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Project EX
Date of Review: November 2006

Project EX is a school-based smoking-cessation clinic program for adolescents that stresses motivation, coping skills, and personal commitment. Consisting of eight 40- to 45-minute sessions delivered over a 6-week period, the program curriculum includes strategies for coping with stress, dealing with nicotine withdrawal, and avoiding relapses. Project EX uses engaging and motivating activities such as games and yoga to reduce or stop smoking among adolescents and teach self-control, anger management, mood management, and goal-setting techniques. Adolescents are provided with accurate information about the social, emotional, environmental, and physiological consequences of tobacco use. The first four sessions are intended to prepare students for an attempt at quitting smoking, which should take place between sessions 4 and 6. The remaining sessions are designed to maintain quit status and enhance quit attempts. Project EX clinics operate during school hours. Each clinic group can accommodate 8 to 15 students.

Descriptive Info Outcomes Ratings Study Populations Studies/Materials Replications Contacts

Descriptive Information

Topics	Substance abuse prevention
Areas of Interest	Tobacco/smoking
Outcomes	Outcome 1: Tobacco use Outcome 2: Motivation to quit tobacco use
Study Populations	Age: 13-17 (Adolescent), 18-25 (Young adult) Gender: Female, Male Race: Asian, Black or African American, Hispanic or Latino, White, Race/ethnicity unspecified (See Study Populations section below for percentages by study)
Settings	School
Implementation History	Project EX has been implemented in about 15 sites with about 700 individuals, in addition to those sites where the program developers have conducted experimental trials. Approximately 12 U.S. sites have been evaluated for outcomes. Project EX also has been implemented and evaluated in Wuhan, China.
Replications	This intervention has been replicated. (See Replications section below)
Adaptations	Project EX has been implemented/adapted for use with adolescents in China.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the applicant.
Public or Proprietary Domain	Proprietary
Costs	Materials costs include $60 for the teacher's manual (with audio CD), $35 for a set of five student workbooks, and $2.50 each for student pretests/posttest surveys plus shipping and handling. Training ranges from $1,100 to $2,000 plus travel reimbursement.
Institute of Medicine Category	Indicated

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Outcomes

Outcome 1: Tobacco use

Description of Measures	Thirty-day use of cigarettes, smokeless tobacco, and cigars was measured at baseline and again at follow-up using time-anchored rating scales, the Nicotine Dependence Scale, and carbon monoxide measurement in expired breath samples. Participants were asked to rate their use of cigarettes, cigars, and smokeless tobacco over the prior 30 days. Participants were coded either as "quitters" (had not used at all over the prior 30 days) or "nonquitters" (had used at all over that period). The outcome of interest was the proportion of participants in the conditions categorized as "quitters" versus "nonquitters" at the follow-up time-point (about 3 months postintervention).
Key Findings	At follow-up about 3 months postintervention, the 30-day abstinence rate for Project EX participants completing the clinic was 30%, compared with 16% for the control group (p < .05). Using a more conservative intent-to-treat analysis that included those who dropped out of the clinic yielded similar results (30% and 16% for the clinic and control groups, respectively; p < .05). Using the most conservative approach and counting all those not contacted at follow-up as still using tobacco produced a 30-day quit rate of 19% across all clinic participants, compared with the 10% found in the control group.
Studies Measuring Outcome	Study 1, Study 2 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	3.0 (0.0-4.0 scale)

Outcome 2: Motivation to quit tobacco use

Description of Measures	Motivation to quit was measured with 16 items, each measured on 4-point Likert scale. Although the development of this measure was based upon a theoretical conceptualization of motivation as comprising three underlying factors, factor analyses indicated that all the items loaded onto a single factor, and thus the measure was analyzed as a single construct.
Key Findings	The results indicate that motivation to quit smoking changed significantly (p < .01) as a function of undergoing the treatment, even taking into account the observed differences in motivation at the pretest. In addition, posttreatment motivation (level of motivation at posttest) significantly predicted nonuse of tobacco in the past 30 days (p < .05).
Studies Measuring Outcome	Study 2 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	3.3 (0.0-4.0 scale)

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Ratings

Quality of Research Ratings by Criteria (0.0-4.0 scale)

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
Outcome 1: Tobacco use	2.8	3.3	2.5	4.0	3.0	2.8	3.0
Outcome 2: Motivation to quit tobacco use	2.0	2.0	3.8	4.0	4.0	4.0	3.3

Study Strengths: The studies used a standard measure for assessing tobacco use, one that has been in use since 1975 and has reasonable evidence of reliability and validity, together with an additional self-report measure of smoking behavior, the Nicotine Dependence Scale, and the measurement of carbon monoxide in expired breath samples. Appropriate research design and choice of statistical analysis further strengthen confidence in the findings. Authors controlled for the effects of potential confounding variables, and analyses were selected and utilized to adjust for attrition and the overreporting of quitting. The motivation measure developed by the authors exhibited an acceptable level of reliability, and factor analysis was used to determine the appropriate means of using the measure in the analysis. Appropriate analyses were also used to test mediating effects of motivation on tobacco use behavior.

Study Weaknesses: Low retention and small effect size weaken confidence in program effectiveness, even where statistical procedures to adjust for attrition and overreporting of quitting were employed. The use of a single-item self-report of 30-day smoking as a major outcome is not ideal, but the inclusion of other indicators of smoking, such as level of addiction, and an objective measure of smoking behavior compensated for this weakness in measurement.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

Implementation Materials	Training and Support	Quality Assurance	Overall Rating
3.0	2.3	1.5	2.3

Dissemination Strengths: The program curriculum is interactive, yet structured and sequenced so that sessions build on one another. The teacher manuals are printed in large font and have teacher prompts that make them easy to reference during real-time implementation. A toll-free number is available for implementation assistance. In-person training is provided to support implementation, and pretest-posttest student surveys are available to assess program outcomes and thus assist in quality assurance.

Dissemination Weaknesses: Materials do not provide implementation information or suggested strategies for gaining cooperation from other teachers and/or on-site administrators. Materials also do not provide any information on assessing the quality of training and support nor do they present any fidelity measure to ensure the program is implemented as intended. The pretest-posttest survey does not include scoring information so that teachers can interpret findings.

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Contact Information

Web site(s):

http://tnd.usc.edu/ex

For information about implementation or studies:

Steve Sussman, Ph.D.
Professor of Preventive Medicine and Psychology
Institute for Health Promotion and Disease Prevention
University of Southern California
1000 South Fremont Avenue, Unit 8, Suite 4124
Alhambra, CA 91803
Phone: (626) 457-4012
Fax: (626) 457-4012
E-mail: ssussma@hsc.usc.edu

Jim Miyano
Institute for Health Promotion and Disease Prevention
University of Southern California
1000 South Fremont Avenue, Unit 8
Alhambra, CA 91803
Phone: (626) 457-4048
E-mail: miyano@usc.edu

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The NREPP review of this intervention was funded by the Center for Substance Abuse Prevention (CSAP).