Smoking Cessation

Getting young adults to quit smoking: A formative evaluation of the X-Pack Program

Lorien C. Abroms, Richard Windsor, Bruce Simons-Morton

Received 29 November 2006; accepted 9 June 2007

The lack of promising smoking cessation interventions targeting young adults is a recognized public health problem. This study was designed to determine the feasibility of a young-adult-oriented program, the X-Pack Program, when administered to college student smokers, and to estimate its effect on smoking cessation. Participants (N583) were randomized after enrollment to receive either a moderately intensive, E-mail-based, young-adult intervention (the X-Pack group) or a less-intensive program aimed at a general adult audience (the Clearing the Air group). Participants were assessed at baseline and at 3 and 6 months after enrollment. Participants in the X-Pack group rated their treatment more favorably overall, were more engaged in program activities, and quit for more consecutive days at the 3- and 6-month follow-ups, compared with the Clearing the Air group. Differences in quit rates favored the X-Pack group at the two follow-ups, but the differences were not significant. These findings offer some support for the X-Pack Program when administered to college smokers.

Introduction

An estimated 23.6% of young adults aged 18–24

years are current smokers (Centers for Disease

Control and Prevention [CDC], 2005). Whereas

smoking rates continue to decline for adults, they

have remained steady for young adults and have

increased for some subgroups (CDC, 2005; Lantz,

2003; Wechsler, Rigotti, Gledhill-Hoyt, & Lee, 1998).

The high level of smoking among young adults has

been partially attributed to the targeted marketing of

tobacco products to young adults (Ling & Glantz,

2004; Sepe, Ling, & Glantz, 2002).

Few smoking cessation programs are aimed at

young adults (Abrams et al., 2003; Curry et al.,

2007). In a nationally representative survey of

smoking cessation programs that serve adolescents

and young adults, only 5.6% were found to serve

primarily young adults (Curry et al., 2007). Of young

adult programs that have been evaluated (Ames et

al., 2005; Escoffery, McCormick, & Bateman, 2004;

Klesges et al., 2006; Obermayer, Riley, Asif, & Jean-

Mary, 2004; O’Neill, Gillispie, & Slobin, 2000;

Rutter, 1990), a handful have been successful in

promoting smoking cessation (Klesges et al., 2006;

Obermayer et al., 2004; Rutter, 1990). These studies

are limited in their reliance on informal designs that

lack randomization or a control group (Obermayer

et al., 2004; Rutter, 1990) and in their use of self-

report of smoking status without biochemical valida-

tion (Klesges et al., 2006; O’Neill et al., 2000). These

studies also are limited in their generalizability, as

participants consist largely of college students

(exceptions include Ames et al., 2005, and Klesges

et al., 2006). The lack of promising interventions

targeting young adults is a recognized public health

problem (Abrams et al., 2003; Backinger, Fagan,

Matthews, & Grana, 2003; Curry, 2003; Lantz, 2003;

Orleans et al., 2003).

Young adulthood represents a distinct develop-

mental period of the life course (Arnett, 2000).

Young adults face unique challenges associated with

the transition to independent living, job and career

selection, partner selection, and parenthood (Arnett,

2000; Goldscheider & Goldscheider, 1999). Young

ISSN 1462-2203 print/ISSN 1469-994X online # 2008 Society for Research on Nicotine and Tobacco

DOI: 10.1080/14622200701767852

Lorien C. Abroms, Sc.D., Richard Windsor, Ph.D., George

Washington University School of Public Health and Health Services,

Washington, DC; Bruce Simons-Morton, Ph.D., National Institutes of

Health, Bethesda, MD.

Correspondence: Lorien C. Abroms, George Washington University

School of Public Health and Health Services, 2175 K. Street, NW, 7th

floor, Washington, DC 20037, USA. Tel: +1 (202) 416-0482; E-mail: [email protected]

Nicotine & Tobacco Research Volume 10, Number 1 (January 2008) 27–33

adulthood is also marked by being a period in the life

course when risk behaviors tend to increase, includ-

ing an increase in cigarette smokers (Johnston,

O’Malley, & Bachman, 2003).

Young adults are distinct in their smoking patterns

and characteristics. Compared with younger smo-

kers, young adults have a higher prevalence of

smoking and are more likely to be regular smokers

and to smoke more cigarettes per day (CDC, 2003;

Johnston et al., 2003). Compared with older adult

smokers, young adults smoke at a similar rate,

although they smoke fewer cigarettes per day, are less

addicted to nicotine, and are more likely to express

interest in quitting and have tried to quit recently

(CDC, 2003). Despite their higher level of quit

attempts, young adults are less likely to succeed in

a given quit attempt compared with older adults

(CDC, 2006a; Garvey, Bosse, Glynn, & Rosner,

1983).

These differences in stage of development and

smoking characteristics suggest that young adults

might benefit from smoking cessation programs

developed around their own needs and preferences

(Andreasen, 1995). This belief motivated the develop-

ment in 2001 of a smoking cessation kit aimed at

young adult smokers called the X-Pack (Abroms,

Winickoff, Lowell, & Mobley, 2003; Population

Services International, unpublished). To date, more

than 20,000 X-Packs have been distributed to young

adult smokers in the United States. This study was

designed to determine the feasibility of a young-adult-

oriented program based on the X-Pack and to estimate

its effect on smoking cessation. Specifically, this study

investigated whether, for a college population, the X-

Pack Program—which included the X-Pack kit and a

series of counseling E-mails—would result in higher

levels of program participation and engagement,

higher levels of participant satisfaction, and more

favorable smoking cessation outcomes compared with

a less-intensive generic program.

Method

Sample

Participants were 83 smokers, who were 18–23 years

old and undergraduate students at a university in the

Washington, D.C., metropolitan area. Eligibility for

this study included being a student (full or part time),

smoking at least 1 cigarette/day in each of the past 7

days, being aged 18–24 years, and being interested in

quitting smoking in the next 6 months. College

students were selected because they represent a

significant proportion of young adults (Lantz,

2003), their smoking prevalence is high (28%;

Wechsler et al., 1998), and they have nearly universal

access to E-mail (Escoffery et al., 2005).

Recruitment was conducted in the fall and spring

of 2004–2005, after the study received institutional

review board approval from George Washington

University and the National Institutes of Health.

Recruitment included the use of flyers and ads in the

college newspaper and a study-staff table outside the

student center. A total of 243 students expressed

some interest in participating and provided contact

information. Of those, 135 students (55.6%) were

able to be recontacted. Of those recontacted, 83

enrolled (61.5%), 44 (32.5%) were no longer inter-

ested in participating, and 8 (5.9%) were ineligible

(two for being too old, four because of smoking less

than 1 cigarette/day, and two for not being students).

Participants were offered financial compensation

for completing the 3-month and 6-month assessment

surveys (US$10 and $15, respectively) but not for

completing the baseline survey. Participants who

reported 7-day abstinence at the 6-month follow-up

were paid an additional $10 for a saliva sample for

cotinine analysis.

Procedures and measurement

Participants were randomized after enrollment to

receive either a moderately intensive, young-adult-

oriented intervention (the X-Pack Program) or a less-

intensive program aimed at a general adult audience

(the Clearing the Air [CTA] Program). Counselors

were assigned a list of identification numbers for

enrolled participants, each of which was randomly

assigned to a participant’s condition. Enrolled

participants were assessed in-person at baseline and

over the phone at 3- and 6-months postenrollment.

Participants who reported during the 6-month

follow-up interview that they had quit smoking met

with research staff in the 2 weeks following the

interview to provide a saliva sample.

The primary smoking cessation outcome of this

study was past 7-day abstinence from smoking at 6

months, which was measured by self-report and

verified by salivary cotinine analysis ((10 ng/ml of

cotinine; Etzel, 1990). Secondary outcomes included

self-report of reductions in the quantity and

frequency smoked. Nicotine dependence was mea-

sured with the Fagerström Test for Nicotine

Dependence (FTND; Heatherton, Kozlowski,

Frecker, & Fagerström, 1991). Depression was

measured with the Center for Epidemiologic

Studies Depression (CES-D) scale (Radloff, 1991).

Process measures—which were assessed as part of

the 3-month survey—included measures of treatment

rating (e.g., ‘‘I liked the program’’), rated on a 5-

point Likert scale from ‘‘strongly disagree’’ to

‘‘strongly agree,’’ and measures of participation in

the quitting process (e.g., ‘‘Did you call a friend or

family member to help with urge?’’), rated on a

28 A FORMATIVE EVALUATION OF THE X-PACK PROGRAM

4-point scale from ‘‘never’’ to ‘‘always.’’ Several

process measure items were specific to the X-Pack

Program (e.g., ‘‘How many of your E-mails did you

read?’’) and therefore were asked only of participants

in the X-Pack group. Also specific to the X-Pack

Program was a measure of E-mail responses received

by counselors. These responses were tabulated from

computer records by counting the number of

instances each participant replied to his or her

counselor after receiving a counseling E-mail.

Data were analyzed by calculating means and

percentages of our key measures for the X-Pack and

CTA groups; t-tests and chi-square tests were used to

determine whether differences between groups were

statistically significant.

Intervention

X-Pack Program. The X-Pack Program consisted of

an in-person counseling session lasting 15 min, a self-

help kit (the X-Pack), and a series of counseling E-

mails. The goal of the in-person counseling session,

which took place in public spaces around the college

campus, was to introduce the participant to the X-

Pack kit, review key information related to smoking

cessation presented in the kit, and to encourage the

participant to set a quit date in the next month. Over

the course of 6 months following the in-person

counseling session, each participant was sent 10–12

counseling E-mails. The intervention components—

the in-person counseling, the kit, and the E-mails—

promoted a common five-step cognitive–behavioral

program for quitting smoking based on social–

cognitive theory (Bandura, 1986). These steps

involved (a) increasing positive outcome expectations

associated with quitting, (b) enlisting a QuitPal, a

friend for social support, (c) setting a quit date, (d)

developing the skills for overcoming cravings, and (e)

quitting and preventing relapse.

The X-Pack kit resembles an oversized pack of

cigarettes and includes a smoking cessation guide-

book, wallet-sized quitting cards; a motivating slide

rule, and various products for use as a substitute to

cigarettes (gum, toothpicks, and putty; Figure 1). The

X-Pack kit was developed specifically for young

adults and involved an intensive year of formative

research with young adults (Abroms et al., 2003;

Population Services International, unpublished).

The counseling E-mails were written by staff

counselors for each participant based on a set of

templates developed from the content of the X-Pack

guidebook and tailored to the participant’s reasons

for smoking, smoking triggers, chosen quit date, and

other information collected at baseline. Participants

were encouraged to reply by E-mail to their

counselors with questions and comments, and to

update their counselors on their cessation progress.

E-mails were sent out weekly for the first month and

then monthly for the following 5 months. Additional

E-mails were sent out around the participant’s quit

date (1 day prequit, on the quit date, 4 days postquit,

and 2 weeks postquit). E-mail counseling was seen as

preferable to phone counseling because young adults

consistently rank phone counseling as low on their

list of preferred assisted options (Abroms et al., 2003;

Lawrance, 2001) and because of the nearly universal

access to E-mail among college students (Escoffery et

al., 2005). Results on the feasibility of the E-mail

component of the X-Pack intervention are reported

elsewhere (Abroms, Windsor, & Simons-Morton,

unpublished).

Counselors, who were undergraduates and masters

of public health students, underwent an 8-hr training

course in smoking cessation counseling. They were

also required to write a series of E-mails for a

hypothetical participant, which were reviewed by the

study supervisor for accuracy of content and

conformance to the study protocol. For their first

month of counseling participants, counselors were

required to first get supervisor approval of E-mails

before sending them out. Counselors met on a weekly

basis with the supervisor to discuss issues pertaining

to participant counseling.

Clearing the Air Program. The CTA Program con-

sisted of an in-person counseling session lasting

15 min and self-help materials (Clearing the Air,

developed by the National Cancer Institute; U.S.

Department of Health and Human Services, 2003).

Similar to the X-Pack Program, the goal of the in-

person counseling session was to introduce the

participant to the materials, go over key information

Figure 1. The X-Pack Smoking Cessation Kit. Contents of X-Pack: (a) Quitting booklet, (b) X-Pack Quit Cards, (c) Success-O-Meter/Ick-U-Lator (slide card showing the harmful chemicals in cigarettes on one side and the money saved and health benefits of quitting on the other side), (d) Wrigley’s Orbit chewing gum, (e) Hotlix cinnamon toothpicks, (f) Preoccupation Putty.

NICOTINE & TOBACCO RESEARCH 29

related to smoking cessation as presented in the

materials, and encourage the participant to set a quit

date in the next month. After the in-person counsel-

ing session, the participant was not provided with

additional assistance in quitting.

Results

Preliminary analyses were conducted to identify pre-

existing differences between the two groups. No

significant differences were found between the two

groups at baseline in demographic characteristics or

smoking characteristics (Table 1). Participants were

on average 19.8 years old, the majority (77.1%) were

of White ethnicity, they smoked on average 9.1

cigarettes/day, and they had relatively low levels of

nicotine dependence. Slightly more males (54.2%)

enrolled than females. Follow-up rates for the sample

were 86.7% at 3 months and 68.7% at 6 months.

Fifty-nine percent of the 17 self-reported quitters at 6

months provided cotinine samples. We found no

significant differences in follow-up rates between

groups at either time point or for the cotinine sample.

One of our hypotheses was that the X-Pack

Program would result in higher levels of program

participation and engagement than the CTA

Program. We found this to be true for several

participation variables examined in both groups at

the 3-month follow-up (Table 2). Although partici-

pants in both groups reported having made a quit

attempt at high levels, those in the X-Pack group

were more likely to report having made a quit

attempt (p,.05). The X-Pack group also was more

likely to use a range of cognitive–behavioral techni-

ques for coping with urges to smoke. They were more

likely to have called up a friend or family member for

help with an urge or a craving (p,.05), to have used

the 4D’s technique for dealing with a craving (delay

from smoking, deep breathing for 10 breaths, drop a

piece of gum in mouth, and distract yourself;

p,.001), and to have read over their own reasons

for quitting smoking (p,.01). No significant differ-

ences were found for setting a quit date, use of

nicotine replacement therapy, or readership of the

guidebook.

In addition to these activities, which cut across

both groups, participation was assessed for activities

specific to the X-Pack Program. At the 3-month

follow-up, the vast majority of participants (91.6%) indicated that they had read most or all of their E-

mails from their X-Pack counselor. In addition,

almost half had replied to their counselor’s E-mails

three or more times during the intervention period.

More than half of participants reported using the

components of the X-Pack kit regularly, with gum

being the most popular, follow by hand putty,

toothpicks, and, last, the slide rule.

Participants also rated the X-Pack intervention

more favorably. On a 5-point Likert scale, partici-

pants from both groups rated themselves between ‘‘neutral’’ to (3) and ‘‘agreeing’’ with (4) the

statement that they had liked their program and

that they would recommend their program to friends.

However, participants in the X-Pack group gave

higher ratings of their program liking (3.8 for X-Pack

vs. 3.3 for CTA; p,.05) and willingness to recom-

mend the program to friends (4.1 for X-Pack vs. 3.5

for CTA; p,.01).

Table 3 presents cessation outcomes at 3 and 6

months postenrollment. An intent-to-treat analysis

was conducted, and those lost to follow-up were imputed to still be smoking or to have no days

without smoking. Overall, the smoking cessation

outcomes favored the X-Pack condition, although

only some of the results were significantly different.

At 3 months, based on self-report of past-7-day

smoking, 31.3% of the X-Pack group and 20.0% of

the CTA group had quit smoking. The odds of self-

reported quitting were nearly twice as great in the

Table 1. Baseline characteristics of participants.

Characteristic Total participants (N583) X-Pack group (n548) CTA group (n535)

Mean age, years (SD) 19.8 (1.3) 19.8 (1.3) 19.8 (1.2) Gender (%)

Female 45.8 47.9 42.9 Male 54.2 52.1 57.1

Race/ethnicity (%) White 77.1 72.9 82.9 Asian 3.6 4.2 2.9 Black 2.4 0.0 5.7 Hispanic 1.2 2.1 0.0 Other 15.7 20.8 8.6

Lives with smoker (%) 37.4 37.5 37.1 Mean cigarettes/ day (SD) 9.1 (6.2) 9.9 (6.5) 8.0 (5.6) Mean past quit attempts (SD) 2.4 (1.5) 2.5 (1.6) 2.3 (1.4) Mean depression total score (CES-D) (SD) 11.4 (7.4) 11.8 (8.5) 10.9 (5.6) Mean baseline nicotine dependence (FTND) (SD) 1.9 (1.8) 2.1 (1.8) 1.5 (1.6)

Note. No significant differences were found between groups for variables included in the table.

30 A FORMATIVE EVALUATION OF THE X-PACK PROGRAM

X-Pack group (OR51.81, 95% CI 0.65–5.09). At 6

months, 25.0% of the X-Pack group and 14.3% of the

CTA group had quit smoking (OR52.00, 95% CI

0.63–6.32). Based on biochemical verification of

cotinine levels of the self-reported quitters who

provided saliva samples at 6 months (58.8% of self-

reported quitters), and using an analysis in which

those lost to follow-up were assumed to be smoking,

quit rates were reduced to 10.2% for the X-Pack

group and 5.7% for the CTA group (OR51.92, 95%

CI 0.35–10.52; ns). Based on the cotinine analysis, the

deception rate was found to be 28.6% for the X-Pack

group and 33.3% for the CTA group (ns).

At 3 months, participants in the X-Pack group had

quit for twice as many consecutive days compared

with the CTA group (p,.05). At 6 months,

participants in the X-Pack group had quit for almost

three times as many consecutive days compared with

the CTA group (p,.05). Participants in the X-Pack

group also reported at 3 months that three times as

many days had passed since their last cigarette,

compared with the CTA group (p,.05). At 6

months, the difference had declined to just under

three times as many days since smoking their last

cigarette, a difference that was not statistically

significant. Whereas individuals in the X-Pack group

also experienced greater declines in cigarettes smoked per week between baseline and the 3- and 6-month

follow-ups, these results did not reach significance.

Discussion

This study was designed to document the feasibility

of a moderately intensive, young-adult-oriented

smoking cessation program (the X-Pack Program). Participants in the X-Pack group were found to be

more engaged in the program activities, to rate their

treatment more favorably overall, and to have quit

for more consecutive days at 3- and 6-month follow-

ups. Differences in quit rates between the groups

favored the X-Pack Program but were not signifi-

cant.

Members of the X-Pack group were more likely to

have made a quit attempt and to have adopted

cognitive and behavioral techniques for coping with urges to smoke. Most of these techniques were

mentioned in both sets of guidebooks and in both

sets of in-person counseling sessions. The greater

adoption of techniques by the X-Pack group may be

related to the more favorable ratings of the X-Pack

Table 2. Exposure to and participation in cessation program (%).

All X-Pack group (n541) CTA group (n531) p value a

Set a quit date 91.7 95.1 87.1 Made at least one quit attempt 87.5 95.1 77.4 * Called friend or family member to help with urge

b 40.3 53.7 22.6 **

Used the 4D’s to deal with craving b

57.0 78.1 29.0 *** Used nicotine replacement therapy 15.3 19.5 9.7 Read over reasons for quittingb 77.8 90.2 61.3 ** Read most/all of the guidebook 58.3 56.1 61.3 Read most/all of the E-mails 91.6 Replied to three or more E-mails

c 48.0

Used contents of X-Pack regularly Gum 80.7 Hand putty 65.1 Toothpicks 63.9 Slide rule 59.0

Note. a Calculated with chi-square tests.

b Percent ever vs. never.

c Tabulated from computer records of E-mail responses received by

counselors. *p,.05; **p,.01; ***p,.001.

Table 3. Smoking cessation outcomes at 3 and 6 months by group.

Outcome

3-Month follow-up 6-Month follow-up

X-Pack group (n548) CTA group (n535) p value

a X-Pack group

(n548) CTA group

(n535) p value a

Quit rate (self-report of past-7-day smoking) b

31.3 20.0 25.0 14.3 Quit rate (cotinine verified)

b 10.2

d 5.7

Days since last cigarette (SD) c

13.7 (22.9) 4.5 (9.1) * 20.0 (47.6) 7.7 (23.1) Consecutive days quit (SD)c 16.3 (17.7) 8.1 (10.0) * 34.0 (49.3) 13.4 (24.4) * Change in number of cigarettes smoked/week

from baseline (SD) 241.9 (45.0) 229.8 (35.8) 235.9(36.4) 223.0(28.2)

Note. a Calculated with t tests and chi-square tests.

b Missing assumed to still be smoking.

c Missing assumed to have no days without

cigarettes. d 59.0% of self-reported quitters provided saliva samples for cotinine analysis. *p,.05; **p,.01; ***p,.001.

NICOTINE & TOBACCO RESEARCH 31

Program, which may have predisposed participants

to follow the program’s prescribed quitting activities.

Alternatively, the higher level of adoption of

techniques may be the result of the additional

mention of these techniques in the E-mails, which

only the X-Pack group received.

Also, participants reported reading their E-mails

at much higher rates than their guidebook. Whereas

92% of the X-Pack participants read ‘‘most’’ or ‘‘all’’

of their E-mails, only 58.3% of all participants read

‘‘most’’ or ‘‘all’’ of their guidebook, and the

difference between groups was not significant. This

finding provides some evidence that E-mail is an

appropriate platform for reaching college students

with health information, and it may be a more

promising platform than standard print materials.

The quit rates between the two groups were not

significantly different at 3 or 6 months. Nevertheless,

the trends were encouraging. At 6 months, both

based on self-report and with biochemical validation,

quit rates were about twice as high in the X-Pack

group. The quit rate of 10.2% is comparable with

other minimally invasive interventions in adults such

as those with phone counseling followed by multiple

mailed tailored materials (Strecher et al., 2005) and is

more than twice as high as the estimated natural quit

rate in youth of 4% (CDC, 2006b).

Also encouraging for the X-Pack Program was

that the average number of consecutive days quit was

almost twice as high in the X-Pack group at 3 months

(p,.05) and almost three times as high in the X-Pack

group at 6 months (p,.05). It is somewhat surprising

that the magnitude of difference increased between 3

and 6 months, especially given that the X-Pack

intervention—at just one E-mail per month between

3 and 6 months—was quite minimal. These E-mails

may have worked by sustaining participants’ motiva-

tion to quit. This finding implies that a monthly

counseling E-mail might be helpful in prolonging the

effects of other brief and intensive smoking cessation

interventions (e.g., physician advice, phone counsel-

ing at a quitline) over time. Given that so little work

has been conducted on the applications of E-mail for

promoting smoking cessation (exceptions include

Etter, le Houezec, & Landfeldt, 2003, and Lenert,

Muñoz, Perez, & Bansod, 2004), further research in

this area is recommended.

The present study had several limitations. First,

because of the study design, it is unclear what aspect

of the X-Pack Program—whether its targeting of

young adults or its inclusion of an E-mail component

(and the associated increase in contact time)—led to

the favorable outcomes associated with the interven-

tion. Future studies should evaluate the effect of the

E-mail component alone, as well as consider the

effect of variations in the source of E-mails

(counselor written and sent versus computer

generated and sent) and in the frequency by which

E-mails are sent.

This study also is limited by a small sample size

and an inclusion of only college students, which

limits its generalizability. As most studies of young-

adult smoking cessation have used college student

samples (Escoffery et al., 2004; Obermayer et al.,

2004; O’Neill et al., 2000; Rutter, 1990), future

studies are very much needed that focus on young

adults outside the college setting.

Strengths of the study include the testing of a

novel, theory-based program aimed at a population

with high smoking prevalence. The findings from this

study indicate that a program targeted to young

adults that includes sequential E-mails and a self-

help kit is feasible and may be more acceptable and

more effective for smoking cessation than a generic

less-intensive program. Furthermore, a monthly E-

mail sent post–quit date may be effective at sustain-

ing quit attempts and preventing relapse following a

more intensive intervention.

Acknowledgments

This study was supported by order #263-MD-510757 to George Washington University from the NICHD. The authors thank the study

staff for their dedication to the project, especially Lisa Ramirez, Ilana

Dickman, and Jennifer Gill.

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