Not On Tobacco

May 2006

Mary Spearen was 8 and her sister Morgan was 6 when they smoked their first cigarettes. They were living with their mother at a women’s shelter in Fayetteville, West Virginia, when the resident bully approached them.

“I smoke,” the older girl said. “And if you want to hang out with me and the cool group, you’re going to smoke too.” And if they didn’t, she said, she would beat them up.

Soon afterward, Mary Spearen was picking cigarette butts off the ground and smoking them. Her younger sister followed behind. By the time they were teenagers, the sisters were each smoking a pack of cigarettes every two days.

“In high school, it was really just considered the norm to be smoking,” said Morgan Spearen, now a 20-year-old sophomore at West Virginia University. “If you weren’t smoking, it was more abnormal than if you were.”

In the late 1990s, the teen smoking rate rose across the country, and West Virginia led the pack: 42 percent of teenagers said they smoked. Then, researchers at the West Virginia Prevention Research Center stepped in. Working with the American Lung Association (ALA), and the state Department of Education and Bureau of Public Health—and with money from the Centers for Disease Control and Prevention—the PRC researchers developed a smoking cessation program that both worked and appealed to teenagers. That program, Not-On-Tobacco (NOT), helped Mary and Morgan Spearen quit smoking and is now helping teenagers quit in all 50 states.  An ALA-adopted national best-practice model, NOT has been translated into Spanish and adapted for use with American Indian youths.

“If we got more funding today, one of the things we’d do is put it into the NOT program to expand it, because we know it would work,” said Bruce Adkins, director of the Division of Tobacco Prevention at the state Bureau of Public Health. According to the American Lung Association, 30 percent of 1,623 students who completed NOT in West Virginia since 1999 have quit smoking, and 53 percent have reduced their smoking.

In a five-state study of field-based NOT programs, 80 percent of participants found the program relevant and helpful for quitting smoking. And in West Virginia, the smoking rate for teenagers declined from 42 percent in 1999 to 28 percent in 2003—in part because of NOT, according to public health officials. Results from the 2005 West Virginia Youth Risk Behavior Survey show that the downturn is continuing.

Part of the reason NOT is so effective is because it reaches kids when they are ready to stop, supporters say.

According to Dean Lee, head of anti-tobacco programming for the state Department of Education, surveys show that 50 percent of teen smokers in West Virginia have thought about quitting. “They just need a vehicle,” he said.

Making the decision to quit smoking can be difficult for teenagers in rural West Virginia, where smoking is seen as a rite of passage. Back at Mary and Morgan’s high school in Fayetteville, three senior girls who went through NOT this fall said their parents bought them or gave them their first cigarettes around age 11. Many homes and restaurants are full of smoke, the students said. And parents aren’t always supportive of a child’s decision to quit.

“My dad at first told me I wouldn’t be able to do it,” said Jessica Hunt, 18, who signed up for NOT because she was having trouble breathing. At her house, everyone smokes. At the restaurant where she works, everyone smokes, and the smokers get extra privileges like breaks outside. But she has seen first-hand the damage smoking can do.

“All of my grandparents now are sick or have died of lung cancer,” Ms. Hunt said. Through NOT, she has reduced her habit from a pack and a half a day to a pack every two or three days, and she can breathe again, she said.

For Kim Smith, 18, who started smoking when she was 11 because her friends smoked, the impetus to quit smoking came when her doctor told her the smoke was affecting her 1-year-old son, Dalton.

“He started getting sick all the time, coughing, asthma,” she said.

Her peers in NOT helped her quit, and she is trying to get two friends—who were expelled from school and are pregnant and smoking—to quit by teaching them skills she learned in NOT.

“Everybody supports everyone else,” Ms. Smith said.

NOT consists of 10 weekly sessions for groups of students, who are divided by gender. The sessions are held at a high school and led by a facilitator who is usually a teacher or school nurse. Students learn quitting techniques and keep journals about their smoking behavior. NOT offers positive peer pressure, skill-building, and self-esteem boosting.

Mary and Morgan Spearen remember specific aspects of NOT that reached them.

According to Mary Spearen, learning the actual ingredients of cigarette smoke, such as carbon monoxide and cyanide, made a big impression on her. So did the answers she learned for every excuse to keep smoking. For example, if she skipped a few cigarettes, the cough she’d get was actually because of the smoke and pollutants coming loose in her lungs and exiting her system.

Morgan Spearen appreciated the method of setting small goals and keeping a journal, and finding a way to modify her thought processes. “The thing I learned the most from NOT was the self-talk,” said Ms. Spearen, who now studies psychology. “If you tell yourself, ‘I can do this, I can stop smoking,’ then you can. If we’d say, we smoke because we’re stressed out, we’d think of ways to not be stressed out.”

Program supporters say that a personal relationship between students and the facilitator sets NOT apart from other stop-smoking efforts. Many of the facilitators are ex-smokers and share their own quitting stories and struggles with the students.

Bev Hall, a life skills teacher at Fayetteville High School, was the facilitator who recruited both girls.

“Every time I’d come in, she’d say, ‘Morgan, you smell like cigarettes, you smell like cigarettes.’”

“There were flyers,” Mary Spearen said. “Mrs. Hall said, ‘Are you going to sign up for this thing?’ I was like, ‘Yeah, whatever.’ I thought, you know, I don’t want to smoke forever. I don’t really like it. This could be fun. Plus, I’ll get out of class.”

She said among her peers, smoking often went hand-in-hand with drinking and other risky behavior, and was permitted by young and uneducated parents. Teens also started smoking because they were bored, she said.

“Girls were not allowed to do as much as boys,” Ms. Spearen said. “We felt so, ‘We gotta get out, we gotta experience.’ Even though we didn’t know exactly what it was we wanted to experience. If you smoked, you could talk to another girl. You could ask for another cigarette. You felt in control.”

Growing up poor with a difficult family situation also made cigarettes attractive. “It was a sign to the world, ‘I’m a deep person and I have issues. I need a cigarette,’” Morgan Spearen said.

Mary Spearen, now a senior theater major at West Virginia University, said NOT helped her realize she could take control of her life not only with smoking, but also with other situations.

“We started to see we weren’t doing it for our teachers or our parents, we were doing it for our health. It was empowering. We learned not only could we quit smoking, we didn’t have to have sex with a guy.”

“Once you get past that addiction, what is it in your head that makes you need that toxic smoke in your lungs?” she wondered. “It does not help you relax, you’re still uncool, you’re not sexy.”

Ms. Spearen lapsed back into smoking her freshman year of college, but she quickly drew on her NOT experiences to quit again. “I realized it wasn’t me anymore,” she said.

Geri Dino, a founder of the program and a scientist at West Virginia University’s Prevention Research Center, said the fact that students return to their NOT knowledge years after their experience shows the staying power of the program.

“To me, that speaks volumes of the program—that they’re able to retain those skills and knowledge,” she said.

The research center is funded by the Centers for Disease Control and Prevention’s Prevention Research Centers Program, which supports research centers at 33 universities across the country to combat chronic disease by creating and testing interventions.

The West Virginia University PRC is now pilot testing a new version of the NOT program that incorporates physical activity into the quitting process.

Morgan Spearen has largely stayed away from cigarettes since going through NOT. She said getting out of Fayetteville and into a dormitory in Morgantown helped too.

“I was like, ‘You have to go outside to smoke a cigarette?’ I couldn’t believe it. For the first time, I met people who didn’t smoke.”

Ms. Spearen, who is carrying an 18-hour class load and working a part-time job, said it is now challenging to be around smokers.

“I hate the smell of it,” she said. “I don’t want to be around it, ever.”