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Smoking Cessation Strategies Among Adolescents:

Critique and Recommendations

Laurie Rogers Trlak

L25958143

May 9, 2014

HLTH 505.D07

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Abstract

Fifty years after the U.S. Surgeon General released a report

showing the dangers of cigarette smoking, tobacco use continues

to be the single most preventable cause of illness and death in

the United States1. In spite of a reduction in the overall rate

of smoking, smoking among adolescents continues to be a major

concern for health practitioners. This paper examines various

smoking cessation methods as well as issues surrounding

adolescent smoking.

Introduction

In 1964 the U.S. Surgeon General released a report about the

dangers of cigarette smoking, yet despite legislation to end

television advertising of tobacco products, and taxes to raise

the price of tobacco, smoking continues to be the single most

preventable cause of death in the U.S.1 While overall smoking

rates have declined, smoking among adolescents continues to be a

major concern for health practitioners. According to the Centers

for Disease Control and Prevention, nine out of ten smokers begin

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smoking before the age of 18, with another 9% starting to smoke

by the age of 261. While smoking has declined significantly since

19642, a high prevalence persists among those under age 18. At

current levels, some 5.6 million young people currently under the

age of 18 will die prematurely due to cancer, emphysema, heart

disease, and other tobacco-related illnesses2.

Background

Since the Surgeon General’s report was released in 1964, massive

efforts at tobacco control have been launched at federal, state,

and local levels. Efforts at tobacco control have included

banning cigarette advertisements on television and radio (1970);

taxing cigarettes and other tobacco products (1988); and banning

smoking on commercial airliners (1990); and bans on smoking in

bars and restaurants. The result has been that cigarette smoking

among adults has declined significantly; however, tobacco use,

including cigarettes, cigars, smokeless tobacco, and electronic

cigarettes, remains at a troubling level among adolescents3.

The report noted that those who smoke are much more likely to die

from smoking-related diseases than those who don’t smoke4. In the

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50 years since the report was released, 20 million people have

died because of illnesses caused by tobacco smoke4. Most of the

deaths have been among smokers, but a significant number, 2.5

million, were among those who inhaled tobacco smoke from the

cigarettes of others, also known as second-hand smoke4. In order

to combat teenaged smoking, a number of smoking cessation efforts

have been tried with varying results. Advertising campaigns in

mass media such as radio and television, heavily patronized by

adolescents, have attempted to deliver targeted messages about

the dangers of smoking. Schools have also used mass media in the

classroom in smoking cessation interventions3. While compulsory

enrollment in mass media programs in lieu of disciplinary action

has not resulted in smoking cessation, voluntary enrollment has

failed to attract students. Adolescents are reluctant to enroll

in such programs voluntarily, possibly due to fears of parental

disapproval and sanctions once their smoking behavior becomes

known. Consequently, 80% of adolescents say they prefer to quit

on their own rather than be enrolled in a smoking cessation

program1. Since teens may be more sensitive to the addictive

effects of nicotine, relapse is more problematic for this age

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group, and this presents unique challenges to public health

officials when designing smoking cessation interventions targeted

for adolescents1. Nevertheless, smoking prevention and cessation

efforts utilizing mass media messaging are considered to be a

viable means of tobacco control. Indeed, in a study by Flynn et

al, significant differences in daily smoking habits were observed

in adolescents who had undergone a mass media intervention

compared with a control group who had not1.

A study by Erol and Erdogan (2008) evaluated the use of

motivational interviewing (MI) based on the five stages of change

outlined in the Transtheoretical Model (TTM)5: precontemplation

(those not yet ready to quit); contemplation (those planning to

quit within six months); preparation (those planning to quit

within 30 days; action (those who quit within the previous six

months); and maintenance, (those who quit more than six months

ago). 60 students from one high school were recruited for an MI

intervention. Prior to its start, smoking status, perceptions of

the pros and cons of tobacco use, and temptations were measured.

At follow-up at three and six months 40% and 55% respectively had

made progress in stage, and 18.3% and 33% respectively had quit5.

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During the MI phase of the intervention the students participated

in five 45 minute sessions during which they were guided in

imagining what their future lives would be like if they continued

to smoke, and what they would be like if they quit. In follow-ups

at three and six months, the students’ progress was assessed, and

the authors concluded that the gains in smoking cessation were

modest at best; however they also concluded that use of

motivational interviewing in conjunction with the five stages of

change in the Transtheoretical Model could be useful for teachers

and health care providers in guiding young people to quit

smoking.

Another smoking cessation strategy that has been studied is the

use of nicotine replacement therapy (NRT), consisting of patches

and gum. Nicotine dependence is a primary cause of the failure of

smoking cessation efforts6, characterized by withdrawal symptoms

and cravings. As noted previously, adolescents may be

particularly susceptible to the addictive effects of nicotine;

however, NRT has not been particularly successful, although the

study in question did not factor in variables such as compliance,

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making it impossible to determine the effectiveness of the

therapy.

In another study on the use of bupropion in adolescent smoking

cessation, 134 adolescents were randomized into four groups:

placebo; placebo plus contingency management; bupropion alone;

and bupropion plus contingency management7. Although combined

treatment for bupropion showed some benefit during the first four

weeks, no benefit was apparent in the final two weeks, or at the

12 week follow-up. The author suggested that study into longer

courses of treatment might provide health care providers greater

insight into the use of bupropion in smoking cessation

interventions.

Most studies of adolescent smoking have focused on smoking

prevention. Ideally preventing the start of smoking is preferable

to cessation, as tobacco addiction is particularly difficult for

many adolescents to overcome1, 8. A study which focused on the

underlying environmental characteristics surrounding the

adolescent emphasized prevention, as opposed to smoking

cessation, showed that students attending schools that enforced

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strong rules against smoking were less likely to smoke than those

attending schools without such restrictions9.

A study by Prokhorov, Hudmon, and Stancic takes an

epidemiological approach to smoking cessation treatment based on

the definition of addiction in the Diagnostic and Statistical

Manual of Mental Disorders: “a maladaptive pattern of substance

use, leading to clinically significant impairment or distress, as

evidenced by the following manifestations, occurring at any time

in the same 12-month period: tolerance, withdrawal, and

persistent desire or unsuccessful efforts to quit10.” The authors

used a modified Fagerstrom Tolerance Questionnaire (FTQ),

developed in 1978 and used for determining tobacco and nicotine

dependence for adult smokers. Consisting of only seven simple

questions, the modified questionnaire found that adolescents

experience the same degree of cravings and withdrawal symptoms as

adults. Based on the results of the study, the authors

recommended that the same behavioral and counseling interventions

shown to be effective with adults be used with adolescents who

want to quit smoking. Specifically, they suggested the

Transtheoretical Model (TTM) of Change could be effective if used

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in adolescent smoking interventions. They also urge health care

providers to prioritize identification of adolescent smokers, and

to incorporate smoking cessation counseling into their treatment

of adolescent smokers, as this has been shown to be effective

with adults.

Another area of study involves disparities in rates of smoking

among adolescents in lower socioeconomic groups. Disparities in

smoking behavior in low socioeconomic groups are difficult to

quantify because the causes of smoking are multi-faceted and

complex. According to Pampel, Krueger, and Justin, et al, unlike

other health behaviors, smoking inception and cessation

disparities are culturally and socially determined, rather than

being dependent on access to information and cessation

programs10. Access to health services such as smoking cessation

programs depends in part on the ability to pay for them, yet

smoking costs an average $1638 per year for a pack-a-day

smoker10.

While factors such as socioeconomic status cannot by themselves

explain the high prevalence of smoking among disadvantaged

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groups, education level appears to be directly connected to

smoking prevalence. When controlled for other socioeconomic

variables, high school dropouts are nearly three times as likely

as college graduates to smoke10. But the high cost of cigarettes

in relation to the lower wages of those without a high school

diploma still does not account for the higher rates of smoking in

the lowest socioeconomic groups. The authors of the study suggest

that stressors such as high unemployment, low wages, and racial

discrimination associated with lower socioeconomic status

contribute to unhealthy behaviors such as smoking, overeating,

and lack of exercise, because they bring pleasure and are a means

of coping with those stresses; however, they acknowledge that the

relationship between smoking and dealing with high-stress

situations needs further study10.

Differences in tobacco prevalence among racial groups are another

source of disparity. According to the Surgeon General’s report,

American Indians and Alaskan Natives have the highest prevalence

of tobacco use, followed by African Americans. As is the case

with socioeconomic status, no single factor is responsible for

the rate of smoking among these groups. Cultural factors, stress

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related to socioeconomic status, and targeted advertising all

contribute to smoking10.

Current Research Efforts

While preventing smoking initiation may be ideal, as opposed to

smoking cessation, some researchers believe that current

strategies aimed at smoking prevention among adolescents are

ineffective when those young people reach their twenties9.

Additionally, the United States Centers for Disease Control and

Prevention reports that despite tobacco control programs aimed at

smoking prevention, nearly one fourth of teenagers smoke10.

An initiative by the West Virginia University Centers for Public

Health Research and Training, partnering with the West Virginia

state health and education departments, the Coalition for a

Tobacco-Free West Virginia, and the American Lung Association,

developed an innovative program specifically targeting adolescent

smokers, the Not On Tobacco (NOT) program. Gender-specific, and

consisting of 10 50-minute group sessions, topics focus on such

issues as stress management, preparation for cessation, and the

health effects of smoking, as well as coping with cravings. Six

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studies between 1997 and 2002 evaluated the effectiveness of the

NOT program, with a more recent follow-up evaluation. A follow-

up study showed that teenagers who participated in NOT were

nearly twice as likely to quit smoking as those who received more

traditional smoking intervention methods, such as a 15 minute

smoking prevention presentation10. Because of the success of the

program, the American Lung Association has approved of it as a

best practice model.

In other research, in 2008 the Tobacco Use and Dependence

Guideline Panel updated its 2000 clinical practice guidelines to

reflect recent scientific literature into smoking cessation

interventions. Sponsored by a number of government and non-

governmental organizations, including the Agency for Healthcare

Quality and Research, the Centers for Disease Control and

Prevention, and the National Cancer Institute, among others, the

guideline identified recent research into effective,

scientifically verified and tested tobacco control interventions.

The Guideline makes 10 recommendations for smoking cessation

interventions:

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1. Tobacco dependence is a chronic disease that often

requires repeated

intervention and multiple attempts to quit. Effective

treatments exist,

however, that can significantly increase rates of long-term

abstinence.

2. It is essential that clinicians and health care delivery

systems consistently

identify and document tobacco use status and treat every

tobacco user

seen in a health care setting.

3. Tobacco dependence treatments are effective across a

broad range of

populations. Clinicians should encourage every patient

willing to make

a quit attempt to use the counseling treatments and

medications recommended

in this Guideline.

4. Brief tobacco dependence treatment is effective.

Clinicians should offer

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every patient who uses tobacco at least the brief treatments

shown to be

effective in this Guideline.

5. Individual, group, and telephone counseling are

effective, and their

effectiveness increases with treatment intensity. Two

components of

counseling are especially effective, and clinicians should

use these when

counseling patients making a quit attempt:

• Practical counseling (problemsolving/skills training)

• Social support delivered as part of treatment

6. Numerous effective medications are available for tobacco

dependence,

and clinicians should encourage their use by all patients

attempting to

quit smoking—except when medically contraindicated or with

specific

populations for which there is insufficient evidence of

effectiveness (i.e.,

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pregnant women, smokeless tobacco users, light smokers, and

some adolescents).

• Seven first-line medications (5 nicotine and 2 non-

nicotine) reliably

increase long-term smoking abstinence rates:

– Bupropion SR

– Nicotine gum

– Nicotine inhaler

– Nicotine lozenge

– Nicotine nasal spray

– Nicotine patch

– Varenicline

• Clinicians also should consider the use of certain

combinations of

medications identified as effective in this Guideline.

7. Counseling and medication are effective when used by

themselves

for treating tobacco dependence. The combination of

counseling and

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medication, however, is more effective than either alone.

Thus, clinicians

should encourage all individuals making a quit attempt to

use both

counseling and medication.

8. Telephone quitline counseling is effective with diverse

populations and

has broad reach. Therefore, both clinicians and health care

delivery

systems should ensure patient access to quitlines and

promote quitline use.

9. If a tobacco user currently is unwilling to make a quit

attempt, clinicians

should use the motivational treatments shown in this

Guideline

to be effective in increasing future quit attempts.

10. Tobacco dependence treatments are both clinically

effective and highly

cost-effective relative to interventions for other clinical

disorders. Providing

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coverage for these treatments increases quit rates. Insurers

and

purchasers should ensure that all insurance plans include

the counseling

and medication identified as effective in this Guideline as

covered benefits.

The guideline notes the increase in available pharmaceuticals for

the treatment of smoking cessation, such as varenicline and

bupropion, among others, and recommends their use to treat

nicotine dependence16.

Discussion

Until recently, tobacco control programs have focused on

preventing smoking initiation among adolescents rather than

cessation; however, given that 23% of adolescents still smoke,

these programs have failed to be efficacious for a variety of

reasons: peer pressure, fear of parental disapproval if the

behavior becomes known, and relapses due to nicotine addiction

have all contributed to high failure rates in tobacco prevention

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programs3. Smoking cessation programs have produced mixed

results, but given that almost a quarter of high school students

still smoke in spite of tobacco prevention programs, more

emphasis is needed on cessation programs. This is especially

important, as adolescents are believed to be more susceptible to

the effects of nicotine addiction8.

The use of mass media – television, radio, and more recently the

Internet - holds promise for influencing young people to quit

smoking. Young people tend to be heavy consumers of mass media,

especially social networking: according to the Centers for

Disease Control and Prevention (CDC), 93% of teens spend time

online, and 55% have a blog or use social networks such as

Facebook and My Space12. More adolescents have cell phones

capable of accessing the Internet than computers, and they use

their phones to communicate with one another via text message; to

play games; download music; to do research for school

assignments; and to obtain health information12. Results from a

study by Solomon, Bunn, and Flynn et al showed that media

messages utilizing social constructs common among adolescents,

such as self-image and the perception of peer norms were

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effective at preventing the start of smoking. Further study

involving the use of media messages based on social cognitive

theory and their effect on teen smokers showed significantly high

rates of smoking cessation3. Clearly, mass media offers a

promising venue for reaching adolescents with smoking cessation

messages.

A study by Scherphof et al involving the use of nicotine

replacement therapy (NRT), and small group class room

interventions did not result in significant cessation numbers;

however, the results are inconclusive, since the studies suffered

from problems such as small sample size and selection bias3. The

study also did not control for compliance, rendering any

conclusions regarding the efficacy of NRT in adolescents invalid.

Further study into these methods is required in order to make a

determination about their efficacy.

Recommendations

An area of concern surrounds funding for state smoking cessation

programs. Funding is often inadequate, in spite of the fact that

such programs have resulted in a marked decrease in the number of

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adults who smoke11. A reduction in smoking related illness would

ease the strain on state Medicaid budgets by reducing the number

of Medicaid patients with chronic illnesses due to smoking.

Additionally, smoking cessation programs accompanied by higher

taxes on cigarettes and legal restrictions on permitted smoking

venues may also play a role in reducing smoking rates, although

the relationship between taxes and legal restrictions, and

reduction in smoking rates is unclear9. Studies into the

effectiveness of higher taxes have found a positive impact on

teenaged smoking, but it had a negligible effect once they

reached adulthood and were earning their own money9, suggesting

that cessation and prevention programs should be available beyond

high school. Once again, further study is required in order to

determine whether higher taxes and anti-smoking ordinances are

effective in promoting smoking cessation.

Despite an overall reduction in the rate of smoking in the United

States, adolescent smoking remains worrisome. Warnings about the

dangers of smoking notwithstanding, a significant number of young

people continue to start smoking3. Emphasis on smoking prevention

has largely failed to reduce the numbers of adolescents who start

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smoking. Furthermore, while smoking cessation efforts have been

successful among adults, teen smoking cessation is more

problematic; however, since nearly one in ten smokers starts

smoking after the age of 18, efforts at tobacco control should

not end at age 18, but should continue into young adulthood.

Regarding racial and socioeconomic disparities, the Surgeon

General recommends heightened surveillance of smoking behaviors,

along with further study to increase understanding of the role

played by ethnic, racial, and cultural norms, and socioeconomic

status in the high prevalence of smoking among ethnic and racial

groups15. Community involvement is extremely important. In order

to reduce smoking rates among both adolescents and adults,

community norms and attitudes towards smoking must be changed15.

Further study is needed to determine the reasons for higher rates

of smoking among lower socioeconomic groups.

It is recommended that increased funding be made available at the

state and federal level to underwrite smoking cessation

programs12, as these programs require infrastructure, to include

administrative staff and sufficient capacity to serve all those

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in need of smoking cessation services. The CDC report Best

Practices for Comprehensive Tobacco Control Programs recommends a

multi-tiered strategy for reducing the numbers of Americans who

smoke, thereby reducing costs associated with damage to health

caused by smoking. Among the recommendations are12:

State and community interventions to include:

Preventing initiation among youth and young adults

Promoting cessation among adults and youth

Eliminating exposure to secondhand smoke

Identifying and eliminating tobacco-related disparities

among population groups

Use of mass media and community wide health interventions

Increase the price of tobacco products via increased

tobacco taxes

Community-wide educational programs

Enlist community involvement in the enforcement of

statutory laws regulating the sale of tobacco products

to minors

State cessation programs with the following goals

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Educating health organizations and providers on the

benefits of screening patients for tobacco use and

including cessation treatment

Provision of technical expertise for health care

organizations and providers to effect changes to health

systems in order to facilitate the inclusion of tobacco

cessation screening and treatment into clinical

treatment protocols.

Provision of assistance to health care organizations

and providers to incorporate the use of electronic

health records for the purpose of tracking tobacco use

and cessation effectiveness

Development of staff and funding to support statewide

smoking cessation efforts.

Sufficient staff numbers to support increased screening

responsibilities

Collaboration between program leaders and leaders in

other departments

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Flexibility within leadership to adjust to changes in

scientific knowledge and funding, especially reduction

of funds.

The funding levels recommended by the CDC report are $3,306

billion in total program costs. This massive outlay of funds is

justified by the fact that savings will be realized in the

reduction of costs due to tobacco-related illness, disability,

and death12. In addition to funding for comprehensive tobacco

control programs, a need exists for further research into the

factors which contribute to higher levels of smoking in the

lowest socioeconomic groups, since the relationship between

socioeconomic status and risky health behaviors is not entirely

clear12.

The Comprehensive Guide also recommends a National Prevention

Strategy to include:

1. Support comprehensive tobacco-free and other evidence-based

tobacco control policies.

2. Support full implementation of the 2009 Family Smoking

Prevention and Tobacco Control Act.

3. Expand use of tobacco cessation services.

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4. Use media to educate and encourage people to live tobacco-

free13.

These recommendations include a commitment by the Department of

Health and Human Services (HHS) to support states, communities,

and tribes in their efforts at smoking cessation. Toward that

end, HHS will launch a website providing information and links to

resources for those desiring to quit smoking13.

Additionally, the Department of Defense is expected to implement

tobacco control initiatives with a view toward unit cohesiveness,

unit readiness, and leadership by example13. In an era when many

young people see military men and women as heroes, the importance

of setting a good example cannot be understated.

Finally, further research into the effectiveness of

pharmaceuticals in treating adolescent smoking should be

conducted to determine whether they are appropriate.

Conclusion

Ultimately, the costs of smoking cessation programs and media

campaigns will be offset by the savings realized in health costs

and lost work days due to smoking-induced health problems. While

smoking cessation in adolescents is a complicated, multi-tiered

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process, the cost of doing nothing in terms of lost work days,

increased health care costs, and millions of premature deaths is

a price we as a nation cannot afford to pay. We should do all we

can to help adolescents stop smoking, for their good and the good

of the nation.

“If anyone causes one of these little ones—those who believe in

me—to stumble, it would be better for them to have a large

millstone hung around their neck and to be drowned in the depths

of the sea17.”

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References

1. Centers for Disease Control and Prevention. Youth and

Tobacco Use. 2014. Updated February 14, 2014.

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth

_data/tobacco_use/. Accessed April 25, 2014.

2. Centers for Disease Control and Prevention. 2014 Surgeon

General’s Report: The Health Consequences of Smoking – 50

Years of Progress.

http://www.surgeongeneral.gov/library/reports/50-years-of-

progress/sgr50-chap-13.pdf. Accessed April 25, 2014.

3. Solomon LJ, Bunn JY, Flynn BS, Pirie PL, Worden JK, Ashikaga

T. Mass media for smoking cessation in adolescents. Health Educ

Behav. 2009;36:642-659.

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4. Centers for Disease Control and Prevention. Let’s Make the

Next Generation Tobacco Free: Your Guide to the 50th

Anniversary Surgeon General’s Report on Tobacco and Health.

http://www.surgeongeneral.gov/library/reports/50-years-of-

progress/consumer-guide.pdf. Accessed April 25, 2014.

5. Erol S, Erdogan S. Application of a Stage Based,

Motivational Interviewing Approach to Adolescent Smoking

Cessation: The Transtheoretical Model-based Study. Patient

Educ Couns. 2008;72(1):42-48.

http://www.sciencedirect.com.ezproxy.liberty.edu:2048/scienc

e/article/pii/S0738399108000207. Accessed May 1, 2014.

6. Scherphof C., van den Eijnden R., Engels R. et al. Short

Term Efficacy of Nicotine Replacement Therapy for Smoking

Cessation in Adolescents: A Randomized Controlled Trial. J

Subst Abuse Treat. 2014;46(2):120-127.

http://rx9vh3hy4r.search.serialssolutions.com.ezproxy.libert

y.edu:2048/?ctx_ver=Z39.88-2004&ctx_enc=info%3Aofi%2Fenc

%3AUTF-8&rfr_id=info:sid/

summon.serialssolutions.com&rft_val_fmt=info:ofi/

fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Short-

SMOKING 29

term+efficacy+of+nicotine+replacement+therapy+for+smoking+ce

ssation+in+adolescents

%3A+A+randomized+controlled+trial&rft.jtitle=Journal+of+Subs

tance+Abuse+Treatment&rft.au=Scherphof

%2C+Charlotte+S&rft.au=Van+den+Eijnden

%2C+Regina+J.J.M&rft.au=Engels

%2C+Rutger+C.M.E&rft.au=Vollebergh

%2C+Wilma+A.M&rft.date=2014-02-

01&rft.pub=Elsevier+Science+Publishers&rft.issn=0740-

5472&rft.eissn=1873-

6483&rft.volume=46&rft.issue=2&rft.spage=120&rft_id=info:doi

/10.1016%2Fj.jsat.2013.08.008&rft.externalDBID=n

%2Fa&rft.externalDocID=352058795&paramdict=en-US. Accessed

May 1, 2014.

7. McVoy M. A Randomized, Double-Blind, Placebo-Controlled

Trial of Bupropion SR, with and without Contingency

Management, for Smoking Cessation in Adolescents. Child Adolesc

Psychopharmacol News. 2009;14:2.

http://search.proquest.com.ezproxy.liberty.edu:2048/docview/

210962458. Accessed May 3, 2014.

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8. Lovato CY, Zeisser C, Campbell HS, et al. Adolescent

Smoking. Am J Prev Med. 2010;39:507-514.

http://www.sciencedirect.com.ezproxy.liberty.edu:2048/scienc

e/article/pii/S0749379710005106. Accessed May 6, 2014.

9. Dougherty M. Unraveling the Smoking Conundrum. In Vivo.

Columbia University Health Sciences.

http://www.cumc.columbia.edu/publications/in-vivo/Vol2_Iss08

_apr28_03/. Accessed May 7, 2014.

10. Prokhorov AV, Hudmon K Suchanek, Stancic N. Adolescent

Smoking: Epidemiology and Approaches for Achieving

Cessation. Paediatr Drugs. 2003;5(1):1-10.

http://rx9vh3hy4r.search.serialssolutions.com.ezproxy.libert

y.edu:2048/?ctx_ver=Z39.88-2004&ctx_enc=info%3Aofi%2Fenc

%3AUTF-8&rfr_id=info:sid/

summon.serialssolutions.com&rft_val_fmt=info:ofi/

fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Adolescent+

Smoking

%3A+Epidemiology+and+Approaches+for+Achieving+Cessation&rft.

jtitle=Pediatric+Drugs&rft.au=Prokhorov+A.V&rft.au=Hudmon+K.

S&rft.au=Stancic+N&rft.date=2003&rft.pub=Adis+International&

SMOKING 31

rft.issn=1174-

5878&rft.volume=5&rft.issue=1&rft.spage=1&rft.epage=1&rft.ex

ternalDBID=n%2Fa&rft.externalDocID=n%2Fa&paramdict=en-US.

Accessed May 8, 2014.

11. United States Centers for Disease Control and

Prevention. Not On Tobacco (NOT) - Smoking Cessation

Program for 14-19 Year Olds Selected As Model Program. West

Virginia University: Prevention Research Center. Updated

February 6, 2012. http://www.cdc.gov/prc/prevention-

strategies/smoking-cessation-program.htm. Accessed May 7,

2014.

12. United States Centers for Disease Control and

Prevention. Sustaining State Funding For Tobacco Control.

Smoking and Tobacco Use. Last updated September 8, 2011.

http://www.cdc.gov/tobacco/tobacco_control_programs/program_

development/sustainingstates/sustaining_funding/. Accessed

May 7, 2014.

13. United States Centers for Disease Control and

Prevention. Best Practices for Comprehensive Tobacco Control

2014. Smoking and Tobacco Use.

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http://www.cdc.gov/tobacco/stateandcommunity/best_practices/

index.htm. Accessed May 7, 2014.

14. Pampel FC, Krueger JM, Denney JT. Socioeconomic

Disparities in Health Behaviors. Annu Rev Sociol. 2010;36(1):

349-370. Doi 10.1146/annurev.soc.012809.102529.

15. Major Conclusions of the Surgeon General’s report.

Smoking and Tobacco Use. Centers for Disease Control and

Prevention.

http://www.cdc.gov/tobacco/data_statistics/sgr/1998/highligh

ts/ataglance/index.htm. Accessed May 8, 2014.

16. Centers for Disease Control and Prevention. Treating

Tobacco Use and Dependence. Clinical Practice Guideline.

2008. http://bphc.hrsa.gov/buckets/treatingtobacco.pdf.

Accessed May 9, 2014.

17. Matthew 18:6. Holy Bible. English Standard Version.

Wheaton, IL: Crossway Publishing; 2001.