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Issue 20 Interview Transcript

Molly Wetterschneider: Welcome to the JNCI podcast, a production of the Journal of the National Cancer Institute. I’m Molly Wetterschneider. According to the 2007 National Survey on Drug Use and Health, every day about 3600 teens between the ages of 12 and 17 smoke their first cigarette. And for some, that first cigarette will not be the last. In fact, nearly a third of those teens will become regular smokers. Given that tobacco use is a veritable death sentence for nearly half of all users, addiction prevention in teens is an effective way to save lives. However, helping those who are already addicted could be just as key. In this issue of the Journal of the National Cancer Institute, researchers in Seattle, Washington present the results of a study looking into the effectiveness of personalized telephone counseling to help teens quit smoking. I spoke with Dr. Scott Leischow about the study. Dr. Leischow is Associate Director of Behavioral and Social Sciences Research at the Arizona Cancer Center, and a Professor of Medicine and Public Health at the University of Arizona in Tucson. Thank you for speaking with me Dr. Leischow.

Scott Leischow: My pleasure.

Molly Wetterschneider: You wrote an editorial about a study looking into the effectiveness of a teen smoking cessation program that used a telephone quit line. Could you tell me a little bit about the study?

Scott Leischow: Yes, this is a study done at the Fred Hutchinson Cancer Center, and this is a very important and innovative study in that the investigators focused on two critical issues in our challenge in smoking cessation in general, as well as adolescent smoking cessation. One is how do you increase reach? In other words, how do you get more people into a smoking cessation program? And that’s an even greater problem with kids because, you know, they’re not necessarily easy to access and they don’t necessarily want to participate in these kinds of activities. So the reach is one critical factor. The other one is, you know, is this very focused, very rigorous intervention that was very well designed and implemented, and, you know, between this effort to increase reach and to implement a very comprehensive treatment regimen, the investigators were able to conduct a study with results that yielded very important findings on how to help adolescent smokers quit.

Molly Wetterschneider: And this program was more effective than other similar efforts?

Scott Leischow: Yes, in fact as the authors point out in their paper, we know very, very little about what works to help adolescent smokers quit. In fact, as they point out, the number of studies which show long term cessation success through other intervention approaches, whether it’s school based or pharmacologic or community based, the number of interventions that have shown success with adolescent smokers is right around zero, you know, maybe one, depending on how you interpret it. But I mean it’s-- we know very, very little about what works to help kids quit. So really, this is the first study that’s shown in a fairly clear way how you can increase quit rates out to a long term time point when in most cases other studies, or virtually every other case-- other studies did not show that same kind of long term efficacy.

Molly Wetterschneider: Why do you think this was an effective method?

Scott Leischow: Well for a couple of reasons, and I alluded to them before. One is, they did a really good job with reach. And let me take a minute and talk about that. This particular research group was able to develop an excellent relationship with the schools that they included in the study. So what they did is in the 11th grade, you know, in the junior year of high school, they conducted a survey to assess which kids were smoking and not, and they put in there at the end of the survey, you know, we, you know, we may very well contact you, you know, for follow up, or to participate in other kinds of, you know, projects related to smoking. So what they did then is, because, you know, these adolescents had, you know, approved this, and, you know, assented, the investigators were able to follow up with them in the senior year to find out which ones are still smoking. And it was that information, you know, the data that they collected on who smoked and who didn’t, it was that information that allowed the investigators to basically focus on, you know, a key population, be able to identify the smokers in order to recruit them into the study. So that was one critical factor, is just how they developed the study in the context of the school system. The other factor is, as I alluded to earlier, is the design of the study. These investigators were meticulous, both in the theoretical rationale for the study and in the implementation of the study. And from

Molly Wetterschneider: What is that? What are motivational interviewing and cognitive behavioral skills training?

Scott Leischow: The motivational interviewing is an approach that even, you know, that any healthcare provider can learn. It’s not a complicated thing. But basically it’s an approach that involves trying to understand what motivates the individual, what, you know, what does the individual find important. So in the case of a smoker, you know, is it important for them to have good health? Is it important for them to, you know, to fit in? I mean what are the factors. And then the idea is to use that information to find out what’s inherently motivating to a person. And then using the second part of the theory, the cognitive behavioral skills training, to build-- help the person build skills that are needed to quit smoking, taking into consideration, you know, that which is, you know, motivating them to begin with. So it’s really a nice sort of a one two punch kind of approach from a theoretical perspective that is important. And then of course, you know, the actual implementation of the study, you know, how it’s-- how the intervention’s applied and how the data’s collected and, you know, checking on the verification of data and so on was very nicely done by these investigators.

Molly Wetterschneider: So how much do you think this type of program would cost?

Scott Leischow: Well that’s a good question and I think a key one. And this is one that in preparing the editorial, my colleague and I, you know, really thought a great deal about because this intervention is a very involved one and it’s not typical of what you’d see in most communities. And in my experience if a community wanted to set this up, it’s by no means impossible but it’s- it would take a good deal of work and time and planning and cost. But the cost in terms of staff time and coordination and collection of data, of intervening and so on, you know, that is not trivial by any means. Having said that, you know, what we have to do is decide on priorities. I mean as a society, you know, we always make decisions, you know, that are influenced, of course, by what works and what doesn’t, but also, you know, what’s gonna give us a great bang for the buck. And, you know, this particular study, given that they found that in, you know, regular, you know, regular smokers, you know, an almost doubling of the quit rate in the regular smoking, most addicted population, you know, that is pretty substantial, and to get kids at that age, you know, before, you know, they’ve entered the work world and got even more of their, you know, behaviors ingrained, you know, that, to me, is probably one of the more cost effective approaches out there, you know.

The intervention here didn’t involve any medications. It certainly involved, you know, a school system playing a role or being involved in some fashion, data collection about who’s smoking and who’s not, and of course somebody has to do the intervention. But, you know, the savings, the life savings on helping kids to quit early, has to be tremendous given what we know of the costs of smoking, you know, downstream.

Molly Wetterschneider: So what were the results of the program? How many of the teens who participated actually quit smoking?

Scott Leischow: So what they found is that when they looked at all smokers, that is, you know, people who were smoking even a small amount in, you know, each month, they found that there was a marginal difference. In this case it was 21.8% versus 17.7% so essentially it was a, you know, a 3% difference and that was not statistically significant but it was close, it was .06. But when they focused on the daily smokers, and what’s important about that, of course, those are the addicted smokers. If they’re smoking daily they’re addicted. So in that case, in those smokers I should say, they found that 10% versus 5% were able to quit, that is the cognitive behavioral motivational interviewing approach resulted in a significantly higher quit rate than the control condition. So that was really, in my mind, the most critical result. You got almost a doubling of the quit rate in the experimental condition.

Molly Wetterschneider: Wow, to see doubling is very impressive, but I was a little disappointed to find that the numbers were so low, even though statistically significant.

Scott Leischow: Absolutely, and I think that’s a very good point. When the, you know, the reality is that when addiction has occurred and this applies to tobacco addiction or cocaine addition or heroin addiction or alcohol addiction, I mean addiction is an amazingly difficult health problem to treat once it’s occurred. And unfortunately we see much the same kind of results in adults when behavioral intervention is provided by itself. Of course, you know, what we probably need to look at with, you know, down the road with adolescent smokers is, you know, how well does, you know, does the combination of behavioral intervention and pharmaco therapy work, because that’s the standard recommendation now for adults. Bottom line is, yeah, treating addictions are-- is tough, and the marginal bene-- you know, what we’re looking at is, you know, the marginal benefits of an intervention versus, you know, a control or a placebo or whatever. And it’s sort of like, you know, with the treatment of lung cancer, you know. If you can see an improvement, you know, of even a few percentage points, you know, oftentimes we say, you know, this is good. It’s not what we want to see ultimately, but it’s certainly an improvement.

Molly Wetterschneider: Well Dr. Leischow, thank you for your insight.

Scott Leischow: Oh my pleasure. Thank you very much.

Molly Wetterschneider: That was Dr. Scott Leischow, Associate Director of Behavioral and Social Sciences Research at the Arizona Cancer Center in Tucson. Dr. Leischow has contributed an editorial in this issue of JNCI commenting on the results of a study using telephone quit lines to help teens stop smoking. You’ve just enjoyed another edition of the JNCI podcast. Please check back in two weeks for our next audio update and a new issue of JNCI. Until then, we’d love to hear from you. Send an email to podcastsatoxfordjournals.org and let us know how we’re doing. In the meantime, you can find even more information on today’s topic, as well as news and commentary about cancer research, online at JNCI.oxfordjournals.org. Also, for the latest cancer news and studies, follow us on Twitter at JNCI_now. I’m Molly Wetterschneider. Thanks for listening.