dren’s Depression Inventory;20 the
Perceived Stress Scale (4 items);21
Self Control Behavioral Capability;22
Multidimensional Anxiety Scale
for Children-10;23 and Prochaska’s
Stages of Change.24 Process evaluation
was used to document the number
of sessions attended by students
(dose) and adherence to treatment
protocol by school nurse.
Counseling Intervention
The school nurse– delivered counseling
intervention, Calling It Quits (Table
1), consisted of 4 weekly private 1-on-1
sessions conducted during 1 month in
the school health clinic. Sessions were
conducted during the school day and
scheduled not to interfere with core
academic classes. Two 30-minute sessions
were conducted before the quit
date, and 2 15-minute sessions after
the quit date. The intervention was
based on the 5 A’s model adapted to be
developmentally appropriate for adolescents
through a workgroup with
school nurses and representatives
from the Massachusetts Department
of Public Health School Nurse Unit and
Tobacco Control Program, and the Department
of Education. The intervention
used a cognitive-behavioral approach
based on social cognitive
theory25,26 to develop health knowledge
and positive outcome expectations and
to build the adolescent’s self-control
and behavioral capacity skills (eg,
goal-setting, self-monitoring, problemsolving)
and self-efficacy to stop smoking.
A patient-centered counseling approach
was used in which school
nurses asked open-ended questions to
elicit the adolescent’s thoughts and
ideas, engage them actively in the discussion,
and allow them to determine
the course of action to take, tailoring
the intervention to their individual