Micah Milton Office on Smoking and Health Ed Ehlinger University of Minnesota

Youth Cessation: A Process Youth Cessation: A Process for Making Informed for Making Informed

DecisionsDecisionsNational Conference on Tobacco or Health, 2002

San Francisco, CA

Micah Milton Office on Smoking and Health

Ed Ehlinger University of Minnesota

Connie Kohler University of Alabama

Sue Lin Yee Office on Smoking and Health

Learning Objectives

• Discuss different ways to assess need for youth cessation programs and services

• Identify considerations for selecting and implementing youth cessation interventions

• Describe the recommended content and ways of delivering youth cessation interventions

• Articulate the type of evaluation data needed to demonstrate effectiveness

What You Should Know About Youth Cessation

• The Consequences…health consequences, progression of tobacco use, dependence

• The Data…prevalence, motivation to quit• The Evidence…about what works• The Difference with Adult Cessation…how we

can’t assume what works for adult will work best for youth

A Process for Making Informed Decisions

Evaluate Efforts DetermineAppropriateIntervention

AssessCommunity Needsand Organization’s Commitment andCapacity

DetermineYour Rolein Tobacco Control

Assess CurrentTobacco Preventionand Control Efforts


1. Assess Current Tobacco Prevention and Control Efforts

Programmatic Goals of a Comprehensive Tobacco

Control Program

• Prevent initiation among young people

• Promote quitting among adults and young people

• Eliminate exposure to SHS

• Identify and eliminate disparities among population groups

Programmatic Components of a Comprehensive Tobacco

Control Program

• Community Interventions

• Countermarketing

• Policy and Regulation

• Surveillance and Evaluation

Comprehensive Tobacco Control Program Matrix

Prevent Initiation

Promote Cessation

Eliminate SHS

Eliminate Disparities

Community Interventions

Countermarketing

Policy and Regulation

Surveillance and Evaluation

Comprehensive Tobacco Control Program:DASH Guidelines

Prevent Initiation

Promote Cessation

Eliminate SHS



Prevention Education

Prevention Education & Cessation Support

Countermarketing


Bans & Restrictions


Routine Program Evaluation

Comprehensive Tobacco Control Program: Community Task Force Recommendations

Prevent Initiation

Promote Cessation

Eliminate SHS



Health Care Provider Reminders & Education

Countermarketing Mass Media

Mass Media


Increased Price

Increased Price & Treatment Coverage

Bans & Restrictions


Comprehensive Tobacco Control Program: PHS Recommendations

Prevent Initiation

Promote Cessation

Eliminate SHS



Health Care Provider 5 A’s & Reminders

Countermarketing


Treatment Coverage


Comprehensive Tobacco Control Program: CDC Best

PracticesPrevent Initiation

Promote Cessation

Eliminate SHS



Countermarketing



Comprehensive Tobacco Control Program:YTS, ATS, YRBS, BRFSS

Prevent Initiation

Promote Cessation

Eliminate SHS



Countermarketing



Comprehensive Tobacco Control Program: Combined Efforts

Prevent Initiation

Promote Cessation

Eliminate SHS



Countermarketing



Comprehensive Efforts Help Youth Quit

Prevention Programs

Price Increases

Change in Social NormsSmoking Bans and Restrictions

Advertising Bans and Restrictions

Mass Media Campaigns

Restricted Access

Advice from Health Care Providers

QuitlinesTreatment Coverage

DASH Guidelines for School Health Programs to Prevent Tobacco Use and

Addiction Are there school policies that…

Prohibit tobacco use on school property, vehicles, and school-sponsored functions? Prohibit tobacco advertising in buildings, at school functions, and in school

publications Are these policies enforced? Is there tobacco use prevention curricula for K-12th that addresses…

short and long-term consequences? social influences and peer norms ? behavioral and social skills?

Does instruction should be more intensive in junior or middle school? Is instruction reinforced in high school? Is there program-specific training for teachers? Is there parental and family Involvement in School-based Prevention Programs? Is there support for Cessation Efforts for all Students and Staff? Is there ongoing evaluation of the prevention program at regular intervals?

Recommendations from the Task Force on Community

Preventive Services Are there smoking bans and restrictions to reduce exposure to SHS? Has the unit price of tobacco products been increase to reduce

initiation and increase cessation? Are there mass media campaigns that educate about the harms of

tobacco use and motivate tobacco users to quit? Are there other prevention or cessation activities occurring concurrently?

Are health care systems implementing reminder systems and provider education to increase cessation?

Is there coverage of behavioral and pharmacological treatment for cessation by the health care system to increase cessation, specifically Medicaid? State Employees Insurance? Large Employers?

Public Health Service Clinical Practice

Guidelines Are health care providers doing the 5A’s?

Asking their patients about their tobacco use Assessing their interest in quitting Advising patients to quit Assisting patients with quitting Arranging follow-up with that patient to support their quit attempt

Are health care systems… Reducing the out-of-pocket costs for cessation treatment? Implementing reminder systems to support doing the 5 A’s? Providing training and/or education to providers about cessation?

CDC Best Practices Are there a wide range of community programs to reduce tobacco use? Are there chronic disease programs to reduce tobacco related diseases? Are there school programs that address tobacco use? Is there enforcement of tobacco control policies? Are there statewide programs that increase local program capacity Are there counter-marketing campaigns? Are there cessation programs? Are the surveillance and evaluation systems to monitor program

accountability? Are there administration and management systems to facilitate

coordination of program components?


2. Determine Your Organization’s Role in Tobacco Control

Ask yourself…

Are we fully implementing what works?

Have those efforts been intensified? Are there any gaps to fill? Are those efforts being sustained?

Important Activities

1. Assess current tobacco prevention and control efforts in your area and determine where further effort is required

2. Determine where your organization might have the greatest impact given your organization’s mission, commitment and capacity


3. Assess Your Community’s Need and Organization’s Capacity and Commitment for Youth Cessation


Your Needs Assessment should provide you with an understanding of Need for youth cessation services

Tobacco use prevalence Outstanding patterns of tobacco use Existing youth cessation services (availability, accessibility, and utilization)

Level of demand for or interest in youth cessation services Motivation and/or readiness to quit Interest in or previous use of cessation services

Need for other substance use services Need for medical or social service needs Lifestyle factors as it relates to provision of services (e.g. after school jobs, caretakers for siblings, extracurricular activities

As identified by your target population.


Your Community Needs Assessment should provide you with an understanding of Need for cessation services among adults and youth

Tobacco use prevalence Outstanding patterns of tobacco use Existing cessation services (availability, accessibility, utilization)

Level of demand and/or support for youth cessation services Competing community needs or priorities

As identified by key stakeholders and community leaders.


Your Organizational Assessment should provide you with an understanding of Role in meeting needs of target population and/or community

Tobacco use prevalence Outstanding patterns of tobacco use Existing cessation services (availability, accessibility, utilization)

Capacity to provide youth cessation services Resources to provide youth cessation services Commitment to providing youth cessation services Credibility with the target population and community Desire or willingness to partner and/or collaborate on other tobacco control efforts Competing needs or priorities

As identified by the key decision makers in your organization.


Ideas for obtaining this information… Formal Needs Assessment Examine Existing Survey Data Environmental Scan Conduct Qualitative Data Collection

Focus Groups of Key Stakeholders Key Informant Interviews

Strategic Plans Review Needs Assessments and Evaluation Reports from other agencies or organizations


4. Select An Appropriate Intervention


Now that you have an understanding of… Tobacco control efforts in youth community Level of need specifically for youth cessation services Demand for or interest in these services Commitment to helping youth quit CAPACITY AND RESOURCES


Key Considerations when selecting the type(s) of youth cessation intervention:

1. Currently little evidence for guidance

2. Different conceptual approaches

3. Variety of ways to intervene

4. Recruitment


Promising Conceptual ApproachCognitive-Behavioral

• Evidence review• Expert opinion


Cognitive-Behavioral ApproachGeneral Concepts

Establish Self-Awareness of their tobacco use

Motivation and Encouragement for Quitting

Preparation for Quitting

Strategies to Maintain Abstinence


Cognitive-Behavioral ApproachParticipants should learn that: Most young persons and adults do not smoke Cigarette smoking and smokeless tobacco use have direct health consequences Tobacco use has short- and long-term physiologic, cosmetic, social and economic consequences Tobacco contains other harmful substances in addition to nicotine Tobacco use is an unhealthy way to manage stress or weight Tobacco use during pregnancy has harmful effects Many persons find it hard to stop using tobacco, despite knowledge about the health hazards to tobacco use


Cognitive-Behavioral ApproachParticipants should be able to demonstrate: Understanding of the impact of their tobacco use Personal commitment not to use tobacco Pride about choosing not to use tobacco Responsibility for personal health Confidence in personal ability to resist tobacco use Willingness to seek and use support for quitting


Cognitive-Behavioral ApproachParticipants should be able to: Communicate knowledge and personal attitudes about tobacco use Demonstrate skills to resist tobacco use Develop methods for coping with tobacco use by significant others and with other difficult personal situations, such as

peer pressure to use tobacco Seek social support to help them remain abstinent


Different Types of Youth Cessation Interventions Brief Advice by Health Care Provider Self-Help, Non-Interactive Support Self-Help, Computer-Based Interactive Support Telephone-Based Counseling Support Individual Face-to-Face Counseling Group Counseling Support

When Selecting a Pre-Packaged Intervention…

Goals, Objectives, and Desired/Expected Outcomes Implementation Protocol and/or Curriculum Facilitator/Provider Characteristics Recommended Recruitment Strategies Training Manuals/Resources Materials for Participants Evaluation Tools Ongoing Support and/or Technical Assistance Detailed Cost Estimates (e.g. per participant, training,

advertising) EVALUATION RESULTS


5. EVALUATE, EVALUATE, EVALUATE!

5. Evaluating Your Efforts and Monitoring Progress

Why evaluate youth cessation interventions?• To monitor progress toward the program’s goals.• To demonstrate that an intervention or activity is

effective.• To learn how to improve interventions.• To justify the need for further funding and support.• To ensure that only effective programs are

maintained and resources are not wasted on ineffective programs and interventions.


• Describing the Intervention and Participants

• Process Evaluation

• Outcome Evaluation

• Using Evaluation Data

Describing Your Intervention and Participants

Description of the Intervention Would Include:• SMART Objectives• Clear, Specific Definition of Desired Outcome• Recruitment Methods • Selection Criteria • Human Subjects and/or Consent Issues• Facilitators/Providers


Description of Intervention Would Include:

• Delivery Location(s)

• Duration and Intervals for Delivery

• Materials

• Incentives

• Other interventions or pharmocotherapy


Description of Participants Would Include:• Demographic Characteristics• Contact Information (if appropriate for follow-up

evaluation)• Tobacco Use Behavior and History• Tobacco Use by Family and Friends• Cessation History and Readiness to Quit• Knowledge, Attitudes, and Beliefs about Tobacco Use

and Cessation Aids• Screen for Psychological or Behavioral Issues






Process Evaluation: Key Questions How did participants hear about the service? How many participants received the intervention?

Received the materials Visited the website Received brief advice by health care provider Attended each session or was reached for each call

How much of the intervention did they receive (e.g number of sessions/calls, contact time, etc)?

What were they given or presented with? What did they receive? What amount of time was spent delivering the intervention/component of the intervention

per participant or session? Where there deviations for implementation protocol? How so? What staffing was required to implement intervention (by session, per participant)? What training occurred for facilitator/providers to deliver intervention? How satisfied were participants with the service? Was there biochemical confirmation of self-report (whether, how many)?






Outcome Evaluation: Key Questions at End of Intervention and Follow-up

How many participants were using/not using tobacco? At the last session or end of the intervention At 6 and 12 months post-intervention

How much/often are participants who have not quit using tobacco? How motivated were participants to quit and remain abstinent? How many participants made a serious quit attempt? Were participants prepared for their quit attempt? What was the longest period of abstinence? Were participants confident they could quit and remain abstinent? Was there biochemical confirmation of self-report?

Critical Concepts in Youth Cessation Evaluation

Recruitment Implementation Compliance Retention Follow-up Period Quit Rates Biochemical Validation of Self-Report

There’s Evaluation, then there’s evaluation…..

Evaluation Basics

The IDEAL approach

(what the Guide says)

Applied Evaluation

What we are doing in the REAL world

Basic - Applied

If intervention has been formally evaluated, determine if evaluation was conducted by those who developed the intervention (risk of decreased objectivity).

Program developers had conducted “efficacy” evaluation; we are conducting “effectiveness” evaluation.

Basic - Applied

Use experimental design (random assignment of individuals) or quasi experimental design (random assignment of schools; matching of individuals, etc.)

We recruited schools to participate in the intervention and then recruited matched “control schools” to the comparison group.

Describing Intervention and Participants

Basic - Applied• Document information

about the intervention (e.g., objectives, outcomes, recruitment methods, facilitators)

• Collect information about the participants (e.g., contact info, tobacco use, KAB)

All information about the intervention was detailed in the program training manual.

We attempted to locate “standardized” measures for this.

Process Evaluation

Basic - AppliedTo determine if

intervention is being implemented according to plan – what is actually happening; who is participating.

Developed data base to track each task the intervention training manual recommended.

Lack of data for a given task may indicate that the task was not do-able.

Key Process Evaluation Questions

Basic - AppliedHow many signed up?

How did they hear about the program?

How many finished the program?

How satisfied were they?

How many chemically validated?

Attendance rosters faxed

Process form completed by facilitators

Attendance rosters

?

Participant records


Basic - AppliedWhat types of activities

occurred?

How much time spent?

What deviated from protocol?

Required staffing?

Staff training?

$ and materials needed?


Attendance rosters

Intervention staff discussions

Intervention staff records


Facilitator process form


Basic - AppliedWhat types of activities

occurred?

How much time spent?

What deviated from protocol?

Required staffing?

Staff training?

$ and materials needed?


Attendance rosters

Intervention staff discussions



Facilitator process form

Outcome Evaluation

Basic - AppliedBy reviewing the process

evaluation data, you can determine exactly what was done to produce the outcomes you have.

Our ability to document what was done in each school will help answer two questions: Can the program be used as intended? & Is the program effective as used?

Key Outcome Evaluation Questions

Basic - AppliedHow many quit

end of program6 months12 months

Number of serious quit attempts

Other tobacco useLongest period of

abstinence

Comparison of baseline and follow-up surveys; salivary cotinine tests for quitters at end of program, 6 and 12 m.

Follow-up survey

Follow up survey

Follow up survey

Key Outcome Evaluation Questions

Basic - AppliedHow prepared or

motivated were participants?

Did reduction or other change in consumption occur?

Comparison of baseline and follow up surveys

Key Outcome Evaluation Concepts

Basic - AppliedRetention

% who stayed

use of “intent to quit”

Implementation compliance

# who attended all or most sessions

Follow-up period

6 months + desirable

Quit rate

Logs of each session

Logs of each session

Problems with loss to follow up, shifting “start dates”

Cost of biochemical validation

Ideas for Ensuring Rigorous Evaluation

Evaluation should be addressed and planned BEFORE selection and implementation of the intervention

External Evaluation of Outcomes Explore hiring or partnering with researchers and

evaluation experts

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Micah Milton Office on Smoking and Health Ed Ehlinger University of Minnesota

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