Conference report ACCESS · 3.2. Winning Hearts as well as Minds (Gerard Hastings) 3.3. Recruitment to Adolescent Smoking Cessation Interventions – A literature review (Peter Dalum)

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Conference report ACCESS

June 18th, 2010 in Vienna at the Hotel Rainers

ACCESS is funded by the European Union,in the framework of the Health Programme

Karl Bohrn

Regina Fenk

Institut für Sozial‐ und Gesundheitspsychologie, Wien

October 2010

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ACCESS is an EU project that aims at increasing the impact of adolescent smoking cessation interventions through supporting providers, developers, funding bodies and policy makers in the development of effective recruitment strategies.

In more detail, the objective of the project is to gain knowledge on how to motivate young smokers to take part in smoking cessation interventions and to transform this knowledge into concrete recommendations for cessation practice. National networks were accordingly established in 10 European countries with the aim of promoting collaboration between the various national stakeholders. In order to illustrate some promising access approaches, the project output consists of a report with guiding principles and recruitment strategies as well as a practice catalogue of motivational activities reported by providers of adolescent cessation interventions in the ACCESS countries.

The project started in September 2009, ran until October 2010 and has received co‐funding from the European Union within the framework of the Health Programme. It has eleven partners across Europe and is coordinated by the IFT Institut für Therapieforschung. The partners are:

- IFT ‐ Institut für Therapieforschung München, Germany - Danish Cancer Society, Denmark - Maastricht University, The Netherlands - General University Hospital in Prague, Czech Republic - Stop smoking NGO, Slovak Republic - Agencia Formacion Investigacion y Estudos Sanitarios, Spain - Slovenian Coalition for Tobacco Control, Slovenia - Riga City Council Department of Welfare, Latvia - Foundation Against Respiratory Diseases, Belgium - Institut für Sozial und Gesundheitspsychologie, Austria - GABO:mi, Gesellschaft für Ablauforganisation, Germany (project management)

More information is available online: www.access‐europe.com

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Report content

1. The ACCESS conference

1.1. Introduction

1.2. Conference program

1.3. Conference report

2. Informing about the ACCESS Project

2.1. ACCESS project aims and objectives (Anneke Bühler)

2.2. Networking in Europe (Alexandra Kmetova)

3. Input from research

3.1. Teen Tobacco Use Cessation: 2010 (Steve Sussman)

3.2. Winning Hearts as well as Minds (Gerard Hastings)

3.3. Recruitment to Adolescent Smoking Cessation Interventions – A literature review (Peter

Dalum)

3.4. About adding friends and becoming fans (Steve Nitzschner)

4. Workshops

4.1. School

4.2. Health care services

4.3. Internet

4.4. Out of school

5. Conclusions (Steve Sussman)

6. Evaluation of the ACCESS conference

7. Summary

Annex

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1. THE ACCESS CONFERENCE

1.1. Introduction

Within the project ACCESS the European consultation conference took place on June 18th, 2010 in

Vienna at the Hotel Rainers, Gudrunstraße 184, A‐1100 Vienna.

After working on the ACCESS Report on guiding principles, strategies, and activities during the first

nine months of the project, the aim of the conference was the consultation of the working paper and

the dissemination of the results. The conference offered a unique opportunity of discussion and

brainstorming as well as a possibility to share experiences across countries and professions.

All in all 88 international stakeholders participated in the conference. The international stakeholders

and participating organizations came from the following countries: Germany, Austria, Spain,

Netherlands, Slovenia, Latvia, Denmark, Belgium, Czech Republic, United Kingdom, Switzerland,

Greece, Slovakia, USA (Los Angeles).

The conference was coordinated by the IFT Institut für Therapieforschung and GABO:mi, Germany. It

was organized and hosted by the local partner organization ISG Institut für Sozial‐ und

Gesundheitspsychologie, Austria.

1.2. Conference program The conference provided the participants with an overview of the working process and the results of

the ACCESS project as well as with a presentation of recent research on the topic of smoking

cessation for young adolescents. In addition, participants should be stimulated in their recruitment

efforts for adolescent smoking cessation (asc) by a non‐asc perspective on communication with

young people. Therefore, three international speakers – Professor Steve Sussman, Professor Gerard

Hastings and Steve Nitzschner – were invited.

For the intended consultation process the afternoon was dedicated to four parallel workshops

followed by a plenary session. This session offered the possibility to share and to discuss the results

from the workshops. The conference agenda is listed in table 1.

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Table 1: Conference agenda 08:30 Registration

09:00 Official start of the conference

Welcome and introduction

Dr. Anneke Bühler

Dr. Karl Bohrn

09:30 ACCESS project aims and objectives

Dr. Anneke Bühler – IFT, Germany

09:45

Effectiveness of youth smoking cessation

interventions and implications for international

translation

Prof. Steven Sussman –

University of Southern California, USA

10:15 Public Health branding – Applying Marketing

for Social Change

Prof. Gerard Hastings ‐ Institute for

Social Marketing and the Centre of

Tobacco Control Research, University of

Stirling, and Open University, Scotland

10:45 Coffee break

11:15 Networking for Youth Smoking Cessation in

Europe

Dr. Alexandra Kmetova – Charles

University, Czech Republic

11:30 Recruitment for Teen Smoking cessation ‐

Results of Literature review

Dr. Peter Dalum – Danish Cancer Center,

Denmark

11:45 Access Strategies for Teen Smoking cessation ‐

– The ACCESS Report

Dr. Anneke Bühler

12:30 Lunch

13:30 Parallel workshops

15:30 Coffee break

16:00 Reporting back from the workshops

16:30 About adding friends and becoming fans Steve Nitzschner ‐ Wildstyle network

16:50 Conclusions Prof. Steven Sussman

17:00 Official end of conference

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Four parallel workshops were conducted. The topic was youth recruitment strategies for cessation

interventions in different settings:

1. In health care settings, social services/institutions

2. In schools/workplaces

3. In out of school settings (leisure, sports, other youth access points)

4. On the internet

At the beginning of the workshop a practice model was presented. Afterwards the guiding principles

were discussed with regard to each of the four settings.

The Conference participants had the possibility to discuss all results of the workshops after the

reporting back in the plenary.

For dissemination purposes, a press conference was organized by the ISG, including Dr. Karl Bohrn

Dr. Anneke Bühler and Dr. Eva Glawischnig from the party “Die Grünen” with three representatives

from the national press. After the press conference interviews were recorded and broadcasted by

several radio stations.

At the moment of the conference the ISG also launched a press release about the ACCESS project and

its impact on national smoking cessation activities. This press release found a lot of feedback and

several national newspapers ( e.g. Die Presse, Der Standard) published articles on the subject.1

1.3. Conference report

For purposes of reporting, in the following the presentations were grouped according to the three

mains themes and aims of the conference:

1. The ACCESS project: presentation of the working process and the results

2. Recent research on smoking cessation for young adolescents: effectiveness and recruitment

3. Consultation process – results from parallel workshops.

Some overall remarks and conclusions on the content of the conference close the report.

1 All relevant articles and interviews can be consulted under http://www.isg.co.at/access/.

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2. INFORMING ABOUT THE ACCESS PROJECT 2.1. ACCESS project aims and objectives (Dr. Anneke Bühler, IFT Institut für Therapieforschung, Germany) In her presentation Mrs. Bühler gave a short description of the background and objectives of the

project. She described the working methods which led to the principles and strategies for creating

effective access strategies for smoking cessation. As suggestion and basis of further discussion, these

results were also presented to the participants of the conference.

Less young people in Europe smoke. But still, one of three young Europeans is a smoker. Even worse,

the proportion of heavy smokers is not decreasing.

A big part of adolescent smokers (about two third) are motivated to quit smoking but they try on

their own and therefore, they often fail in their cessation efforts.

The two possible pathways from smoker to non‐smoker is outlined in the following diagram:

From smoking to non‐smoking

Smoker

Motivation to quit smoking

Motivation to use cessation interventions

Participation in effective interventions

Stop smoking

Non‐smoker

So one important question is: How to motivate young smokers to participate in cessation

interventions? This is the starting point of the ACCESS project: By identifying best practice and

experiences with recruitment strategies for adolescent smoking cessation the aim of the project is to

increase the impact of these effective cessation aids as more participants will be reached

(RECRUITMENT X INTERVENTION = IMPACT). In the long run, this has the potential to decrease the

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smoking prevalence in adolescents and thus prevent the tremendous negative health consequences

of smoking in the European Union.

The general objective of the ACCESS project can be formulated as follows: “To gain knowledge on

how to motivate young smokers to take part in smoking cessation interventions and to transform this

knowledge into concrete recommendations for cessation practice.”

The specific objectives are:

• To have national networks of stakeholders in teen (health) development

• To have a collection of recruitment strategies practiced in Europe (good practice) and

documented in the literature

• To have guiding principles regarding recruitment strategies in teen smoking cessation

• To have an European network of stakeholders in teen smoking cessation for transferring this

knowledge into practice

The ACCESS report: Guiding principles and strategies

The aim of the ACCESS report is to support providers, developers, funding bodies and policy makers

in the development of effective recruitment strategies to increase the impact of youth smoking

cessation interventions.

The working process of the ACCESS project followed three lines:

1. The first pillar were several network meetings where the project partners discussed current

practice experiences from their countries. These discussions led to several conclusions about what to

consider in recruitment.

2. The second line was the literature review which provided a scientific base of recruitment issues.

Intervention studies and studies on relevant individual, social and structural factors in recruitment

were included in this review.

3. The third line was the provider survey which was carried out by a standardized questionnaire that

has been translated into the relevant national languages. In each participating country, at least five

providers of smoking cessation programs filled out the questionnaire. This knowledge and

experiences from practice were collected and resumed in the recruitment strategies.

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The results of the project as published in the ACCESS report are based on scientific evidence,

practical expertise and consensus. They provide an instrument to take well informed decisions about

how to motivate young smokers to participate in effective smoking cessation interventions.

In the ACCESS report (conference version) the results of the complex working process are

documented as:

• 9 Guiding principles: What should generally be considered when trying to motivate young

smokers to participate in cessation interventions?

These guiding principles are mainly generated from national meeting discussion results and

literature review. (Table2)

• 24 Strategies: What kind of motivating methods/techniques are actually used in recruitment?

These strategies are generated from a provider survey and reflect the actual recruitment

practice implemented by 36 cessation aids identified in ACCESS countries.(Table 3)

• 36 Activities:

These activities show the real world implementation of these methods and have been

identified through the provider survey (and a literature review realized during the ACCESS

project).

Table 2: The Guiding principles2

Preconditions: Principles 1 to 3 1. Establishment of non‐smoking as a social norm

Social environment conducive to quitting 2. Availability of effective youth specific smoking cessation interventions

Effectiveness Availability

3. Evidence oriented recruitment Extensive knowledge of teen behavior in relation to tobacco use and cessation aids Documentation of available support Theory and evidence based development of strategies

Specific aspects of strategies: Principle 4 to 9 4. Positive branding of cessation interventions

Promote smoking cessation interventions as a desirable and useful consumer product 5. Dissemination of information about cessation aids

Information on smoking cessation interventions must be communicated regularly and extensively

2 For further details please refer to the ACCESS report.

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6. Pro‐activity and personal touch Providers actively reach out to smokers Effective interpersonal communication

7. Choosing the right language Respectful of the individual Youth specific terms and simple language Tailoring of messages Participation of young people in the development process

8. Using incentives Option for those providers who have the financial resources to increase attractiveness of participation

9. Creating partnership Networking with entities that are part of young peoples‘ lives Media Policy makers, health professionals, communities

Table 3: Recruitment strategies

1. Interpersonal communication 1.1. Authority 1.2. Adult person of trust 1.3. Peer to peer 1.4. Face to face/one to one provider‐ tobacco user

2. Marketing 2.1. Advertising 2.2. Specific information about an intervention 2.3. Education 2.4. Tobacco industry manipulation 2.5. Media advocacy 2.6. Testimonials 2.7. Ambassadors 2.8. Fun

3. Tailoring 3.1. Non‐stigma 3.2. Broader approach 3.3. Gender specific

4. Behavioral Learning Techniques 4.1. Reflecting own behaviour 4.2. Repeating 4.3. Incentive 4.4. Emotional arousal combined with self‐efficacy enhancing elements 4.5. Visualisation 4.6. Norm‐setting

5. Structural Change 5.1. Policy and infrastructure 5.2. Mandatory/ Obligation to participate 5.3. Tailoring to organisational needs

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The reported activities show how these recruitment strategies are actually used by providers of

smoking cessation programs in the participating countries. Some of these strategies are very popular

(e.g. information about intervention, advertising) and are used in a large number of recruitment

campaigns while others get less attention by providers (e.g. testimonials, visualisation).3 This fact

reveals the innovative power of the ACCESS report as this report shows new and alternative ways for

recruitment.

2.2. Networking in Europe (MD Alexandra Kmetova, General University Hospital Prague, Czech Republic) Mrs. Alexandra Kmetova gave an overview on the establishment of national networks in the

participating countries which was one of the aims of the ACCESS project.

These national networks were planned to consist of at least eight members from five different

categories as health professionals, teachers, providers of smoking cessation programs etc.

During the project in 2010 the networks pursued the following goals:

• Identification of recruitment strategies

• Exchange of ideas and experiences

• Dissemination of ACCESS project results

Their long term goal is to promote the multidisciplinary cooperation of organizations and institutions

• who work in the social environment of youth and

• who support non‐smoking as a norm and through their activities promote stopping

smoking.

Building up networks was challenging, for some participants more than for others because of

different starting points with regard to availability of smoking cessation for adolescents or general

interest in smoking cessation issues.

In the different participating countries, the number of network members varies from seven to 41. To

cover a wide range of social environment of youth, network members come mainly from three

categories:

• Players promoting and supporting cessation programs

3 For further details see the Power Point Presentation in the annex.

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• Players working in the social environment of youth

• Organizations developing and offering cessation programs

Network members have been involved in the project at different levels: All of them received

information about the project at its different stages and were invited to national meetings. Those

working in smoking cessation received the ACCESS questionnaire on recruitment practice and have

been invited to the Vienna conference.

Beyond the end of the ACCESS project in 2010 the national networks will ensure continued exchange

of information and experience as well as continued transfer of knowledge and will help building a

good practice database and sharing of resources.

The contact addresses and further details about the national networks are provided in the

powerpoint presentation in the annex.

3. INPUT FROM RESEARCH

Four international speakers were invited give an overview on recent findings in the field of

recruitment and smoking cessation for adolescents:

• Steve Sussman summed up recent evidence on factors influencing effectiveness of teen

smoking cessation.

• Gerhard Hastings enlarged the perspective to the importance of “public health branding”

and presented the Help Campaign as an example and finally.

• Peter Dalumn´s presentation resumed literature on recruitment strategies for smoking

cessation interventions for adolescents (ACCESS partner Denmark).

• Steven Nitzschner gave some innovative ideas about access to young people.

3.1. Effectiveness of Teen smoking cessation: 2010 (Professor Steve Sussman, University of Southern California, USA)) In his presentation Professor Sussman gave a complete and detailed overview on scientific evidence

on those factors which influence the effectiveness of smoking cessation interventions for

adolescents. The presentation was mainly based on his recent meta‐analysis (Sussman & Sun 2009) 4

including studies with a wide range of established methods as well as empirical reviews of less

4 Sussman S., Sun P.: Youth Tobacco Use Cessation: 2008 Update. Tob Induc Dis [2009] Jan 30;5(1):3.

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studied methods like pharmacologic adjunct, intensive contingency management, internet‐based

interventions, telephone‐based interventions, mass media campaigns and policy studies.

A total of 130 studies were located; only 64 of these studies were controlled trials that were selected

for the meta‐analysis. The primary outcome measure was the difference between the quit rate in the

intervention group minus the quit rate under the control condition. Data were entered as intent‐to‐

treat (ITT) quit rates (not compliance sample rates).

As important factors which influence the effectiveness of a smoking cessation project for adolescents

Professor Sussman pointed to the theoretical background, setting, and number of sessions.

Theoretic background:

The included studies represented a wide a range of theories, as:

1. Social influence‐oriented: refusal assertion, tobacco industry promotions, media and peer social

influences, correction of social informational inaccuracies, advocacy (activism) techniques

2. Cognitive‐behavioral: self‐monitoring and coping skills, topography of tobacco use, seek out social

support, relaxation, wait out urges, self‐management, problem solving

3. Motivation enhancement: clarify desire for change and reduce ambivalence toward change (e.g.,

motivational interviewing, response‐contingent reinforcement [reinforces quit‐behavior with chance

for money or prizes], stages‐of‐change techniques)

4. Medical: Ease physical effects of withdrawal, or emphasis on recovery from addiction

5. “Other”: Supply reduction (e.g., price increases or restricted access) and affect clarification

approaches (e.g., clarify and remove conflicted affect)

Quit rates are significantly higher for social influence, cognitive‐behavior, and motivation

interventions. There are too few studies in the medical category still to infer consistent effects.

Setting:

When different settings are compared, the results are more positive for classroom and school clinics;

medical setting also shows a significant effect. Too few studies for computer or other public settings

(and they are not yet significant effects). Only one family‐based study has been available.

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Number of sessions:

As for the numbers of sessions the analysis shows statistically significant better results for

interventions with 5 or more sessions.

The following other youth cessation interventions were also examined:

• Pharmacologic adjuncts: Thus far, a PA approach for teens is not promising.

• Intensive contingency management: These results look promising but only small pilots have been

completed so far; the relapse rates are high and wether this approach be institutionalized is

questionabel .

• Internet‐based: Four studies completed thus far: Three are controlled studies; two studies

reported quit data. Basically there is no evidence for the utility of the internet yet.

• Telephone‐based: Using the telephone modality right now looks promising, the interactive

personal contact seems important.

• Mass media: One study shows that four matched pairs of media markets in four states were

randomized to receive or not receive a 3‐year television/radio campaign aimed at adolescent

smoking cessation based on social cognitive theory. The past month quit rate was significantly lower

in the experimental than control at 3‐year follow‐up, adjusted for baseline smoking status. The media

campaign did not impact targeted mediating variables. The role of theory‐based constructs is

unclear. (Solomon et al. 2009)

As for policy, Prof. Sussman mentioned price, smoking area restriction and limiting retail access as measures that have some impact on smoking prevalence.

Conclusions

Why is teen tobacco use cessation worth the investment?

– A 4% absolute effect over many years would lead to many life years saved (Wang et al. for

prevention indicated a saving of $13K per LY saved); teen cessation programs likely are cost‐effective.

– Recovery, cognitive‐behavior, motivation combined programs with at least 5 sessions could obtain

a 10% absolute difference, or doubling of quit rates in school‐based or medical clinic settings.

– Relapse rates are lower than with adults.

– Policy, mass media, telephone, and clinic combinations would reach large numbers and might

produce the largest effects.

– Institutional support, however, is the key.

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3.2. Winning Hearts as well as Minds (Professor Gerard Hastings, Institute for Social Marketing and the Centre of Tobacco Control Research, University of Stirling, and Open University, Scotland) Professor Hastings´ presentation dealt with the idea of “the brand” which he applied to the field of

social marketing. He first tapped on the recent discussion about tobacco control and unassisted

cessation in the adult population, then explained the concept of “making a brand” and finally

described the Help campaign as one example of good practice.

Tobacco control and unassisted cessation

Europe seems to lead the world in tobacco control, but Chapman and others5 are right when they

speak up for unassisted cessation and the need for energetic population level effort. They remind us

that:

• The real world effectiveness of NRT is debatable (51%/22% pharma/non‐pharma trials; 71% of

blinding fails).

• Only a tiny proportion of smokers will use cessation services so these can never have an important

impact on prevalence.

• An overly heavy emphasis on cessation services can be counter‐productive: “Any promotion that

makes smokers feel they cannot quit smoking without treatment is potentially harmful at a

population level.” (Zhu 2006)

• The increasing medicalisation and commodification of cessation is a worrying phenomenon.

• The ‘‘hardening’’ hypothesis (hard‐core smokers are coming to dominate the remaining population

of smokers) is a myth.

• The vast majority of ex‐smokers quitted by their own.

The National Institute for Clinical Excellence (NICE, 2009), the National Cancer Institute (2009) and

the Department of Health (2009) also support large scale population level and mass media

campaigns.

Making a brand

For illustration of the meaning of “brand” Professor Hastings used a story taken from everyday´s life:

The setting is the King’s Head (a pub); the characters are: Dave ‐ husband; Catriona ‐ his wife; Helen ‐ 5 Chapman S, MacKenzie R (2010): The Global Research Neglect of Unassisted Smoking Cessation: Causes and Consequences. PLoS Med 7(2): e1000216. doi:10.1371/journal.pmed.1000216

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the landlady Catriona is sitting in the pub and is waiting for her husband Dave. She´s waiting and

waiting, but he doesn´t show up and slowly but surely, she gets angry… When Dave finally enters the

pub, Helen gives him a sign to come to see her first. She whispers: “Remember, Catriona has had her

hair done.”

This story resumes the essence of marketing:

•It focuses on consumers needs, not on product characteristics: Helen sells marital harmony (and

beer).

• Her customers define her product; her focus is on relationships.

• In a malevolent, manipulative way, this is what the tobacco industry does. They don’t sell nicotine

to young people, they sell hope, adulthood, rebellion…

And it works – even in a dark market like the UK tobacco brands are still driving teen smoking:

“Branding constructs such as brand familiarity and brand image more significantly predict future

intention to smoke than peer influence.”6

Professor Hastings then resumed the mechanism of branding:

• Recognition: the power of simply being there; of consistency

• Promise: I know what you stand for

• Delivery: continuously offering your benefit

Finally, he described the “Help Campaign” as an example for public health branding: It is the world’s

biggest antismoking campaign (in 27 countries; 22 languages), runs since six 6 years and it starts to

build a brand. The actual focus of the campaign is on digital communication e.g. the websites in

different languages, virals, e‐cessation, user generated content, facebook and the Helpers viral e mini

series.

The campaign has created different partnerships to increase audience power and to initiate a process

of letting go. One example for a partnership is the Youth Parliament.7

6 Grant et al (2008). The influence of branding on adolescent smoking behaviour International Journal of Nonprofit and Voluntary Sector Marketing, 13(3): 275‐285 page 282. 7 – The Youth Parliament that declares in 2009: “1. Calls for a total ban on smoking in enclosed public places, with the exception of offices equipped with especially designed smoking rooms; 2. Urges Member States to extend existing anti‐smoking campaigns to ensure that non‐smokers are fully aware of the potential damage to their health from second hand smoke;

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As key qualities of the digital campaign Professor Hastings pointed out:

• Interactive

• Letting go

• Joint effort

• Peer to peer

• Experimental

• Risky

3.3. Recruitment for Teen Smoking Cessation Interventions – A literature review (Peter Dalum, Danish Cancer Society, Denmark)

Peter Dalum reported the results of the literature review that was carried out as part of the ACCESS

project. The target question for this review was: ”What factors are important for how young people

are recruited to smoking cessation interventions?”. The literature review reflects the scientific

knowledge about recruitment of young people for smoking cessation interventions.

Different search terms as smoking cessation, recruitment, young people and program were used

(both as Medical Subject Headings (MeSH) and as free text searches). The main results are presented

in sum (for details see Dalum et al, 20108.

Adolescents are more likely to participate in school‐based ASC interventions if they:

• previously have tried stopping.

• have higher motivation.

• experience less stress.

• are more dependent on nicotine.

• have more positive smoking expectancies.

• come from schools with lower percentage of low‐income students.

(…) 4. Calls upon the European Commission to draft updated proposals for: a) A total ban of tobacco product advertising, (… )Recommends the introduction of measures to reduce the accessibility of tobacco and alcohol products including: 9. The removal of such products from vending machines (…))‐Resolutions of the 61st International Session of the European Youth Parliament; www.eypey.org. 8 Dalum et al (2010). Recruitment to Adolescent Smoking Cessation Interventions – A literature review. ACCESS Project

Trust

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Barriers to participation in smoking cessation programs may be:

• They do not perceive themselves as smokers.

• They are ambivalent in relation to smoking cessation in the nearest future.

• Wish to stop on their own or with help from friends.

• Do not know about the available smoking cessation interventions.

• Do not consider interventions to be attractive and relevant.

• Are worried about privacy and do not want their parents or other grown ups to know that they

smoke.

• Have an idea that smoking cessation interventions have a condescending attitude to youth

smokers.

In all included publications, the most used recruitment strategies were:

• Word of mouth, followed by public announcements and screening. Incentives, class release time

and posters were also used by a large number of providers of smoking cessation programs.

The main conclusions on important factors in recruitment can be summed up:

• Create easy access: Higher recruitment when students come from schools where programs are

offered during normal school hours.

• Use active recruitment strategies: Several studies indicate that it may be an advantage to

employ an active rather than a passive recruitment strategy.

• Tailor programs to the need of adolescents.

For a scientific answer to the questions “which strategies are the most effective to recruitment young

people for smoking cessation?” which conclusions can be drawn from the findings of the literature

review? In fact, the publications do not allow to answer this question because of different reasons:

There are not many studies that focus specifically on recruitment (they generally focus on

treatment), studies are not randomized and do not compare different recruitment strategies (for the

same intervention). And it is difficult to separate recruitment from the intervention. Many studies

are from US where the smoking prevalence is much lower than in most European countries and

smoking is considered much more problematic among youth.

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3.4. About adding friends and becoming fans (Steve Nitzschner, CEO Wildstyle networks, Germany) Steve Nitzschner focused on the question: “How do you create a communication that connects with

youth?”. He stimulated the audience to think about this topic by presenting short statements and

questions related to the agencies work in youth marketing and communication.

He underlined the importance of “going to places and events” where young people spend their

leisure time, of direct contact to young people and discussion with them to get in touch with new

trends and actual topics in different youth cultures.

He focused on the notion “friend” , which can be a key to win hearts: “90% believe what friends say”

– so we should create a “friend‐brand” and behave like a friend: listen – think – answer. From a

communication / marketing perspective, “Non‐smoking” can be seen as a product: if we start

thinking differently in selling a message or a feeling we have a chance to get different and better

results.

4. WORKSHOPS

The main purposes of the workshops were

• to relate the principles and strategies identified by the ACCESS‐project to the personal experience

of participants,

• to discuss the importance of these principles and strategies and

• to find out if anything should be added to these principles and strategies.

Even if there was some discussion about details, there was consent about the general usefulness of

the guiding principles and strategies in all workshops.

The practice examples illustrated how recruitment strategies were already successfully used in

existing projects.

4.1. Workshop: School/ Workplace

Practice Example:

As a practice example „Losgelöst“, a smoking cessation program for adolescents developed by the IFT

München on behalf of the Federal Center of Health Education in Germany was presented.

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Recruitment activities for the program include:

• Information session + provider meeting with interested smokers:

The information session takes place prior to the cessation aid, and is mandatory for smoking and

non‐smoking students of the targeted age group and held during school hours. It mainly comprises

motivation enhancement to stop smoking and to participate in the intervention (by discussing pros

and cons of smoking/cessation, pronouncing and visualising the norm of non‐smoking, investigating

tobacco industry youth marketing methods, and informing about the how and when of the

intervention). The information session is followed by a meeting for interested smokers to clarify

further questions and tailor the intervention time schedule to the needs of participants.

• In‐school‐social workers:

In‐school social workers who know the target group well approach potential participants and ask

them repeatedly to join the intervention using a motivational interviewing style of discussion. They

also introduce the provider of the intervention.

• Incentives:

For motivation enhancement participants receive vouchers (media store, movies) or T‐Shirts for

attendance.

Discussion: Discussion about the ACCESS principles and strategies at first took place in small groups

of 4 persons. These groups then presented their discussion results to the whole group. Afterwards all

participants agreed on conclusions that were to be presented as results of the workshop in the final

plenary session.

Conclusions ‐ Guiding principles:

A suggestion to the principle 9 “Creating partnership”: In order to create multilevel and

multidisciplinary approaches the institutionalization of programs is useful.

Principle 4 “Positive branding” and principle 7 “Choosing the right language” should be merged into

one principle.

Conclusions ‐ Strategies:

The strategy “peer to peer” is attractive but it is difficult to implement. The use of videotapes is one

idea to share personal experience in an easy way.

As for the use of incentives, they should be creative, funny and non‐monetary (eg. Class credits).

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4.2. Workshop: Health care services

Practice Example: Oxsimobil (Slovenian Coalition for Tobacco Control ‐ SCTC)

The Oxsimobil is a car driving around in Slovenia and it stops at village festivals, in the front of

schools etc. Health professionals and students hand out brochures about smoking and carbon

monoxide measures are carried out. When adolecents see their own results they start to think and

put attention on what smoking means.

In this practice model we could identify several recruitment strategies e.g. visualization, pro‐activity

(go where the young people are, also trying to reach persons in remote areas), dissemination of

information about cessation aids, choosing the right language.


• The first principle “Establishment of non‐smoking as a social norm” should change into

“Denormalize tobacco consumption” which is a term that is often used on an international level.

• The principle “choosing the right language” was intensively discussed: Finally there was no

consensus but the idea that different levels of communication should be used as “authority” (ex.

Doctors), “peers”, “adult person of trust”, “celebrities” (eg. Football players). The language should

be appropriate for each situation. Eg. a physician doesn´t have to use the latest slang to be

acknowledged.


• The strategy „Fun“ seems to be important, as well in recruitment as in treatment.

• “Visualization of the effects to smoking” has to be combined with information on how to stop

smoking, otherwise there might be no effect on behaviour.

• In recruitment campaigns, different strategies should be combined: Use different channels to

reach different groups of young people.

To get new ideas on how to use the guiding principles and strategies in actual recruitment practice, a

brainstorming was held among the participants of the workshop:

• Training of professionals who carry out recruitment activities: In general, health professionals are

trained in running cessation programs but they should also get a training about specific

recruitment activities. Also other persons who are in contact with young people (as teachers,

educators, youth leaders) need instruction and motivation if they should inform young people

about health issues as smoking cessation.

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The principles and strategies identified in the ACCESS project can also easily be used on this level:

They can help to design successful training for persons who are doing recruitment.

What characteristics should a person/ an adult have if he/she wants to recruit adolescents? Do

we need a “champion”? Some suggestions were

– “it must be someone who understands the way of youngsters, what they are

thinking”, personal competence;

– medical students are seen as “small doctors” and are often well accepted by

youngsters (example from Germany);

– peers – trying to get the young people with the right attitude

– someone who is skilled/ trained to communicate with young people.

• During medical consultation, smoking should be screened and cessation should be offered

systematically. Unfortunately, doctors often lack time, motivation, knowledge and competence

to do so. Need for a change in the medical system, to engage health professionals in prevention

activities. To principle 9 “Creating partnership” the following amendment should be added: “esp.

With health professionals”.

• Concerning smoking policies, there are many differences among the (EU) countries. Young people

orient themselves on their environment; the situation depends also on the health systems.

Therefore every country has specific needs also in recruitment. The principles and strategies

found by the ACCESS project are valid everywhere, but they should be adapted to the local

situation. For example, “Establishment of non‐smoking as a social norm” is a general principle that

applies to every country.

• A simple idea for evaluation: Together with information leaflets hand out coupons that people

give back to the provider of a smoking cessation program when they enrol in the program. So you

can see the effect of recruitment.

4.3. Workshop: Internet

Practice Example:

The practical example that is used in this workshop is called ‘Smoke Alert’ (www.smokealert.nl).

Smoke Alert is a computer tailored smoking cessation intervention for Dutch adolescents and is

developed by Maastricht University.

The Smoke Alert intervention is a computer tailored smoking cessation intervention in which

adolescents received three personal advices within six months time. During regular class hours

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students would go to a computer room that was supervised by a teacher and filled in an online

questionnaire. When logging in to the Smoke Alert Website, respondents would fill out a

questionnaire about smoking behavior and smoking related cognitions (e.g. attitude, social influence,

self‐efficacy). After 6 months results were very satisfying. There was a significant increase in smoking

cessation in the experimental group compared to control group. Over 27% of the adolescents who

used Smoke Alert quit smoking after 6 months compared to 17% of the adolescents in the control

group. Besides, an additional positive effect of the interventions has been found. Only 4% of the non‐

smokers that used Smoke Alert started smoking afterwards, compared to 10% in the control group.

Therefore, it can be concluded that the intervention is effectively for cessation as well as for

prevention (side effect). Due to its effectiveness, the program is currently (started September 2010)

provided by STIVORO (the Dutch knowledge center for smoking behaviors).

Discussion:

More evidence‐based internet interventions are needed. There is a lack of studies that have tested

the effectiveness of online cessation interventions.

Conclusions ‐ Guiding Principles:

As most important issues the participants pointed out:

• Social norm

• Effective interventions

• Positive framing

• Evidence oriented recruitment

• Positive branding of cessation

• Meeting needs of target groups


• Broader approach in tailoring

• Needs specific tailoring

• Setting approach (reaching via sport clubs, magazines…)

• New phone technology in combination with internet (PDA…)

• Linkage to conventional media (TV, broadcast…)

• Create reasons for quitting today

• Gaming

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Brainstorming:

• More scientific evidence is needed concerning the best strategies

• Interested in continuing exchanges and maybe new common EU initiatives

4.4. Workshop: Out of school

Practice Examples: 3 projects from Riga and two from Switzerland

1st project: „Carrot or cigarette?“

Teens approached smoking persons on the street and asked them if they were willing to change their

cigarette(s) for a carrot. People who gave their whole package away got a voucher for ice‐skiing in

return. Approx. 100 persons changed their cigarette for a carrot, 50% gave away a whole package.

2nd project: „Don´t give up your dream...“

A labyrinth was built on a public place where young people are usually gathering (for skateboarding,

biking, etc.). After entering the labyrinth they had to answer questions (yes/no) which led them to

different directions. In the end, there were two exits: The first: “alive, healthy”, the second:

“addicted, dead”.

On the first day young people from 12‐15 years participated, the next day they brought friends and

parents, grandparents who stood in the row for hours to participate.

3rd project: „I want to tell you....“

Teens wrote letters to themselves, parents, friends etc. about addiction and/or painted pictures. The

best ones were chosen for a book and exhibited.

4th project: www.feelreal.ch

This project offers a genderspecific approach for girls between 13 and 25 years. The main message is:

„I want to smell good, have a nice skin and be attractive“. After the first meeting girls often return

with their friends (snow‐ball effect, mouth‐to‐mouth propaganda). Girls attend the meetings due to

their own intrinsic motivation. 8 – 20 girls participate in each group.

Recruitment is done via internet but also by communal‐police, streetworkers etc.

5th Project: Live‐chat with former „Dr. Sommer“ from Bravo‐Magazine. Feelreal provides workshops

in youth‐centers since 1 year where they use morphing software to show the teens how they would

like to be at the age of 55 as smokers and non‐smokers (where they provide food, beverages and

give‐aways like make‐up mirrors).

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The following principles we rated to be the most important:

1. Establishment of non‐smoking as a social norm

4. Positive branding of cessation interventions

6. Pro‐activity and personal touch

7. Choosing the right language

9. Creating partnership

Three principles were added:

• Tailoring of messages (strategies)

• Change of attitude: cessation not a goal – instrument solve life

• Believe in the capacity of smokers – not to attack them


• The strategy “Tailoring” is very important and therefore should be moved to the principles.

• Policy and infrastructure are the most important strategies.

• Among the strategies “interpersonal communication” authority is not a preferred strategy.

• Among the 2nd group of strategies – “Marketing” ‐ advertising should be changed into media

campaigns. The most important points are: Fun, media campaigns, tobacco industry

manipulation, media advocacy.

• The idea of “getting a picture of the whole personality of the young individual” should be added

to the “behavioral learning techniques”.

Brainstorming:

• Create positive characters/comic stories that lead healthy lifestyles that accompany children from

childhood to adolescence and which are marketed together with frequently used consumer

products.

• Organize “cool” non smoking parties/events.

• Another strategy: „Buddy‐system“: pairs of 1 smoker and 1 non‐smoker > Focus on peer‐

influence.

• One idea in relation to the 1st principle: is to add the Quitline telephone number to the warning

labels of cigarettes.

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5. CONCLUSIONS (Professor Steve Sussman)

In the end of the conference Professor Steve Sussman gave some conclusions about adolescent

smoking cessation in general, the content of the ACCESS report, and the discussion during the

conference:

• In smoking cessation a multi level approach is needed at population level and at the

individual level. These are two different, but complementary ways of changing social climate.

• A (more or less) standardized tool for the evaluation of recruitment practice could help to

change experiences and to build up an inventory of recruitment practices in different

countries.

• We must be aware that teens are not adults: This means that approaches which work with

adults cannot be transferred one to one to teens. They have to be adapted and must take in

account e.g. in lifestyle or language. This will lead to differences in recruitment, in

treatment, in approach between programs for adults and programs for teens.

• “We do not know what youth thinks unless we ask them directly. Do not work on (weak)

assumptions!”

• Better networking and strategies inside the health system can maximize the effects of

recruitment and treatment.

• One guiding idea in recruitment could be “maximizing education and enjoyment of life” (and

not moralizing).

• Motivating messages (“better stop today than tomorrow”) might have a greater chance to be

heard and accepted.

• During a smoking cessation intervention, it is motivating if the effort of the teens who

participate in the program is recognized ‐ cessation is not (always) fun and the “non‐smoking

image” might appear not very attractive.

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6. EVALUATION OF THE ACCESS CONFERENCE9

The evaluation of the conference has been performed by two methods: (1) an online questionnaire

and (2) taking interviews. The online questionnaire was send to each participant of the conference in

the week after the conference. This questionnaire entailed 33 questions of which the largest part

were multiple‐choice questions. The interviews took place during and directly after the conference.

From each participating country one attendee was selected to be interviewed.

The online questionnaire

The online questionnaire was filled out by 33 persons (Response Rate (RR) = about 40%). First, the

results of the multiple choice items will be presented and discussed. They are subdivided into three

main aspects; the conference, the ACCESS project and report, and the future and network

development. Here we will only present the evaluation of the conference, for further details refer to

the complete evaluation report.

Results of the evaluation of the conference

Question / Determinant Mean Score SD

Met expectations 4.21 0.65 Organization 4.58 0.56 Program 4.30 0.68 Talk 1: Steve Sussman 3.82 0.88 Talk 2: Gerard Hastings 4.30 0.88 Talk 3: Steve Nitzschner 4.33 0.99 Contribution conference 3.30 0.88 Worth visiting 4.19 0.75

Overall, it can be concluded that all the aspects had a quite high mean score. Concerning the

conference related questions, there were two remarkable outcomes that were slightly different from

the general tendency of the results. The first remarkable outcome was the relatively low score on the

question whether the conference contributed to the solution of the difficulties concerning the

recruitment of adolescents for smoking cessation intervention. The mean score was 3.30, a score

9 Extract from Kann & De Vries (2010): Evaluation report, ACCESS Project.

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that can be interpreted as slightly positive. The second remarkable outcome was the relatively low

grade that has been given to the presentation of Prof. Steve Sussman. This score was significantly

lower than the scores of both other speakers of the conference (Steve Nitzschner and Prof. Gerard

Hastings).

The workshops were evaluated separately. The results are presented in the following table. It can be

concluded that in general every workshop has been graded (quite) positive as also mentioned by

some attendees within the context of the general remarks they could make in the questionnaire. The

workshop with regard to school‐based interventions is evaluated as highest and the workshop

concerning out‐of‐school interventions as lowest.

Evaluation of the workshops

Workshop N Mean Score SD

School‐based interventions 7 4.14 .38 Internet‐based interventions 5 4.00 1.00 Health‐care setting interventions 9 3.44 1.33 Out‐of‐school delivered interventions 6 3.00 0.89

The open‐ended questions were stated to get some deeper information about a certain opinion of

the attendees and the reason why they were attending the conference. It should be stated that the

open‐ended questions were not obligated to fill out and therefore the amount of answers differed

slightly between each questions. The most mentioned reasons for attending the conference were:

networking (meeting other colleagues), getting information (about ACCESS), and interest in smoking

cessation.

The explorative questions concerning critical opinions combined, have resulted in a few remarks

concerning the (results of the) project. The most mentioned or salient critics were: (1) it was too

theoretical to use (too less translation to practice), (2) it did not mention anything new (it is already

all familiar), (3) hosts / speakers did not seemed to be too prepared, (4) there was no good discussion

about opinions that attendees had during plenary sessions (high risk for false‐positive outcomes in

the report), and (5) the establishment of an European network is much more complex than it looks

like this way (therefore it could be that the establishment fails).

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The interviews

The interviews were conducted to get more in depth information about the expectations that

participants had when they came to the conference and also what their opinions were about the

program of the day. Furthermore, we wanted to know whether some topics were missed in the

program and whether their expectations of the conference were met or not.

Most of the attendees indicated that they came to the conference to get more knowledge and

information. This knowledge could be about ACCESS and its results in general, about the recruitment

strategies specifically, or about ways to force governments to change smoking policies. Improving

own skills and interaction with other people from different countries working on the same topic were

also mentioned as reasons to attend the conference. A vast majority indicated that the conference

met their expectations and a small minority has indicated that it did partially.

Almost all the interviewed attendees told that they are willing to make use of the results of ACCESS

in their future work. Since there were people with a variety of backgrounds, everyone was intending

to use it on his or her own way. Therefore the next table provides an overview of the answers that

have been given. This seems more appropriate than listing up all these answer in text.

‘How will the outcomes of ACCESS influence your future work?’: The results.

- I will use it for my upcoming school‐based or internet‐based intervention. - It can help me to reach the young smokers for my program easier. - We would like to use the report (especially guiding principle 1 ‘Social norm’) to force the

government to change their smoking policy. - We try to use the strategies and settings in our national campaigns. - I will not directly use them, but will help distribute them among members op the ENSP. - We will use them as a base for our new cessation program. - We want to use them to fill the gap we have discovered in our current smoking cessation

programs for youth. - It provides a lot of new ideas. I have to think about its possibilities. - Hopefully it makes developing a cessation program in our country somewhat easier. - It inspires me to do more to help young smokers to quit. I will try to mobilize the national and

local governments. More than half of the respondents indicated that they did not have missed anything during the

conference. The persons who have indicated that they missed something, mentioned the following

issues: manipulation of the tobacco industry, a bit more information on the cessation part, important

further steps for implementation, and somewhat more in depth discussion and elaboration about the

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national networks and national cessation programs. The ones that indicated that they missed

something concerning the future or cessation part told explicitly that they were fully aware of the

fact that ACCESS is especially targeted at the recruitment part of a cessation program.

Some remarks that were mentioned could be very useful to consider when performing another

conference in the future. Three persons have indicated that they would have appreciated it when

they received the ACCESS report before the actual start of the conference. By having the documents

earlier they would have been more prepared for the conference and would be able to have more in

depth discussion about the principles during the workshops. It would also be appreciated when there

was somewhat more time planned for the workshops. Now, there is a feeling that somewhat is not

completed, because there was (way) too little time to have a (lively) discussion about the outcomes

of the workshops. Finally, it was mentioned that is recommendable that the report would have been

written in the same ‘language’ as the FCTC. If all projects working on the same topic (smoking

cessation) would use the same ‘language’, the impact of these projects would be higher.

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7. SUMMARY Within the project ACCESS the European consultation conference took place on June 18th,

2010 in Vienna. After working on the ACCESS Report on guiding principles, strategies, and activities

during the first nine months of the project, the aim of the conference was the consultation of the

working paper and the dissemination of the results. The conference offered a unique opportunity of

discussion and brainstorming as well as a possibility to share experiences across countries and

professions. Finally, 88 international stakeholders participated in the conference. The international

stakeholders and participating organizations came from 13 European countries and the USA.

The conference provided the participants with an overview of the working process and the

results of the ACCESS project as well as with a presentation of recent research on the topic of

smoking cessation for young adolescents. In addition, participants were inspired in their recruitment

efforts for adolescent smoking cessation by a non‐tobacco control perspective on communication

with young people. Three international speakers were invited. For the intended consultation process

four parallel workshops were run followed by a plenary session. This session offered the possibility to

share and to discuss the results from the workshops.

Anneke Bühler informed the audience about the goals and working process of the ACCESS

project and gave a first insight into the contents of the ACCESS report. Alexandra Kmetova presented

the status of the national networks in each ACCESS‐country and their members. Steve Sussman

reported about which adolescent smoking cessation interventions are effective and how effective

they are. Peter Dalum shared the scientific knowledge about effective recruitment in adolescent

smoking cessation. Gerard Hastings conveyed the message that “branding” adolescent smoking

cessation is of utmost importance in the recruitment process. Steve Nitzschner encouraged the

audience to intensively get in contact with the target group when creating recruitment strategies and

to perceive “non‐smoking” as a product. In the workshops, proposed guiding principles, strategies,

and activities were consulted for different settings (health care settings, social services/institutions;

schools/workplaces; out of school settings (leisure, sports, other youth access points); internet).

The evaluation shows that the conference can be described as successful as it did reach its

formulated goals. Most of the attendees were satisfied by the program of the day as well as the

organization. They gave positive feedback concerning the workshops as they did concerning the

ACCESS report. Most attendees reported that the work of ACCESS has made a contribution and that

there is potential that the work will go on (in a more or less extent) in the future within the

established national networks.

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ANNEX: Practice examples of the workshops

Documents

Conference report ACCESS · 3.2. Winning Hearts as well as Minds (Gerard Hastings) 3.3. Recruitment to Adolescent Smoking Cessation Interventions – A literature review (Peter Dalum)