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Intervention Summary

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Project EX

Project EX is a school-based smoking-cessation clinic program for adolescents that stresses motivation, coping skills, and personal commitment. Consisting of eight 40- to 45-minute sessions delivered over a 6-week period, the program curriculum includes strategies for coping with stress, dealing with nicotine withdrawal, and avoiding relapses. Project EX uses engaging and motivating activities such as games and yoga to reduce or stop smoking among adolescents and teach self-control, anger management, mood management, and goal-setting techniques. Adolescents are provided with accurate information about the social, emotional, environmental, and physiological consequences of tobacco use. The first four sessions are intended to prepare students for an attempt at quitting smoking, which should take place between sessions 4 and 6. The remaining sessions are designed to maintain quit status and enhance quit attempts. Project EX clinics operate during school hours. Each clinic group can accommodate 8 to 15 students.

Descriptive Information

Areas of Interest Substance abuse prevention
Outcomes Review Date: November 2006
1: Tobacco use
2: Motivation to quit tobacco use
Outcome Categories Tobacco
Ages 13-17 (Adolescent)
18-25 (Young adult)
Genders Male
Female
Races/Ethnicities Asian
Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Settings School
Geographic Locations No geographic locations were identified by the developer.
Implementation History Project EX has been implemented in about 25 sites with about 1,000 individuals, in addition to those sites where the program developers have conducted experimental trials. Approximately 12 U.S. sites have been evaluated for outcomes. Project EX also has been implemented and evaluated in Wuhan, China.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: Yes
Adaptations Project EX has been implemented/adapted for use with adolescents in China.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories Indicated

Quality of Research
Review Date: November 2006

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

McCuller, W. J., Sussman, S., Wapner, M., Dent, C., & Weiss, D. J. (2006). Motivation to quit as a mediator of tobacco cessation among at-risk youth. Addictive Behaviors, 31, 880-888.  Pub Med icon

Study 2

Sussman, S., Dent, C. W., & Lichtman, K. L. (2001). Project EX: Outcomes of a teen smoking cessation program. Addictive Behaviors, 26, 425-438.  Pub Med icon

Supplementary Materials

Sussman, S., McCuller, W. J., Zheng, H., Pfingston, Y. M., Miyano, J., & Dent, C. W. (2004). Project EX: A program of empirical research on adolescent tobacco use cessation. Tobacco Induced Diseases, 2, 119-132.

Sussman, S., Sun, P., & Dent, C. W. (2006) A meta-analysis of teen cigarette smoking cessation. Health Psychology. 25 (5), 549-557.  Pub Med icon

Zheng, H., Sussman, S., Chen, X., Wang, Y., Xia, J., Gong, J., et al. (2004). Project EX: A teen smoking cessation initial study in Wuhan, China. Addictive Behaviors, 29, 1725-1733.  Pub Med icon

Outcomes

Outcome 1: Tobacco use
Description of Measures Thirty-day use of cigarettes, smokeless tobacco, and cigars was measured at baseline and again at follow-up using time-anchored rating scales, the Nicotine Dependence Scale, and carbon monoxide measurement in expired breath samples. Participants were asked to rate their use of cigarettes, cigars, and smokeless tobacco over the prior 30 days. Participants were coded either as "quitters" (had not used at all over the prior 30 days) or "nonquitters" (had used at all over that period). The outcome of interest was the proportion of participants in the conditions categorized as "quitters" versus "nonquitters" at the follow-up time-point (about 3 months postintervention).
Key Findings At follow-up about 3 months postintervention, the 30-day abstinence rate for Project EX participants completing the clinic was 30%, compared with 16% for the control group (p < .05). Using a more conservative intent-to-treat analysis that included those who dropped out of the clinic yielded similar results (30% and 16% for the clinic and control groups, respectively; p < .05). Using the most conservative approach and counting all those not contacted at follow-up as still using tobacco produced a 30-day quit rate of 19% across all clinic participants, compared with the 10% found in the control group.
Studies Measuring Outcome Study 1, Study 2
Study Designs Experimental
Quality of Research Rating 3.0 (0.0-4.0 scale)
Outcome 2: Motivation to quit tobacco use
Description of Measures Motivation to quit was measured with 16 items, each measured on 4-point Likert scale. Although the development of this measure was based upon a theoretical conceptualization of motivation as comprising three underlying factors, factor analyses indicated that all the items loaded onto a single factor, and thus the measure was analyzed as a single construct.
Key Findings The results indicate that motivation to quit smoking changed significantly (p < .01) as a function of undergoing the treatment, even taking into account the observed differences in motivation at the pretest. In addition, posttreatment motivation (level of motivation at posttest) significantly predicted nonuse of tobacco in the past 30 days (p < .05).
Studies Measuring Outcome Study 2
Study Designs Experimental
Quality of Research Rating 3.3 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 13-17 (Adolescent)
18-25 (Young adult)
66% Male
34% Female
48% Hispanic or Latino
30% White
7.5% Black or African American
7% Asian
6.5% Race/ethnicity unspecified
Study 2 13-17 (Adolescent)
18-25 (Young adult)
66% Male
34% Female
48% Hispanic or Latino
30% White
7.5% Black or African American
7% Asian
6.5% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Tobacco use 2.8 3.3 2.5 4.0 3.0 2.8 3.0
2: Motivation to quit tobacco use 2.0 2.0 3.8 4.0 4.0 4.0 3.3

Study Strengths

The studies used a standard measure for assessing tobacco use, one that has been in use since 1975 and has reasonable evidence of reliability and validity, together with an additional self-report measure of smoking behavior, the Nicotine Dependence Scale, and the measurement of carbon monoxide in expired breath samples. Appropriate research design and choice of statistical analysis further strengthen confidence in the findings. Authors controlled for the effects of potential confounding variables, and analyses were selected and utilized to adjust for attrition and the overreporting of quitting. The motivation measure developed by the authors exhibited an acceptable level of reliability, and factor analysis was used to determine the appropriate means of using the measure in the analysis. Appropriate analyses were also used to test mediating effects of motivation on tobacco use behavior.

Study Weaknesses

Low retention and small effect size weaken confidence in program effectiveness, even where statistical procedures to adjust for attrition and overreporting of quitting were employed. The use of a single-item self-report of 30-day smoking as a major outcome is not ideal, but the inclusion of other indicators of smoking, such as level of addiction, and an objective measure of smoking behavior compensated for this weakness in measurement.

Readiness for Dissemination
Review Date: November 2006

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Project EX pretest and posttest student surveys

Project EX Web site, http://tnd.usc.edu/ex/

Sussman, S., & Lichtman, K. (2004). Project EX: A teen tobacco use cessation program. Student workbook. Los Angeles: University of Southern California.

Sussman, S., & Lichtman, K. (2004). Project EX: A teen tobacco use cessation program. Teacher's manual with CD (1st ed.). Los Angeles: University of Southern California.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.0 2.3 1.5 2.3

Dissemination Strengths

The program curriculum is interactive, yet structured and sequenced so that sessions build on one another. The teacher manuals are printed in large font and have teacher prompts that make them easy to reference during real-time implementation. A toll-free number is available for implementation assistance. In-person training is provided to support implementation, and pretest–posttest student surveys are available to assess program outcomes and thus assist in quality assurance.

Dissemination Weaknesses

Materials do not provide implementation information or suggested strategies for gaining cooperation from other teachers and/or on-site administrators. Materials also do not provide any information on assessing the quality of training and support nor do they present any fidelity measure to ensure the program is implemented as intended. The pretest–posttest survey does not include scoring information so that teachers can interpret findings.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Teacher's manual with audio CD $60 each Yes
Student workbook $35 for five Yes
1-day, on-site training $1,100-$1,300 for up to 25 participants, plus travel expenses No
2-day, on-site training $1,800-$2,000 for up to 25 participants, plus travel expenses No
Student surveys Free No
Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

Zheng, H., Sussman, S., Chen, X., Wang, Y., Xia, J., Gong, J., et al. (2004). Project EX: A teen smoking cessation initial study in Wuhan, China. Addictive Behaviors, 29, 1725-1733.  Pub Med icon

Contact Information

To learn more about implementation or research, contact:
Leah Meza
(800) 400-8461
leahmedi@usc.edu

Steve Sussman, Ph.D.
(323) 442-8220
ssussma@usc.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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