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

1. Youth Cessation: A Process for Making Informed DecisionsNational Conference on Tobacco or Health, 2002San 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

2. 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

3. 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

4. Assess Community Needs and Organization’s Commitment and Capacity Assess Current Tobacco Prevention and Control Efforts Determine Appropriate Intervention Determine Your Role in Tobacco Control Evaluate Efforts A Process for Making Informed Decisions

5. A Process for Making Informed Decisions • Assess Current Tobacco Prevention and Control Efforts

6. 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

7. Programmatic Components of a Comprehensive Tobacco Control Program • Community Interventions • Countermarketing • Policy and Regulation • Surveillance and Evaluation

8. Comprehensive Tobacco Control Program Matrix

9. Comprehensive Tobacco Control Program:DASH Guidelines

10. Comprehensive Tobacco Control Program: Community Task Force Recommendations

11. Comprehensive Tobacco Control Program: PHS Recommendations

12. Comprehensive Tobacco Control Program: CDC Best Practices

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

14. Comprehensive Tobacco Control Program: Combined Efforts

15. Comprehensive Efforts Help Youth Quit Change in Social Norms Smoking Bans and Restrictions Advice from Health Care Providers Mass Media Campaigns Prevention Programs Price Increases Advertising Bans and Restrictions Restricted Access Treatment Coverage Quitlines

16. 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?

17. 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?

18. 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?

19. 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?

20. A Process for Making Informed Decisions • Determine Your Organization’s Role in Tobacco Control

21. Ask yourself… • Are we fully implementing what works? • Have those efforts been intensified? • Are there any gaps to fill? • Are those efforts being sustained?

22. Important Activities • Assess current tobacco prevention and control efforts in your area and determine where further effort is required • Determine where your organization might have the greatest impact given your organization’s mission, commitment and capacity

23. A Process for Making Informed Decisions • Assess Your Community’s Need and Organization’s Capacity and Commitment for Youth Cessation

24. 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.

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

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

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

28. A Process for Making Informed Decisions • Select An Appropriate Intervention

29. 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

30. 4. Select An Appropriate Intervention Key Considerations when selecting the type(s) of youth cessation intervention: • Currently little evidence for guidance • Different conceptual approaches • Variety of ways to intervene • Recruitment

31. 4. Select An Appropriate Intervention Promising Conceptual Approach Cognitive-Behavioral • Evidence review • Expert opinion

32. 4. Select An Appropriate Intervention Cognitive-Behavioral Approach General Concepts • Establish Self-Awareness of their tobacco use • Motivation and Encouragement for Quitting • Preparation for Quitting • Strategies to Maintain Abstinence

33. 4. Select An Appropriate Intervention Cognitive-Behavioral Approach Participants 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

34. 4. Select An Appropriate Intervention Cognitive-Behavioral Approach Participants 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

35. 4. Select An Appropriate Intervention Cognitive-Behavioral Approach Participants 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

36. 4. Select An Appropriate Intervention 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

37. 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

38. A Process for Making Informed Decisions • EVALUATE, EVALUATE, EVALUATE!

39. 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.

40. 5. Evaluating Your Efforts and Monitoring Progress • Describing the Intervention and Participants • Process Evaluation • Outcome Evaluation • Using Evaluation Data

41. 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

42. Describing Your Intervention and Participants Description of Intervention Would Include: • Delivery Location(s) • Duration and Intervals for Delivery • Materials • Incentives • Other interventions or pharmocotherapy

43. Describing Your Intervention and Participants 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

44. 5. Evaluating Your Efforts and Monitoring Progress • Describing the Intervention and Participants • Process Evaluation • Outcome Evaluation • Using Evaluation Data

45. 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)?

46. 5. Evaluating Your Efforts and Monitoring Progress • Describing the Intervention and Participants • Process Evaluation • Outcome Evaluation • Using Evaluation Data

47. 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?

48. Critical Concepts in Youth Cessation Evaluation • Recruitment • Implementation Compliance • Retention • Follow-up Period • Quit Rates • Biochemical Validation of Self-Report

49. 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

50. 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.