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Tobacco Dependence: Treatment Behavioral Solutions for Quitting
Tobacco Dependency continuing education social worker CEUs

Section 10
The Influence of Coping Skills on Counseling Adolescents
for Tobacco Dependence

CEU Question 10 | CEU Test | Table of Contents | Addictions
Social Worker CEUs, Psychologist CEs, Counselor CEUs, MFT CEUs

Adolescent smokers have less research available to facilitate their smoking cessation efforts. The existing research analyzes the reasons adolescents smoke, some of the factors that help them stop smoking, how they choose a method to stop smoking, which methods are more effective, and how to quantify an individual adolescent's addiction to nicotine. Stanton (1995), in one of many reports analyzing a cohort of 1,037 New Zealand youngsters, determined the prevalence of nicotine dependence among 18-year-old smokers. Stanton used the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (American Psychiatric Association [APA], 1987), criteria to assess dependence. Although 19% of the sample were tobacco dependent, the percentage jumped to 56% when the sample was narrowed to include only those 18-year-olds who had started smoking before the age of 15. Stanton found that the major reasons adolescents wanted to stop smoking were (a) cost, (b) health, (c) fitness, and (d) unacceptable/bad image. Although most adolescents in the study chose to quit on their own, most found it to be an ineffective strategy. These adolescents found that controlling the number of cigarettes smoked and keeping busy with other activities were far more effective strategies. Like their counterparts in Stanton's cohort, the adolescents studied by Hines (1996) chose to stop smoking on their own. They said their criteria for choosing a method included likelihood of success, convenience, and cost. Hines found that cost was a very important consideration for adolescents because the method they chose as most likely to be successful (nicotine patches) was only chosen by 2% of respondents, presumably because of cost. These adolescents overestimated the odds of successfully stopping smoking, especially those of the unassisted methods, perhaps indicating a high self-efficacy level.

Like adults, adolescents smoke to fill some emotional needs. Weinrich et al. (1996) discovered that adolescents are more likely to smoke to control stress if they have less social support. Adolescents who smoke have fewer anger-coping skills and are more likely to manifest somatic symptoms in response to anxiety when compared with adolescents who do not smoke under stress. Weinrich et al. noted that African American adolescents smoke less in response to stress than do White adolescents. There is evidence to suggest that African American youth use cigarettes to successfully augment their self-esteem (Crump, Lillie-Blanton, & Anthony, 1997). (Crump et al., 1997, found that adolescent African American girls [more so than boys] augmented their self-esteem by smoking. The authors speculated that these girls saw smoking as a way to improve their image among their peers.)

Conventional wisdom suggests that it might be easier for adolescents to stop smoking because they have not smoked as long as adults and perhaps do not smoke as much. Although it is easier for adult light smokers to quit (Rossi, Prochaska, & DiClemente, 1988), few adolescents succeed at stopping smoking (Stanton, 1995). The younger a person is when they start smoking, the less likely they are to succeed at quitting (Breslau & Peterson, 1996) and the deeper is their addiction (Stanton, 1995). From our observation, many adults, perhaps due to maturity, develop such a strong desire to stop smoking that they are able to overcome the effects of early initiation of smoking behavior and successfully stop smoking. Counselors need to be aware that many adolescents who smoke also use alcohol, often heavily (Patton et al., 1996), so smoking behavior may be indicative of other problems in adolescent clients. Adolescents smoke for some of the same reasons adults do — nicotine dependence and affect control. Like adults, most adolescents want to stop smoking on their own, but that is not the most effective means to achieve smoking cessation.

Comparing Adult And Adolescent Issues
It may be useful to study what happens in the years of transition between adolescence and adulthood. In a study of young adults, Rose, Chassin, Presson, and Sherman (1996) analyzed factors that made 18- to 32-year-olds more likely to try to stop smoking. As young people take on more adult social roles, such as work, marriage, and parenthood, the chances increase of making a "serious" quit attempt (not necessarily successful). Young adults ages 18 to 32 who attend college (see also Breslau & Peterson, 1996), gain employment, and do not see themselves as still smoking in 1 year are more likely to successfully stop smoking. Rose et al. also found that living with children or social pressures from others made a quit attempt less likely to succeed. Young adults were more likely to try to stop smoking if they thought there were personally relevant health effects from smoking.

Adolescents seem to have perceived high levels of self-efficacy. Adolescents not only believe they will stop smoking within 5 years (Hines, 1996), they also overestimate their chances of success (Stanton, Lowe, & Gillespie, 1996). Self-efficacy for adolescents increases with a peer-led smoking cessation program (Prince, 1995).

Social support is helpful for adults (Mermelstein et al., 1986) when they stop smoking, but it can have undesirable effects for adolescents. Adults who bring a support person with them to a stop smoking class are more likely to stop smoking (Mermelstein et al., 1986). Conversely, adolescents who attend a stop smoking class with a friend are less likely to be successful (Prince, 1995). Fortunately, the influence of peers during early adolescence seems to decline in late adolescence (Stanton, Currie, Oei, & Silva, 1996). People of all ages who have fewer smoking friends are more successful at quitting (Prince, 1995; Rose et al., 1996), although that is not always the case for young adults (Rose et al., 1996). Many adolescents are willing to help their peers stop smoking (Smart & Stoduto, 1997; Stanton, Lowe, et al., 1996). A peer-led smoking cessation program can be just as effective as one led by adults (Prince, 1995). When young adults try to quit because of social pressures from others, they are less likely to succeed (Rose et al., 1996). As young people take on more adult social roles, they are more likely to try to stop smoking (Rose et al., 1996).

Like adults, most adolescents prefer to quit smoking on their own (Glasgow et al., 1985; Hines, 1996). When adolescents choose a method to stop smoking, they consider issues of ease, cost, and likelihood of success (Hines, 1996). They believe quitting on their own is the most effective way, so they are more likely to choose that course of action (Hines, 1996). Unfortunately, they report that relying on their own will power is one of the least effective methods (Stanton, 1995). Counseling increases chances of success for adults (Jenks et al., 1969; Orleans et al, 1991; Zhu et al., 1996) and adolescents (Prince, 1995), even if it only increases the likelihood that the smoker will actually read smoking cessation materials (Glasgow et al., 1981) or cooperate with the process (Orleans et al., 1991). Success rates increase even with brief counseling (Condiotte & Lichtenstein, 1981; Glasgow et al., 1985; Orleans et al., 1991) and when counseling is done over the phone (Orleans et al., 1991; Zhu et al., 1996).

Stress relief is a major reason for smoking (Glasgow et al., 1985; Patton et al., 1996; Stanton, Lowe, et al., 1996; Weinrich et al., 1996; Zelman et al., 1992). Adults with a high degree of "perceived stress" are less likely to be successful quitters when compared with their more relaxed peers (Glasgow et al., 1985). Adolescents, especially girls, who are regular smokers (when compared with nonsmoking peers) complain of higher levels of anxiety and depression (Patton et al., 1996). From our observation, adults — especially women — also frequently smoke to alleviate anxiety and depression. Lack of anger-control skills contributes to stress-induced smoking among adolescents (Weinrich et al., 1996).

As adolescents take on the roles of adults, they are more likely to succeed at stopping smoking (Rose et al., 1996). Social support (Mermelstein et al., 1986; Orleans et al., 1991) and self-efficacy (Condiotte & Lichtenstein, 1981; Orleans et al., 1991; Zhu et al., 1996), factors that help adults stop smoking, may not have the same positive effect on adolescents. Adolescents arid adults smoke to control affect (Glasgow et al., 1985; Patton et al., 1996; Stanton, Lowe, et al., 1996; Weinrich et al., 1996; Zelman et al., 1992). Adults and adolescents both prefer to quit smoking on their own but would benefit from assistance (Jenks et al., 1969; Orleans et al., 1991; Prince, 1995; Zhu et al., 1996).

Counselors should be informed about the needs of adult and adolescent clients who smoke. Because smoking causes death and disease (CDC, 1997), all counselors should be knowledgeable about smoking cessation. The counseling literature provides some guidance for that purpose. For a client with high negative affect, the counselor can be supportive, at first, and then introduce skills training (Zelman et al., 1992). Recognizing that adults may prefer cognitive strategies (Glasgow et al., 1985), other effective coping skills such as distraction or substitution can be explained and recommended (Zhu et al., 1996). Simply keeping busy was reported as very helpful for adolescents (Stanton, 1995). Because stress relief is clearly a major component of a smoking habit (Glasgow et al., 1985; Patton et al, 1996; Stanton, Lowe, et al., 1996; Weinrich et al., 1996; Zelman et al., 1992), counselors should introduce stress management for such clients. Counselors can increase a client's motivation by helping him or her to discover personally relevant health effects from smoking (Rose et al., 1996).

Many questions have been raised by the research on smoking cessation. Does counselor assistance augment the success of clients' smoking cessation efforts only because it causes clients to work at quitting or to read self-help materials? What factors would influence a smoker to seek counselor assistance to stop smoking?

If more adult and adolescent smokers can be persuaded to seek help from a counselor in some format, these smokers may be more likely to successfully stop smoking. Because telephone counseling has been shown to have a success rate comparable with a group smoking cessation program, perhaps more interventions should be conducted using that format. Even a brief phone call to boost motivation and perceived self-efficacy can increase the chances that an adult will stop smoking (Zhu et al., 1996). Because adolescents prefer a less expensive yet effective means of stopping smoking (Mines, 1996), and they seem to do just as well when assisted by peers (Prince, 1995), perhaps the telephone would be a viable instrument to use for trained adolescents to conduct peer-led smoking cessation counseling.

Counselors should be aware of certain factors in the lives of their adolescent patients who seek smoking cessation assistance. Adolescents may already be dependent on nicotine; in fact, those whose initiation into smoking occurred before the age of 15 may be more addicted than adolescents who started smoking later (Stanton, 1995). Adolescents who smoke are more likely to report higher levels of anxiety and depression and may use alcohol (Patton et al., 1996). They may need extra help with anger-coping skills (Weinrich et al., 1996). Influence of peers weakens in late adolescence, but younger adolescents are more likely to smoke when those closest to them smoke (Stanton, Currie, et al., 1996). Social support (Mermelstein et al., 1986), an important asset in adult cessation, can have a different effect for adolescents (Prince, 1995). Counselors should use caution when suggesting that adolescents make use of support from friends in cessation efforts. Friends who smoke can perpetuate an adolescent's smoking habit; however, if fewer friends smoke, it is easier to quit, and if adolescents lead the effort to quit, it can be successful (Prince, 1995). More research needs to be done on the dynamics of peer support regarding adolescent smoking cessation.

More research is needed on the impact of self-efficacy for adolescents. Is adolescents' confidence in their ability to quit merely indicative of immaturity? Is the effect of self-efficacy on smoking cessation different for adolescents and adults? Should counselors try to augment the already high self-efficacy levels of adolescents?

More research is also needed on the dramatic increase in the rate of African American adolescent smoking (CDC, 1997). It has been shown that African American adolescents use cigarettes less than their White peers do to cope with stress (Weinrich et al., 1996); and they use cigarettes to boost their self-esteem (Crump et al., 1997). What factors account for the 80% increase in smoking rates over a 6-year period (CDC, 1997)? Has the tobacco industry developed very effective targeted advertisements to African American adolescents? Could smoking prevention programs in schools be biased toward the dominant culture? Are socioeconomic differences contributing to higher smoking rates? What other needs do cigarettes fill for African American adolescents, individually and collectively?

Adults and adolescents can benefit from the knowledgeable assistance of a counselor when making an attempt to stop smoking. Even brief intervention by a counselor to increase motivation and perceived self-efficacy can strengthen a client's attempt at smoking cessation. Research has identified similarities and differences between the experiences of adults and adolescents regarding issues that cause them to consider stopping smoking as well as succeeding with that goal. Counselors should consult the counseling literature for guidance in establishing a strategy for assisting clients in their efforts to stop smoking.
- Singleton, Mary G and Mark Pope; A Comparison of Successful Smoking Cessation Interventions for Adults and Adolescents; Journal of Counseling & Development; Fall 2000; Vol. 78 Issue 4

Personal Reflection Exercise #3
The preceding section contained information about the influence of coping skills on counseling adolescents for smoking cessation.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 10
What are four main reasons adolescents have for wanting to stop smoking? Record the letter of the correct answer the CEU Test

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