Challenging Dogma - Spring 2011

Sunday, May 8, 2011

Tobacco cessation and prevention in adolescents: a critique of motivational interviewing the emergency department setting and proposal for a wellness

Despite the knowledge that it is a potentially lethal habit, smoking continues to be a major public health issue. At present there are an estimated 46 million people, or 20.6% of all adults (aged 18 years and older)(1), in the United States smoke cigarettes. Each day in the United States, approximately 3,450 young people between 12 and 17 years of age smoke their first cigarette, and an estimated 850 youth become daily cigarette smokers (2). Some of the most common risk factors for teenage/adolescent cigarette smoking include low socioeconomic status, use and approval of tobacco use by peers or siblings, lack of skills to resist influences to tobacco use, smoking by parents or guardians and/or lack of parental support or involvement, accessibility/availability/price of tobacco products, a perception that tobacco use is the norm, low levels of academic achievement, low self-image or self-esteem, and aggressive behavior (e.g., fighting, carrying weapons)(3) Public health clinicians have recognized that adolescents are an important group to focus on for targeted intervention both for prevention and cessation of tobacco abuse. In this paper, one ineffective adolescent focused intervention that uses motivation interviewing in the emergency room setting will be critiqued and an alternative intervention that addresses the limitations of this study will be proposed.

The use of the motivational interview of teenagers in the emergency room

Dr. Horn et al at West Virginia University proposed an intervention focused on teenagers in the emergency room setting that involved motivational interviewing for smoking cessation. The motivation interview is based on aspects of the social cognitive theory, the theory of self efficacy and the transtheortical model or stages of change. In this study, 75 participants were recruited and randomized to either have standard education or the intensive interviewing. For those who had the intensive interview, this included a 15- to 30-minute patient-tailored face-to-face motivational interview including a readiness assessment, a reflection on smoking behaviors, and a health inventory. This was provided by trained intervention providers that had relevant backgrounds in social work, psychology and public health education. It also included a stage-matched, self-help take-home workbook with audio, a handwritten personal postcard within 3 days of the ED visit and three follow-up “booster” phone calls at 1, 3, and 6 months post-ED visit. Those participants randomized to the standard care received a brief advice intervention consisted no more than 2 minutes of generic advice to quit smoking, referral to the state 1-800 telephone help information line, a general information source and one follow-up phone call 6 months post-ED visit. (4) This method was selected to address many of the hypothesized failures of other smoking cessation/prevention interventions. The study designers noted that school based interventions are thought to be somewhat ineffective given the higher rate of smokers in students that have high rates of absenteeism or drop out, hold negative attitudes toward school or attend schools with limited resources. They felt that providing the intervention in an emergency room would allow contact with adolescents that do not attend school or have a negative association with school They also felt having a one time intensive intervention would address the higher rate of failure of other programs due to “drop out rate” for interventions with multiple/schedule follow up. (4) The study did not show a statistically significant reduction in quit rates, in fact both the motivation interview group and standard education group each had only one person quit. The motivational interview group did have a higher rate of reduction in smoking compared with standard group.

Why motivational interviewing does not work with adolescents

Adolescence is a critical time to intervene with respect to tobacco use/abuse. This developmental period is crucial because of accelerated biological, cognitive, social, and emotional changes that influence behavioral choices (5). When we consider the risk factors for adolescent smoking reviewed in the first paragraph, the motivational interview does not address many of these. The social theories/models used in this particular study and the intervention type itself have not been shown to be effective in this demographic, and may even be detrimental. The intervention described above is based on multiple social theories including the social cognitive theory, the theory of self efficacy and the transtheortical model or stages of change. While each of these theories may be effective in certain populations, they are likely not to be in teenagers.

Why social cognitive theory will not work with adolescents

The social cognitive theory states that behavior is determined by expectancies and incentives. Expectancies include the effect of environmental cues, meaning how events are connected with outcomes, ie cause and effect. It also looks at the consequences of one’s actions. Incentives are defined as the value of a particular object or outcome. Outcomes could be health status, physical appearance, approval of others or economic gain/loss. (7). While use of these theories may be effective in an older population that is starting to appreciate issues of morbidity and mortality, teenagers feel they are invincible and likely may not see the harm in tobacco use. Or they are aware of the effects of tobacco abuse but do not think these effects will happen to them. They also state that they plan to only smoke when they are young and quit when they are older. (8) Unfortunately they will likely already be addicted by that time. Therefore, using facts regarding health and the potential consequences of smoking to persuade adolescence not to smoke has been found to be ineffective.

Why self efficacy theory and the transtheortical model will not work with adolescents in this setting

Self efficacy is also part of social cognitive theory and this focuses on one’s own belief in their competency to perform the behavior needed or desired. The transtheoretical model identifies the 5 stages of change in which a person goes through to start or stop a behavior. The 5 stages are: pre-contemplation, contemplation, preparation, action and maintenance of a behavior. This provides a temporal illustration to describe to the person where they are versus where they would like to be with a certain behavior and helps the person that wants to change to determine a plan to achieve their goals based on where they are on that spectrum. (9) These models are based on the idea that the individual has a desire to stop the undesired behavior, in this case smoking. However as teens likely do not see the harm in smoking and are mostly engaging in this behavior for social acceptance, they likely do not wish to quit and therefore these models are not likely to be effective in tobacco cessation.

Consider why adolescents smoke- the role of psychological reactance

In review of many articles that describe why young people smoke despite the knowledge that it is a potentially harmful habit, psychological reactance was mentioned repeatedly. Psychological reactance, or reverse psychology, is the idea that when one’s perceived freedom to do an activity is threatened, they are more likely to engage in that activity. Adolescence are just beginning to gain independence from their parents and smoking is one outlet for them to assert themselves against the perceived restrictors of freedom (ie parents, teachers, healthcare providers) telling them not to do an activity. These are well understood reactions people will have, and corporations have used this data to increase sales in teenagers. One example of this is came from a study in the Netherlands where it showed that by placing restrictive labels on video games for violence and sexual content, this made the games more attractive to children as young as 7-8 years of age as a king of “forbidden fruit”. (10). Perhaps a more pertinent example would be the use of this tactic by the tobacco companies. Big tobacco has realized that young adults like to express their freedom by doing activities that they have been told not to do and conducted advertising campaigns with this in mind. In the study by Henriksen et al, they compared the reaction of several 9th and 10th graders ages 14 to 18 and compared their reaction to “antismoking” ads from Phillip Morris, RJ Reynolds and Lorillard. It also compared these with the “truth” campaign. The different campaigns used different strategies to tell teens not to smoke. Lorillard, which was the most likely to use phrases like “Think. Don’t smoke”, which is a command, were the most likely to increase a teen’s interested in smoking, rather than avoiding smoking. (11). As psychological reactance is a reason why teens often start smoking, having an adult/authority figure talk at length with an adolescent is likely to not be effective at getting them to quit, and may even increase their tobacco use as a way to rebel. This reason may contribute to why the motivational interviewing was not successful, as it was administers by a health care professional, an adult.

What has been successful in the past

An extensive review of the literature was performed to see what have been successful interventions for tobacco prevention and cessation in the past. The vast majority have been in group level interventions rather than individual interventions. Examples of successful interventions have been the NOT program, Project EX and the Native FACETS programs. These programs use “fun techniques” for learning about tobacco’s effects as well as effective means of resisting peer pressure. They were all school based programs which were implemented for a fixed period of time. Data critiquing these interventions listed reasons why they felt the success rates were not even higher than they are were that once the intervention was over, it was less likely to be effective (6). Other studies have listed the successful programs as programs that have focused on populations that were at risk for tobacco use, either by ethnicity or socioeconomic standing. They also noted that having community involvement also increased the likelihood of success with an intervention. Using this information and applying it to several of the risk factors for smoking listed in the beginning of this paper, a community center focused on wellness has the potential to be successful for both preventing and decreasing tobacco use/abuse in adolescents.

What could be successful in the future: youth community center focused on wellness.

When designing an intervention, 3 factors are key: what are the contributing factors to the issue, what has worked in the past and what has failed in the past. As was listed in the earlier sections of this paper, some of the most common reasons why adolescents try smoking include: low socioeconomic status, use and approval of tobacco use by peers or siblings, lack of skills to resist influences to tobacco use, smoking by parents or guardians and/or lack of parental support or involvement, accessibility/availability/price of tobacco products, a perception that tobacco use is the norm, low levels of academic achievement, low self-image or self-esteem, and aggressive behavior (e.g., fighting, carrying weapons). Our intervention will focus on those with a low socioeconomic standing, low self esteem and low levels of academic achievement. When looking back at the successful programs and remember what was most effective, the longer an adolescent is exposed to reinforcement about smoking, the higher the chance of success. This is highlighted by the fact that the “one moment in time” interview with a teen, as was used in the motivational interview, was unsuccessful and therefore the intervention should be ongoing. Having a community based support system also lead to higher success rates. I propose that a youth center for at risk teens, focused on wellness, would provide continued education and support to teens to help prevent or stop tobacco abuse. The focus on wellness, rather than just tobacco prevention is for two reasons. The first is based on the results of a study on the Native FACETS program. This dual armed study, one that was only tobacco focused and one that was tobacco and dietary changes, showed a more significant reduction in tobacco use in the group that focused on both dietary and tobacco(6). It was likely a focus on overall well being rather than just tobacco that resulted in a decrease in tobacco use. Other studies confirmed that smoking, physical inactivity and obesity often occur together and that treating one may help to improve the status of the other variables (12) One could also postulate that teens would be more likely to engage in a group focused on a broad topic such as wellness rather than a very focused an socially stigmatized topic such as tobacco abuse. The emphasis of this “club” would be well being with focus on eating well, activities and healthy living. The adolescents involved would come at regular intervals, at least once a week, where they would engage in social activities and work shops to learn healthy lifestyles and techniques to deal with peer pressure. They would also engage in physical activity. This idea was partly generated by a paper written by Sarah MacDonald, Heather Rothwell and Laurence Moore titled “Getting it right: designing adolescent-centered smoking cessation services”. In this paper, they interviewed 13 -18 year olds and asked them what would be the most effective means for getting them to not/stop smoking. They listed as the top choices: the important role of friends, including friends and quitting together, creating smoke free spaces and undertaking leisure activities together as a diversion from smoking (13). In addition to targeting the most at risk population with an intervention that was “chosen” by teens themselves, two social theories would play a role in this intervention, the theory of social norms and psychological reactance.

Theory of social norms

Teenagers feel they are invincible and immune to the effects of tobacco. This was one of the reasons why using social cognitive theory was ineffective at reducing tobacco use in the motivation interviewing study. Adolescents are very concerned with fitting in and being considered “normal”. Social norms theory states that much of people’s behavior is influenced by their perception of how other members of their social group behave. According to social norms theory, people tend to misperceive, i.e., exaggerate, the negative health behavior of their peers. If people think harmful behavior is typical, they are more likely to engage in that type of behavior. This theory takes an environmental approach that shapes social and cultural environments as the way to then influence individuals. One way in which social norms theory has been utilized is in small group interventions. (14) By creating a youth center, you could have small groups where the adolescents get to know each other and become bonded to each other. The overall focus of the center on wellness would establish that the norm is to be healthy- eat healthy, be active and tobacco free and to deviate from this would be a “deviant” behavior.

Self efficacy

The theory of self efficacy was addressed in the critique of the motivational interview as a negative attribute as it would not achieve the intended goal of tobacco cessation as the teens did not have motivation to quit. Self efficacy would be important in the proposed youth center, though as part of the focus and activities would be to discuss the pressures to try tobacco. One very effective intervention in the literature was the use of positive adolescent life skills. This intervention enhanced teen resilience to avoid peer pressure and avoid negative environmental influences. (15) Here again role playing and games were used to simulate real life experiences and help teens to have prepared ways to avoid unhealthy behaviors.

Psychological reactance

One of the major critiques of the Motivational interview intervention was that this may induce psychological reactance as this would be coming from an adult/authority figure. We have adjusted for that by having the “team leaders” or interventionalists be slightly older adolescents or teens. We could have college students mentoring high school students and high school students for middle school students. By acting in the leadership position, they could be seen as a role model or peer leader that could relate better to the situations that adolescents are often in. Most people, when picturing a teenager, can picture them imploring to a parent “oh you just don’t understand what it is like to be a teenager”. Older students would be more in touch with the needs and pressures that teenagers have, and therefore perhaps their messages of healthy living and ways to avoid peer pressure would be better received.

Tobacco prevention and cessation in adolescents is a complicated issue, but one that cannot be ignored. It is important to review who is most at risk, what has worked in the past and what has been in effective to create new successful health programs.


1. Centers for Disease Control and Prevention. Vital Signs: Current Cigarette Smoking Among Adults Aged ≥ 18 Years―United States, 2009. Morbidity and Mortality Weekly Report 2010;59(35):1135–40

2. Substance Abuse and Mental Health Services Administration. Results from the 2009 National Survey on Drug Use and Health: Detailed Tables

3. U.S. Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000

4. Horn et a. Efficacy of an Emergency Department-based Motivational Teenage Smoking intervention. Prevention of Chronic Disease. Volume 4(1) January 2007 (pubmed)

5. Kandel DB, Yamaguchi K, Chen K. Stages of progression in drug involvement from adolescence to adulthood: further evidence for the gateway theory. J Stud Alcohol. 1992;53(5):447–457

6. Sherman EJ, Primack BA. What Works to Prevent Adolescent Smoking? A Systematic Review of the National Cancer Institute’s Research-Tested Intervention Programs Journal of School Health. 2009 Sep;79(9):391-9

7. Rosenstock I, Stretcher V, Becker M. Social learning and the Health Belief Model Health Education Quarterly. 1988 Summer;15(2):175-83.

8. Nilsson, Emmelin "Immortal but frightened"-smoking adolescents' perceptions on smoking uptake and prevention. BMC Public Health. 2010 Dec 21;10:776

9. Glanz, Rimer, Vinswanath Health behavior and health education- Theory, research and practice. Jossey-Bass (2008)

10. Bijvank, Konijn, Bushman, Roelofsma. Age and Violent-Content Labels make Video Games Forbidden Fruits for Youth Pediatrics. 2009 Mar;123(3):870-6

11. Henriksen L, Dauphinee AL, Wang Y, Fortmann SP. Industry sponsored anti-smoking ads and adolescent reactance: test of a boomerang effect. Tobacco Control. 2006 Feb;15(1):13-8

12. Lampert T. Smoking, Physical inactivity and obesity associations with social status. Deutsches Arzteblatt International 2010: 107(1-2)

13.MacDonald S, Rothwell H, Moore L. Getting it right: designing adolescent-centered smoking cessation services. Addiction. 2007 Jul;102(7):1147-50.

14. Higher Education Center for Alcohol, Drug Abuse, and Violence Prevention Higher education center.

15. Campbell-Heider N, Tuttle J, Knapp TR. The Effect of Positive Adolescent Life Skills Training on Long Term Outcomes for High-Risk Teens. Journal of addictions nursing 2009 Jan 1;20(1):6-15.

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