Program Profile: Project EX

This is a school-based tobacco cessation program for high school students, which incorporates motivational activities to discourage smoking. The program is rated Promising. Participants in the treatment groups had a statistically significant lower likelihood of reporting tobacco use in the past 30-days, compared with participants in the control group.

A Promising rating implies that implementing the program may result in the intended outcome(s).

A Promising rating implies that implementing the program may result in the intended outcome(s).

Program Goals

Project EX is a school-based tobacco cessation program that targets high school youth between the ages of 14 and 19. The program is delivered in a clinical setting in school and involves motivational activities such as games, mock talk shows, and alternative activities such as yoga. The goal of the program is to encourage youths to stop or reduce cigarette smoking by providing information about environmental, social, physiological, and emotional consequences of tobacco use. Students participating in Project EX learn information about tobacco addiction and disease and gain an empathic understanding of the effects of tobacco use on friends. The curriculum emphasizes coping with stress, dealing with nicotine withdrawal, relaxation techniques, and how to avoid relapse. It aims to teach self-control, anger and mood management, and goal-setting techniques.

Program Theory

Teenagers who smoke usually fail to quit for three main reasons: social influences, chemical dependency, and lack of motivation (Sussman, Dent, and Lichtman 2001). Project EX uses these reasons as the theoretical framework for the design of the program. By teaching youth new skills to cope with or avoid tobacco use, giving them accurate information on how to manage withdrawal symptoms, and engaging youth in discussions on why they should discontinue their tobacco use, Project EX works to motivate youth to make positive changes to current behaviors and future life goals.

Program Components

Students use an interactive curriculum to examine the difference between habits and addictions, how tobacco use actually increases stress, and how it is easier to quit at a younger age. Project EX consists of eight sessions that are delivered over 8 weeks—two sessions a week for 2 weeks, followed by one session a week for 4 weeks. Project EX uses a variety of exercises such as healthy breathing, yoga and meditation, relaxation, and motivational games and discussions. The motivational theory-driven “talk show” activity, patterned after television programs such as Dr. Phil and The Oprah Winfrey Show, is featured heavily throughout four of the eight sessions.

• Session 1 discusses the ground rules for the program and encourages students to think about the reasons why they use tobacco and how they can quit.
• Session 2 discusses how tobacco use can actually cause stress instead of relieving it. Guests, such as ex-smokers or psychologists, give presentations on the relationship between tobacco and stress, and teach students healthy alternatives to cope with stress.
• Session 3 discusses the harm in using tobacco by highlighting the damaging substances in tobacco products.
• Session 4 establishes the first step in breaking tobacco addiction and youth are given the chance to discuss ways of quitting.
• Session 5 focuses on managing withdrawal symptoms and developing strategies to cope with any symptoms that occur while quitting.
• Session 6 focuses on maintenance strategies, such as avoiding weight gain and learning yoga to maintain a sense of balance.
• In Session 7, students learn more maintenance strategies, such as anger management and meditation skills.
• The final meeting, Session 8, teaches students ways to avoid relapse and how the new skills they have learned can also be applied to other patterns of substance use.

During the first four sessions, students are not asked or required to quit immediately. They are instead prepared through the Project EX curricula to strengthen their attempt to quit. Students usually stop using tobacco around sessions 4 through 6.

Study

The Sussman, Dent, and Lichtman (2001) study recruited participants from 18 continuation high schools (CHS's) in California. CHS's are alternative public schools where students are referred, once they are of high school age, due to functional reasons such as behavioral problems or poor academic performance. CHS students are at a greater risk for tobacco addiction and for their addiction to continue into adulthood. The schools were assigned to three conditions: 1) control group, 2) treatment group (Project EX), and 3) treatment group (Project EX with a school-as-community [SAC] component). The SAC component uses the school’s Associated Student Body (ASB), under teacher supervision and support, to organize service, recreational, and job training events that emphasize non-tobacco use behaviors. Through the use of project newsletters the ASB also publishes anti-tobacco use literature. The CrimeSolutions review of this study focused on the differences between both treatment groups combined (Project EX and Project EX with the SAC component) and the control group.

The study used a randomized block design procedure. This procedure involved calculating factor scores derived from archival school demographic information, arranging schools along a single-factor score continuum, and then randomly assigning adjacently scored schools to conditions.

Student participation in cessation clinics was voluntary; individuals willing to participate were given credit and class release time. To be eligible for the study, participants had to have used tobacco within 30 days prior to the first session and had to join the clinic in the first 2 of the 6 weeks (on or before session 4). A total of 335 students were included in the study with 259 smokers participating (139 students at the clinic-only schools; 120 students in the clinic-plus-SAC schools, and 76 students at the control schools). Among the cigarette smokers, 46 percent smoked only cigarettes, 36 percent smoked both cigarettes and cigars, 6 percent used both cigarettes and smokeless tobacco products, and 12 percent used all three types of tobacco. Based on the initial nicotine dependence questionnaire, 25 percent of tobacco users scored in the no or weak signs of addiction range, 58 percent scored in the moderate addiction range, and 17 percent scored in the heavy addiction range.

A total of 64 percent of the sample were male. Of the sample, 47 percent were Latino, 27 percent were white, 8 percent were Asian, 6 percent were African American, and 12 percent were “other.” The mean age was 16.8, with a range from 14 to 19. The demographics of the clinic enrollees did not differ significantly among program conditions.

Clinic participants were measured at baseline (pretest), immediately following the program, and at a 3-month follow-up. At control schools, tobacco-using students volunteered to take the baseline and 3-month follow-up surveys. Self-report measures included tobacco use, behavior and intentions, nicotine dependence, and demographic measures (age, gender, and ethnicity). Reports of nonsmoking were verified by Carbon Monoxide (CO) levels in expired-breath samples, using a cutoff of 9 parts per million. The study authors conducted additional analyses to examine the difference between the Project EX treatment group and the Project EX with the SAC component treatment group in smoking cessation.

Comparative Research

Sussman, Dent, and Lichtman (2001) conducted additional analyses to examine the difference between participants in the Project EX treatment group and participants in the Project EX with the school-as-community (SAC) component treatment group. They found no statistically significant difference between the treatment groups in smoking cessation.

CrimeSolutions doe not consider comparative research learn more about how CrimeSolutions treats comparative effectiveness research.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Idrisov, Bulat, Ping Sun, Leila Akhmadeeva, Thalida Em Arpawong, Polina Kukhareva, and Steve Sussman. 2013. “Immediate and Six-Month Effects of Project EX Russia: A Smoking Cessation Intervention Pilot Program.” Addictive Behaviors 38:2402–8.

McCuller, William Jason, Steve Sussman, Michael Wapner, Clyde Dent, and David J. Weiss. 2006. “Motivation to Quit as a Mediator of Tobacco Cessation Among At-risk Youth.” Addictive Behaviors 31:880–88.

Sun, Ping, James Miyano, Louise Ann Rohrbach, Clyde W. Dent, and Steve Sussman. 2007. “Short-term Effects of Project EX-4: A Classroom-based Smoking Prevention and Cessation Intervention Program.” Addictive Behaviors 32:342–50.

Sussman, Steve. 2012. “International Translation of Project EX: A Teen Tobacco Use Cessation Program.” SUCHT 58(5):317–25.

Sussman, Steve, Clyde W. Dent, and Kara L. Lichtman. 2001. “Project EX Outcomes of a Teen Smoking Cessation Program.” Addictive Behaviors 26:425–38.

Sussman, Steve, James Miyano, Louise Ann Rohrbach, Cyde W. Dent, and Ping Sun. 2007. “Six-Month and One-Year Effects of Project EX-4: A Classroom-based Smoking Prevention and Cessation Intervention Program.” Addictive Behaviors 32:3005–14. (This study was reviewed and did not meet Crime Solutions' criteria for inclusion in the overall program rating.)

Sussman, Steve, James Miyano, Louise Ann Rohrbach, Cyde W. Dent, and Ping Sun. 2010. “Corrigendum to ‘Six-Month and 1-Year Effects of Project EX-4, A Classroom-Based Smoking Prevention and Cessation Intervention Program' [Addictive Behaviors 32/12 (2007) 3005–3014].” Addictive Behaviors 35:803.

Sussman, Steve, William J. McCuller, Hong Zheng, Yvonne M. Pfingston, James Miyano, and Clyde W. Dent. 2004. “Project EX: A Program of Empirical Research on Adolescent Tobacco Use Cessation.” Tobacco Induced Diseases 2(3):119–32.

Zheng, Hong, Steve Sussman, Xinguang Chen, Yuanhong Wang, Jiang Xia, Joe Gong, Chunhong Liu, Jianguo Shan, Jennifer Unger, and C. Anderson Johnson. 2004. “Project EX–A Teen Smoking Cessation Initial Study in Wuhan, China.” Addictive Behaviors 29:1725–33.