•  

Intervention Summary

Back to Results Start New Search

Not On Tobacco (N-O-T)

Not On Tobacco (N-O-T) is a school-based smoking cessation program designed for youth ages 14 to 19 who are daily smokers. N-O-T is based on social cognitive theory and incorporates training in self-management and stimulus control; social skills and social influence; stress management; relapse prevention; and techniques to manage nicotine withdrawal, weight, and family and peer pressure. The program consists of 50-minute group sessions conducted weekly for 10 consecutive weeks, plus four optional booster sessions. The sessions are delivered in gender-specific groups of 10-12 teens by same-gender facilitators. N-O-T can be implemented by schools or other community organizations using teachers, school nurses, counselors, and other staff and volunteers who are trained to facilitate group sessions.

Descriptive Information

Areas of Interest Substance abuse prevention
Substance abuse treatment
Outcomes Review Date: February 2008
1: Smoking cessation
2: Smoking reduction
3: Cost-effectiveness
Outcome Categories Cost
Tobacco
Ages 13-17 (Adolescent)
Genders Male
Female
Races/Ethnicities American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
Race/ethnicity unspecified
Settings School
Geographic Locations Urban
Suburban
Rural and/or frontier
Implementation History According to the American Lung Association, more than 150,000 teens have participated in N-O-T. Between 2002 and 2004, three independent evaluations of the program were conducted in high schools in Illinois, Virginia, and Wisconsin.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: Yes
Adaptations Not On Tobacco has been adapted for Native American youth.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories Indicated

Quality of Research
Review Date: February 2008

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

Horn, K. A., Dino, G. A., Kalsekar, I. D., & Fernandes, A. W. (2004). Appalachian teen smokers: Not On Tobacco 15 months later. American Journal of Public Health, 94(2), 181-184.  Pub Med icon

Study 2

Dino, G. A., Horn, K. A., Goldcamp, J., Maniar, S. D., Fernandez, A., & Massey, C. J. (2001). Statewide demonstration of Not On Tobacco: A gender-sensitive teen smoking cessation program. Journal of School Nursing, 17(2), 90-97.

Dino, G., Horn, K., Abdulkadri, A., Kalsekar, I., & Branstetter, S. (2008). Cost-effectiveness analysis of the Not On Tobacco program for adolescent smoking cessation. Prevention Science, 9(1), 38-46.  Pub Med icon

Dino, G., Horn, K., Goldcamp, J., Fernandes, A., Kalsekar, I., & Massey, C. (2001). A 2-year efficacy study of Not On Tobacco in Florida: An overview of program successes in changing teen smoking behavior. Preventive Medicine, 33(6), 600-605.  Pub Med icon

Dino, G., Kamal, K., Horn, K., Kalsekar, I., & Fernandes, A. (2004). Stage of change and smoking cessation outcomes among adolescents. Addictive Behaviors, 29(5), 935-940.  Pub Med icon

Supplementary Materials

Horn, K., Dino, G., Kalsekar, I., & Mody, R. (2005). The impact of Not on Tobacco on teen smoking cessation: End-of-program evaluation results, 1998 to 2003. Journal of Adolescent Research, 20(6), 641-661.

Outcomes

Outcome 1: Smoking cessation
Description of Measures Smoking cessation was measured using the Smoking History Form, a self-report instrument that assessed participants' smoking patterns, including age of onset, number of cigarettes smoked per day, and baseline stage of readiness to quit smoking. Carbon monoxide readings were used to validate self-reported smoking status.
Key Findings Two studies compared teen smokers who received either N-O-T or a brief intervention (BI) on smoking cessation that included self-help brochures and a 10- to 15-minute presentation of scripted advice.

In the first study, conducted with Appalachian teens in North Carolina and West Virginia, 8.1% of N-O-T participants reported smoking cessation 3 months after the intervention, compared with only 2.2% of BI participants (p < .05). This difference, however, was largely accounted for by the female segment of the sample; 10.3% of females who received N-O-T reported smoking cessation, compared with only 2.6% of females who received BI (p < .05). Among males, 5.4% of N-O-T participants and 1.8% of BI participants reported cessation, a difference that was not statistically significant.

In the North Carolina sample, the percentage of students who reportedly quit smoking 15 months after the intervention was higher in the N-O-T group than in the BI group (9.8 vs. 1.6, p < .05).

In the second study, conducted in Florida, 21.7% of N-O-T participants reported smoking cessation 5 months after the intervention, compared with only 12.6% of BI participants (p < .05). Again, this difference was largely accounted for by the female segment of the sample; 33% of females who received N-O-T reported smoking cessation, compared with only 11.4% of the females who received BI (p < .05). Males did not report statistically significant differences in smoking cessation.

To determine if the interventions were more effective for students who were at different stages of readiness to quit smoking at baseline, students were classified as precontemplators (not planning to quit in the next 6 months), contemplators (planning to quit in the next 6 months), or preparers (planning to quit in the next 30 days). Among BI participants, preparers were more likely to quit smoking than precontemplators (p < .05), a finding associated with a large effect size (odds ratio = 25.51). In contrast, among N-O-T participants, there were no differences in cessation between precontemplators, contemplators, or preparers, indicating that the intervention was equally effective for smokers regardless of their stage of readiness.
Studies Measuring Outcome Study 1, Study 2
Study Designs Quasi-experimental
Quality of Research Rating 3.6 (0.0-4.0 scale)
Outcome 2: Smoking reduction
Description of Measures Smoking reduction was measured using the Smoking History Form, a self-report instrument that assessed the number of cigarettes smoked on weekdays and weekends.
Key Findings A study in Florida compared teen smokers who received either N-O-T or a brief intervention (BI) on smoking cessation that included self-help brochures and a 10- to 15-minute presentation of scripted advice. Among students who continued to smoke after the intervention, N-O-T participants had larger reductions in reported weekday smoking than BI participants (53.2% vs. 34.7%, p < .05). This difference was statistically significant among males (65.9% vs. 31.1%, p < .05), but not among females. Among students who continued to smoke, N-O-T participants also had larger reductions in reported weekend smoking than BI participants (74% vs. 41.2%, p < .05). This difference was statistically significant among both males (80% vs. 34.6%, p < .05) and females (73.2% vs. 36.6%, p < .05).
Studies Measuring Outcome Study 2
Study Designs Quasi-experimental
Quality of Research Rating 3.5 (0.0-4.0 scale)
Outcome 3: Cost-effectiveness
Description of Measures The cost-effectiveness analysis was conducted using estimated life expectancies and school cost data. Due to the lack of data on the life expectancies of smokers and nonsmokers below the age of 25, Markov transition models were used to estimate participants' future smoking status at the age of 25 based on baseline and 7-month postbaseline data collected in a previous efficacy study. Costs in the analysis included those for relevant training and implementation and were measured in terms of dollars in the year 2000.
Key Findings A study in Florida compared teen smokers who received either N-O-T or a brief intervention (BI) on smoking cessation that included self-help brochures and a 10- to 15-minute presentation of scripted advice. Compared with students who received BI, students who received N-O-T were predicted to have an increased life expectancy of 7.46 years. Best-case and worst-case scenarios found that this increased life expectancy ranged from 6.76 to 9.5 years. The average financial cost for each additional year of life expectancy for those completing N-O-T was $442.65. This estimate ranged from $273.60 to $1,028.90 per life-year saved.
Studies Measuring Outcome Study 2
Study Designs Quasi-experimental
Quality of Research Rating 3.5 (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) 56% Female
44% Male
93.4% White
6.6% Race/ethnicity unspecified
Study 2 13-17 (Adolescent) 56% Female
44% Male
81.3% White
8.8% Hispanic or Latino
4.3% Race/ethnicity unspecified
1.8% Black or African American
1.6% American Indian or Alaska Native
1.1% Asian
1.1% Native Hawaiian or other Pacific Islander

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: Smoking cessation 4.0 4.0 3.5 3.5 3.3 3.5 3.6
2: Smoking reduction 3.5 3.5 3.5 3.5 3.3 3.5 3.5
3: Cost-effectiveness 3.5 3.5 3.5 3.5 3.3 3.5 3.5

Study Strengths

The researchers used reliable and valid measures; used well-developed procedures for training, implementation, and evaluation; tested for differential attrition consistently; and used generally appropriate analyses, including intent-to-treat and compliant sample analyses. The length of follow-up in the Appalachian study was unusually long and still found significant effects. Overall, the methodological quality was high in these studies.

Study Weaknesses

Because neither study used a randomized design, potential confounds (e.g., preexisting group differences in nicotine dependence, motivation to quit smoking) may have biased results. Analyses did not account for potential intraclass correlation within schools or within groups but were otherwise appropriate.

Readiness for Dissemination
Review Date: February 2008

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.

American Lung Association. (2003). N-O-T: Not On Tobacco. The premier teen smoking cessation program. New York: Author.

Program Web site, http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=39866

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
3.3 2.3 1.0 2.2

Dissemination Strengths

Program materials recognize the importance of engaging school administrators and teachers to facilitate organizational implementation. Master trainers are available to train program implementers through the American Lung Association. Some tools are available to support quality assurance.

Dissemination Weaknesses

Very little information is provided on ensuring organizational preparedness. It is unclear how facilitators are selected or trained. No formal support is available to program implementers. Quality assurance materials do not include guidance for assessing program delivery, training effectiveness, or facilitator competence.

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
Implementation materials Contact the developer Yes
Training About $300 per participant Contact the developer
Technical assistance/consultation and quality assurance information Contact the developer Contact the developer

Additional Information

Training costs vary by State and region. Cost information can be obtained by contacting the American Lung Association (1-800-LUNG-USA).

Replications

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

Dino, G. A., Horn, K. A., Goldcamp, J., Kemp-Rye, L., Westrate, S., & Monaco, K. (2001). Teen smoking cessation: Making it work through school and community partnerships. Journal of Public Health Management and Practice, 7(2), 71-80.  Pub Med icon

Dino, G. A., Horn, K. A., Zedosky, L., & Monaco, K. (1998). A positive response to teen smoking: Why N-O-T? NASSP Bulletin, 82(601), 46-58.

* Dino, G., Horn, K., Goldcamp, J., Fernandes, A., & Kalsekar, I. (2001). A 2-year efficacy study of Not On Tobacco in Florida: An overview of program successes in changing teen smoking behavior. Preventive Medicine, 33(6), 600-605.  Pub Med icon

Doll, L., Dino, G., Duetsch, C., Holmes, A., Mills, D., & Horn, K. (2001). Linking science and practice: Two academic/public health collaborations that are working. Health Promotion Practice, 2(4), 295-300.

Horn, K., Dino, G., Gao, X., & Momani, A. (1999). Feasibility evaluation of Not On Tobacco: ALA's new stop smoking program for adolescents. Journal of Health Education, 5, 192-206.

Horn, K., Dino, G., Kalsekar, I., Massey, C. J., Manzo-Tennant, K., & McGloin, T. (2004). Exploring the relationship between mental health and smoking cessation: A study of rural teens. Prevention Science, 5(2), 113-126.  Pub Med icon

Horn, K., Fernandes, A., Dino, G., Massey, C. J., & Kalsekar, I. (2003). Adolescent nicotine dependence and smoking cessation outcomes. Addictive Behaviors, 28(4), 769-776.  Pub Med icon

Horn, K., McCracken, L., Dino, G., & Brayboy, M. (2008). Applying community-based participatory research principles to the development of a smoking cessation program for American Indian teens: "Telling our story." Health Education and Behavior, 35(1), 44-69.  Pub Med icon

Horn, K., McGloin, T., Dino, G., Manzo, K., McCracken, L., Shorty, L., et al. (2005). Quit and reduction rates for a pilot study of the American Indian Not On Tobacco (N-O-T) program. Preventing Chronic Disease, 2(4), A13.  Pub Med icon

Massey, C. J., Dino, G. A., Horn, K. A., Lacey-McCracken, A., Goldcamp, J., & Kalsekar, I. (2003). Recruitment barriers and success of the American Lung Association's Not-On-Tobacco Program. Journal of School Health, 73(2), 58-63.  Pub Med icon

Contact Information

To learn more about implementation, contact:
Bill Blatt, M.P.H., CHES
(202) 785-3355
bblatt@lungusadc.org

To learn more about research, contact:
Kimberly Horn, Ed.D., M.S.W.
(304) 293-0268
khorn@hsc.wvu.edu

Geri Dino, Ph.D.
(304) 293-1898
gdino@hsc.wvu.edu

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