A Smoking Prevention Interactive Experience (ASPIRE)

More than 600,000 middle school students and 3 million high school students smoke cigarettes. Although tobacco use by adolescents has declined significantly in the last 40 years, about 1 in 10 high school seniors were daily smokers in 2011, according to the Office of Adolescent Health, U.S. Department of Health and Human Services.  Centers for Disease Control and Prevention data show that adverse health effects from cigarette smoking cause an estimated 443,000 deaths, or about 1 of every 5 deaths, each year. In addition to causing lung diseases such as emphysema, bronchitis, and chronic airway obstruction, cigarette smoking causes many types of cancer, most notably lung cancer, but also acute myeloid leukemia and cancers of the bladder, cervix, esophagus, larynx, pharynx, oral cavity, kidney, pancreas, and stomach.  Nearly all tobacco use begins in youth and young adulthood, with 88% of adult daily smokers having smoked their first cigarette before they were 18 years old.  Helping teens and young adults avoid initiating tobacco use will help them live longer and healthier lives.

A Smoking Prevention Interactive Experience (ASPIRE) is an interactive, multimedia smoking prevention and cessation curriculum for culturally diverse high school students.  ASPIRE was developed jointly by the MD Anderson Cancer Center and The University of Texas Health Science Center at Houston.  Originally developed as a CD-ROM program for classroom use, the curriculum is now delivered exclusively as a self-paced, online program through the MD Anderson Cancer Center's ASPIRE Website.

ASPIRE is based on social cognitive theory, which posits that people learn by observing what others do and will not do, and the Transtheoretical Model of Change, which assesses an individual's readiness to change and provides stage-based strategies to move an individual to act and adopt a new healthier behavior. The main goal of the program is to help students choose a tobacco-free lifestyle.

The original CD-ROM version of the intervention, which was evaluated in the 4-year randomized clinical trial reviewed for this summary, centered on a nine-stage model of change that is specific to smoking prevention and cessation among adolescents. For the nonsmoker, the stages of change leading to the prevention of smoking acquisition are (1) acquisition -- precontemplation, (2) acquisition --contemplation, (3) acquisition -- preparation, and (4) recent acquisition. For the smoker, the stages of change leading to cessation are (5) precontemplation, (6) contemplation, (7) preparation, and (8) action. Stage 9, maintenance, applies both to nonsmokers who did not initiate smoking and smokers who quit. Participants were classified into one of the eight smoking acquisition or cessation stages at the start of each session (1-4 for nonsmokers, 5-8 for smokers).  Participants were then provided with a series of activities tailored to stage of intention to promote movement through the stages toward smoking cessation (for smokers) or reduced likelihood of initiation (for nonsmokers). Animations, video segments, and interactive activities designed to be culturally appropriate for the target population were used to engage cognitive processes facilitating progression through the stages of change.

The online ASPIRE program now being disseminated differs from the earlier version in that the same instructional and behavior-change information is delivered to all participants regardless of smoking status and stage of change.  Available in English and Spanish versions, the online program takes about 3.5-5 hours to complete and includes five learning modules, each with pre-and posttests/quizzes, and a participant satisfaction survey.  Participants receive information about mental health and smoking cessation resources and a certificate upon completing the curriculum.

The online program takes about 3.5-5 hours to complete. The modules are self-paced and can be completed over several sessions.

ASPIRE is designed for middle and high school students. In the randomized clinical trial, the intervention was evaluated with students in 10th through 12th grade to capture both nonsmokers and smokers.

Students can access ASPIRE from any location with broadband Internet access, including home (e.g., as an extra-credit assignment) or school (e.g., in an afterschool setting or as an alternative to suspension for smoking on school grounds). It has been used by school districts as a complement to physical education and health curriculum already in place but also can be appropriate for local volunteer organizations, departments of health, hospitals, health insurance carriers, or other organizations interested in tobacco prevention education.

Materials required for implementation include:
-- ASPIRE Website

For the costs associated with the program, please contact the developer: Alexander Prokhorov. (See products page on the EBCCP website for developer contact information.)

A 4-year, nested-cohort, group randomized clinical trial compared the effects of the CD-ROM-based ASPIRE curriculum and the National Cancer Institute's Clearing the Air self-help booklet (standard care) on smoking initiation at 18-month follow-up in culturally diverse 10th-grade students from 16 urban high schools.  Participants were recruited during assembly and in-class presentations by Project ASPIRE staff and school personnel. Study eligibility required that participants could speak, read, and write in English and submit a signed informed consent form (provided in English and Spanish). 

A total of 2,500 students were invited to participate; 1,935 provided informed consent, and 1,608 completed the baseline survey (an 87-item self-report questionnaire), for a participation rate of 64.3% overall and 83.1% among students for whom informed consent was received. Baseline data were analyzed for the 1,574 participants who reported their smoking status in the baseline survey.  The mean age of participants was 15.6 years in the intervention group and 15.8 years in the comparison group; the randomized sample was 58.8% female, 50.6% Hispanic, 39.5% African American, and 5.9% Caucasian.

Participants' sociodemographic characteristics and smoking status were established through the baseline survey.  Participants were characterized as smokers if they reported they "smoke every other week", "smoke less than a pack a week", "smoke one pack a week", "smoke more than a pack a week", "smoke a pack a day", or "smoke more than a pack a day." Students who were not current smokers were classified as never smokers ("never smoked even part of a cigarette"), experimenters ("only smoked part of a cigarette" or "smoked only a few times") or former smokers ("used to smoke regularly but quit in last 12 months" or "quit more than 12 months ago"). 

The intervention was delivered in five weekly sessions in one semester and two booster sessions in the following semester. Each session was 30 minutes in duration. Students accessed the intervention using desktop computers in the classroom during regular lesson periods.

The study assessed the rate of smoking initiation at 18-month follow-up, defined as the proportion of participants who were nonsmokers at baseline and reported current smoking at follow-up. To determine whether secondary factors known to influence smoking behavior in adolescents had a mediating effect on this outcome, the following secondary outcomes were also measured:

-- Decisional balance, measured by a 12-item Likert scale on which a higher score indicates higher agreement with reasons not to smoke

-- Temptations to smoke, measured by the Temptations to Try Smoking Inventory, a 10-item scale on which a lower score indicates fewer temptations to smoke

-- Self-efficacy, measured by a 10-item scale that asks respondents "how confident are you to resist?" in various situations

-- Aids to smoking resistance (resistance skills), measured by a 14-item questionnaire on which each item was rated on a scale from 0 ("doesn't help at all") to 5 ("helps a lot")

The follow-up rate at 18 months was 72.1%.  Although the intervention group had a higher percentage of Hispanic students than the comparison group, Hispanic ethnicity was not significantly related to the outcomes, and the interaction between ethnicity and condition was not significant.  There were no missing data for the main outcome, and the few missing score values for the secondary, mediating outcomes were addressed by the statistical modeling of the dataset.

• At 18-month follow-up, the percentage of baseline nonsmokers who had initiated cigarette smoking was smaller in the intervention group than in the group receiving standard care (1.9% vs. 5.8%, p<.05).  In both groups, students classified as never smokers at baseline had the lowest rate of smoking initiation. All 1.9% of baseline nonsmokers in the intervention group who reported initiating cigarette smoking at 18-month follow-up were of Hispanic origin.

Additional Findings

• At 18-month follow-up, students in the intervention group had higher decisional balance scores against cigarette smoking (p<.05) and lower temptation to smoke scores (p<.05) than students in the comparison group after controlling for baseline scores and school of origin.