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Health Education Research Advance Access originally published online on September 19, 2007
Health Education Research 2008 23(2):359-368; doi:10.1093/her/cym053
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Published by Oxford University Press [2007].

Factors associated with recruitment and retention of youth into smoking cessation intervention studies—a review of the literature

Cathy L. Backinger1,*, Carol N. Michaels2,{dagger}, Anne Marie Jefferson3,{dagger}, Pebbles Fagan1, Ami L. Hurd4,{dagger} and Rachel Grana5,{dagger}

1 Tobacco Control Research Branch, National Cancer Institute, Bethesda 20892, USA
2 Valley Preferred, Lehigh Valley Physician Hospital Organization, Inc., Allentown, Pennsylvania, USA
3 Department of Psychology, University of West Georgia, Carrollton, Georgia, USA
4 Sharp HealthCare, San Diego, California, USA
5 Scientific Consulting Group, Inc., Gaithersburg, Maryland, USA

* Correspondence to: C. L. Backinger, Tobacco Control Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 6130 Executive Boulevard, EPN 4039B, Bethesda, MD 20892-7337, USA. E-mail: backingc@mail.nih.gov


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conclusions
 Funding
 Conflict of interest statement
 Acknowledgements
 References
 
This paper examines factors associated with high levels of recruitment and retention of youth into smoking cessation interventions. Fifty-five articles published from 1976 to June 2004 reported cessation outcomes were analyzed to examine the associations between selected variables and recruitment and retention rates. Studies with participants who smoked ≤5 cigarettes per day (cpd) were more likely to have recruitment rates ≥85%. Yet, studies with participants who smoked ≥6 cpd were more likely to have high retention rates. Studies that did not use incentives were more likely to have retention rates at end of intervention ≥85%. Findings indicate a lack of information reported about recruitment and retention procedures in adolescent tobacco cessation studies. Additional analyses and research need to be conducted to identify successful methods.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conclusions
 Funding
 Conflict of interest statement
 Acknowledgements
 References
 
The prevalence of smoking among youth has significantly declined from 37% in 1975 to ~23% of high school students (15–18 years old) in 2005 [1]. Almost 55% of US high school students who are current smokers report that they have tried to quit in the past year, with ~4% of youth aged 12–19 years reporting quitting in any one year [1–3]. Smoking among youth has negative health consequences such as increased frequency and severity of respiratory illnesses and poorer physical endurance [4]. Quitting smoking reduces tobacco-related diseases with the greatest health benefits of smoking cessation seen in those who have smoked for relatively few years and have only smoked a few cigarettes a day [5]. Consequently, it is critically important to develop and implement successful smoking cessation interventions for youth.

Effective strategies to help young people quit remain unclear and understanding these strategies is often fraught with challenges to recruiting and retaining youth in cessation programs. In fact, researchers funded under the National Institutes of Health RFA, ‘Prevention and Cessation of Tobacco Use by Children and Youth in the US’, indicated that recruitment and retention were their greatest challenges [6, 7]. Researchers who have conducted both adult and youth cessation studies have discussed these challenges and note obvious differences that contribute to recruiting and retaining youth in cessation studies. In the United States, as well as in many other countries, it is illegal to sell tobacco products to those <18 years of age. The United Kingdom is an example of an exception, with 16 years being the legal age to purchase cigarettes. It is also illegal in 43 US states for children to possess and/or use tobacco products [8]. Children report that they often use tobacco as a means of expressing independence from authority figures [9, 10]. Furthermore, many children state that they do not want adults, especially parents and teachers, to know they use tobacco [11].

Given the unique aspects of tobacco use among adolescents, including the illegal nature of the product and issues of independence and secrecy, as well as the changing social norm to make smoking increasingly socially unacceptable, significant barriers exist to enroll adolescents in intervention studies to help them quit [12]. Consequently, we undertook analyses of the published literature with the aim to investigate whether we could identify factors associated with high rates of recruitment and retention in order to provide insight for future youth smoking cessation intervention studies. Because theoretical models addressing recruitment and retention for this population do not exist and are mostly absent for other populations, we restricted our analyses to variables identified in prior published literature [13]. Additionally, we excluded psychosocial variables such as social support and motivation because we could not include variables for which we had an insufficient number to analyze. This study focused on the following variables: type of recruitment, use of incentives, intervention site, sample size, number of cigarettes smoked per day and length of follow-up. This study was driven by several hypotheses: (i) ‘active’ recruitment will result in significantly higher recruitment rates than ‘passive’ recruitment; (ii) studies that use incentives will observe significantly higher rates of recruitment and retention than those without incentives; (iii) school-based sites will observe higher recruitment and retention than medical settings; (iv) studies that aim to recruit and retain smaller sample sizes will have greater success than studies that aim to recruit and retain larger numbers; (v) youth who smoked fewer cigarettes per day (cpd) may be easier to recruit and retain than heavier smokers and (vi) shorter lengths of follow-up will have significantly higher rates of recruitment and retention than longer lengths of follow-up.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conclusions
 Funding
 Conflict of interest statement
 Acknowledgements
 References
 
A literature search was conducted using Medline and PsycINFO to examine youth smoking intervention studies published from 1970 to June 2004 using the following keywords: youth or adolescent or children, smoking or cigarette or tobacco and quitting or cessation. Sixty-six previously identified studies [14] were combined with the literature search and yielded 70 studies. Because the focus of this analysis was on intervention studies, studies analyzing effects of policy on youth smoking cessation, those who did not report a cessation outcome and those addressing smokeless tobacco cessation were excluded. Consequently, 55 studies from 1976 to June 2004 were included for analysis [15–65]. Table I provides a summary of these studies, including author, country in which the study was conducted; year the study was conducted, recruitment method, use of incentives, intervention site, sample size, minimum number of cigarettes smoked for study enrollment and length of follow-up. The year of the study was not always reported; therefore, estimates were inferred from the article. Estimates are noted by a tilde in front of the year.


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  		Table I. Youth cessation intervention studies included in analysis

 
At least two research staff reviewed each study, which was coded for the variables of interest. These variables of interest included recruitment method (active, passive, combination or not reported), use of incentives, intervention site (school, medical site, home), sample size, minimum number of cigarettes smoked to enroll in the study and length of follow-up. Active recruitment methods were defined as one-on-one interactions for a specific target audience. Examples of active methods include classroom presentations, telephone screening, person-to-person invitations, in-patient referrals and mandatory enrollment. Passive recruitment methods were defined as modes with broad distribution not issued to specific individuals. Examples of passive methods included flyers, brochures, and posters at facilities such as schools and medical clinics; newspaper, television and radio advertisements; press releases and announcements. Minimum number of cigarettes smoked to enroll in the study reflects the number of cigarettes that the youth consumed on a monthly, weekly, daily basis that met the criteria to be considered a ‘smoker’ in each study. Youngest age at enrollment was initially included as a variable of interest because we thought that the age of study participants may have been a recruitment and retention factor. This variable was dropped from analysis, however, because age breakdown could not be reliably determined for the majority of studies. For example, we could not determine the number of enrollees by each year of age in a study that enrolled adolescents aged 11–17 years versus a study that used adolescents aged 13–18 years.

Variables of interest were then collapsed for data analysis into the following dichotomous categories: active recruitment versus all other recruitment methods, passive recruitment versus all other recruitment methods, incentives versus all other recruitment methods, school versus medical office, sample size of either up to 149 versus ≥150, ≤5 versus ≥6 cpd and length of follow-up ≤3 versus ≥4 months. Fisher's exact tests were conducted using these variables and the following recruitment and retention rates of interest: recruitment rate of ≥85% versus all others, retention rate at end of intervention of ≥85% versus all others and retention rate at follow-up of ≥85% versus all others. The cut-points for sample size, length of follow-up and recruitment and retention rates were selected based on categories used by a Youth Tobacco Cessation Collaborative evidence review panel for evaluating the quality of youth smoking cessation studies [13]. For cpd, the cut-point of 5 cigarettes or fewer per day was specifically chosen because the majority of studies used youth who had to smoke at least 6 cpd to be enrolled in the study and we thought that smoking fewer cpd may positively impact both recruitment and retention. In addition, the overwhelming majority of high school students (almost 90%) smoke <10 cpd [1].


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conclusions
 Funding
 Conflict of interest statement
 Acknowledgements
 References
 
Forty-five of the studies were conducted in the United States, three in the United Kingdom, two in Australia and one each in Canada, China, New Zealand, Sweden and Thailand. Five studies were conducted in the 1970s, 13 in the 1980s, 31 in the 1990s and 8 in the 2000s.

Descriptive statistics are provided in Table II. Thirty-five percent (n = 21) of studies reported a combination of recruitment methods. Sixty-four percent (n = 35) reported recruitment in the school setting, and the majority of studies reported sample sizes <150. Enrollment into studies by number of cigarettes smoked varied. Thirty-three percent required that participants smoke at least 10 cpd. Twenty-seven studies (49%) had lengths of follow-up ≥4 months, 16 studies (29%) had lengths of follow-up of ≤3 months and 12 studies (22%) did not report length of follow-up.


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  		Table II. Characteristics of studies

 
Twenty studies used some type of incentives, with all but two also using some other means for recruitment. Incentives were provided as compensation for attendance and/or for biochemical validation of smoking status. Nine of the studies utilized cash and/or gift certificates as incentives with a range of $3–135, a mean of $68.11 and a median of $70. Other incentives included class release time, class credit or extra credit and pizza. Distinguishing whether an incentive was used as a means of recruitment and/or retention could not be reliably deduced from the manner in which the studies reported use of incentives.

Results of Fisher’s exact test for each variable of interest are shown in Table III. Studies that enrolled participants who smoked ≤5 cpd were significantly more likely to have recruitment rates that exceeded 85% than those that enrolled participants who smoked ≥6 cpd (P = 0.003). However, studies that enrolled participants who smoked ≥6 cpd were significantly more likely to have retention rates at end of intervention ≥85% than those that enrolled participants who smoked ≤5 cpd (P = 0.046). Studies that did not use incentives were significantly more likely to have retention rates at end of intervention ≥85% (P = 0.013). None of the other variables (recruitment method, site, sample size and follow-up) was statistically significant.


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  		Table III. Variables by recruitment and retention rates

 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conclusions
 Funding
 Conflict of interest statement
 Acknowledgements
 References
 
To our knowledge, this study is the first to provide a review of youth cessation recruitment and retention methods reported in the published literature. Most studies relied on a combination of recruitment methods, which is not surprising due to the lack of information about successful means of recruiting and retention. As prior research indicates, most studies were conducted in the school setting [14]. The majority of studies was fairly small, enrolling <150 participants.

Although we did not examine personal characteristics of participants, we did find that number of cpd as an enrollment criterion was statistically significantly related to higher recruitment and retention rates. Specifically, this analysis found that those studies that recruited lighter smokers (i.e. ≤5 cpd, including less than daily smokers) had statistically significantly higher levels of recruitment. However, analyses also revealed that youth who smoked a minimum of 6 cpd at enrollment were more likely to be retained. The present analysis suggests that it may be easier to recruit lighter smokers, but easier to retain heavier smokers up until the end of the intervention. Motivation by both lighter and heavier smokers may play a role in both recruitment and retention highlighting the complexity of this issue. These findings present a challenge to researchers: do they design interventions for adolescents that show symptoms of dependence; or should studies be designed to intervene with adolescents who express a desire to quit smoking, regardless of number of cigarettes smoked or days smoked be able to participate [66]?

It was somewhat surprising that those studies with smaller sample sizes and shorter lengths of follow-up were not different with regard to recruitment and retention compared with those with larger sample sizes and longer lengths of follow-up. It might be easier to recruit and keep smaller numbers of adolescents in studies and follow them over shorter periods of time; however, additional investigation is needed in this area.

There were no significant differences for recruitment and retention rates between those studies conducted at schools versus medical centers. Schools and medical centers offer differing positive and negatives aspects for implementing adolescent smoking cessation studies and may vary given individual preferences. For schools, being in a familiar environment may be a positive for some, while having others at school know that one participating in a smoking cessation study could be a negative aspect. Conversely, participating in a study at a medical site could be perceived as a positive aspect by some, since it could provide some degree of anonymity, while issues of transportation and travel time could be a negative aspect.

Our analysis did not find any significant differences in rates of recruitment and retention at follow-up with the use of incentives. We did find that those studies not using incentives were associated with higher retention rates at end of intervention. This finding was surprising, but the wide range of types of incentives, used as either compensation for attendance or validation of non-smoking status, made the use of incentives unclear. Also, we were not able to tease out whether or not incentives were used for recruitment and/or retention. In accordance with the principles of self-determination theory, youth may achieve greater participation with smoking cessation if they are intrinsically more motivated to quit than extrinsically motivated, for example, by providing external incentives such as money [67]. Thus, self-determination theory may help explain why youth were not recruited or retained at follow-up at higher rates than those who did not receive incentives. Additional research is needed to explore whether incentives of varying types and amount are useful as recruitment and/or retention methods, including extrinsic and intrinsic motivation by youth.

The majority of studies used several recruitment methods and it was not necessarily a straightforward task to classify studies as using either a predominant active or passive recruitment method. Given limited information regarding recruitment and retention methods, we used our best judgment to classify these methods for analysis. We included four studies that used mandatory enrollment as a type of active recruitment, which could have skewed our analysis regarding recruitment. No significant differences, however, were found between active and passive recruitment rates.

In addition to the limitations concerning classification of recruitment methods, other limitations of this analysis are noted. Because the primary focus of the cessation intervention articles was the results of the intervention study, the authors may not have explored in detail about recruitment and retention methods. In addition, recruitment and retention methods may have been shortened in manuscripts in order to accommodate word length limitations of specific scientific journals. Due to the limited numbers of studies in each category, it was not possible to conduct logistic regression analyses of these variables so that it is not known which, if any, of the variables are independent from each other. This study did not assess whether recruitment and retention was associated with cessation outcomes. Previously reported reviews have highlighted the variability of study design and limited statistically positive cessation outcomes [13, 14].

Despite these limitations, this analysis highlights the need for more critical study of recruitment and retention factors. Youth smokers say that they want to quit smoking and many indicate an interest in receiving help to quit [7, 68, 69], yet investigators face a challenge of getting them into studies. It is unknown how many of these studies used adult recruitment strategies. Additional factors, not addressed in this review because they were not widely reported in the published literature, need to be considered when planning recruitment and retention. These factors include, but are not limited to issues surrounding parental consent; perceived confidentiality by youth concerning the study; intensity of intervention in terms of both length of individual session and overall length of intervention; individual characteristics of the study population such as gender, race/ethnicity; whether enrolled in school; living in urban or rural environment; intervention site of study and other study characteristics such as individual or group setting and type of materials used and transportation and scheduling issues.


   Conclusions
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
Funding
 Conflict of interest statement
 Acknowledgements
 References
 
This literature review and data analysis highlight the challenges for recruitment and retention of youth into smoking cessation intervention studies. When factors of recruitment method, intervention site, sample size, minimum number of cigarettes smoked to enroll in the study and length of follow-up were considered, number of cigarettes and use of incentives were associated with higher recruitment and retention rates.

Given the difficulties of recruitment and retention of youth into smoking cessation intervention studies, more analysis of study data and in-depth reporting in the published literature is needed. Recruitment and retention is worthy of study in and of itself and should not be relegated to a summary paragraph within a cessation outcome paper. It is important to study this topic as an essential component of youth tobacco cessation research. Much more study and analysis of both successful and unsuccessful recruitment and retention methods need to be reported in the literature in order to inform future youth smoking cessation studies.


   Funding
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Funding
Conflict of interest statement
 Acknowledgements
 References
 
National Cancer Institute; SAIC, Frederick, Inc. (to A.M.J.); Scientific Consulting Group (to R.G.).


   Conflict of interest statement
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Funding
 Conflict of interest statement
Acknowledgements
 References
 
None declared.


   Footnotes
 
{dagger} Employed by the Tobacco Control Research Branch, National Cancer Institute, at the time when the study was conducted. Back


   Acknowledgements
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Funding
 Conflict of interest statement
 Acknowledgements
References
 
We would like to acknowledge and thank Richard P. Moser for his assistance with statistical analyses.


   References
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Funding
 Conflict of interest statement
 Acknowledgements
 References
 
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Received on December 15, 2006; accepted on July 18, 2007


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