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Tobacco Use Outcomes of Adolescents Treated Clinically for Nicotine Dependence
Christi A. Patten, PhD;
Steven C. Ames, PhD;
Jon O. Ebbert, MD;
Troy D. Wolter, MS;
Richard D. Hurt, MD;
Thomas R. Gauvin, MS
Arch Pediatr Adolesc Med. 2001;155:831-837.
ABSTRACT
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Objective To evaluate the tobacco use outcomes and baseline characteristics of
adolescents treated for nicotine dependence.
Design Retrospective cohort study.
Setting Mayo Clinic Nicotine Dependence Center, Rochester, Minn.
Patients Ninety-six adolescents (60 boys, 36 girls) receiving clinical services
for treatment of nicotine dependence between January 1, 1988, and November
30, 1997. Their mean age was 15.6 years (range, 11-17 years), and 91.7% were
white.
Intervention The Nicotine Dependence Center intervention involves a 45-minute consultation
with a nicotine dependence counselor. A treatment plan individualized to the
patient's needs is then developed. Telephone follow-up is conducted at 6 and
12 months. As part of this study, a long-term follow-up was conducted by telephone
at a mean of 5.3 years (range, 1.6-10.6 years) following the intervention.
Main Outcome Measures Self-reported 7-day point-prevalence abstinence from tobacco at 6 and
12 months, and 30-day point-prevalence tobacco abstinence at the long-term
follow-up.
Results The tobacco abstinence rates were 17.7% (17/96 patients) at 6 months,
7.3% (7/96 patients) at 12 months, and 11.5% (11/96 patients) at the long-term
follow-up. A high proportion of the sample had smoking-related medical morbidity
and psychiatric diagnoses documented in the medical record prior to or at
the time of the intervention.
Conclusions Adolescents utilize the medical community to seek treatment for nicotine
dependence. The 6-month tobacco abstinence rate is higher than the estimates
of the natural history of smoking cessation in adolescents. Medical and psychiatric
diagnoses are common in this population.
INTRODUCTION
RECENT EFFORTS have been targeted toward the development of effective
interventions for adolescent tobacco users.1, 2
Smoking prevalence among high school students increased substantially during
the 1990s.3 The results of a 1999 National
Youth Tobacco Survey indicate that 12.8% of middle school students and 34.8%
of high school students had used tobacco during the previous 30-day period.4 Moreover, some adverse health consequences of tobacco
use, including changes in pulmonary function and lipid proteins, have been
demonstrated among adolescent smokers.5, 6
A recent review of research done on the behavioral treatment of tobacco
use among adolescents found generally poor outcomes, with end-of-treatment
abstinence rates averaging 20.7% (range, 0%-36%), and a mean abstinence rate
of 13% at 3 to 6 months.7 To date, the 2 nicotine
patch trials conducted with adolescent cigarette smokers found the smoking
abstinence rate to be approximately 5% at 6-month follow-up.8, 9
In contrast, estimates of the natural history of smoking cessation among adolescents
range from 0% to 11% throughout a 6-month period.10, 11
There is, however, debate as to how best to define treatment outcomes for
adolescent tobacco users.2 Many studies have
reported data on quit attempts or reductions in cigarettes smoked per day
among adolescents treated for smoking cessation.7
Currently there are few data on whether these potential intermediate criteria
predict later success at abstinence. In addition, only 1 study reported a
follow-up greater than 6 months.9 Thus, little
is known about long-term abstinence following interventions with adolescent
tobacco users.
There are few studies on the tobacco use outcomes of adolescents receiving
clinical services for treatment of nicotine dependence. Research with adults
has repeatedly demonstrated that tobacco use interventions conducted in medical
settings can increase success rates.12 Hollis
et al13 found that a nurse-delivered intervention,
consisting of one 60-minute office visit and telephone follow-up, was no more
effective than a no-treatment control group for adolescent smoking cessation.
The American Medical Association recently designed a brief office intervention
specifically for adolescent tobacco users, consisting of four 15- to 20-minute
visits with a health care provider.14 A pilot
study of 54 adolescent smokers found that at the end of treatment, 31% had
made a stop attempt, and 50% reduced the number of cigarettes smoked per day.15 The smoking abstinence rates were not reported.
The Nicotine Dependence Center (NDC) at the Mayo Clinic (Rochester,
Minn) has provided clinical services for treatment of nicotine dependence
to more than 20 000 patients since 1988.16
Among adults who received a nicotine dependence consultation, the 6-month
self-reported smoking abstinence rate was 22.2%.17
The purpose of this investigation was to assess the tobacco use outcomes and
baseline characteristics of 96 adolescents aged 11 to 17 years who received
clinical services for treatment of nicotine dependence at the NDC during the
period from 1988 to 1997.
METHODS
NICOTINE DEPENDENCE INTERVENTION
The treatment model used by the NDC is a comprehensive intervention
that combines behavioral, addiction, and pharmacological approaches.17, 18 Patients complete a comprehensive
tobacco use history questionnaire prior to the consultation. The intervention
involves a 45-minute consultation with a nicotine-dependence counselor. The
counselors carry a portable instrument to measure levels of expired air carbon
monoxide to provide feedback to patients on the health risks of continued
tobacco use, and to enhance motivation. The counselor also assesses symptoms
of nicotine dependence based on the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV).19
In addition, stage of readiness to stop smoking is assessed, based on the
definitions of Prochaska and DiClemente20 that
were adapted for use in our clinical program. A treatment plan individualized
to the patient's specific needs is then developed based on the stage of readiness.16 Treatment components include behavioral, chemical
dependency, pharmacologic, and relapse prevention strategies.
Although the intervention is based on the adult model developed for
the overall program, the approach used with adolescents generally differs
from that of adults in many ways. There is a focus on health concerns and
other consequences that may be more meaningful to adolescents (eg, wrinkles,
yellow teeth, money, dating). The communication style used with the adolescent
is tailored to their developmental level. To avoid being perceived as condescending
or "preachy," counselors are careful about the manner in which they present
information. To decrease vulnerability for tobacco use, a greater emphasis
is placed on behavioral techniques. More attention is given to the influences
of peer pressure, self-image, self-efficacy for change, lifestyle, the family
environment, and smoking behaviors of family members. Counselors assess any
prior experience with cessation to help develop realistic treatment plans.
For several reasons, they are less likely to recommend use of medication in
adolescents than in adults: (1) many medications have not been tested nor
approved for use in teens; (2) there are concerns about safety and adverse
effects; (3) some adolescents are not interested in taking medications; (4)
many adolescents are situational or intermittent smokers who may not have
concerns about withdrawal; (5) some medications may be prohibited in a school
setting (eg, nicotine gum); and (6) some medications are not feasible for
use during sports and in social settings.
As part of the routine scheduled telephone follow-up, an attempt is
made to collect information on the patient's self-reported tobacco use status
6 months after the nicotine dependence consultation. The telephone follow-up
is conducted by a trained interviewer who is not associated with the provision
of the intervention. In addition, all patients are mailed a survey 12 months
following the initial consultation.
PROCEDURE
This study was approved by the Mayo Clinic's institutional review board.
Data for this study were gathered from an existing NDC database, a medical
record review, an institutional database, and a long-term telephone follow-up
interview. The study was initiated in 1998 and includes data on adolescents
who were treated since the time the NDC opened in 1988, and for whom a follow-up
contact had been attempted at 12 months. Thus, the sample included the 96
of 108 adolescents who were treated from 1988 through the end of 1997, and
who consented to general research authorization.
NDC Clinical Database Review
All patients seen by the NDC staff complete a baseline questionnaire
assessing demographics, tobacco use history, referral source, and items from
the Fagerström Test for Nicotine Dependence (FTND).21
The FTND consists of 6 items with scores ranging from 0 to 10; scores of 6
or higher indicate nicotine dependence. The counselor assesses and records
the patient's stage of change at the beginning of the consultation.20 Available data on self-reported tobacco use outcomes
at the 6- and 12-month follow-ups are routinely entered into the NDC database
and were used as part of this study.
Medical Record Review
Medical records were reviewed for information on patient baseline characteristics
that were missing from the NDC database and medical and psychiatric diagnoses
that were recorded at the time of, or prior to, the initial NDC consultation.
We created a comprehensive list of medical and psychiatric diagnoses that
might be present in adolescent tobacco users. The list was based on the psychiatric
diagnoses that were self-reported by adolescents in our recent nicotine patch
study,8 studies on the health consequences
of tobacco use in adolescents,5, 6, 22
and our previous work on tobacco-related morbidity.23
The medical records were abstracted by a physician investigator (J.O.E.).
Institutional Database Review
To assist in locating the patient for the long-term telephone follow-up
interview, the institutional database was reviewed to obtain information on
ZIP code of residence at the time of the adolescent's initial NDC consultation,
date of birth, sex, and most recent address and telephone number.
Telephone Follow-up Interview
The long-term telephone follow-up was conducted in 1999. Prior to the
telephone call, a letter was sent directly to the patient describing the study
with an option to refuse participation if desired. For adolescents younger
than 18 years, a letter was sent to the parent or guardian with an option
to refuse the adolescent's participation. The letters emphasized that the
study was voluntary, and that refusal would in no way effect the parent's
or the adolescent's future care at the Mayo Clinic.
Patients were contacted by telephone by a trained interviewer from the
Mayo Survey Research Center to obtain information on their tobacco use. A
total of 5 telephone attempts were made at varying days and times of the week.
During the telephone call, the interviewer first described the details of
the study, and then asked the patient if he or she agreed to be interviewed.
Informed consent was implicit in the adolescent's verbal agreement to participate.
The duration of the structured telephone interview was approximately
15 minutes. Adolescents were asked to report the number of days, if any, on
which any tobacco use occurred during the previous 30-day period. The National
Cancer Institute24 recommends a 30-day recall
period to measure current tobacco use in adolescents. Patients were also asked
about their tobacco use at 6 months and 12 months following the initial nicotine
dependence consultation. For these periods, we used a 7-day recall duration
to be consistent with the time that was assessed for those patients with available
tobacco use outcomes in the NOC database. Strategies were used to enhance
recall, such as use of holidays and other key dates.25
Tobacco use outcomes were based only on patient self-report, and biochemical
verification of self-reported tobacco abstinence was not obtained. Information
on the type(s) of tobacco cessation programs or approaches (eg, pharmacologic,
behavioral) that the patient had used subsequent to the initial NDC consultation
was also obtained.
STATISTICAL ANALYSIS
Current tobacco abstinence rates (with 95% confidence intervals [CI])
for the previous 30-day period and the tobacco abstinence rates at 6 and 12
months following the NDC consultation were summarized. Patients were considered
currently abstinent from tobacco if, when contacted, they self-reported no
tobacco use in the 30 days prior to the telephone call. Those who had missing
data on tobacco use status because of an inability to contact or refusal to
participate were classified as currently using tobacco. Patients were considered
abstinent from tobacco if, following the NDC consultation, they self-reported
no tobacco use for the 7 days prior to the 6- and 12-month follow-up dates.
If we were unable to contact the patient by telephone, we used the 6-month
and 12-month outcomes recorded in the NDC database, if available, for those
time points. If we were unable to contact the patient at the long-term follow-up,
and tobacco use outcomes at 6 and 12 months were both missing from the NDC
database, we classified the patient as using tobacco at those times.
We examined the univariate predictability of the baseline demographic
characteristics (Table 1) on determining
6-month tobacco abstinence using the  2 test for categorical
variables, and a 2-sample rank sum test for continuous variables. We chose
the 6-month outcome because the extent of missing data was less at that time
(Figure 1). P .05 were considered evident of findings not attributable to chance.
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Table 1. Baseline Characteristics of Adolescents at the Time of the
Nicotine Dependence Intervention*
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The number of adolescents studied, the follow-up periods, and the
number of adolescents with available or missing data at each point.
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RESULTS
Figure 1 shows the number
of adolescents studied, the follow-up periods, and the number of adolescents
with available or missing data at each point.
BASELINE CHARACTERISTICS
Baseline characteristics of the 96 adolescents (60 boys, 36 girls) are
summarized in Table 1. Most (88.2%)
of the adolescents were seen by a counselor for treatment of cigarette smoking
only, and 86% lived within 25 miles of the Rochester area. Medical and psychiatric
diagnoses recorded in the medical records prior to or at the time of the NDC
consultation are presented in Table 2. There was a high proportion of smoking-related medical morbidity and psychiatric
diagnoses. In particular, asthma, bronchitis, sinusitis, adjustment disorder,
and abuse or dependence on alcohol and other drugs were common diagnoses in
this adolescent sample.
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Table 2. Medical and Psychiatric Diagnoses*
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TOBACCO USE OUTCOMES AT 6-MONTH AND 12-MONTH FOLLOW-UP
Using an intent-to-treat approach, the self-reported tobacco abstinence
rates were 17.7% (17/96 patients) (95% CI, 10.7%-26.8%) at 6 months and 7.3%
(7/96 patients) (95% CI, 3.0%-14.4%) at the 12-month follow-up. With the exception
of the FTND score (P = .036), no other variables
were univariately predictive of tobacco abstinence at 6 months. Adolescents
with a FTND score of 6 or more were less likely to be abstinent from tobacco
than patients with FTND scores of 5 or less.
LONG-TERM FOLLOW-UP
Telephone contact was attempted with all adolescents in 1999 —
an average of 5.3 years (SD, 2.5; range, 1.6-10.6 years) following the initial
NDC consultation. At that time, their mean age was 21.6 years (SD, 3.1; range,
14-28 years). Of the 96 adolescents, 54 were reached at long-term follow-up,
and 48 patients (50%) agreed to be interviewed. To explore potential respondent
biases, the baseline characteristics listed in Table 1 were compared between survey responders and nonresponders.
Referral source was significantly different (P =
.03) between the 2 groups. The percentages referred by a Mayo Clinic provider;
self, parent, or guardian; or a source outside of the Mayo Clinic were 32%,
68%, and 0%, respectively, for responders; and 53%, 43%, and 4%, respectively,
for nonresponders. No other significant differences were found between the
2 groups, which indicated that adolescents who responded to the survey were
fairly representative of the entire sample.
Tobacco Use Outcomes
Using an intent-to-treat approach, the self-reported tobacco abstinence
rate at long-term follow-up was 11.5% (11/96 patients; 95% CI, 5.9%-19.6%).
Because the length of the time between the initial NDC consultation and the
long-term follow-up varied widely, we examined whether those with a longer
follow-up duration were more likely to be abstinent from tobacco. Using the
2-sample rank sum test, there was no significant association observed between
length of follow-up and tobacco abstinence status (P
= .126).
Survey Findings
Thirty seven of the 48 adolescents who were interviewed had used tobacco
during the 30 days prior to the interview (35 had smoked cigarettes only,
1 had smoked cigars only, and 1 had both smoked cigarettes and used snuff/chew).
Of the 36 cigarette smokers, the number of days smoked averaged 25.6 (SD,
8.3; range, 1-30 days), and the mean number of cigarettes on days smoked was
13.8 (SD, 10.3; range, 1-40 cigarettes). Forty-one (85.4%) had made at least
1 serious attempt to stop tobacco use subsequent to the NDC consultation.
After the consultation, 50.0% reported that they had used a nicotine patch,
20.8% had used nicotine gum, 18.8% had used bupropion hydrochloride (Zyban,
GlaxoSmithKline Inc, Greenford, England), 4.2% had used the nicotine inhaler
or nasal spray, 4.2% had used self-help strategies, and 6.3% had talked with
a physician about their tobacco use.
COMMENT
This study yields new information on the outcomes of adolescent tobacco
users treated clinically for nicotine dependence. The 6-month self-reported
tobacco abstinence rate of 18% compares favorably with the results of our
previous open-label nicotine patch trials in adolescents, in which only 5%
of subjects were abstinent at 6 months.8, 9
Moreover, the 6-month abstinence rate is consistent with the observed rate
in adults who received the NDC intervention.17
A study limitation is that we are reporting on the outcomes in a clinical
series in the absence of an untreated control or comparison group. However,
the 6-month self-reported tobacco abstinence rate of 17.7% (95% CI, 11%-27%)
is higher than the estimates of the natural history of smoking cessation in
adolescents, which range from 0% to 11%.10, 11
Our study adds to the knowledge on the long-term outcomes of adolescents treated
for nicotine dependence. At long-term follow-up, 11.5% were abstinent from
tobacco, whereas 1 previous study9 found the
1-year smoking abstinence rate to be 5%. Because the duration of long-term
follow-up in our study varied widely, the findings do not generalize to any
particular time following a nicotine dependence intervention. Length of follow-up,
however, was not associated with the tobacco abstinence rates; adolescents
with shorter or longer follow-up periods had similar outcomes. Moreover, we
used a conservative intent-to-treat approach, which classified missing outcome
data as tobacco use. Thus, these abstinence rates may underestimate the true
abstinence rates for this adolescent population.
It is interesting to note that the abstinence rates decreased from the
6-month to the 12-month follow-up, but then increased at long-term follow-up.
It is likely that during the follow-up period, adolescents had more opportunities
to attempt to stop smoking. They may have also participated in additional
nicotine dependence interventions. A number of adolescents reported use of
pharmacotherapy subsequent to the consultation; however, we did not assess
the timing of these interventions, whether the use of pharmacotherapy was
associated with additional follow-up treatment, nor whether these interventions
were linked to specific NDC counselor recommendations. Moreover, use of treatments
following the NDC consultation was only assessed for the 48 adolescents who
responded to the survey. Thus, we cannot determine directly the effects of
the NDC intervention vs follow-up interventions on the long-term tobacco abstinence
rates.
While the tobacco abstinence rates observed in this study are encouraging
given the brevity of the intervention, most of the adolescents continued to
use tobacco, reinforcing the need to develop more effective treatments for
younger smokers. Our study focused on the end point of tobacco abstinence,
but intentional quit attempts or reductions in cigarettes per day could also
be considered indicators of success.2 Of the
48 adolescents contacted at long-term follow-up, 85.4% had made one or more
serious attempts to stop tobacco use after the NDC consultation. Most smokers
make multiple stop attempts before achieving abstinence from tobacco.20 Perhaps a behavioral intervention could be developed
to capitalize on the adolescent's stop attempts and other behavioral changes
to increase the likelihood of eventual abstinence from tobacco. Further studies
could also collect information on reasons for relapse among those who made
a quit attempt, which may help guide the development of effective interventions.
The NDC counselors typically use a different approach with adolescents
than with adults. Future efforts will focus on systematically tailoring the
intervention to adolescents, which could enhance the ability to replicate
the treatment in other clinical settings and with other health care providers.
The recently published clinical practice guidelines on treatment of tobacco
use and dependence state,
When treating adolescents, clinicians may consider prescriptions
for bupropion or nicotine replacement therapy when there is evidence of nicotine
dependence and desire to quit smoking. However, because of the psychosocial
and behavioral aspects of smoking in adolescents, clinicians should be confident
of the patient's tobacco dependence and intention to quit before instituting
pharmacotherapy. Factors such as degree of dependence, number of cigarettes
smoked per day, and body weight should be considered.12(pp101-103)
Since higher levels of nicotine dependence were associated with lower
tobacco abstinence rates at 6 months, nicotine-dependent adolescents may need
pharmacological therapy to enhance their success.
Our findings on tobacco use outcomes should be interpreted in light
of some methodological limitations of this study. We relied on self-reported
abstinence from tobacco, which is similar to most treatment outcome studies
conducted among adolescent tobacco users.7
Adolescent reports may be patient to more sources of error than those of adults
because of underreporting or overreporting, or unintentional errors owing
to irregular smoking patterns.26, 27
There is an obvious need to enhance the validity of the findings with adolescents
by using biochemical verification. Relatedly, at long-term follow-up, some
adolescents were asked to report retrospectively on their smoking status at
6 and 12 months following the consultation. Although strategies were used
to enhance accuracy, these retrospective reports are patient to recall biases.
To address this, we examined the consistency of reports of tobacco use status
among those with data from both the NDC database and the long-term follow-up
interview. Outcome status was consistent for 71% (15/21 patients) at 6 months,
and 75% (6/8 patients) at 12 months. These results indicate a fairly accurate
recall of tobacco status at long-term follow-up. Only 50% of the sample was
contacted at long-term follow-up, but this rate is similar to that obtained
with follow-ups of 6 months or less in treatment outcome studies.7, 8 Moreover, the survey sample did not
seem to be biased, in that the baseline characteristics were similar for responders
and nonresponders. Incentives and other strategies may be needed to enhance
the retention of adolescents over time.
Another study limitation is the small sample size for evaluating univariate
associations between baseline characteristics and 6-month tobacco use outcomes.
Only the FTND score was associated with the 6-month outcome; however, the
power to detect these associations was low. In general, with an overall sample
of 96 and a total of 17 adolescents abstinent from tobacco at 6 months, the
power was, at most, 50% to detect any baseline characteristic as being a significant
predictor of 6-month abstinence with an effect size corresponding to an odds
ratio of 3.0. A larger sample of adolescents is needed to determine factors
multivariately associated with tobacco abstinence.
Our results provide information on the characteristics of adolescents
treated for nicotine dependence. Findings from the medical record review are
consistent with some studies demonstrating that psychiatric disorders and
adverse health consequences of tobacco use already exist at an early age.5, 6, 22 These findings could
be used clinically by health care providers treating adolescents to emphasize
the short-term health effects of tobacco use and personalizing the benefits
of abstinence from smoking. A limitation of these results is that the psychiatric
diagnoses were determined from a medical record review rather than a structured
diagnostic interview. The majority of adolescents presenting for treatment
in our clinic were males approximately midway through their teenage years.
Evidence suggests that the earlier the onset of tobacco use, particularly
prior to age 15 years, the less effective tobacco cessation interventions
tend to be.1 Nearly two thirds of the sample
were male, and females may present different challenges for health care providers
in delivering tobacco cessation treatment.28
Moreover, 91.7% of the adolescents were white, and the findings may not generalize
to adolescents of different ethnic backgrounds. Alaska Native adolescents
who have a markedly high rate of tobacco use,29
and other ethnic groups, may benefit from an intervention that is culturally
tailored. In addition, most of the adolescents in our sample had made at least
one prior serious stop attempt and reported being somewhat motivated or very
motivated to discontinue tobacco use.
AUTHOR INFORMATION
Accepted for publication March 2, 2001.
This study was supported by a clinical research grant from the Mayo
Clinic, Rochester.
The findings were presented in part at the Annual Meeting of the Society
for Research on Nicotine and Tobacco, Arlington, Va, February 2000.
The authors would like to acknowledge Kenneth Offord, MS, Ivana Croghan,
PhD, and Leigh Gomez-Dahl, BS, for their contribution to the conduct of the
study and/or data analysis.
From the Nicotine Dependence Center (Drs Patten, Ames, and Hurt, and
Mr Gauvin), the Department of Psychiatry and Psychology (Dr Patten), the Department
of Internal Medicine (Dr Ebbert), and the Section of Biostatistics (Mr Wolter),
the Mayo Clinic, Rochester, Minn.
Corresponding author and reprints: Christi A. Patten, PhD, Nicotine
Dependence Center, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (e-mail: patten.christi{at}mayo.edu).
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Adolescent and young adult tobacco prevention and cessation: current status and future directions
Backinger et al.
Tobacco Control 2003;12:iv46-53.
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