Applying a Social–Ecological Framework to Factors Related to Nicotine Replacement Therapy for Adolescent Smoking Cessation

Abstract

Objective:

This systematic review synthesizes factors related to nicotine replacement therapy (NRT) use among adolescents seeking to quit smoking, using the social–ecological model as a guiding framework.

Data Source:

Searches of PubMED, ProQuest, EBSCOhost, and ERIC were conducted in July 2016.

Study Inclusion and Exclusion Criteria:

Original studies of cigarette smokers younger than 18 years that discussed NRT were included.

Data Extraction:

Two reviewers individually extracted study purpose, sample, design, and results.

Data Synthesis:

Factors were categorized by social–ecological model level and summarized.

Results:

A total of 103 907 articles were identified during initial search. After narrowing to peer-reviewed articles in English and eliminating reviews and adult-only studies, we reviewed 51 articles. These 51 articles identified factors from studies at each level of the social–ecological model: intrapersonal (k = 20), interpersonal (k = 2), organizational (k = 7), community (k = 11), and public policy (k = 14).

Conclusion:

Findings provide insight into the applicability of NRT for adolescent smoking cessation, and factors by social–ecological model level highlight areas for additional research. Future adolescent NRT studies should assess factors at the interpersonal, organizational, and community levels, as well as the interactions between levels.

Keywords

smoking cessation adolescents nicotine replacement therapy

Introduction

Tobacco use remains the leading preventable cause of disease and death worldwide.¹ Despite decades of tobacco prevention efforts, 3200 adolescents initiate smoking each day, many of whom will become lifetime users.² Adolescents are more susceptible to the addictive chemicals within combusted cigarettes and, therefore, more likely to become addicted despite sporadic smoking habits.³ Furthermore, successful quit attempts among adolescent smokers are rare, perhaps due partly to the lack of best practice guidelines for this population.³

Nicotine replacement therapy (NRT) is widely recommended for adult cessation as these medications can improve the odds of successfully quitting by 50%.^3

-6 The NRT is available in the form of gum, inhaler, nasal spray, transdermal patch, and lozenge, all of which increase adult tobacco abstinence rates. Although NRT has been found safe for adolescent use, it is not widely recommended due to the lack of evidence on the effectiveness of NRT among adolescents.³ While some countries, including the United Kingdom and New Zealand, recommend NRT for individuals older than 12 years, the World Health Organization only includes it on the adult essential medications list, and many countries, including the United States and Canada, restrict it to individuals older than 18 years.⁷ Compared to the vast amount of research among tobacco prevention and adult cessation, there is minimal literature related to NRT use among adolescents quitting smoking and thus hesitancy to recommend. While several authors^8

-11 have reviewed safety and efficacy studies related to NRT use among adolescents, no one yet has summarized additional factors related to NRT use, such as access, preferences, parental influence, and health-care influence. Identifying such factors may provide insight into why NRT has been ineffective among adolescents and provide information to improve future cessation efforts. Because NRT use for adolescent smoking cessation involves multiple levels of influence, a social–ecological framework was selected to synthesize information. Social–ecological approaches recognize that people participate in risky behaviors, such as tobacco use, because of a complex social system.¹² Therefore, researchers and practitioners are encouraged to use multilevel models to recognize the dynamics involved.

The social–ecological model (SEM) proposed by McLeroy et al¹³ suggests behaviors result from influences at 5 levels: intrapersonal, interpersonal, organizational, community, and public policy (Figure 1). At the intrapersonal level are individual characteristics that influence behavior such as beliefs, attitudes, knowledge, and skills. At the interpersonal level are processes and groups that provide identity and support, including family, friends, and peers. For example, adolescents with parents who use NRT may be more likely to use themselves.^14,15 Within the organizational level are structures that constrain or promote behaviors such as schools, stores, and churches. Influences at the organizational level may include school health programs that provide adolescents NRT. The community level refers to broader social networks and community or cultural norms, which may include advertisements promoting NRT that may normalize NRT use.¹⁶ Finally, the public policy level includes local, state, and federal policies and laws that regulate or support healthy practices and actions.

Figure 1.

Social–ecological model.

The social–ecological perspective also emphasizes the interaction between, and interdependence of, factors within and across all levels of a health problem. Those who employ social–ecological approaches recognize that participating in risky behaviors such as tobacco use is the result of a complex social system.^12,17 Because individual behavior has multiple levels of influence and is shaped by and shapes the surrounding environment, it is necessary to identify and understand the factors within each level.

The purpose of this study was to systematically review the literature within the framework of the SEM to identify a comprehensive list of factors related to NRT use among adolescents seeking to quit smoking. For the purposes of this study, adolescent refers to any study which includes individuals younger than 18 years, due to NRT restrictions among this age-group in the United States. Further understanding of the factors related to adolescents using NRT for smoking cessation and the corresponding levels of influence may benefit clinicians working directly with this population as well as researchers and policy makers.

Methods

Data Sources and Extraction

The search process was initially conducted in January 2016, and then repeated in July 2016, to identify any additional published articles. Four databases (EBSCOhost, ERIC, ProQuest, and PubMed) were searched using the following keyword string: (adolescen* OR teens OR “young adults” OR students OR youth) AND (smoking OR cigarette OR tobacco OR nicotine) AND (NRT OR “Nicotine Replacement Therapy” OR Patch OR Gum OR Lozenge OR “Pharmacological treatment”). Initial search across all databases resulted in 103 907 articles, which were narrowed to peer-reviewed, full-text articles (7401 articles). Abstracts (164) and full texts (107) were reviewed to determine whether articles met the inclusion criteria (Figure 2). Broad inclusion criteria were used to ensure comprehensiveness. The inclusion criteria were (1) original research (no reviews or commentaries) that contained (2) information related to NRT for (3) adolescent smokers younger than 18 years of age.

Figure 2.

Article search process.

Data Synthesis

Two reviewers independently analyzed articles for factors related to adolescents using NRT for smoking cessation. Study purpose, sample characteristics, design, and results were extracted. Factors related to NRT were coded for the corresponding SEM level (intrapersonal, interpersonal, organizational, community, or policy). Because individual factors were coded as opposed to entire articles, some articles identified factors at multiple levels. Coders used past models on other public health topics, including smoking initiation, as examples for determining which factors fit within each level.^18,19 Within each SEM level, factors were grouped by topic areas and findings were compared and synthesized. Any disagreements were discussed and resolved with input from a third reviewer.

Quality assessment

We conducted quality assessments for each of the studies using 1 of 3 tools. These findings were used to provide an overall understanding of study quality and identify areas for improvement. For experiments and randomized trials, we used the Cochrane Risk of Bias tool which covers 6 areas of bias: random sequence generation, allocation concealment, performance bias, detection bias, attrition bias, and reporting bias.²⁰ For cross-sectional studies, we used the National Institute of Health’s Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, a 14-item measure which covers selection bias, measurement bias, and confounders, resulting in a rating of good, fair, or poor quality.²¹ For qualitative studies, we used the Critical Appraisal Skills Programme Qualitative Research Checklist, a 10-item tool which assesses whether qualitative methods, recruitment, data collection, and analysis were conducted appropriately.²² Two reviewers independently assessed each of the studies and discussed discrepancies with a third reviewer.

Results

Fifty-one articles with factors related to NRT for adolescents younger than 18 years were analyzed for this study. Articles identified or assessed factors at each level of the SEM (Table 1), with most at the intrapersonal or policy level. Study methodologies included cross-sectional surveys, randomized controlled trials, focus groups, secondary analyses, nonrandomized trials, experimental studies, and qualitative interviews. Quality ratings varied by study type. Interventions and randomized trials were typically low risk of bias, with nonrandomized trials limited in areas of blinding and randomization. Most cross-sectional studies were rated fair and could be improved by controlling for potential confounding factors and better descriptions of measures used. Most qualitative studies were rated as good per the Critical Appraisal Skills Programme tool, with the most frequent areas for improvement in justifying which qualitative approach was selected and addressing potential bias of the researcher within the study. Factors are organized below by SEM level (Figure 3) following a brief overview of NRT prevalence.

Table 1.

Factors Related to Adolescent NRT Use by Social–Ecological Model Level.

First Author, Year	Design	Sample	Quality Appraisal	Relevant Findings
Prevalence (12 Articles)
Klesges, 2003	Cross-sectional survey	4078 adolescents (younger than 18)	NIH—fair	5% reported trying or using NRT: 40% to quit; 75% for reasons other than trying to quit Females were less likely to have used than males; African Americans were less likely to have used than European Americans (P < .001)
Moolchan, 2004	Cross-sectional survey	980 adolescent smokers (ages 13-17)	NIH—fair	24.1% of students had used NRT; European Americans (27.5%) more likely to have used than African Americans (19.3%) 25.8% of those who tried to quit previously used NRT on a subsequent attempt, compared to 10.9% who used NRT on first quit attempt (P = .0006)
Hyland, 2006	Cross-sectional survey	562 safe and drug-free school coordinators	NIH—fair	Most adolescents use NRT while smoking (90%), trying to quit (16%), or to experiment (16%)
Ham, 2007	Cross-sectional survey	300 adolescent males (10th-12th grade)	NIH–good	12.2% used nicotine gum; 8.2% used other aids, including acupuncture, patches, and herbal medicine; 17.7% used nicotine-free tobacco
Botello-Harbaum, 2010	Cross-sectional survey	120 adolescent smokers (ages 13-17)	NIH—fair	NRT was not frequently used by youths during quit attempts. Older (P = .01), nicotine-dependent (P = .001), and European American (P = .003) adolescents were more likely to use NRT than their counterparts
Dalton, 2010	Cross-sectional survey	4078 adolescents (high school students)	NIH—fair	Approximately 5% of students reported former or current use of NRT products: 42% gum, 29% patch, and 29% both gum and patch Males (P = .0003), risk takers (P = .0006), and/or smokers (P < .0001) were at greatest odds for NRT use
Rainio, 2010	Cross-sectional survey	5840 adolescents (ages 12-18)	NIH—fair	NRT use increased with age: 2% of 14-year-olds had used NRT; 6% of 16-year-olds; 9% of 18-year-olds 79% of NRT users were daily smokers, 2% were never smokers
Lane, 2011	Secondary analysis of cross-sectional survey	29 296 adolescents (9th-12th grade)	NIH—fair	21.1% of youth smokers in Canada had ever used NRT and 5.1% were currently using NRT Odds of NRT use highest among daily smokers, males, and youths with multiple quit attempts (P < .05)
Morris, 2011	Cross-sectional survey	62 patients (ages 13-17)	NIH—poor	19.5% of survey respondents had used NRT before to quit
Raisamo, 2011	Cross-sectional survey	4834 adolescents (ages 14-18)	NIH—fair	10% had used NRT Males (11.5%) more likely to have used than females (8.7%, P < .001)
Raisamo, 2013	Secondary analysis of cross-sectional survey	5198 adolescents (ages 14-18)	NIH—good	23.8% had used NRT Males (28.5%) more likely to have used than females (20.9%) NRT users more likely to perceive themselves as addicted to smoking than non NRT users
Swanson, 2013	Nonrandomized open-label trial	34 adolescent smokers (ages 14-21)	ROB—high risk	Younger youth were less likely to choose to receive NRT (P = .07). Those who had ever made a quit attempt were more likely (P = .06), but those with a recent quit attempt (within last 30 days) were less likely (P = .03)
Intrapersonal (20 Articles)
Killen, 2001	Prospective study	92 adolescent smokers (ages 13-18)	ROB—unclear risk	Belief in wearing a patch played a role in cravings Expectancies about NRT influenced subjective aspects of withdrawal more than NRT Conclusion: NRT not effective at reducing cravings
Lawrance, 2001	Cross-sectional survey	2457 adolescents (ages 13-20)	NIH—fair	When asked to select from a list of pharmacological approaches, 33.4% chose gum while 18.3% chose patch 4% selected pharmacological as their overall preference
Prokhorov, 2001	Cross-sectional survey	5624 adolescents (ages 15-18)	NIH—fair	Nicotine dependence and withdrawal interfere with adolescents’ abilities and readiness to quit Conclusion: potential role for NRT
O’Loughlin, 2002	Focus groups	64 adolescents (ages 14-17)	CASP—fair	Respondents did not feel other forms of nicotine could substitute for cigarettes
Moolchan, 2005	Randomized controlled trial	120 adolescent smokers (ages 13-17)	ROB—low risk	Compliance higher for patch (78.4%-82.8%) than gum (38.5%-50.7%)
Al-Delaimy, 2006	Cross-sectional survey	5857 adolescents (ages 12-17)	NIH—fair	Never smokers (P < .0001), males (P = .003), younger adolescents (P < .0001), Hispanic and African Americans (P < .0001) were more likely to believe NRT helps people quit than their respective counterparts
Amos, 2005	Qualitative interviews	99 adolescent smokers (ages 16-19)	CASP—good	Adolescent smokers aware of NRT but concerned about cost and becoming addicted to it. Many students believed NRT only for those who do not have control
Molyneux, 2006	Focus groups	135 smokers (ages 13-16)	CASP—good	NRT perceptions based on brief, negative, and largely experimental use of products; cost and difficulty of obtaining NRT were significant barriers to use
Jannone, 2007	Qualitative interviews	64 adolescent smokers (mean age 16.2)	CASP—good	None of the students reported interest in NRT
Leatherdale, 2007	Cross-sectional survey	26 739 adolescents (9th-12th grade)	NIH—good	More than half reportedly would use NRT, the only formal cessation aid the majority would consider using
MacDonald, 2007	Qualitative interviews	25 adolescent former and current smokers (ages 13-18)	CASP—fair	NRT could help, though accessing NRT is a potential barrier
Dickmann, 2009	Randomized controlled trial	43 males, 57 females	ROB—unclear risk	There is an overlap between withdrawal symptoms and premenstrual symptoms, which hormonal contraceptives lesson. Might be why studies show NRT not as effective in women as men
Owusu-Dabo, 2011	Cross-sectional survey	1144 adolescents (ages 14-19)	NIH—good	Of the 7 smokers within the 14-19-year-old age-group, 2 had heard of NRT (28.6%)
Rainio, 2010	Cross-sectional survey	5840 adolescents (ages 12-18)	NIH—fair	Over 25% of 12-year-old females and 15% of males did not know what NRT products were. Awareness increased with age
Morris, 2011	Focus groupsCross-sectional survey	21 patients (ages 13-17)62 patients (ages 13-17)	CASP—fairNIH—poor	When asked what would help them quit, the greatest response was for NRT (30.6%). All smokers within the focus groups expressed the opportunity to use NRT
Wiium, 2011	Cross-sectional survey	509 smokers (ages 16-20)	NIH—fair	62% of males and 66.2% of females reported interesting in using gum or patches
Bailey, 2013	Randomized controlled trial	141 adolescent smokers (ages 14-18)	ROB—low risk	Self-reported nicotine patch compliance during treatment was highest at week 5 (44%) and lowest during week 7 (31%). The average number of days of self-reported patch use each week was around 4 of 7 days (range: 3.6–4.1)
Buswell, 2013	Qualitative interviews	12 adolescent smokers (ages 13-16)	CASP—good	Some found NRT lozenges helpful, but adolescents did not like the taste
Scherphof, 2014	Randomized controlled trial	256 adolescent smokers (mean age 16.7)	ROB—low	Three compliance trajectories: compliers, moderate decreasers, and strong decreasers. More compliers were abstinent at 6-month follow-up (10.4%) compared to moderate (3.1%) or strong (6.1%) decreasers Conclusion: Compliance impacts abstinence
King, 2016	Cross-sectional survey	198 adolescents (6th-12th grade)	NIH—fair	When asked to select the best way to help teens stop using tobacco, combination of methods was most frequently selected (31.6%), followed by “cold turkey” (19.5%), e-cigarettes (16.8%), NRT (14.7%), counseling (10.5%), and alternative therapies (6.8%)
Interpersonal (2 Articles)
Al-Delaimy, 2006	Cross-sectional survey	5857 adolescents (ages 12-17)	NIH—fair	Adolescents who lived with an adult who used NRT more likely to think NRT is a sure way to quit (P = .0003)
Wyman, 2006	Cross-sectional survey	456 parents of middle and high school students	NIH—fair	Majority of parents (75%) were not supportive of providing NRT. Parents in lowest 2 income groups more likely than those in the highest 2 income groups to support schools providing NRT (P = .001)
Organizational (7 Articles)
Price, 2003	Cross-sectional survey	250 school-based health centers	NIH—fair	70% of schools had not seriously thought about offering prescription services for NRT; 11.8% had provided NRT for a year or longer; 8.4% were thinking about providing (P < .01) Respondents from schools that did not provide NRT were more likely to believe that students would not use services (22.3% vs 11.1%), students would abuse NRT (31.5% vs 0%), parents would object to offering (28.4% vs 3.7%), staff did not have experience (32% vs 3.7%), and staff did not have authority (35% vs 3.7%); Ps < .01
Chun, 2007	Cross-sectional survey	12 adolescent substance use residential treatment centers	NIH—fair	42% of sites provided NRT: 25% patch, 17% gum; 1 site patch and Zyban
Milne, 2007	Cross-sectional survey	57 pediatricians	NIH—fair	Confidence in knowledge of NRT was significantly related to physicians’ likelihood to assist and arrange for support with adolescent smokers (P < .01)
Price, 2007	Cross-sectional survey	203 pediatricians	NIH—fair	Pediatrician perceptions: highly safe (45%); moderately (70%) or highly (15%) effective; low (53%) or high (15%) confidence in ability to effectively use NRT Prescribing practices: 76% of pediatricians had not considered prescribing NRT or had considered but not taken any steps to prescribe it; 17% currently prescribing; 3% formerly prescribed Reasons for prescribing: request from adolescent (68%), openness to quitting (64%), or health problem exacerbated by smoking (49%) Factors considered: previous quit attempts (24%), amount smoked per day (22%), and years adolescent smoked (21%) Products prescribed: patches (81%), gum (53%), combination of patch and gum (25%), and inhaler (3%) Reasons for not prescribing: adolescents not complying (22%), not enough testing (17%), lack of insurance (14%), cost (14%), and adolescents not wanting parents to know (13%) Pediatricians more likely to prescribe if receiving majority of smoking cessation information from continuing medical education or professional journal articles (P < .01)
Morris, 2011	Qualitative interviews	11 health-care professionals	CASP—fair	Professionals’ views split on NRT with some stating medications were inappropriate and others stating they were not used enough
Langley, 2011	Secondary analysis	400 000+ records of 12- to 17-year-old patients	NIH—fair	NRT prescribing highest among 16- to 17-year olds and lowest among 12- to 13-year olds (P < .001); females prescribed more frequently than males (P < .001)
Muilenburg, 2015	Cross-sectional survey	63 counselors from 22 adolescent treatment programs		Of the 9 pharmacotherapies available for tobacco cessation, nicotine patch (39.7%) was most available compared to bupropion (29.6%), clonidine (21.4%), nicotine gum (12.7%), varenicline (10.2%), nicotine lozenge (8.1%), nicotine inhaler (4.8%), nortriptyline (3.7%), and nicotine nasal spray (1.6%). Pharmacotherapies were recommended by counselors for very few adolescents, although most often nicotine patch
Community (11 Articles)
Klesges, 2003	Cross-sectional survey	4078 adolescents (younger than 18)	NIH—fair	50% of adolescents reported easy access to NRT
Price, 2003	Cross-sectional survey	250 school-based health centers	NIH—fair	Schools in the West were twice as likely (20.8%) as those in the South (8.3%) or Midwest (10.7%) to have offered prescription services (P < .01)
Johnson, 2004	Observational case series	165 stores that sold OTC medicines	NIH—fair	In most stores which stocked NRT, buyer’s age was not asked during purchase attempt (79%) and minor could purchase (81%)
Wakefield, 2005	Archival record analysis	TV advertising exposures from 75 largest US markets	NIH—good	Tobacco company advertisement exceeded public health sponsored advertising; pharmaceutical companies were the largest sponsor of tobacco-related advertising for households
Al-Delaimy, 2006	Cross-sectional survey	5857 adolescents (ages 12-17)	NIH—fair	Data suggest NRT advertisements may be influencing belief among adolescents that if they were to start, they can quit anytime
Durkin, 2006	Random experimental	718 adolescents (ages 14-16)	ROB—unclear risk	Exposure to NRT and Zyban advertising in experimental context does not influence youth smoking beliefs, especially those vulnerable to becoming regular smokers
Wakefield, 2006	Random experimental	492 adolescents (ages 12-14)	ROB—low risk	After viewing ads, youth more likely to agree NRT and Zyban ads made it seem easy to quit smoking (P < .001), however more enduring perceptions not changed
Wyman, 2006	Cross-sectional survey	456 parents of middle and high school students	NIH—fair	Parents in rural locations were more likely to support providing NRT than those in urban locations (11% vs 6%)
Botello-Harbaum, 2010	Cross-sectional survey	120 adolescent smokers (ages 13-17)	NIH—fair	European American adolescents reported more access than minorities Hispanic or African American adolescents
Rainio, 2010	Cross-sectional survey	5840 adolescents (ages 12-18)	NIH—fair	Underaged youth obtained NRT from friends (42%), pharmacies (22%), family members or at home (16%), retailers (13%), or health-care personnel (4%)
Lane, 2012	Secondary analysis	29 296 adolescents (9th-12th grade)	NIH—fair	Students in schools located within an urban area were more likely to use NRT than those in rural areas (OR = 1.28, 95% CI, 1.03-1.60). A higher density of pharmacies surrounding a school was inversely associated with current NRT use (OR = 0.85, 95% CI, 0.76-0.95)
Policy (14 Articles)
Smith, 1996	Nonrandomized open-label trial	22 adolescent smokers (ages 13-17)	ROB—high risk	At end of treatment, 13.6% were abstinent Conclusion: patch safe for adolescent use
Hurt, 2000	Nonrandomized open-label trial	101 adolescent smokers (ages 13-17)	ROB—high risk	At end of treatment, 10.9% were abstinent Conclusion: patch does not appear effective
Hanson, 2003	Randomized controlled trial	100 adolescent smokers (ages 13-19)	ROB—low risk	Active nicotine patch group had significantly lower craving and withdrawal symptom scores (P = .025). Abstinence at end of treatment: 28% patch and 24% placebo Conclusion: patch is promising
Killen, 2004	Randomized controlled trial	211 adolescent smokers (ages 15-18)	ROB—low risk	At end of treatment, in patch and placebo group, 28% abstinent; in patch and bupropion group, 23% abstinent
Moolchan, 2005	Randomized controlled trial	120 adolescent smokers (ages 13-17)	ROB—low risk	Continuous abstinence at 3 months: 17.7% for patch, 6.5% gum, and 2.5% placebo (P = .066) Conclusion: patch with therapy effective
Hyland, 2006	Cross-sectional survey	562 safe and drug-free school coordinators	NIH—fair	Increased access to NRT after deregulation has not caused widespread abuse of NRT among adolescents. The abuse rate of OTC NRT is low and less than abuse of diet pills
Roddy, 2006	Randomized controlled trial	98 adolescent smokers (ages 11-21)	ROB—low risk	End of treatment abstinence: 10.2% patch and 4.1% placebo Conclusion: not likely to be effective, perhaps due to difficulty recruiting and retaining adolescent smokers
Gerlach, 2008	Secondary analysis	5510 adolescents (ages 12-19)	NIH—fair	Abuse potential of NRT after deregulation is very low
Hanson, 2008	Randomized controlled trial	103 adolescent smokers (ages 13-19)	ROB—unclear risk	End of treatment decrease in cigarettes per day: 45.0% patch, 47.2% gum, and 46.6% placebo Conclusion: no difference among treatment methods in reducing cigarettes per day
Langley, 2011	Secondary analysis	400 000+ records of 12- to 17-year-old patients	NIH—fair	Recent changes in marketing license had little or no effect on prescribing practices
Bailey, 2013	Randomized controlled trial	141 adolescent smokers (ages 14-18)	ROB—low risk	None of the 73 adverse events reported during the open-label treatment phase were deemed to be medically serious by the study physician
Swanson, 2013	Nonrandomized open-label trial	34 adolescent smokers (ages 14-21 years)	ROB—high risk	There were minimal adverse reactions Those who got NRT were 12 times more likely to complete the intervention (P = .008), but NRT was not associated with abstinence at end of treatment
Scherphof, 2014	Randomized controlled trial	256 adolescent smokers (mean age 16.7)	ROB—low risk	End of treatment abstinence: 14.8% patch and 13.1% placebo Conclusion: patches might be effective, if compliance can be ensured
Scherphof, 2014	Randomized controlled trial	256 adolescent smokers (mean age 16.7)	ROB—low risk	At 6 months, abstinent rates were 8.1% for patch and 5.7% for placebo. At 12 months, rates were 4.4% for patch and 6.6% for placebo Conclusion: NRT fails in helping adolescents quit smoking at 6- and 12-month follow-ups

Abbreviations: CASP, Critical Appraisal Skills Programme Qualitative Research Checklist used to assess qualitative studies, ratings include good, fair, or poor; CI, confidence interval; NRT, nicotine replacement therapy; NIH, National Institute of Health’s Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies used to assess cross-sectional studies, ratings include good, fair, or poor; OR, odds ratio; OTC, over-the-counter; ROB, Cochrane Risk of Bias tool used for interventions, ratings include low, high, or unclear risk of bias.

Figure 3.

Factors at each social–ecological model level.

Prevalence of NRT Use

Twelve studies^{23

-34} examined NRT prevalence among adolescents. These studies found between 2%²⁹ and 23.8%³⁰ of adolescents had ever used NRT. In demographic analyses, males were more likely to have used NRT than females,^{23,26,27,30,31} older adolescents were more likely to have used NRT than younger adolescents,^29,32,33 and European Americans were more likely to have used NRT than African Americans.^26,33,34 Additionally, adolescents who had previously attempted to quit smoking were more likely to have used NRT.^32,34 The reasons adolescents used NRT included to quit smoking, as a substitute when smoking not possible, and to try it.^26,27,31,35

Factors at the Intrapersonal Level

Twenty articles identified factors at the intrapersonal level related to NRT use among adolescents (see Table 1). Factors included physiological effects such as withdrawal and cravings, awareness and knowledge of NRT, attitudes, preferences, compliance, perceived cost and availability, and addiction concerns.

Awareness, knowledge, and beliefs

Lack of awareness^29,36 and knowledge^37
-39 of NRT for smoking cessation were common among adolescents surveyed, as were misperceptions related to health consequences and safety.³⁷ However, Rainio and colleagues²⁹ found NRT awareness increased with age and was much greater among daily smokers than never smokers, suggesting lack of awareness may not be generalizable to all adolescents.

Beliefs related to perceived success were also identified as a factor for adolescent NRT use, both beliefs in effectiveness⁴⁰ and relevance.^15,37 Amos and colleagues³⁷ found adolescents believed NRT was for older or more addicted smokers and therefore lacked confidence in its relevancy. On the other hand, Al-Delaimy and colleagues¹⁵ found younger adolescents were more likely than older adolescents to believe NRT helps people quit smoking. They also found never smokers were more likely than established or experimental smokers to believe NRT helps people quit, males were more likely than females to believe NRT helps people quit, and Hispanics and African Americans were more likely than European Americans to believe NRT helps people quit.¹⁵

Preferences

Several articles discussed adolescent preferences for NRT, with some adolescents expressing great interest,^28,41,42 while others reported some^23,43 or no interest in NRT.⁴⁴ In other studies, students were as likely to use glucose and candy as an alternative to NRT.⁴⁵ Specific reasons given for such preferences were that adolescents did not like the taste^45,46 and they felt NRT did not adequately substitute for handling cigarettes.⁴⁶

Compliance

Compliance is an important factor for any medication use and was mentioned several times within the efficacy studies as well as some of the preference articles.^47

-50 Adolescents were noncompliant for a number of reasons, including forgetfulness, side effects, lack of effect, and wanting to smoke.^47,50 Factors associated with compliance included extraversion, higher education, and agreeableness.⁵⁰

Perceived barriers

Concerns with using NRT included cost,^37,38,43 access,^38,51 and addiction to NRT.³⁷ According to Lane and colleagues,²⁷ adolescents with increased spending money were more likely to use NRT, which may support adolescents’ reported cost concerns. However, the same study also found those with no disposable income were likely to use NRT, suggesting use may also be related to availability.²⁷

Physiological effects

Physiological effects refer to withdrawal, addiction, and cravings. Three studies addressed these factors in relation to NRT among adolescents. Raisamo and colleagues³⁰ found NRT users were more likely to perceive themselves as addicted to smoking, a finding also supported by heaviness of smoking. After identifying a correlation between nicotine dependence and withdrawal symptoms among adolescents, Prokhorov and colleagues⁵² concluded NRT is important for adolescent cessation because nicotine dependence and withdrawal interfere with adolescents’ readiness to quit. Dickmann and colleagues⁵³ also examined adolescent withdrawal, within the context of craving systems in relation to gender. Dickmann and colleagues⁵³ found similar levels of withdrawal but higher craving in females, with females not using hormonal contraceptives experiencing the highest level of cravings. The overlap between withdrawal symptoms and premenstrual syndrome symptoms is lessened by hormonal contraceptives, but cravings are not impacted, which could explain why NRT is traditionally found to be less effective in women than men.

Factors at the Interpersonal Level

Two studies addressed interpersonal relationships and adolescent NRT use, both addressing the role of parents. Al-Delaimy and colleagues¹⁵ found adolescents who lived with an adult who used NRT were more likely to think NRT is a sure way to quit, while Wyman and colleagues⁵⁴ found few parents of middle and high school students agreed the school should provide nicotine patches for students who are trying to quit.

Three articles, which were included within this study for their focuses on NRT at other SEM levels, mentioned interpersonal characteristics in adolescent preferences for smoking cessation. Although NRT use was not the main focus for the interpersonal characteristics mentioned, potentially related factors identified were advice from friends,⁴¹ contracts with friends,⁴³ and seeking professional support with friends to eliminate the potential social cost related to participating in a cessation program.⁵¹

Factors at the Organizational Level

Seven articles addressed factors related to adolescent NRT use at the organizational level, including an analysis of school characteristics related to NRT, and studies related to access to NRT prescriptions within schools, substance treatment facilities, mental health-care facilities, and general health-care settings.

Price and colleagues⁵⁵ assessed NRT availability within 250 school-based health centers and found most schools had not seriously thought about offering prescription services for NRT and few had provided NRT for a year or longer. School health-care center beliefs related to NRT were also assessed, with over half reporting they believed NRT increases the likelihood of quitting. Schools that did not provide NRT were more likely to believe that students would not use services, students would abuse NRT, parents would object to offering, staff did not have experience with NRT, and staff did not have the authority to provide NRT. Some of the specific reasons for not offering NRT were that the centers were run by nurses without prescriptive authority, lack of evidence to support recommending it, and high cost.⁵⁵

In a survey of 12 adolescent substance use residential treatment centers, Chun et al⁵⁶ found less than half of sites provided NRT to adolescents. In a similar study among mental health centers, Muilenburg et al⁵⁷ also found less than half of centers provided the nicotine patch, though the counselors stated pharmacotherapies were used by very few adolescents. Also surveying mental health-care providers, Morris and colleagues²⁸ found the professionals were split on their views regarding NRT, with half viewing medications as inappropriate for youth, whereas the other half asserted these cessation aids were not utilized enough.

Physicians were more likely to assist adolescent smokers if they had greater knowledge of and confidence using NRT,⁵⁸ though the majority of pediatricians had not prescribed NRT.⁵⁹ The most common reasons for prescribing NRT were request from adolescent, openness to quitting, or health problem exacerbated by smoking.⁵⁹

Factors at the Community Level

Four studies discussed media influence related to NRT use. Wakefield and colleagues¹⁶ found public health antitobacco campaigns in the United States were matched or exceeded by tobacco and pharmaceutical cessation advertising.¹⁶ Three studies looked at the effects of NRT and Zyban advertising on youth perceptions.^15,60,61 Although 2 of the studies found that NRT ads may influence youth perceptions on quitting,^15,61 long-term perceptions such as intention to smoke or health effects were not changed.^60,61

Five articles discussed access to NRT, with 1 reporting over half of adolescents having easy access.²⁶ Adolescents acquired NRT from friends and retailers.²⁹ In test purchases, NRT products were successfully obtained in most purchases by a minor buyer without proof of age.⁶² If the minor was asked his age, the store was much less likely to sell NRT. Stores where the cash register gave an age prompt or where alcohol was sold were more likely to ask about age and less likely to sell NRT.⁶² In Lane and colleagues’⁶³ spatial analysis of school characteristics related to student NRT use, students in schools located near more pharmacies were less likely to use NRT.

While none of the studies directly assessed cultural norms related to NRT use, 3 studies did use geographic location, which is a primary contributor to norms, as a covariate. Price and colleagues⁵⁵ found schools in the Western part of the United States twice as likely as those in the South or Midwest to have offered prescription services. Wyman and colleagues⁵⁴ found parents of students in rural locations were more likely to agree schools should provide NRT, though Lane and colleagues⁶³ found students in schools within urban areas were more likely to use or have used NRT.

Factors at the Public Policy Level

Two studies looked at the effect of policy on NRT use and similarly found that NRT use rates among adolescents did not increase after deregulation.^29,35 Another study estimated the effects of the change in policy on NRT prescriptions to adolescents and found prescribing was highest among older adolescents and females, but there were no major differences after deregulation.⁶⁴

Eleven articles assessed the efficacy and/or safety of NRT for adolescent cessation. Although none of the studies found NRT to be unsafe for adolescents, efficacy results varied. Three studies^49,65,66 found promising results in assessing NRT, while the remaining studies concluded NRT was ineffective for adolescent smoking cessation.^67

-71 The methodologies and outcomes of these studies have been reviewed elsewhere.^8

-11

Discussion

This systematic review retrieved and analyzed 51 articles related to NRT for adolescent smoking cessation. The goal of this study was to identify factors related to adolescent use of NRT for smoking cessation within the framework of the SEM. According to the SEM, there are a number of factors influencing the use of NRT which exist at multiple levels. The 23 factors (Figure 3) identified within this study fit into each of the 5 SEM levels, though a majority were focused at the intrapersonal level, on individual factors.

At the intrapersonal level, 14 factors were identified including reasons for use, lack of knowledge, and preferences. While the majority of factors identified were at this level, there were few duplicate findings across studies. This may reflect the lack of funding for replication studies or indicate low interest in NRT for cessation. Additionally, many of the studies were focused on general cessation as opposed to NRT specifically and therefore contained limited relevant information. However, awareness, knowledge, and preferences do appear important factors for adolescent NRT use.

Only 2 studies focused on the interpersonal level, suggesting parental influence is important for adolescent NRT use. Peer influence related to NRT use among adolescents has not been studied, despite it being a major influence on smoking initiation.^72,73 Within smoking prevention literature, peer and parental influence are heavily cited factors, yet there is little interpersonal focus related to adolescent cessation. It is possible that medication and treatment are perceived more as individual decisions, and, therefore, peer influence is not important for cessation; however, this has not yet been determined.

There were also fewer studies at the community and organizational levels compared to the intrapersonal and policy levels. A few studies focused on the health-care perspective, finding that health-care providers did not provide adolescents NRT for a range of reasons, including lack of education. This is important when considering NRT is currently restricted to adolescents younger than 18 years in many jurisdictions, as, theoretically, the only way to obtain it would be through a doctor’s prescription. Additionally, studies thus far have only looked at whether NRT was prescribed and not at whether it was accompanied by diagnosis or education. Research indicates prescribing NRT in itself is not effective; NRT prescriptions should be accompanied with diagnosis, rational dosing, instructions and warnings, and follow-up.⁷⁴ At the community level, some articles mentioned cultural aspects but none directly studied cultural influences in using NRT. Cultural influences such as rural designation have been linked to tobacco use² and, as suggested by the limited findings within this review, possibly NRT. However, further analyses are needed to confirm and understand these potential differences.

Most articles at the policy level were related to efficacy and safety, which contribute to clinical guidelines and regulations. Clinical guidelines and regulations, while nested within the public policy level, impact all other levels within the SEM. For example, guidelines inform practitioners who then prescribe medications to adolescents. A few studies assessed these potential cross-level interactions. Specifically, increases in NRT abuse and prescriptions related to changes in regulations were identified as potential factors related to adolescent use. However, the studies reviewed found little change, whether in increased use or abuse or in prescriptions for NRT use relative to regulation. There was 1 other cross-level interaction study, parent perception of schools providing NRT. Additional research should explore interactions across levels, including what influences individual perceptions (eg, health-care advice, peer use). Understanding how factors across levels interact will provide greater context and will improve interventions to address such issues. In applying the findings to a real-world example, based on the factors identified and SEM theory which recommends addressing factors across levels, an intervention seeking to increase NRT use for adolescent smokers may seek to address individual factors such as perceived safety of the product through individual education as well as parent and health-care provider education.

Despite reviewing 51 articles for this study, there remains a sense of limited research regarding NRT for adolescent smoking cessation. One limitation, which may indicate a trend within the field, is the lack of studies on NRT directly related to adolescents, specifically those younger than 18 years of age. There were several potential factors that were discovered in articles that did not meet the adolescent age inclusion criteria that are likely applicable to this population, such as readability of NRT instructions.⁷⁵ Therefore, this cannot be assumed to be an exhaustive list of factors that contribute to adolescents using NRT. For example, several potential factors discussed within the reviewed studies were related to general smoking cessation strategies, as opposed to specifically NRT. Such factors include adolescent preferences which may be specific to NRT, such as confidentiality,⁴³ flexible programming,⁵¹ and preferring resources not at school.⁵¹ Finally, there are several limitations within the current study. First, authors reviewed only published literature, which introduces the possibility for publication bias. Additionally, the SEM tool as a framework has limitations, notably, factors may not clearly fit within a level. For example, some models suggest media at the community level, while others place it at the policy or macro level. Also, the studies reviewed may not have used SEM during design or analysis and therefore may not have considered multilevel or across-level interactions.

Despite these limitations, the factors identified provide insight into NRT for adolescent smoking cessation. While a number of factors have been identified at the adolescent and policy levels, additional research should be conducted at the interpersonal, organizational, and community levels to allow researchers, clinicians, and policy makers a more holistic understanding of NRT use among adolescents seeking to quit smoking.

So What?

Adolescent smoking remains an issue, yet there are no best practices for cessation. The NRT is widely recommended for adults, yet limited evidence exists for adolescent use. This review identified 51 articles related to NRT for adolescent smoking cessation and used a social–ecological model framework to identify factors that influence adolescents using NRT. The majority of factors were identified at the intrapersonal or public policy levels. Future research should explore factors at the interpersonal, organizational, and community levels, as well as interactions across levels in order to improve interventions utilizing NRT for adolescent cessation.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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