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Not On Tobacco (N-O-T) is a smoking cessation program designed for 14- to 19-year-olds. It is based on social cognitive theory and incorporates training in self-management and stimulus control, social skills and social influence, stress management, relapse prevention, and techniques to manage nicotine withdrawal, weight management, and family and peer pressure. N-O-T consists of 50-minute group sessions recommended for weekly dosage for 10 consecutive weeks. There are also four optional booster sessions. Teachers, school nurses, counselors, and other staff and volunteers specially trained by the American Lung Association (ALA) facilitate sessions in schools and other community settings. No more than 10 to 12 participants are recommended per group. Facilitator training is provided by the ALA and includes the bound curriculum and evaluation tools.
Because males and females may start and stop smoking for different reasons, the N-O-T program is gender-tailored to include different components, content, and techniques. Thus, it is recommended that small groups be held with each gender, led by same-gender facilitators.
Participants are encouraged to take an active role during each group session. One of the key reasons groups are divided by gender is to make participants more comfortable sharing issues and supporting one another. Sessions offer support, guidance, and instruction on topics such as understanding reasons for smoking, preparing to quit, understanding nicotine addiction and withdrawal, accessing and maintaining social support, coping with stress, and preventing relapses.
N-O-T does not directly address academic achievement. However, it does address factors that may affect school performance, such as goal setting, stress management, self-esteem/self-efficacy, and cognitive restructuring. These factors are addressed across sessions.
This voluntary, nonpunitive program uses life-management skills to help teen smokers handle stress, decision-making, and peer and family relationships. N-O-T teaches youths how to effectively communicate with family members, provides informative handouts to parents and family members, and offers youths strategies for asserting their needs with family who use tobacco. The program also addresses unhealthy lifestyle behaviors, such as alcohol or illegal drug use, and related healthy lifestyle components such as exercise and nutrition.
The four optional booster sessions provide participants with support after they complete the core program. A brief Alternative to Suspension program is available, which is designed to address student violation of a school tobacco-use policy. The program is also available in Spanish and an American Indian adaptation of N-O-T is currently under evaluation.
This program has been evaluated both with and without a comparison group over a 6-year period. Those studies used a matched design with a comparison group. Study schools were matched with the comparison schools on several different sociodemographic variables. The study schools implemented the N-O-T program in same-gender groups consisting of 8 to 12 participants. The comparison schools gave “treatment as usual,” which consisted of 10 to 15 minutes of group-administered (about 20 participants) advice to stop smoking and distribution of pamphlets. The N-O-T facilitators kept track of attendance and reasons for attrition. Trained researchers collected data both preprogram and postprogram.
Given a matched design, critical variables were used to examine the baseline similarity of the N-O-T and brief intervention participants. These variables included age, grade level, nicotine dependence (using the Fagerstrom Tolerance Questionnaire), number of cigarettes smoked per day on weekdays, number of cigarettes smoked per day on weekends, age of onset, length of time since last cigarette, and motivation to quit smoking and confidence in quitting smoking. The Bonferroni correction was used to correct for experimentwise error. Finally, baseline comparisons were performed each year to determine if there were any biases attributable to attrition. To assess possible attrition bias, the baseline data of youths who provided postintervention data (present) was compared with the data of those who did not (absent). Multivariate analyses of variance were performed on the baseline variables, using recommended procedures for handling missing data. Significant multivariate effects were examined with univariate tests. Any variables showing systematic differences were examined to determine if they were related to outcome.
Evaluations were also done without comparison groups in both school and community settings. In these settings, the facilitator and ALA representatives collected data and as such did not employ rigorous research standards.
Not On Tobacco appears to promote decreases in substance use and increases in positive attitudes and behaviors. A systematic review of N-O-T evaluation studies between 1998 and 2003 found that the baseline daily smoking rate was 14 cigarettes across six controlled studies. Intent-to-treat and compliant quit rates have been calculated at several follow-up points: 3 months postbaseline (end-of-program), 7 months postbaseline, and 15 months postbaseline. Research and evaluation data has been collected in six States: Florida, New Jersey, North Carolina, Ohio, West Virginia, and Wisconsin.
Substance Use
End-of-program results from controlled studies revealed an aggregate quit rate of 15 percent and 19 percent for intent-to-treat and compliant analyses, respectively. End-of-program field-based evaluations revealed an aggregate quit rate of 27 percent and 31 percent for intent-to-treat and compliant analyses, respectively. Among 6,130 youths from five States and 489 schools, the end-of-program intent-to-treat quit rate across all evaluations is 18 percent.
Increases in Positive Attitudes and Behaviors
Across studies, youths who did not quit smoking completely showed significant reduction in smoking. For example, in one study 50 percent of nonquitters cut their smoking in half 6 months after the program ended.
Another study found that N-O-T appeared to moderate nicotine dependence. A brief intervention comparison group was effective only for low-nicotine-dependent smoking. N-O-T was effective for a range of dependence, including highly-nicotine-dependent smokers.
Another study found a similar effect with stages of change. Where the brief intervention achieved cessation with smokers in the preparation stage, N-O-T was effective across a range of stages and also helped move smokers along the stage of change continuum.
In the multiyear review, youths who quit smoking reported being abstinent for almost 3 weeks at follow-up. This timeframe suggests that youths maintained commitments to their quit dates as set during the program.
In one study, where 1 was “strongly disagree” and 5 was “strongly agree,” 96.8 percent of youths indicated that they liked the N-O-T program (m=4.6, sd±0.56). Also, 87.1 percent either agreed or strongly agreed that being in a group was helpful in trying to quit smoking (m=4.2, sd±0.93). Some comments were a) “[The group] helps you make friends,” b) “We had a good teacher—he was fun,” c) “I can skate longer—[I] feel better physically,” d) “I think more about school—[I’m] not as immature,” e) “I learned how to relax,” and f) “[I] increased my self-esteem.”
In another study, process data indicated that 80.5 percent of N-O-T participants (n=128/159) believed the program helped in areas of their lives beyond smoking cessation. These areas included feeling better about themselves (55.4 percent), dealing better with stress (54.6 percent), exercising more (43.1 percent), making new friends (36.9 percent), dealing better with family (33.8 percent), eating better (30.0 percent), and going to school more often (20.8 percent). Overall, participants felt quite positive about N-O-T; a significant majority (84.6 percent) believed the program helped alter their smoking behavior.
Facilitators felt that the values and ideas presented in N-O-T were consistent with their own values and ideas about smoking (m=4.7, sd±0.30) and compatible with their schools’ policies and concerns about smoking (m=4.7, sd±0.47). In addition, they either agreed or strongly agreed that the N-O-T training they received was very helpful for implementing the program (m=4.7, sd±0.47) and that it taught them valuable information even if they never implemented N-O-T again (m=4.5, sd±0.52). Facilitators rated N-O-T as having a flexible and user-friendly curriculum (m=4.3, sd±0.77). Overall, they reported that N-O-T is a worthwhile program (m=4.9, sd±0.30) and that they would recommend it to personnel at other schools (m=4.8, sd±0.41). Some direct comments from facilitators were 1) “My girls had weight loss, increased exercising, and were sleeping better,” 2) “All of my girls had grade improvement,” 3) “Kids would apologize for missing group,” 4) “[The kids had] someone who cares,” and 5) “If they’d let me, all I would do is teach N-O-T.”
Other Types of Outcomes
N-O-T youths were twice as likely as comparison youths to quit.
Dino, Geri A., Kimberly A. Horn, Jennifer Goldcamp, Ancilla Fernandes, Iftekhar Kalsekar, and Catherine J. Massey. 2001. “A 2-Year Efficacy Study of Not On Tobacco in Florida: An Overview of Program Successes in Changing Teen Smoking Behavior.” Preventive Medicine 33:600–05.
Dino, Geri A., Kimberly A. Horn, Jennifer Goldcamp, Sameep D. Maniar, Ancilla Fernandes, and Catherine J. Massey. 2001. “Statewide Demonstration of Not On Tobacco: A Gender-Sensitive Teen Smoking Cessation Program.” The Journal of School Nursing 17(2):90–97.
Dino, Geri A., Kimberly A. Horn, Lenore Zedosky, and Karen Monaco. 1998. “A Positive Response to Teen Smoking: Why N-O-T?” NASSP Bulletin November:46–56.
Dino, Geri A., Khalid Kamal, Kimberly A. Horn, Iftekhar Kalsekar, and Ancilla Fernandes. 2004. “Stage of Change and Smoking Cessation Outcomes Among Adolescents.” Addictive Behaviors 29(5):935–40.
Horn, Kimberly A., Geri A. Dino, Jennifer Goldcamp, Iftekhar Kalsekar, and Reema Moody. In press. “The Impact of Not On Tobacco on Teen Smoking Cessation: End-of-Program Evaluation Results, 1998–2003.” Journal of Adolescent Research.
Horn, Kimberly A., Geri A. Dino, Iftekhar Kalsekar, Catherine J. Massey, Karen Manzo–Tennant, and Tim McGloin. 2004. “Exploring the Relationship Between Mental Health and Smoking Cessation: A Study of Rural Teens.” Prevention Science 5(2):113–26.
Horn, Kimberly A., Ancilla Fernandes, Geri A. Dino, Catherine J. Massey, and Iftekhar Kalsekar. 2003. “Adolescent Nicotine Dependence and Smoking Cessation Outcomes.” Addictive Behaviors 28(4):769–76.
Horn, Kimberly A., Tim McGloin, Geri A. Dino, Karen Manzo–Tennant, Lynn Lowry–Chavis, Lawrence Shorty, Lyn McCracken, and N. Noerachmanto. 2005. “Quit and Reduction Rates for a Pilot Study of the American Indian Not On Tobacco (N–O–T) Program.” Preventing Chronic Disease: Public Health Research, Practice, and Policy. 2(4).
Piper, Douglas, Maura Kirkham, Barbara Lazaris, and Kathleen Di Novella. 2002. A Replication of the Not On Tobacco (N-O-T) Smoking Cessation Program. Brookfield, Wis.: American Lung Association of Wisconsin.
University of Illinois at Chicago. 2002. Evaluation of The American Lung Associations Serving Illinois Not On Tobacco Project—A Teen Smoking Cessation Project. Chicago, Ill.
Virginia Commonwealth University Survey and Evaluation Research Laboratory. 2003. American Lung Association of Virginia N-O-T: Not On Tobacco Virginia Summary Report. Richmond, Va.
Kimberly Horn, Ed.D., M.S.W.
Centers for Public Health Research and Training, Office of Drug Abuse Intervention Studies
West Virginia University, P.O. Box 9190
Morgantown, WV 26506
Phone: (304) 293-0268
Fax: (304) 293-8624
E-mail: khorn@hsc.wvu.edu
Web site: http://www.hsc.wvu.edu/odais
Bill Blatt, MPH, CHES, Manager, Tobacco Control Programs
National Headquarters, Washington Office
American Lung Association
1150 Eighth Street NW, Suite 900
Washington, DC, 20036
Phone: (202) 785-3355
Fax: (202) 452-1805
E-mail: bblatt@lungusadc.org
Web site: http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=39870
