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Project EX

Ages 14-19

Rating: Level 2


Project EX is a school-based, tobacco-use cessation program for high school youths ages 14–19. The program is delivered in a clinic setting and involves enjoyable, motivational activities including games, mock talk shows, and alternative activities such as yoga. At the completion of this program, youths will be able to stop or reduce cigarette smoking and state accurate information about environmental, social, physiological, and emotional consequences of tobacco use.

Students participating in Project EX will learn accurate information about tobacco addiction and disease and gain an empathic understanding of the effects of tobacco use on friends. The curriculum emphasizes coping with stress, dealing with nicotine withdrawal, relaxation techniques, and how to avoid relapse. It aims to teach self-control, anger management, mood management, and goal-setting techniques, and it enhances self-esteem.

Project EX consists of eight 40- to 45-minute sessions that are delivered over 6 weeks—two sessions a week for 2 weeks, followed by one session a week for 4 weeks. During the first four sessions, students are not asked or required to quit immediately but are strengthened for their attempt to quit, which occurs between sessions 4 and 6. The last four sessions, held once a week, concentrate on helping students maintain their nonsmoking status and enhance their quit attempt.

Program facilitators recruit students by visiting classrooms and making a short presentation, offering elective class credits and class release time, by teacher or student referral. Participant groups can contain 8 to 15 students per clinic, but up to four clinics may operate simultaneously in one school. Students use an interactive curriculum to examine the difference between habits and addictions, how tobacco use actually increases stress, and how it is easier to quit while one is younger.

Project EX involves exercises such as healthy breathing, yoga and meditation, relaxation, and motivational games and discussions. The motivational theory–driven “talk show” activity, patterned after popular television programs such as The Oprah Winfrey Show, is highly ranked by students. Students volunteer to role-play talk show “guests,” the teacher/facilitator acts as “host,” and the class is the audience. After some defining information about the guest is presented, the audience interacts with the guest on his or her personal smoking-related issues. The talk show activity is used during four of the eight program sessions.


The Project EX program has been evaluated on several occasions and with a variety of methods. The main trial of Project EX (EX–1) tested the original eight-session, school-based cessation clinic program using a three group experimental design: 1) clinic-only, 2) clinic plus a school-as-community (SAC) component, and 3) standard care control. Eighteen schools were assigned to the three conditions based on use of a randomized block design procedure. This procedure involves calculation of factor scores derived from archival school demographic information, arranging schools along a single-factor score continuum, and then randomly assigning adjacently scored schools to conditions. Student participation in cessation clinics was voluntary, and individuals willing to participate were given credit and class release time. To be eligible for the study, participants had to have used tobacco within 30 days prior to the first session and had to join the clinic in the first 2 of the 6 weeks (on or before session 4). A total of 335 smokers participated in the study (139 at the clinic only schools; 120 in the clinic plus SAC schools; and 76 in the control). Among the cigarette smokers, 85 percent smoked daily, with an average of 8.8 cigarettes/day. A total of 64 percent of the sample were male; 47 percent were Latino, 27 percent were white, 8 percent were Asian, 6 percent were African-American, and 12 percent were “other.” The mean age was 16.8, with a range from 14 to 19. The demographics of the clinic enrollees did not differ significantly between program conditions. Clinic participants were measured at baseline (pretest), immediately following the program, and at a 3-month follow-up. At control schools, tobacco-using students volunteered to take the baseline and 3-month follow-up surveys. Self-report measures included tobacco use, behavior and intentions, nicotine dependence, and demographic measures (age, gender and ethnicity). Reports of nonsmoking were verified by CO level in expired-breath samples, using a cutoff of 9p/pm.

Three other evaluations of the program have or are being conducted. Project EX–2 tested generalizability of the program in Wuhan, China; Project EX–3 was a randomized trial that used the addition of nicotine gum as a pharmacological adjunct; and Project EX–4 adapts the program from a clinic setting to the classroom. Currently, only the clinic-based version of Project EX (EX–1, EX–2, EX–3) is now being disseminated.


The evaluation suggests that Project EX promotes decreases in substance use, improvements in positive attitudes/behaviors, and reductions in negative attitudes/behaviors.

Decreases in substance use are shown as follows:

  • EX–1 results. At 3-month follow-up, 17 percent of youths in the two treatment conditions reported having quit smoking for at least 30 days, compared with only 8 percent of those teens in the control condition. This includes attrition rates that are adjusted based on readings that corrected 15 percent overreporting of quitting. No differences in quit rates between Project Ex–only and Project Ex plus SAC were seen.
  • EX–2 results. Adjusting for biochemical validation, a 14 percent intent-to-treat quit rate was achieved at 4-month follow-up.
  • EX–3 results (regular and continuation high schools). At 2-month follow-up, the intent-to-treat 7-day quit rates were 11 percent in the Nicorette condition and 13 percent in the CigArrest condition. At 6-month follow-up, the intent-to-treat 7-day quit rates were 16 percent in the Nicorette condition and 15 percent in the CigArrest condition.

Improvements in Positive Attitudes/Behaviors included

  • Accurate knowledge of the course of tobacco addiction and disease
  • Empathic understanding of the effects of tobacco use on friends
  • Effective communication, refusal, and cognitive coping skills
  • Novel stress-coping and relaxation activities
  • Self-control, anger management, mood management
  • Goal-setting techniques
  • Self-esteem enhancement

Reductions in Negative Attitudes/Behaviors included

  • Poor social skills
  • Tobacco-use myths

Risk Factors


  • Favorable attitudes toward drug use/Early onset of AOD use/Alcohol and/or drug use
  • Life stressors
  • Poor refusal skills

Protective Factors


  • Healthy / Conventional beliefs and clear standards
  • Positive / Resilient temperament
  • Social competencies and problem-solving skills


  • High quality schools / Clear standards and rules
  • Opportunities for prosocial school involvement


  • SAMHSA: Model Programs


Dent, Clyde W., Kara L. Lichtman, and Steven Y. Sussman. 2001. “Case Study 4. Use of a Theme Study for Adolescent Tobacco Use Cessation.” In Steven Y. Sussman (ed.). Handbook of Program Development in Health Behavior Research and Practice Thousand Oaks, Calif.: Sage Publications, Inc.

Lichtman, Kara L., Clyde W. Dent, Brian Colwell, D. Smith, and Steven Y. Sussman. 2001. “Case Study 5. Project EX Component Study.” In Steven Y. Sussman (ed.). Handbook of Program Development in Health Behavior Research and Practice Thousand Oaks, Calif.: Sage Publications, Inc.

Sun, Ping, Jennifer B. Unger, and Steven Y. Sussman. 2004. “A New Measure of the Stages of Smoking Initiation and Progression Among Adolescents.” American Journal of Health Behavior 29:3–11.

Sussman, Steven Y. 2001. “School-Based Tobacco Use Prevention and Cessation: Where Are We Going?” American Journal of Health Behavior25(3):191–99.

———. 2002. “Effects of 66 Adolescent Tobacco Use Cessation Trials and 17 Prospective Studies of Self-Initiated Quitting.” Tobacco Induced Diseases 1(1):35–81.

Sussman, Steven Y., Clyde W. Dent, and Kara L. Lichtman. 2001. “Project EX Outcomes of a Teen Smoking Cessation Program.” Addictive Behaviors26:425–38.

Sussman, Steven Y., Kara L. Lichtman, and Clyde W. Dent. 2001. “Case Study 3. Use of Focus Groups for Adolescent Tobacco Use Cessation.” In Steven Y. Sussman (ed.) Handbook of Program Development in Health Behavior Research and Practice. Thousand Oaks, Calif.: Sage Publications, Inc.

Sussman, Steven Y., William J. McCuller, Hong Zheng, Yvonne M. Pfingston, James Miyano, and Clyde W. Dent. 2004. “Project EX: A Program of Empirical Research on Adolescent Tobacco Use Cessation.” Tobacco Induced Diseases 2(3):119–32.

Zheng, Hong, Steven Y. Sussman, Xinguang Chen, Yuanhong Wang, Jiang Xia, Jie Gong, Chunhong Liu, Jianguo Shan, Jennifer B. Unger, and C. Anderson Johnson. 2004. “Project EX—A Teen Smoking Cessation Initial Study in Wuhan, China.” Addictive Behaviors 29:1725–33.


Steve Sussman, Ph.D., FAAHB
Institute for Health Promotion and Disease Prevention Research
1000 S. Fremont Avenue, Unit 8, Building A–4, Room 6129
University of Southern California
Alhambra, CA 91803
Phone: (626) 457-6635
Fax: (626) 376-0389
Web site:

Technical Assistance Provider

James Miyano
Institute for Health Promotion and Disease Prevention Research
1000 S. Fremont Avenue, Unit 8, Building A–4, Room 6129
University of Southern California
Alhambra, CA 91803
Phone: (626) 457-4048
Fax: (626) 457-4012