Whereas some data are available about late smoking relapse among adult quitters, there are none for teen quitters. This study is a 6-year follow-up of teen quitters (n=253) for whom we collected (retrospectively) data on the extent and timing of relapse. We found that even after a strictly defined quit (six-months prolonged abstinence) at one year, substantial relapse occurred both early and late: the majority (55%) of relapses occurred after the 0–1year interval after having quit. These findings have implication for the need for research into the relapse process for teen quitters, and for the need to develop interventions for teens (as for adults) to prevent (early and) late relapse.

Attrition is of great concern to longitudinal studies and randomized controlled trials (RCTs) because it can negatively affect internal and external validity, statistical validity, and the perceived quality of a study. This case study considers the design process and results of a survey of nonrespondents to an initial survey used in the long-term follow-up of a hardto- reach cohort of young adults. The original study cohort consisted of 2,151 teenage smokers who participated in an RCT of an experimental smoking cessation intervention. A successful intervention impact, detected at one year post-high school, prompted a Wave 3 follow-up at seven years post-high school in order to determine if the impact persisted into young adulthood. Initial survey response in the Wave 3 follow- up fell well short of our minimum design goal of 80 percent. We used an analysis of nonrespondents, a review of the literature on increasing response rates, and an internal incentive test to inform the design of a new questionnaire and survey procedures for a nonrespondent follow-up study. The nonresponse follow-up study achieved a response rate of 42.9 percent, which succeeded in raising the overall response for the Wave 3 follow-up from 68.6 percent to 81.5 percent. It also succeeded in making the final respondent sample more representative of the study cohort and reduced the potential for nonresponse bias in the study's most important end point. Most importantly, it allowed us to answer questions about the long-term impact of a cancer prevention intervention with increased validity.

Background: Adolescent smoking cessation efforts to date have tended to focus on regular smokers. Consequently, infrequent and occasional smokers' receptivity and response to smoking cessation interventions is unknown. To address this gap, this study examines data from the Hutchinson Study of High School Smoking a randomized trial that examined the effectiveness of a telephone-delivered smoking cessation intervention for a large, population-based cohort of adolescent smokers proactively recruited in an educational setting.Methods: The study population included 1837 proactively identified high school smokers. Intervention receptivity, engagement, and outcomes were examined among adolescent infrequent (1-4 days/month) and occasional (5-19 days/month) smokers and compared with regular smokers (20 or more days/month).Results: With regard to treatment receptivity, intervention recruitment did not differ by smoking frequency. For engagement, intervention completion rates were higher for infrequent smokers (80.5%) compared with occasional (63.8%) and regular smokers (61.5%, p < 0.01). Intervention effect sizes were not statistically different across groups.Conclusions: Adolescent infrequent and occasional smokers are at least as receptive to a proactively delivered smoking cessation intervention as regular smokers and can benefit just as much from it. Including these adolescent smokers in cessation programs and research with the goal of interrupting progression of smoking before young adulthood should help reduce the high smoking prevalence among young adults. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Background The Hutchinson Study of High School Smoking was the first randomized trial to show effectiveness of a smoking cessation intervention on 6-months prolonged smoking abstinence at one year post-intervention in a large population-based sample of adolescent smokers. An important question remains: Do the positive effects from teen smoking cessation interventions seen at up to 12 months post-intervention endure into young adulthood? This study examines for the first time whether such positive early effects from teen smoking cessation intervention can endure into young adulthood in the absence of additional intervention. Methods High school smokers (n = 2,151) were proactively recruited into the trial from fifty randomly selected Washington State high schools randomized to the experimental (Motivational Interviewing + Cognitive Behavioral Skills Training telephone counseling intervention) or control (no intervention) condition. These smokers were followed to 7 years post high school to ascertain rates of six-year prolonged smoking abstinence in young adulthood. All statistical tests are two-sided. Results No evidence of intervention impact at seven years post high school was observed for the main endpoint of six-year prolonged abstinence, neither among all smokers (14.2% in the experimental condition vs. 13.1% in the control condition, difference = +1.1%, 95% confidence interval (CI) = -3.4 to 5.8, p = .61), nor among the subgroups of daily smokers and less-than-daily smokers, nor among other a priori subgroups. But, observed among males was some evidence of an intervention impact on two endpoints related to progress towards quitting: reduction in number of days smoked in the past month, and increase in the length of the longest quit attempt in the past year. Conclusions There was no evidence from this trial among adolescent smokers that positive effectiveness of the proactive telephone intervention for smoking abstinence, observed previously at one year post-intervention, was sustained for the long-term into young adulthood. In light of the positive short-term effectiveness consistently observed from this and other trials for teen smokers, together with the lack of evidence from this study that such short-term impact can endure into young adulthood, sustained interventions that continue into young adulthood should be developed and tested for long-term impact. Trial Registration ClinicalTrials.gov NCT00115882

Only one prior study has examined why adolescent smoking cessation interventions are effective. To address this understudied and important issue, we examined whether a large adolescent smoking cessation intervention trial's outcomes were mediated by social cognitive theory processes. In a randomized trial (N = 2,151), counselors proactively delivered a telephone intervention to senior year high school smokers. Mediators and smoking status were self-reported at 12-months postintervention eligibility (88.8% retention). At least 6-months abstinence was the outcome. Among all enrolled smokers, increased self-efficacy to resist smoking in (a) social and (b) stressful situations together statistically mediated 55.6% of the intervention's effect on smoking cessation (p < .001). Among baseline daily smokers, increased self-efficacy to resist smoking in stressful situations statistically mediated 56.9% of the intervention's effect (p < .001). Self-efficacy to resist smoking is a possible mediator of the intervention's effect on smoking cessation.

Background: Quitline smoking cessation counseling results in a mere 12% success rate. Testing of new telephone-delivered cessation counseling approaches is needed.Objective: Determine the feasibility of the first telephonedelivered Acceptance and Commitment Therapy ( ACT) intervention for smoking cessation.Design: Fourteen adults (57% racial/ethnic minority, 8/14) in a single-arm study. Counselor proactively delivered a 5-session (90-min total) ACT telephone intervention for smoking cessation. Hypothesized ACT processes were selfreported at baseline and posttreatment. Smoking status was self-reported at baseline, 20-day posttreatment (93% retention, 13/14), and 12-month posttreatment (93% retention, 13/14).Results: (a) Delivery length and duration: average of 3.5 calls and 81.9-min intervention duration. (b) Receptivity: 100% (14/14) felt respected by the counselor, 86% (12/14) said that intervention was a good fit, and 93% (13/14) said that intervention helped them quit. (c) ACT processes: (i) acceptance of physical cravings, emotions, and thoughts that cue smoking increased from baseline to posttreatment (p =.001, p =.038, and p =.085, respectively) and (ii) commitment to quitting increased from baseline to posttreatment (p =.01). (4) Intenttotreat cessation outcomes: (i) at 20-day posttreatment, 43% (6/14) had not smoked the day of the survey and 29% (4/14) had not smoked in past 7 days and (ii) at 12-month posttreatment, 29% (4/14) had not smoked at all in past 12 months. These quit rates are over double the 12% quit rates of current standard telephone counseling.Conclusion: Telephone-delivered ACT shows promise for smoking cessation and warrants future testing in a well-powered randomized trial.

BACKGROUND The Hutchinson Study of High School Smoking randomized trial was designed to rigorously evaluate a proactive, personalized telephone counseling intervention for adolescent smoking cessation. METHODS Fifty randomly selected Washington State high schools were randomized to the experimental or control condition. High school junior smokers were proactively identified (N = 2151). Trained counselors delivered the motivational interviewing plus cognitive behavioral skills training telephone intervention to smokers in experimental schools during their senior year of high school. Participants were followed up, with 88.8% participation, to outcome ascertainment more than 1 year after random assignment. The main outcome was 6-months prolonged abstinence from smoking. All statistical tests were two-sided. RESULTS The intervention increased the percentage who achieved 6-month prolonged smoking abstinence among all smokers (21.8% in the experimental condition vs 17.7% in the control condition, difference = 4.0%, 95% confidence interval [CI] = -0.2 to 8.1, P = .06) and in particular among daily smokers (10.1% vs 5.9%, difference = 4.1%, 95% CI = 0.8 to 7.1, P = .02). There was also generally strong evidence of intervention impact for 3-month, 1-month, and 7-day abstinence and duration since last cigarette (P = .09, .015, .01, and .03, respectively). The intervention effect was strongest among male daily smokers and among female less-than-daily smokers. CONCLUSIONS Proactive identification and recruitment of adolescents via public high schools can produce a high level of intervention reach; a personalized motivational interviewing plus cognitive behavioral skills training counseling intervention delivered by counselor-initiated telephone calls is effective in increasing teen smoking cessation; and both daily and less-than-daily teen smokers participate in and benefit from telephone-based smoking cessation intervention.

BACKGROUND:Effective smoking cessation for youth is urgently needed, but the literature guiding such efforts is nascent. We evaluated the implementation of a proactive intervention for adolescent smoking cessation that incorporated motivational interviewing (MI) and cognitive behavioral skills training (CBST).METHODS:We proactively identified 1058 smokers via classroom survey of enrolled juniors in 25 experimental high schools. After parental consent was obtained, trained counselors telephoned participants to invite their participation and deliver personalized smoking cessation counseling that combined MI and CBST. Implementation quality was assessed via weekly supervision of counselors, monitoring of counselor adherence to protocol via review of 5% of each counselor's calls, and formal evaluation of counselor fidelity to MI via review of a random sample of 19.8% of counseling calls using the Motivational Interviewing Treatment Integrity Code.RESULTS:Among identified smokers, 948 (89.6%) were eligible for intervention by age (> or =18 years) or parental consent, 736 (70%) agreed to participate in telephone counseling, 691 (65%) completed one or more counseling calls, and 499 (47%) completed all planned calls. Telephone delivery of the personalized MI and CBST counseling intervention to a general population of adolescents was done with greater than 90% adherence to the intervention protocol. Review of the random sample of counselors' calls demonstrated that more than 85% of counselors' calls met or exceeded benchmark scores for four of six evaluated behaviors: MI spirit (99.1%), empathy (96.2%), ratio of reflections to questions (97.2%), and MI adherent (85.7%).CONCLUSION:An effective proactive telephone counseling intervention consisting of MI and CBST can be successfully implemented with reach and fidelity in a general population of adolescent smokers.

Participant recruitment and retention have been identified as challenging aspects of adolescent smoking cessation interventions. Problems associated with low recruitment and retention include identifying smokers, obtaining active parental consent, protecting participants' privacy, respecting participants' autonomy, and making participation relevant and accessible to adolescents. This paper describes nine strategies for minimizing these recruitment and retention problems via a proactive telephone counseling intervention, and reports on their simultaneous implementation among 1,058 smokers from 25 high schools in Washington state. Results are as follows: (a) 85.9% of parents of minor-age seniors provided active consent for their teen's participation, (b) 89.8% of eligible smokers were successfully contacted by counselors, (c) 86.5%of contacted smokers consented to participate in the cessation counseling, (d) 93.8% of consented smokers participated in smoking cessation counseling calls, and (e) 72.2% of participating smokers completed their full intervention. These results demonstrate that older teens who smoke, and their parents, are receptive to confidential cessation counseling that is personally tailored, supportive of their autonomy, and proactively delivered via the telephone.

OBJECTIVE:Well-documented challenges have hampered both intervention development and research in teen smoking cessation. Addressing these challenges, the Hutchinson Study of High School Smoking (HS Study), the largest group-randomized trial in adolescent smoking cessation to date, incorporates several design innovations to investigate the effect of a counselor-initiated, individually tailored telephone counseling smoking cessation intervention for older adolescents. This paper presents and discusses these innovative design features, and baseline findings on the resulting study population. METHOD:The trial used a population-based survey to proactively identify and recruit all high school juniors who had smoked in the past month - potentially expanding intervention reach to all smokers, even those who smoked less than daily and those not motivated to quit. For ethical and intervention reasons, some nonsmokers were enrolled in the intervention, also. Other important design features included the random allocation of schools into experimental conditions (intervention vs. no-intervention control) and a multi-wave design. RESULTS AND CONCLUSION:The design innovations address problems and challenges identified in adolescent smoking cessation literature. The heterogeneous baseline characteristics of the study population, well-balanced between the two arms, have three significant implications: They (1) demonstrate the effectiveness of the trial's design features, (2) highlight several intervention-related issues, and (3) provide assurance that the trial's evaluation of intervention effectiveness will be unbiased.

For scientific and public health reasons, it is important to identify the role of family influences on child smoking acquisition. Using a well-followed (>90%) cohort of 3,012 children and their parents, this study prospectively investigated the influence of smoking by 0 vs. 1 vs. 2 parents when the children were young (3rd grade), on whether the children subsequently became daily smokers. It is the only study to investigate the prediction of child/adolescent smoking at the end of the smoking acquisition period (12th grade) by parental smoking at the start of the period (3rd grade). Logistic regression analyses revealed that having one parent who smokes substantially increases the risk that children will become daily smokers, relative to families where neither parent smokes (OR=1.90, p<.01). There is no evidence that the increased risk depends on parent or child gender. These results suggest the need for public health interventions that inform parents of young children that their own smoking behavior increases their children's risk for future smoking.

AIMS:The first prospective investigation of the extent to which parental smoking cessation predicts their children's daily smoking.DESIGN:Parental smoking status was assessed when children were aged 8/9 years and children's smoking status was assessed at age 17/18 years.SETTING:Twenty Washington State school districts in the control group of the Hutchinson Smoking Prevention Project.PARTICIPANTS AND MEASUREMENTS:Questionnaire data were gathered on 3012 children (49% female and 91% Caucasian) and both of their parents in a cohort with a 95% retention rate.FINDINGS:When both parents quit smoking, children's odds of daily smoking were reduced by 39% (95% CI = 15%,56%) compared to when both parents were current smokers.Furthermore, when both parents never smoked then children's odds of daily smoking were reduced by 71% (95% CI = 62%,78%).CONCLUSIONS:Parental smoking cessation is associated with reduced risk of their children's daily smoking. Parents who quit still place children at substantially higher risk compared to parents who never smoked.

We value greatly the three insightful commentaries on our paper (Chassin et al. 2003; Jarvis 2003; Swan 2003). We appreciate their comments about our study's novel and useful contribution to the scientific literature on children's smoking initiation. Both Chassin et al. and Swan noted with favorable comments our result that smoking cessation by one parent is associated with a 25% reduction in the odds of children's daily smoking, while cessation by two parents is associated with a 39% reduction in the odds of children's daily smoking. All of the commentaries noted the public health implications of our study: if parents who smoke are able to quit then they may help reduce the odds that their children will become smokers. All the commentaries pointed out the methodological strengths of the paper, including: its prospective design, which spans the ages at which children are at highest risk for smoking acquisition; our large sample with high retention; parental and children's self-report of their smoking; biochemical validation of children's smoking, and use of multiple smoking outcome measures. We strongly agree with Chassin and colleagues that an important area for future research is to identify mediators of our result that parental smoking cessation is associated with lowered odds of children's smoking. Consistent with Chassin et al. (2002), one important class of mediators to investigate is parental practices that discourage their children from smoking. We would hypothesize that parents who quit smoking will tend to engage in anti-smoking practices that limit their children's exposure to a smoking environment. Such practices could protect children from smoking. Direct modeling is theorized to be a powerful predictor of smoking behavior (Bandura 1977), and there is evidence to support that theory (Petraitis, Flay & Miller 1995). Therefore, it is possible that parental actions that limit children's environmental exposure to smokers may lower the risk that children become smokers. Examples of such parent anti-smoking practices to limit environmental exposure to smokers could include prohibiting smoking in the home, asking to sit in non-smoking sections and asking smokers not to smoke around them. Our hypothesis is that parents who have quit smoking are strongly motivated to be against smoking. Such motivation would encourage parents to engage in behaviors to try to protect their children from being near smokers. Chassin et al. and Jarvis believe that a limitation of our study is that we did not examine parental smoking cessation occurring after children were age eight. We agree that this issue is worthy of future study. If there is evidence that quitting after children are age eight is associated with lowered odds of children's smoking, then the public health implication would be that even those parents can influence their children not to smoke. Moreover, we think it is also important for future research to examine whether parental relapse may influence the odds of children's smoking. Compared to parents who quit and then relapse, perhaps parents who quit and remain quit may be the ones who are more likely to influence their children not to smoke. All of the commentators, especially Swan, made thoughtful observations about the potential role of genetics and exposure to a variety of social environments to explain our results. We believe that a theoretical model is needed that comprehensively integrates three important etiological factors: family genetics, children's personality traits and children's exposure to social environmental models of smoking. Regarding family genetics, children of parents who quit may nevertheless inherit a vulnerability to engage in addictive behaviors. These children might also inherit the vulnerability for personality traits (such as sensation seeking and rebelliousness), which themselves moderate their risk of smoking. It is possible that children of parents who quit are clustered within social environments with more models of smoking behavior than children whose parents never smoked. Parents who quit may continue to have relationships with people with whom they used to smoke (e.g. friends and colleagues), and it is reasonable to speculate that parents who quit may still have extended family who continue to smoke. It would be valuable for future research to investigate the interaction between these genetic factors, personality and social environmental exposures to help explain the association between parental smoking cessation and children's smoking. In summary, we gratefully appreciate the commentators’ positive comments on our research and their constructive ideas for future investigations on parental smoking cessation and children's smoking. We agree that some important areas for future research on this topic are to examine factors that mediate the association between parental smoking cessation and children's smoking as well as the timing of parental smoking cessation. We think that a theoretical model that integrates genetic, personality and social environmental factors may be a useful framework for future studies to examine the association between parental smoking cessation and children's smoking.

BACKGROUND:The effects of mothers' attitudes and concerns about tobacco use on whether their children take up smoking are largely unknown. This study examined the predictive effects of mothers' attitudes about tobacco and concerns about their children smoking.METHODS:Self-reported data from a large number of 12th-grade students (2,736) and their mothers were used. Mothers' attitudes and concerns were assessed when their children were 3rd graders (age 8), at the start of the smoking acquisition period; their children were then followed prospectively (with attrition of only 5%) for 9 years to the end of the period (12th grade) for the assessment of smoking behavior.RESULTS:In households in which both parents are nonsmokers, strong maternal antismoking attitudes are associated with a statistically significant approximately 50% reduction (P < 0.05) in the prevalence of smoking by adolescent children. In contrast, in households in which one or both parents are current smokers, there was no reduction in adolescent smoking associated with mothers' antismoking attitudes.CONCLUSIONS:Maternal antismoking attitudes when their children are young predict adolescents' adoption of smoking at 12th grade, but only when parental behavior is consistent with these attitudes.

INTRODUCTION:This paper describes the experimental design and baseline characteristics of the Hutchinson Smoking Prevention Project (HSPP), a 15-year trial to determine to what extent a grade 3-12 school-based tobacco use prevention intervention can deter tobacco use throughout and beyond high school.DESIGN:Trial design features include use of the school district as the unit of randomization, inclusion of the school district's entire enrollment of 3rd graders, long-term follow-up of the entire original cohort, and sample size and evaluation methods that account for the group-randomization and intraclass correlation of endpoints within school districts. The theory-based intervention is teacher-led and includes grade 3-10 curriculum units, teacher training, grade 9-12 tobacco use cessation materials, and high school staff newsletters.RESULTS:Baseline data were collected on the trial cohort of 8388 children and their parents and on the 40 collaborating school districts and communities. A comparison of the distribution of baseline variables between experimental conditions shows good balance. CONCLUSIONS. The HSPP trial's experimental design will provide a rigorous test of the intervention. The balance in baseline variables between the experimental and control conditions will help provide assurance that the trial's intervention effectiveness results, scheduled for publication in 2000, will be unbiased.

Nonadherence to accepted design principles for randomized trials has been a limitation of school-based intervention research. Designed to overcome these limitations, the Hutchinson Smoking Prevention Project (HSPP) is a 15-year randomized trial to determine the extent to which a school-based (grades 3–12) tobacco use prevention intervention can deter youth tobacco use throughout and beyond high school. This paper presents the HSPP experimental design, together with methods for its implementation, and an evaluation of the degree to which HSPP has adhered to principles of randomized trials. Results from the experimental design and its conduct include (1) a recruitment rate of 97.6% (40 of 41 targeted school districts), (2) full and active participation for the trial's duration by 100% of the 40 school districts recruited, (3) implementation by virtually all teachers (99%+), with 86% implementation fidelity, and (4) outcome determination for 94.3% (7910) of 8388 original study participants identified 12 years previously at baseline. The high degree of rigor achieved by the HSPP experimental design ensures confidence in the trial's soon-to-be available intervention effectiveness results. Equally important, for future school-based trials, the HSPP design and its execution have illustrated that school-based research can adhere to the principles of rigorous randomized trials, with high rates of implementation, and very high rates of recruitment, maintenance, and follow-up of study participants, even for studies with decade-long follow-up periods. Rigor in school-based trials can be achieved through a combination of (1) commitment to the principles of randomized trials, (2) attention to the special challenges of trials specific to the school setting, (3) adoption and meticulous execution of proven methods for trial conduct, and (4) establishment at the outset of principles for maintaining positive collaborative relationships with participating school districts for the duration of the trial. These findings are important in light of the great potential for using the nation's schools to access youth for health promotion/risk-factor prevention. Control Clin Trials 2000;21:144–165

Most adolescent smoking prevention studies employ designs in which classrooms, schools, school districts, or sometimes whole communities are assigned to treatment conditions while observations are made on individual students. The critical design feature in such community trials is the nesting of intact social groups within treatment conditions. This combination requires that the treatment effect be assessed against the between-group variance; unfortunately, that variance is usually larger than for randomly constituted groups and its precision is usually less than that for the within-group variance. These factors often combine to reduce power so that it is almost impossible to detect important treatment effects in an otherwise well designed and properly executed study. To address these problems, investigators need good estimates of the intraclass correlation for the variables of interest, which together with the number of observations per unit determine the magnitude of the extra variation in the nested design. The purpose of this paper is to describe the methods and results from a study designed to generate estimates of intraclass correlation for common outcomes in adolescent smoking prevention studies and to discuss the use of these estimates in the planning of new studies.