a teenager has smoked even one cigarette in the past 30 days, or ask specifically how many cigarettes he or she has smoked in the past week.

Keep confidences. Adolescents may be more open to talking about smoking behavior if they are assured the information is kept confidential. To ensure confidentiality, a clinician may have to ask about cigarette use when a parent is not in the room.

Understand how teens think. Adolescents tend to spend less time than adults mentally preparing to quit smoking, which may reduce the chances that they will succeed. They are also less able to plan for the future, partly because human brain circuitry is not yet fully developed until the early 20s.Therefore teens are more likely than adults to act on impulse and discount long-term consequences.

For these reasons, a clinician may need to spend extra time educating a teen about why it's important to stop smoking, and then provide specific instructions about how to avoid situations where peers might be smoking, or what to do when the temptation to smoke occurs. Offering concrete tips for how to deal with cravings and find other habits to substitute may also help.

Leverage teen motivations. Because teen girls may be smoking in order to stay thin or lose weight, clinicians may have to provide information about nutrition and exercise as well as offer stop-smoking strategies. Some research indicates that teen boys are more likely to try to quit smoking if they want to participate in school sports. Emphasizing the physical benefits of quitting may help in such cases.

School-based programs

The meta-analysis mentioned earlier concluded that school-based smoking cessation programs aimed at teens work better than clinic-based interventions. The authors concluded that the most effective programs last for at least five sessions and use motivational enhancement, cognitive behavioral techniques, or social influence approaches.

Two model programs endorsed by the Substance Abuse and Mental Health Services Administration meet these criteria: the Not on Tobacco (NOT) program and Project EX. Though they differ in some respects, both use an approach that combines the following three elements:

  • motivational enhancement, so that teens are encouraged to quit

  • coping skills instruction, so that teens learn to deal with nicotine withdrawal, stress, and relapse triggers

  • goal setting, so that teens make a personal commitment to quitting.

The NOT program involves a series of weekly group sessions held separately for teenage boys and girls — on the assumption that the reasons for smoking and motivations to quit vary by sex in this age group. The program helps the students understand why they started to smoke, learn about nicotine addiction and the deadly effects of smoking, and then identify social supports that will help them to quit. At various points, the students engage in role playing, learn relaxation techniques, and write about thoughts and emotions in journals.

Project EX covers some of the same areas, such as coping with nicotine withdrawal and finding ways to avoid relapse. However, it differs from the NOT program in that it encourages teens to take up yoga or begin meditating to deal with stress, instead of smoking, and it also includes a number of interactive games.

Both programs involve expenses for classroom materials and training of facilitators, although exact costs may depend on the school district and what state subsidies are available. The NOT program is endorsed and promoted by the American Lung Association.

Resources

Not on Tobacco (NOT) and Project EX www.modelprograms.samhsa.gov

Youth Tobacco Cessation: A Guide for Making Informed Decisions www.cdc.gov/tobacco/quit_smoking/cessation/YouthTobacco.htm

Additional options

Clinicians, school officials, and public health leaders who want to explore other programs may find it useful to consult a guide published by the U.S. Department of Health and Human Services in 2004. Youth Tobacco Cessation: A Guide for Making Informed Decisions provides detailed and practical steps for evaluating programs and putting them into practice in a particular community or other setting. It also provides case studies about how one state health department and one rural school system chose and implemented a smoking cessation program for young people. The guide is available free.

Additional guidelines and options are likely to become available in the future, as research on how to better target smoking cessation programs for adolescents continues. The culture may also move further towards making smoking socially unacceptable. In the meantime, the fact that smoking rates among youths have been falling since the late 1990s is something to be celebrated — because the easiest way to kick a habit is to avoid developing it in the first place.

Grimshaw GM, et al. "Tobacco Cessation Interventions for Young People," Cochrane Database of Systematic Reviews (2006): Issue 4, Article No. CD003289.

McVea KL. "Evidence for Clinical Smoking Cessation for Adolescents," Health Psychology (September 2006): Vol. 25, No. 5, pp. 558–62.

"NIH State-of-the-Science Conference Statement: Tobacco Use: Prevention, Cessation, and Control," Annals of Internal Medicine (December 5, 2006): Vol. 145, No. 11, pp. 839–44.

Sussman S, et al. "A Meta-Analysis of Teen Cigarette Smoking Cessation," Health Psychology (September 2006): Vol. 25, No. 5, pp. 549–57.

For more references, please see www.health.harvard.edu/mentalextra.