Project EX-4

Cigarette smoking and exposure to tobacco smoke cause an estimated 440,000 premature deaths each year in the United States.  Cigarette smoking accounts for at least 30% of all cancer deaths. Not all the health problems related to smoking result in death. Smoking affects a smoker's health in many ways, harming nearly every organ of the body and diminishing a person's overall health. 

Nationwide, 20% of high school students were smoking cigarettes in 2009. Each day 3,600 adolescents aged 12-18 try their first cigarette, and 1,100 additional adolescents become regular smokers. Quitting attempts by youth are rarely planned and typically unassisted and unsuccessful. As an assisted method, tobacco cessation programs have been shown to almost double the likelihood that a young smoker will succeed in quitting. 

Alternative high school (i.e. students who have transferred out of the regular school system in California due to functional problems, such as lack of credits and drug use) students report almost twice the amount of cigarette use in the last 30 days as regular high school students; students at these alternative schools who do not smoke are confronted with smoking among their peers on a daily basis. Therefore, alternative high schools are an appropriate setting to reach all students with educational programming to stop current use of tobacco and prevent potential future use. 

Project EX-4 is an adaptation of the previous Project EX program (based in the school clinic) to a classroom-based setting. Project EX-4 addresses smoking cessation among adolescent smokers and smoking prevention for nonsmokers.  The program stresses motivation, coping skills, and personal commitment. It uses engaging and motivating activities such as games, mock talk shows, and yoga to prevent, reduce, or stop smoking among adolescents. The program also teaches self-control, anger management, mood management, and goal-setting techniques. Adolescents are provided with accurate information about the social, emotional, environmental, and physiological consequences of tobacco use. 

Consisting of eight 40-45-minute sessions delivered over a 6-week period, the program curriculum includes strategies for coping with stress, dealing with nicotine withdrawal, and avoiding relapses. The first four sessions are held in a 2-week period and are intended to prepare students for an attempt to quit smoking. The second four sessions are held approximately once per week during the following month, focusing on intentions not to use tobacco or attempts to quit.  The classroom-based sessions are delivered to all students enrolled in the subject area selected by the school for program implementation (e.g., health, science, biology, or physical education).

The Project EX-4 classroom program consists of eight 40-45-minute sessions delivered over a 6-week period.

The intended audience for Project EX-4 is students (both smokers and nonsmokers) attending alternative high schools.

Project EX-4 is implemented in classrooms in alternative high schools.

-Project EX Teacher's Manual
-Project EX Student Workbook
-Audio exercise files
-Four questionnaires (Project EX-4 pretest, posttest, 6-month follow-up, 1-year follow-up)

The current study examined maintenance of effects of the Project EX-4 program on 6-month and 1-year self-reported weekly and monthly cigarette smoking. Twelve alternative high schools in four southern California counties were randomly assigned to receive Project EX-4 or standard care, which consisted of the tobacco prevention or cessation activities, if any, provided directly by the school.  Participants were 1,097 students, aged 13-19 (mean age=16.5 years, SD=1.0 year). The sample was 62.7% male; 16.4% White, 70.9% Hispanic, 3.5% Asian, 5.1% African American, and 4.1% other ethnicity.  Smoking behavior was assessed at pretest and at three posttest intervals (immediate, 6 months, and 1 year). Items assessed included weekly use of cigarettes, which was assessed with the fill-in-the-blank item asking, "How many cigarettes have you smoked in the last 7 days?" and a similarly constructed item that assessed monthly (last 30-day) use of cigarettes.  For analyses reported here, data were recoded to form a dichotomous variable, such that a report of zero cigarettes smoked was considered "nonsmoking" and a report of one or more cigarettes smoked was considered "smoking."  A pipeline assessment protocol was also conducted where self-reported weekly and monthly cigarette use were measured together with carbon monoxide level in expired breath samples.

• After adjusting for baseline cigarette smoking, baseline nicotine dependence level, age, gender, and ethnicity, students participating in the Project EX-4 program experienced a significantly greater decrease in prevalence of weekly and monthly smoking at both 6-month and 1-year follow-ups. At the 6-month follow-up, the program reduced the prevalence of weekly and monthly smoking by 7.6% (p<.01) and 6.0% (p<.01), respectively. At the 1-year follow-up, the program reduced the prevalence of weekly and monthly smoking by 5.1% (p<.05) and 6.9% (p<.01), respectively. 

• Last 30-day smoking quit rate was examined among students who smoked during the last 30 days before the baseline survey. The smoking quit rate in the control group was 12.8%, 24.8%, and 24.3% at the immediate posttest, 6-month, and 1-year follow-ups, respectively. The quit rates among former smokers who received the Project EX-4 program were 25.3%, 30.6%, and 30.7%, respectively. The quit rate was significantly higher among students who received the Project EX-4 program compared to students in the control group at immediate posttest (p=.004) and 1-year follow-up (p=.05).