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Innovation Attempt

Intensive Counseling of Students by School Nurses Does Not Have Larger Impact on Long-Term Smoking Rates Than Briefer Sessions

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Over a 2-year period, trained school nurses in 16 Massachusetts public high schools held four weekly one-on-one sessions with students who smoke, providing intensive support tailored to adolescents based on the well-established "5 A's" model. Known as Calling It Quits, the program focused on developing the health knowledge, self-control, behavioral capacity, and self-efficacy needed to stop smoking. Compared with a group of students who attended four shorter, information-focused sessions, the program improved 3-month quit rates among male adolescents, but these improvements faded after 12 months. Female adolescents derived no short- or long-term benefit from the more intensive counseling compared with the briefer sessions. However, long-term quit rates among males and females in both groups were meaningfully above those typically achieved by programs targeted at teen smokers, suggesting that both the intensive counseling and the brief information-focused sessions had a positive impact.
begin doxml

Developing Organizations

University of Massachusetts Medical School
Worcester, MAend do

Date First Implemented

The program ran from 2006 to 2008, with 1-year followup assessments occurring through 2009.begin pp

Patient Population

Age > Adolescent (13-18 years)end pp

Problem Addressed

Roughly one quarter of graduating high school seniors smoke, a figure that has stabilized at a level well above public health goals. Most smoking adolescents want to quit but face tremendous difficulties in doing so. School nurses are in an excellent position to help, but few schools have programs in place that support them in playing this role.
  • A common problem: Approximately 3 million U.S. adolescents smoke cigarettes, and almost a quarter of those who graduate from high school smoke. Many will continue to smoke into adulthood; in fact, 90 percent of adults who smoke began doing so by age 18.1 Although smoking rates among adolescents have fallen since the mid-1970s when they peaked at nearly 40 percent, the rate of decline has since stalled. Tobacco use among adolescents decreased from 36.4 percent in 1997 to 21.9 percent in 2003 and then declined more gradually, to 19.5 percent in 2009, well above the Healthy People 2010 goal of 16 percent or less.1,2
  • Difficulties quitting: Most adolescent smokers want to quit and have tried to do so, with two-thirds of female smokers and 56 percent of male smokers having attempted to stop in the past year.1,3,4,5 However, the majority of these attempts fail; only 11.5 percent of females and 13 percent of males who try to quit succeed.1,6
  • Unrealized potential of school nurses: The vast majority of adolescents (95 percent) attend school,7 while approximately half of high schools have a full-time registered nurse and another one-third have a part-time nurse.8 These nurses have the skills and credibility to provide ongoing support to smoking adolescents,9 and students can easily access them in confidence, at no cost, and without parental involvement. Yet relatively few school districts encourage these nurses to engage in cessation counseling or support them in doing so.

What They Did

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Description of the Innovative Activity

Trained school nurses in 16 Massachusetts public high schools held four weekly one-on-one sessions with students who smoke, providing intensive counseling tailored to adolescents based on the well-established "5 A's" model. Known as Calling It Quits, the program focused on developing the health knowledge, self-control, behavioral capacity, and self-efficacy needed to stop smoking. Key program elements are outlined below:
  • Nurse training: Nurses in participating schools attended an all-day training session in which they learned to deliver interventions consistent with Public Health Service guidelines and the 5 A's model (ask, advise, assess, assist, arrange), tailored to adolescents. A workgroup of school nurses and representatives from the Massachusetts Department of Public Health and U.S. Department of Education spearheaded this tailoring process. Training included demonstrations of counseling and opportunities to practice delivering the program with peers.
  • Two longer sessions before quit date: Once trained, nurses held two 30-minute, one-on-one sessions with the students, engaging them in a two-way conversation focused primarily on the advise, assess, and assist components of the 5 A's model. (The "ask" component occurred before the program began, with research assistants asking about smoking status as part of determining eligibility for the program.) Held a week apart in the school clinic and scheduled so as not to interfere with academic classes, the two sessions worked as follows:
    • First session: The nurse advised the student to stop smoking by clearly stating that doing so is the single best thing for his or her health. The nurse engaged the student in a conversation that covered the pros and cons of smoking, the individual's personal reasons for wanting to quit and any anticipated problems in doing so, and past quit attempts. The nurse and adolescent also discussed nicotine addiction and the methods available to assist in quitting. The nurse emphasized the importance of setting a quit date and discussed strategies for meeting that goal.
    • Second session: Because the adolescent had not yet reached the target quit date, support tended to focus on preparing to quit, including the following:
      • Managing triggers for smoking, such as social situations, eating, and boredom
      • Recognizing and managing withdrawal symptoms
      • Managing cravings using the "4 D's": delay, deep breathing, drink water, and do something else
      • Managing stress and minimizing weight gain without cigarettes
      • Identifying those who can help in quitting and the specific ways in which they can do so
      • Controlling the environment by eliminating easy access to cigarettes and related materials (e.g., removing them from cars, purses, pockets)
      • Rewarding oneself by estimating how much money could be saved by quitting and setting aside that money to purchase a reward for quitting  (e.g., an expensive electronic device)
  • Two shorter sessions after quit date: After the established quit date, the nurse held two 15-minute sessions with the adolescent, also a week apart. These sessions also began with an assessment of the current smoking status and readiness for change, which again allowed the nurse to tailor the session accordingly. The focus for these final two sessions depended on whether the adolescent had attempted to quit, and if so, whether the attempt had succeeded thus far, as outlined below:
    • For those who quit and maintained abstinence: The nurse congratulated the student on his or her success, reviewed how difficult situations had been handled, assessed the benefits realized from quitting, and discussed problems anticipated in avoiding relapse and strategies to address them.
    • For those who quit but relapsed: The nurse congratulated the adolescent for his or her attempt, assessed the length of the quit and what went well, discussed what led to relapse and how the adolescent could better handle this issue during the next attempt, elicited a recommitment to quitting and a new quit date, and developed a new, modified plan for quitting.
    • For those who did not try to quit: The nurse assessed the barriers to making an attempt, acknowledged the difficulty of quitting, elicited a recommitment to quit and a new quit date, and developed a new, modified plan for quitting.

Did It Work?

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Compared with students attending four shorter, information-focused sessions, the program did not have an impact on long-term quit rates. However, long-term quit rates in both groups were meaningfully above those typically achieved by other programs targeted at teen smokers, suggesting that both the intense counseling and the brief information-focused sessions had a positive impact.
  • Higher short-term quit rates in males than with briefer sessions: Overall, 10.7 percent of students in the 16 participating public high schools reported not smoking 3 months after the sessions ended, compared with 5.9 percent in a control group of students in 19 similar schools who received four weekly, 10-minute visits from a school nurse who distributed educational materials, inquired about smoking status, and briefly educated students. Male students accounted for the entire difference, with 15 percent of participating males quitting, versus 4.9 percent in the comparison group. For females, 7 percent of participants reported abstinence at 3 months, roughly equivalent to the 6.6 percent rate in the comparison group.10
  • No long-term impact on quit rates (versus briefer sessions): After 12 months, self-reported quit rates were roughly the same in both groups (15.3 percent among participants, 14.3 percent in the comparison group).10
  • Similar findings with most other metrics: Compared with the information-focused sessions, other metrics also showed either no improvement or only short-term improvement that faded over time, including number of cigarettes smoked in the past week, number of days in which smoking occurred in the past week, student expectations regarding positive and negative outcomes associated with quitting, smoking-related knowledge scores, confidence in the ability to quit, and number of quit attempts. Only one metric showed improvement at both 3 and 12 months—the length of time that those who attempted to quit were able to refrain from smoking.10
  • Higher quit rates in both groups than with other programs: The 12-month abstinence rates found in both groups (between 13 and 14 percent for males and 15 and 17 percent for females) are significantly higher than the 9-percent average abstinence rate found in a meta-analysis of cessation programs targeted at teen smokers.11 This finding suggests that both the intense counseling and brief information-focused sessions may have had a positive impact on quit rates, although further study is needed to confirm this finding.

What They Learned

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  • Support school nurses in promoting quitting: School nurses are in an ideal position to help students quit smoking. They are accessible and credible to students and have the skills and knowledge base to support them. As noted, the evaluation of this program suggests that nurse-led counseling over a period of time had a positive impact, as both the intense counseling and brief information-focused regimens led to higher long-term quit rates than the typical cessation program targeted at teens.
  • Encourage relationship-building between nurse and student: Success seems to depend in part on the ability of the nurse to build and maintain a meaningful relationship with the student through multiple contacts, both in formal sessions and informal encounters (e.g., in the hallways between classes).
  • Evaluate program impact to determine ideal structure: The program evaluation raises questions about the ideal structure of the nurse-led counseling, including the number and intensity of sessions. Consequently, research is needed to test the effectiveness of various models. To that end, program developers are pilot testing an enhanced version of the program and will compare it with a minimal intervention in which school nurses distribute educational materials to smoking students. (This control group is more representative of "usual care" than the four 10-minute sessions used in the original comparison group.) The enhanced intervention consists of six sessions, allowing for greater support during the maintenance phase after the initial quit. Each session begins with students filling out a 12-item assessment to identify their top three concerns. Half the session focuses on the three items, with the remainder spent on core competencies that all students should understand. The enhanced version also features a computer system that allows students to see a graphical representation of their progress over time, such as changes in symptoms. The evaluation should help confirm the program's impact versus usual care and shed light on the best way to structure the sessions, including how to ensure that both males and females benefit.

More Information

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Contact the Innovator

Lori Pbert, PhD
Division of Preventive and Behavioral Medicine
University of Massachusetts Medical School
55 Lake Ave N.
Worcester, MA 01655
Phone: (508) 856-3515

References/Related Articles

Pbert L, Druker S, DiFranza JR, et al. Effectiveness of a school-nurse delivered smoking-cessation intervention for adolescents. Pediatrics. 2011;128:926-35. [PubMed]

Links to detailed information on Public Health Service guidelines on treating tobacco use and dependence can be found at

The "5 A's" model is described in the following reference: Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008. Available at:
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Program-related materials, including a detailed counseling protocol, can be obtained from the innovator; see section below for contact information.


1 Cigarette use among high school students - United States, 1991-2009. MMWR Morb Mortal Wkly Rep. 2010;59(26):797-801. [PubMed]
2 National Institute on Drug Abuse, University of Michigan, Institute for Social Research. The monitoring the future, national results on adolescent drug use. Overview of key findings. Bethesda, MD. National Institute on Drug Abuse, U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health; 1999.
3 Grimshaw G, Stanton A, Blackburn C, et al. Patterns of smoking, quit attempts and services for a cohort of 15- to 19-year-olds. Child Care Health Dev. 2003;29(6):457-64. [PubMed]
4 Mermelstein R. Teen smoking cessation. Tob Control. 2003;12(suppl 1):i25-34. [PubMed]
5 Sussman S. Effects of sixty-six adolescent tobacco use cessation trials and seventeen prospective studies of self-initiated quitting. Tob Induc Dis. 2002;1(1):35-81. [PubMed]
6 Centers for Disease Control and Prevention. High school students who tried to quit smoking cigarettes: United States, 2007. MMWR Morb Mortal Wkly Rep. 2009;58(16):428-31. [PubMed]
7 U.S. Department of Commerce. Historical Statistics of United States Colonial Times to 1970; Current Population Reports, Series P-20, Various Years; and Current Population Survey, October 1970 through 2007. Washington, DC: U.S. Department of Commerce; 2009.
8 National Association of School Nurses. School nursing in the United States quantitative study: Burkhardt Research Services, 2007.
9 Broussard L. School nursing: not just bandaids anymore! J Spec Pediatr Nurs. 2004;9(3):77-83. [PubMed]
10 Pbert L, Druker S, DiFranza JR, et al. Effectiveness of a school-nurse delivered smoking-cessation intervention for adolescents. Pediatrics. 2011;128:926-35. [PubMed]
11 Sussman S, Sun P, Dent CW. A meta-analysis of teen cigarette smoking cessation. Health Psychol. 2006;25(5):549-57. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: October 24, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 21, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

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