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ARCHIVED - Quit4Life - 12 Month Follow-up Evaluation

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August 2005

Table of Contents

List of Tables

List of Figures

  • Figure 1 When participants attended a Q4L Program
  • Figure 2 Gender
  • Figure 3 Average cigarettes per day
  • Figure 4 Do you smoke fewer, the same or more cigarettes?
  • Figure 5 Smoking habit over time
  • Figure 6 Smoking status while attending Q4L (Recall)
  • Figure 7 Quit attempts over time
  • Figure 8 Quit attempts: CTUMS and Q4L Follow up
  • Figure 9 Did Q4L help increase your motivation to quit?
  • Figure 10 Motivation to quit: post program and follow-up
  • Figure 11 Most important factor that helped with quitting/reducing/motivation
  • Figure 12 I feel confident in my ability to quit
  • Figure 13 Assessment of how the program had helped
  • Figure 14 Participants assessment of how much Q4L had helped them over time
  • Figure 15 Recommend Q4L to a friend
  • Figure 16 Had used Q4L material again

Executive summary

Health Canada has been involved in developing and evaluating teen smoking cessation programs since the early 1990's. In 2003/2004, Health Canada piloted and evaluated the revised Quit4Life (Q4L) group program in partnership with five organizations at five sites across the country. The program showed very promising short-term results. In 2005, participating youth were surveyed again. This report presents findings from the follow-up survey of youth at all five pilot sites, 12-18 months after their first participation in Q4L programs (2003-2004).

The follow-up study assessed the feasibility of obtaining longer-term outcome data from youth participants. The key outcome questions, however, remained similar to those asked at the pilot evaluation stage:

  • Who was reached with the follow-up survey?
  • How effective is Q4L in promoting youth cessation over time (12-18 months)?
  • How satisfied were participants with the Q4L Program in retrospect?

A total of 114 surveys were collected between 12 and 18 months after program completion, corresponding to 31% of the entire sample of Q4L pilot participants. Follow-up surveys were matched to previously collected pre- and post-program surveys wherever possible (90, 24%). All survey data were entered into an expanded SPSS data base (building on the one previously used for the short-term outcomes). Descriptive statistical procedures were applied, and summary tables prepared.

Findings from the follow-up evaluation suggest that:

  1. It is possible and effective to do a 12-18 month follow-up with adolescent program participants in a school setting, when it is planned for from the outset.
  2. Q4L continues to be effective in promoting youth cessation over time. 12-18 months after participating in Q4L, youth showed the following smoking behaviours:
    • They maintained quit rates or reduction rates, in comparison to their rates at program start-up and immediately after program completion:
      • Average number of cigarettes smoked was 12.4 per day at program entry, 5.9 at program end, and 7.7 at 12-18 month follow-up.
      • 73% of Q4L participants indicated that they were still smoking less than when they started the program.
      • At follow-up, 16% of participants indicated that they had quit smoking (12% had quit immediately after the program finished).
    • They maintained quit rates to a greater extent than similar youth who did not participate in Q4L:
      • Overall, CTUMS suggests that 5% of youth can be considered long-term quitters (have not smoked for one year); in comparison, between 8%-16% of Q4L participants were long-term quitters one year post-program.
    • They increased their number of quit attempts:
      • At program entry, they reported 1.9 quit attempts in the previous year, compared to 2.5 quit attempts at follow-up.
    • They continued to feel very motivated to quit:
      • 56% at follow up, compared to 42% at program end.
    • They indicated that health factors and the strategies that they had learned during the program were the most important factors which had motivated or will help them in future to quit.
    • They felt confident in their ability to quit in the future (self-efficacy):
      • Two thirds (64%) indicated that they felt very confident.
  3. 12-18 months after participating in a Q4L program, youth remained highly satisfied with the program; almost all (96%) would recommend it to a friend. Those who continued to use Q4L materials obtained during the program found them helpful.

Background

Almost all persons who have ever smoked had their first cigarette sometime in their teens, and at least half of all ever-smokers have tried smoking by age 15 1. Youth smoking in Canada is a serious health issue. In the first half of 2004, 20% of Canadian teens aged 15-19 were smokers. Adolescence presents a crucial window of opportunity to intervene with smoking cessation programs: 70% of current smokers aged 15-19 reported one or more attempts to quit in the previous 12 months. 3

Recognizing that it is critical to capitalize on adolescents' motivation to quit smoking while still in their teens, in 1993 Health Canada developed a youth cessation program in partnership with the Canadian Lung Association and Ciba-Geigy Ltd. Directed at 15-19 year olds, the Quit 4 Life/Vie 100 Fumer (Q4L) youth cessation program was a minimal contact, self-help program for teens who smoke cigarettes on a daily basis.

During the late 1990's, Q4L was converted to website format. The program was available exclusively online and contained the original information, highlighted through the use of four youths' stories on their smoking behaviour and the challenges they faced in quitting smoking. Many youth simply came across the website while internet surfing and decided to follow the program on their own. The popularity of the program and the emergence of new information about best practices in youth cessation from international researchers 4, including the effectiveness of cognitive behavioural approaches with adolescents, led Health Canada to update the Q4L program in 2002.

In 2002, the updated web program was re-designed by Dr. Paul McDonald of the University of Waterloo , to include the following changes:

  • Targeted towards a younger age group (13-18).
  • Aimed at youth who smoke daily or occasionally, and those who want to reduce as well as quit.
  • Introduction of behavioural principles, including counter conditioning, stimulus control and creating environments supportive of quitting, in order to increase youth's chances of success through examining their smoking behaviour.
  • According to Dr. McDonald,greater focus on building self-efficacy: "Care was also taken to create self-efficacy through encouraging users to 'practice' quitting"; to practice being a non-smoker, and to build their personal capacity to undertake a significant behavioural change.
  • Greater focus on motivation: "Although there is, as of yet, insufficient evidence to make conclusive statements, approaches based on motivational interviewing seem to be particularly promising. Therefore, a considerable amount of material was included to build motivation based on the principles of Miller and Rollnick (1991)".
  • Change in navigational aspects of program, so users can either follow the whole program or pick and choose those sections of the Q4L program/site in which they are most interested. McDonald again cites best practice information, "The review also suggests that intensive interventions are more likely to be effective. This is problematic because other research suggests that adolescents prefer to use simple, brief interventions. An attempt was made to balance these competing demands."
  • Addition of a Facilitator's Guide, evaluation tools and a Guide to Evaluation, developed by Dr. Kate Dahlstrom and Gentium Consulting, respectively, to support the program when delivered in a group setting, based on best practice information suggesting that interventions that take place in school, in a voluntary but structured environment, facilitated by a teacher or other credible adult, may yield greater successful outcomes.
  • The Quit 4 Life website remained available for use by youth who came across it, individually or as part of a group application.

In 2003/2004, Health Canada piloted and evaluated the revised Q4L group program in partnership with five organizations at five sites across the country:

  • Fraser House Society - Mission , British Columbia
  • Manitoba Lung Association - Winnipeg , Manitoba
  • Nipissing First Nations Health Centre - Garden Village , Ontario
  • Canadian Research Institute for Social Policy - University of New Brunswick
  • Fredericton , New Brunswick
  • Pictou County Women's Centre - New Glasgow, Nova Scotia.

Health Canada 's objectives for the pilot were:

  • To develop a procedure for overseeing evaluation of pilot sites.
  • To provide ongoing contacts and supports to pilot site coordinators regarding the evaluation component of the pilot project.
  • To develop templates and other tools, in consultation with pilot site coordinators, that will enable and facilitate the collection of data by coordinators.
  • To collect and analyze base-line, post-program data, as well as Facilitator and Peer Assistant feedback from the pilot sites.
  • To produce a final evaluation report on the pilot sites detailing methodology, process, outcomes, impacts and providing recommendations for adapting the program based on pilot site findings.
  • To develop evaluation tools to be used by Health Canada and pilot sites at 6 and 12 month intervals post-program delivery.
  • To develop an evaluation tool to be used on the Quit 4 Life website to gauge the program's effectiveness as a self-help program.

A previous evaluation report 4 provided detailed information on the pilot and the evaluation process, including an overview of program implementation and participants; summarized short-term outcomes; and recommended improvements to Q4L materials and program implementation. Health Canada issued a revised version of the Q4L Facilitator Guide and Participant's Booklet in 2005. The Q4L website also was revised to become an interactive stand-alone self-help cessation program. Detailed discussion of the short-term outcomes is included in the report and was also reported during a presentation at the national tobacco conference, June 2005 in Ottawa 6 (Greene & Meyer, 2005).

In 2005, participating youth were again surveyed. This report presents the findings of the follow-up survey of participants from all five pilot sites, 12-18 months after their first participation in Q4L programs (2003/2004).

1. Evaluation Questions

The key outcome evaluation questions used during the Q4L pilot evaluation remained largely the same, addressing both the feasibility of this method to obtain longer-term outcome data and the actual outcomes of the Q4L intervention:

  • Who was reached with the follow-up survey?
  • How effective is Q4L in promoting youth cessation over time (12-18 months)?
  • Specifically, did youth who participated in Q4L:
    • Maintain quit rates or still smoke less compared to when they started Q4L and immediately after completing Q4L?
    • Maintain quit rates to a greater extent than similar youth who did not participate in Q4L?
    • Increase their number of quit attempts?
    • Feel motivated to quit?
    • Feel confident in their ability to quit (self-efficacy)?
  • How satisfied were participants with the Q4L Program in retrospect?

The following report summarizes findings from the follow-up survey in light of these evaluation questions.

Method

1. Data collection

A follow-up survey had been developed, tested, and revised during the pilot evaluation phase.

Health Canada contracted the five pilot sites to take part in the follow-up evaluation, and administer the survey to former Q4L participants. Four of the five site coordinators for the follow-up had been also involved in the pilot evaluation; one was new to the project.

The evaluators provided coordinators with a list of all participants at each site who had completed baseline or follow-up surveys during the pilot evaluation phase (information originally collected in anticipation of the follow-up survey).

Coordinators at each site used different strategies to reach former participants. Working with the school administration, several invited participants through the PA system to a meeting for former Q4L participants, at which the follow-up surveys were administered. They also provided incentives for participants to complete the survey (concert tickets, gum). Others contacted the teachers who had previously implemented the program, and asked them to contact former participants. One coordinator had created an email tree and used this tree to reach participants. Most coordinators also approached youth individually to encourage them to participate in the follow-up.

Surveys were collected between 12 and 18 months after program completion, and returned to the evaluators for coding and analysis. We included the 18-month data because a few Q4L programs had started earlier in 2003. Three quarters of surveys (75%, 86) were collected at 12-month follow-up; 18% (21) fall into the 18-month follow-up category, and 5% (3) provided a different date. Two of these three participants indicated that they had attended another Q4L program.

Figure 1 - When participants attended a Q4L Program

Figure 1 - When participants attended a Q4L Program

Canadian Tobacco Use Monitoring Survey. Youth Smoking in Canada Fact Sheet , Health Canada , (2001.)

2. Data Analysis

Follow-up surveys were matched to previously collected pre and post program surveys wherever possible. All survey data were entered into an expanded SPSS data base (building on the one previously used for the short-term outcomes). Descriptive statistical procedures were applied, and summary tables prepared.

Findings

1. Who was reached with the follow-up survey?

Attrition is inevitable in any longitudinal survey, as participants become unreachable or withdraw for a variety of reasons over time. This can be an especially challenging issue with adolescent and school-based populations, who frequently leave not only their school, but also their residence or even their community, when they complete high school (as they enter the workforce or begin post-secondary education). In the case of Q4L, however, a total 114 participants completed the follow-up survey. Furthermore, both baseline and post-program survey data were available for 90 of these respondents (79%).

In summary, data were collected from 370 participants for the entire Q4L evaluation (baseline, post program, and follow-up). We were able to match all three surveys for one quarter (24%) of survey respondents.

Table 1 - Surveys collected

 

Frequency

Percent

All (pre, post, follow-up)

90

24%

Pre and post survey only

153

41%

Only pre survey

68

18%

Only post survey

35

10%

Only follow-up

14

4%

Pre only and follow-up

10

3%

Total

370

100.0

Types of surveys collected across sites are displayed in Table 2 below

Table 2 - Survey data across pilot sites - Crosstabulation
   

Survey data available

Total

Pilot Site

 

Pre and Post survey

Only pre survey

Only post survey

Only 12m

All

Pre on& 12m

 

BC-Fraser House

Count

73

33

18

1

38

0

163

 

% of Total

19.8%

9.0%

4.9%

.3%

10.3%

.0%

44.3%

Manitoba Lung Association

Count

14

7

2

1

7

0

31

 

% of Total

3.8%

1.9%

.5%

.3%

1.9%

.0%

8.4%

ON Nipissing First Nations

Count

4

1

2

1

10

0

18

 

% of Total

1.1%

.3%

.5%

.3%

2.7%

.0%

4.9%

NS Pictou Women's C

Count

18

7

0

1

16

1

43

 

% of Total

4.9%

1.9%

.0%

.3%

4.3%

.3%

11.7%

NB University

Count

44

20

13

8

19

9

113

 

% of Total

12.0%

5.4%

3.5%

2.2%

5.2%

2.4%

30.7%

Total

Count

153

68

35

12

90

10

368

 

% of Total

41.6%

18.5%

9.5%

3.3%

24.5%

2.7%

100.0%

1.1 Characteristics of respondents (follow-up)

Most respondents were between 15-19 years of age (92%). 4% were 14 and younger, and 5% were 20 years and older. Average age at follow-up of the matched sample was 16.9 compared to 15.8 at program beginning, reflecting the one-year time lapse between when they first attended a Q4L program and the follow-up.

Table 3 - Grade

Grade

Frequency

Valid Percent

Cumulative Percent

9-10

27

24%

24%

11-12

72

63%

87%

13

1

1%

88%

Grade 8 and less

2

2%

90%

Other

5

4%

94%

N/A

7

6%

100.0

Total

114

100.0

 

At program start the average grade of the matched sample was grade 10 and at follow-up grade 11.

Slightly more females (58%) than males (42%) participated in the follow-up survey. The proportion reflected the original gender distribution of the pre and post survey (exactly the same proportions).

Figure 2 - Gender

Figure 2 - Gender

The mother tongue distribution of 12-month follow-up and pre-survey respondents was almost the same: 82% indicated English as mother tongue, 15% French and 3% a different language (as indicated by participants: 2 Micmac, 1 Irish, 1 French also, 1 English also). (Baseline survey: English 83%, French 11%, both 4%, and other 2%).

Table 4 - Mother tongue
 

Frequency

Percent

Valid

English

92

82%

 

French

17

15%

 

Other

3

3%

 

Total

112

100.0

The majority of respondents was born in Canada (97%).

Table 5 - Place of birth
 

Frequency

Percent

Yes

109

97%

No

3

3%

Total

112

100.0

Three quarters were White. One in five (21%) identified themselves as Aboriginal; another 10% as North American Indian, and 5% as Métis. 3% were Black. Some respondents provided more than one answer

Table 6 - Ethnicity - Categories from Canadian Census

 

Frequency

Percent

White

83

78%

Aboriginal

16

21%

North American Indian

9

10%

Métis

4

5%

Black

2

3%

Other

7

9%

 

121 *

 

*7 respondents indicated more than one ethnicity, e.g., Aboriginal and North American Indian; or White and Aboriginal

2. How effective is Q4L in promoting youth cessation over time (12-18 months)?

2.1 Do youth who participated in Q4L maintain quit rates or reduction rates, compared to when they started Q4L and immediately after completing Q4L?

Smoking habits

Daily cigarette consumption dropped from an average of 12.4 cigarettes per day at baseline to 5.9 at program end, and went slightly up to 7.7 cigarettes at the one-year follow-up mark. This figure is still well below the Canadian average of 11.8 cigarettes smoked daily (CTUMS, 15-19 year olds in 2004).

Figure 3 - Average cigarettes per day

Figure 3 - Average cigarettes per day

The range of the number of cigarettes smoked per day dropped. At baseline, respondents smoked between 1 and 69 cigarettes per day; at program end, between 0 and 45, and at 12-month follow-up, between 0 and 25. It is worth noting that at follow-up no respondent indicated smoking more than 25 cigarettes per day.

67 respondents answered whether they smoked more, less, or the same amount since they had started the Q4L program. Three quarters (73%) indicated that they were smoking fewer cigarettes than at baseline; 15% smoked the same amount, and 12% were smoking more cigarettes on a daily basis.

Figure 4 - Do you smoke fewer, the same or more cigarettes?

Figure 4 - Do you smoke fewer, the same or more cigarettes?

At baseline, 94% were daily smokers. This dropped to 66% immediately after the program was completed, but went up to 81% again at follow-up. Although the proportion of occasional smokers at baseline and at 12-month follow-up is similar (6% and 4%), it is worth noting that 16% of respondents indicated that they had quit at 12-month follow-up.

Figure 5 - Smoking habit over time

Figure 5 - Smoking habit over time

Respondents who smoked less (either had quit or smoked 1-10) at program end, maintained that status: they were also significantly more likely to smoke less at 12-month follow-up. This finding was significant at p<.00. These figures indicate that respondents who cut down or quit during Q4L were able to maintain lower smoking rates.

Respondents also were asked to report on what they recalled of their smoking habit while attending the program. Of the matched sample (n=90) 21% (18) remembered quitting, and 67% reported that they had cut down during Q4L. Only 8% indicated that they smoked the same, and 5% that they increased their smoking while participating in the program.

Figure 6 - Smoking status while attending Q4L (Recall)

Figure 6 - Smoking status while attending Q4L (Recall)

When comparing these results with what students actually reported immediately after the program, we found that 16% (13) indicated that they had quit at program end. However, an additional 7 respondents in the follow-up survey indicated that they had quit immediately after the program was finished, accounting for the discrepancies. A cross tab revealed that a total of 5 respondents who had indicated quitting in the follow-up survey also had reported that they had quit after the program was finished. Consequently, students seem to be reporting their quit status consistently across surveys.

Smoking habit across sites

The smoking habits of students at follow up across sites are displayed in Table 7 below. Detailed results for each site are included in the Appendix.

Table 7 - Smoking status across sites

 

Quit

Smoke Occasionally

Smoke daily

BC Fraser House (N=39)

6

15%

2

5%

31

80%

Manitoba Lung (N=8)

1

13%

0

0

7

88%

Nipissing First Nations (n=11)

4

36%

0

0

7

64%

NB-UNB (N=36)

4

11%

0

0

32

89%

NS Pictou Women's Centre (N=18)

3

17%

2

11%

13

72%

 

18

 

4

 

90

 

Heavy smokers

None of the five heavy smokers at baseline (21 cigarettes and more daily) had been able to quit or stay quit at follow-up (matched sample). Immediately after program completion, 2 of the heavy smokers reported that they had quit, indicating that they must have relapsed in the year following the program. However, it is encouraging to report on the reduced daily cigarette consumption of these previously heavy smokers at follow-up, indicating that the Q4L program seems to have some success even with these smokers. At follow-up three of the previously heavy smokers reported smoking only between 1 and 10 cigarettes per day, one was smoking between 11-20 cigarettes daily, and only one still was smoking more than 21 cigarettes daily. Additional studies could explore if ongoing support provided to the previously heavy smokers would assist with increased smoke-free maintenance and prevent relapse.

2.2 Do youth who participated in Q4L maintain quit rates to a greater extent than similar youth who did not participate in Q4L?

According to CTUMS 2004, 5% of 15-19 year olds are considered former smokers (have not smoked for a year). At follow-up, three times as many of the Q4L participants 16% (18) indicated that they had quit. However, only 8% (9) indicated that they had stayed quit since they had completed the program. Another 8% (9) had quit after the program finished. We do not know, however, at what point these participants quit, and for how long they had stayed quit at the time of the survey. It is also important to note that follow-up data for some participants were collected 18 months after completion of the original program. When exploring the quit rates of the 18 month follow up participants immediately after the program, only one of the participants indicated that he or she had quit. This participant had not remained smoke-free at follow-up.

Quit rates reported at follow up may actually underestimate the proportion of long-term quitters/former smokers, as calculated by CTUMS. The 8% figure of those participants who indicated that they had remained smoke-free since they completed the program is still larger than the 5% CTUMS figures of former smokers (one year smoke-free). The proportion of former smokers at follow-up, therefore, can be anywhere between 8% and 16%.

One in ten Q4L participants (11%) had relapsed in the 12-18 months after the program finished: they indicated that they had started to smoke again. On the other hand, one in four (24%) reported that they only had begun to cut down on the amount they smoked after the program was completed. This trend also points to a continuous process that teens are involved in concerning their smoking habits.

Many youth also checked more than one option (see options provided, below) suggesting considerable fluctuations in smoking status.

  • I stayed quit
  • I quit after the program was finished
  • I am smoking fewer cigarettes than before I started the program
  • I started to cut down after the program was finished
  • I started smoking again
  • I smoke the same amount as before the program
  • I smoke more than before the program

These figures indicate that a percentage of participants appear to be relapsing, and then quitting again in the year after completing the program. This repeated pattern of multiple attempts and 'practice quitting' before finally quitting for good is a common pattern among teenager smokers and smokers in general. As reported in another study (CTUMS, 2001), about one half of all youth quitters (49%) reported making more than one attempt before they successfully quit smoking. On average youth made 2.7 tries before finally becoming long-term quitters (CTUMS, 2001; "Quitting Smoking Among Youth" ).

As suggested in the Pilot Evaluation Report (Meyer & Estable, 2004) there may be a need for follow-up support, or occasional sessions after the program has been completed, to prevent relapse.

2.3 Do youth who participated in Q4L increase their number of quit attempts?

Overall, participating youth increased the number of times they attempted to quit. At baseline, youth had quit (or remembered that they had tried) on average 1.9 times, compared to an average of 2.5 quit attempts at follow-up.

Figure 7 - Quit attempts over time

Figure 7 - Quit attempts over time

Although to some extent this can be explained by the simple fact that time elapsed, giving greater opportunity for more attempts to be added to the total, nevertheless, when compared to the theoretical control group of 15-19 year old Canadian youth (CTUMS), Q4L participants continue to show more quit attempts.

Figure 8 - Quit attempts: CTUMS and Q4L Follow up

Figure 8 - Quit attempts: CTUMS and Q4L Follow up

2.4 Did the Q4L program motivate youth to quit?

Participants were asked to rate on a scale of 1 to 3 (1=not at all; 3=a lot) if the Q4L program had helped motivate them to quit. At follow-up, the average score was 2.5, indicating a high degree of motivation to quit. More than half indicated that it had helped them a lot (56%) and more than a third that it helped them somewhat in their motivation to quit. Only 5% indicated that it had not helped their motivation.

Figure 9 - Did Q4L help increase your motivation to quit?

Figure 9 - Did Q4L help increase your motivation to quit?

Immediately after program completion participants had ranked how much the program had motivated them to quit slightly lower at 2.3. 42% indicated that it had motivated them a lot to quit, 49% that it had helped them somewhat, and 10% that id had not motivated them. Overall there was a slight increase in participants' assessment of how much the program had motivated them to quit at follow-up. In summary, participants found that the program had motivated them to quit even more upon reflection.

Figure 10 - Motivation to quit: post program and follow-up

Figure 10 - Motivation to quit: post program and follow-up

Participants were asked at follow up in an open-ended question, to remember the one thing of the Q4L Program that had helped them the most to quit, reduce, or increase their motivation to cut down on their smoking. Three quarters (75%, 86) of respondents answered the question. Answers were coded according to themes (see Table 9, and Figure 11 below).

Figure 11 - Most important factor that helped with quitting/reducing/motivation

Figure 11 - Most important factor that helped with quitting/reducing/motivation

Table 8 - Most important factor that helped with quitting/reducing/motivation

 

N=86

%

Health issues (Talking about lung cancer and other diseases, statistics, effect of smoking on the body, weight)

28

33%

Strategies, steps, what to do, survival kit items

28

33%

Visuals (video, gruesome pictures, lungs of a smoker)

23

27%

Support (trainer, from group)

14

16%

Knowing how much money is spent

5

6%

Other

4

4%

One third (33%) mentioned health issues as the most motivating factor that had helped them reduce or quit.

"When we talked about the health risks of smoking and second hand smoke can do to you."

"Talking about lung cancer and other diseases."

"The stories about how people had died or seriously injured their bodies due to smoking."

"The chemicals that I was putting into my body."

Another third (33%) also remembered the strategies or steps that they had learned during the program to cut down or quit.

"The different strategies to hold off having a smoke. That's why I smoke half as much as I used to."

« Le séance du programme mais il y a eu quelques activités initie par les infirmières "théorie du choix et visite au centre oncologie. »

"Count how many times I smoked a day. It made me realize how much I was smoking."

"The fact that it's all in your head, your body wants to have a cigarette but you can hold yourself back by keeping it completely off your mind."

A quarter (27%, 23) emphasized the impact that visuals had had on them, either in form of 'gruesome' pictures, or a video which they had watched as part of the program.

"We watched a video on people that had cancer and mouth cancer, it struck me at that moment 'I want to quit'. It helped me cut down a lot! In the near future I will be a non-smoker."

"Looking at those lungs that were black and gross looking."

"Gasp magazine, disgusting pictures."

A smaller percentage (16%) mentioned the importance of the support that they had received either from the facilitator or other group members as most memorable program element.

"The support from the others in the class, they were helping and they were trying, so I wanted to quit too."

"Having others support from the group."

"The fact that there were more people who needed help, not just me."

Saving money was mentioned by 6% as the most memorable factor that helped them quit or cut down.

"The program showed me that I can spend the same amount of money for a month's membership as I would for cigs in one week."

"It made me realize that there was no point in wasting my money anymore and I wanted to live a healthier lifestyle."

It is important to note again that participants did not select these issues from a predetermined list, but mentioned them spontaneously.

3. What is youth's level of confidence in their ability to quit (self-efficacy indicator)?

At follow-up respondents felt very confident that they were able to quit, rating it at 4.1 on average on a scale from 1 to 5, 1=strongly disagree; 5=strongly agree.

Two thirds (64%) agreed or strongly with the statement about feeling confident that they were able to quit smoking. 5% (5 respondents) did not feel confident, and one third (32%) was undecided whether or not they felt confident that they were able to quit smoking.

Figure 12 - I feel confident in my ability to quit

Figure 12 - I feel confident in my ability to quit

This question was added in the follow-up survey based on recent studies suggesting that level of confidence in the ability to quit is an important measure to assess long term success rates in smoking cessation. Previous surveys did not include this question assessing level of confidence.

Respondents who had been able to smoke less and/or quit were significantly more likely (p>.008) to also feel confident that they were able to quit. All quitters also felt confident in their ability to quit smoking. A third of those who smoked 1-10 cigarettes daily also agreed that they were confident in their ability to quit, and 9% of those who smoked 11-20 cigarettes agreed.

It is anticipated that a higher level of confidence leads to positive action to implement smoking cessation.

4. How satisfied were participants with the Q4L program in retrospect?

4.1 Program Satisfaction

At follow-up respondents were asked to rate on a scale from 1 to 3 (1=not at all; 3=a lot), how much the Q4L program had helped them with a number of different things. On average, respondents thought that the program had helped them a lot with cutting down (2.7), knowing how to quit in future (2.7) and had motivated them to quit (2.5). It had helped them to live a healthier life (2.4); reduce the money the spent on smokes (2.3) and reduce their concern about cancer (2.3). Although still rated higher than average, participants ranked 'helped quit smoking' lowest of all the options (average 1.9).

Figure 13 - Assessment of how the program had helped

Figure 13 - Assessment of how the program had helped

As illustrated in Figure 14 below, follow-up and post program average ratings are almost identical. Even though many participants had actually quit smoking during the period of time after the program ended, their assessment of how much Q4L helped them did not change. Quitting is not the only outcome anticipated from Q4L. The program is designed to also encourage cutting down. Even if participants did not feel that the program helped them with quitting, they were very satisfied with how the program helped them achieve the other outcomes, as anticipated in the program design.

Figure 14 - Participants assessment of how much Q4L had helped them over time

Figure 14 - Participants assessment of how much Q4L had helped them over time

At follow-up the majority (95%) would still recommend Q4L to a friend, and 6% had already done so. 5% might recommend it to a friend. Immediately after the program, 89% said they would recommend Q4L to a friend, 10% thought that they might, and 1% that they would not.

The findings suggest that, over time, participants became even more convinced that Q4L is a good program that also might help their friends. Facilitators who are planning to run another Q4L program might want to involve former participants in the recruitment process, given their positive assessment of the program.

Figure 15 - Recommend Q4L to a friend

Figure 15 - Recommend Q4L to a friend

Immediately after the program finished, a number of participants commented, that they would have liked to continue with the program or participate in another program. In the 12 to 18 months after the pilot program ended, 15% indicated that they actually did attend a second Q4L session. Two thirds (68%) would still like to attend another session to quit or help them stay quit. Another quarter might (27%) be interested in another session; whereas only 5% (5) would not.

Only one participant of the twelve who had attended another Q4L program was now smoke-free. Two of the three occasional smokers at follow up also had attended another Q4L session.

  • We explored the answers of the five respondents who indicated no interest in attending another Q4 program in more detail, to find out why they might not be interested in participating. These five respondents were now daily smokers. While attending the program, one had quit, three had cut down the numbers of cigarettes they smoked. All five had made quit attempts in the past year, between one time and more than four times. One had quit for 6-month, another one for five weeks, two between 2 and 6 days, and one for only 8 hours. Three were smoking now between 6-10 cigarettes daily, one between 11-15 and one did not provide information on how much he or she was currently smoking.
  • Two of the five strongly agreed that they were able to quit in future, two were undecided and one did not feel confident that he or she would be able to quit in future. She felt, however, that the program had motivated her somewhat to quit and had helped her somewhat with cutting down, but had not helped her at all to quit.
  •  In summary, it seems that all five who indicated that they would not attend another program, nevertheless had benefited to some extent from the Q4L program. They had tried to quit and also had been successful in cutting down their cigarette consumption, another explicit outcome goal of the Q4L program.

4.2 Program material

Program material can be one source of support in the absence of any other available support. At follow up, over a third of respondents (38%) indicated that they had used program material after the program had been finished, whereas 43% had not and 19% could not remember. Half (50%) of the quitters had used the material again, compared to only 37% of the participants who indicated that they were currently smoking daily. None of the 3 occasional smokers had used the material again.

Figure 16 -Had used Q4L material again

Figure 16 -Had used Q4L material again

Do you have any comments about the material?

In a final open-ended question participants were asked if they had any comments about the materials which they received during the program. A quarter of respondents (23%, 27) provided comments, e.g. "It is appreciated that you guys care enough to help us, and you know it's hard to quit, thank you."

Half of the participants (48%, 13) stated that the materials had been helpful, useful or good. "It was really helpful and useful." "The material (pamphlets, etc.) were really helpful."

Four (15%) emphasized the educational value of the information which the materials provided. "Informative, learned about dangers that I didn't know before." "Very educational." "C'était intéressant. »

Three (11%) indicated that the materials had helped with motivation. "It helps keep you motivated if you read a little everyday." "The material was fantastic and really helped and motivated me."

Another 3 (11%) mentioned that the material had helped them to quit. "It helped me prepare to quit smoking; they were a big help." "It was very helpful when quitting."

Five respondents included some critical comments:

"It was pretty bubble-gum, it should have been more serious."

"Booklet alright but would be better if it didn't come from the government."

"It should have been written by teen smokers or teens that struggled to quit and have."

Table 9 - Assessment of Q4L material

 

#

% n=27

Helpful, useful, good

13

48%

Informative, educational

4

15%

Helped to motivate me

3

11%

Helped to prepare me to quit

3

11%

Some criticism

5

19%

Other

2

7%

Conclusion

Findings from the follow-up evaluation suggest that It is possible and effective to do a 12-18 month follow-up with adolescent program participants in a school setting, when it is planned for from the outset.

Q4L continued to be effective in promoting youth cessation over time. 12-18 months after participating in Q4L, youth:

  • Maintained quit rates or still smoked less compared to when they started Q4L and immediately after completing Q4L
  • Maintained quit rates to a greater extent than similar youth who did not participate in Q4L
  • Increased their number of quit attempts
  • Continued to feel motivated to quit
  • Felt confident in their ability to quit in future (self-efficacy).

3. 12-18 months after participating in a Q4L program, youth remained highly satisfied with the program and almost all would recommend it to a friend. Those who continued to use Q4L materials obtained during the program found them helpful.

What next?

The following issues remain to be explored in future research.

Longer-term follow-up

It is encouraging that Q4L participants were able to maintain lower cigarette consumption rates over time, compared with their smoking rates at program entry. It might be useful to know if these lower smoking rates are maintained over longer time frames. This would require following a cohort of participants on a regular basis in future. Follow-up survey participants indicated an interest to continue to be involved. More than half provided contact information, such as an email address or telephone number, and stated that they were willing to continue to be surveyed. It would require a relatively modest allocation of resources to continue with this cohort, and would contribute to a better understanding of the longer term impact of adolescent smoking cessation programming on young adult smoking status.

Ongoing support

A number of participants had repeated the Q4L program. Others indicated that they would have liked to do so; only a few would not consider attending another program. There seems to be an interest in receiving more ongoing support. This suggests questions for further investigation. For example: Does the availability of ongoing support increase quit rates or facilitate maintenance of reduced smoking rates? What type of support do former participants find most useful? Do they prefer a formal (programs, regular meetings) or a more informal (drop-in, email contact) way of receiving such support? How important are personal relationships between facilitators and participants to assist with maintaining lower smoking rates?

Heavy smokers

The Q4L program seemed to have some success to reduce smoking rates even with heavy smokers, although the numbers are too small to be conclusive. Future research could explore the following: How effective is the program with the already 'hard core' smokers? What role could nicotine replacement play for these smokers in combination with other strategies?

Confidence level

In many recent studies, the level of confidence in the ability to quit has become an important indicator for predicting smoking cessation. Additional research on the impact of Q4L could explore the following questions: Does the level of confidence in the ability to quit predict quit rates over time? What is the impact of unsuccessful quit attempts or relapse on teen's level of confidence? How can confidence level be restored for those teens who believe that they are unable to quit? Is a cessation program the best vehicle, or what other programs can be used?

Quit strategies

The Q4L program includes many strategies that seem to assist participants to quit, reduce, or increase their motivation to quit. Deeper analysis could be done, to determine the following: Which of these strategies (or combination) did youth who quit actually use? Was there one specific strategy that all participants used to achieve their goals (quitting or reducing), or that was used more often than other strategies?

This study is not unique in finding out that teens are much more concerned about long term health effects than was previously believed. More research could be done to study the impact of Q4L on motivation, for example, How much do health concerns that were awakened or confirmed during the Q4L program really impact on teens' motivation to quit? How can these concerns be best used to encourage smoking cessation?

1 Canadian Tobacco Use Monitoring Survey. Youth Smoking in Canada Fact Sheet , Health Canada, (2001)

2 Canadian Tobacco Use Monitoring Survey. Annual Results 2004, Health Canada , (2004).

3 Canadian Tobacco Use Monitoring Survey. Youth Smoking in Canada Fact Sheet , Health Canada , (2001).

4 Sussman. Steve. (2000). Effects of Sixty Six Adolescent Tobacco Use Cessation Trials and Seventeen Prospective Studies of Self-Initiated Quitting, Canadian Tobacco Control Research Initiative.

5 Meyer, M.C. & Estable, A. (2004) Quit4Life Pilot Evaluation Report. Health Canada .

6 Greene, J. & Meyer, M.C. (2005). (Un)Hook Them While They Are Young: Evaluating the Quit4Life Youth Cessation Program. Presented at the 4 th National Conference on Tobacco. Ottawa , June 20 th, 2005.