Tobacco is a major cause of preventable death in the world. According to the World Health Organization (WHO), smoking kills almost 5 million people each year. By 2030, this number is expected to double . Every day, about 100,000 young people become addicted to tobacco in the world . Preventing tobacco addiction is a public health priority designated by the Framework Convention for Tobacco Control of the WHO, in force since February 27, 2005. The adolescent population is a major target of this endeavour.
Almost all smokers become regular smokers before age of 20 . In France, the average age of smoking initiation is 13.4 years, and 33% of teenagers at age 16 smoke every day . Most of these young smokers are already dependent on tobacco . In one study, 86% of teenage smokers said they were addicted; almost one-quarter of smokers aged 17-18 years said they had tried to stop but only a small proportion (5%) had managed to quit smoking . Teenagers, even if they never smoked on a daily basis, may encounter significant difficulties in their attempts to quit. They experience the same withdrawal symptoms as do adults and underestimate the difficulty of quitting smoking .
Despite this, efforts to fight against smoking in the teenage population have focused largely on programs to prevent rather than quit smoking. Systematic surveys have identified twice as many trials aimed at preventing smoking  as trials aiming at smoking cessation [8, 9]. To date, the effectiveness of different methods of quitting has been well demonstrated for adults , but evidence is lacking for adolescents. Two meta-analyses of trials of strategies for smoking cessation among teenagers have recently been published [8, 9]. They stressed the advantage of programs based on a psychosocial approach and implemented within schools. They also demonstrated the moderate effectiveness of withdrawal programs among teenagers. In both studies, the authors concluded the need for further research because the data were still too fragmentary and were based on research studies of varying quality. In addition, evidence is lacking on the effectiveness of the combination of the two strategies for adolescents -- pharmacological and cognitive-behavioural -- which has demonstrated a synergistic effect on adults .
Moreover, programs for helping with smoking withdrawal offered to young people were developed on the basis of programs for adults and do not sufficiently take into account the specific forms of tobacco addiction among the young and their needs . The traditional model for adults of the progressive development of nicotine addiction (from the experimental stage to the casual stage, then daily consumption increasing in frequency until the stage of addiction) , does not seem to fit young smokers. Some adolescents may have experienced their first symptoms of dependence before smoking daily or began smoking daily upon experiencing their first symptoms . Their smoking habit is also more influenced by their environment (family, friends, and media) .
Many criteria for successful smoking cessation programs for teenagers have been described in the scientific literature [8, 9, 13, 14]. The first lecture delivered in the programs should be informative but not preachy. Accessibility of treatment programs, notably by implementing them within schools (integrating the programs during school hours), and their cost-free character (for consultation and nicotine replacement substances) are important for attracting teenagers to become involved in smoking cessation programs. Few teenagers spontaneously consult a physician for withdrawal assistance because they tend to underestimate the difficulty of quitting. The anonymity of a program as regards parents is also crucial in increasing the motivation of young people to participate. Inclusion in a program must be voluntary. Finally, programs to aid in breaking the tobacco habit should be based more specifically on the psycho-social skills of the individual and should take into account the psychological aspects involved in the process of smoking withdrawal by means of individual and collective coaching. The combination of all these factors would allow for maximizing the participation rate of teenage smokers in a program to aid smoking withdrawal.
On this basis, a smoking cessation program (TABADO, TABagisme chez les ADOlescents) was developed by a team of tobacco addiction specialist physicians and public health researchers. This program combines pharmacological therapy with cognitive-behavioural therapy in a vocational school setting and is intended for adolescents from 15 to 20 years. It comprises 3 stages: (i) a lecture about general information on tobacco addiction for all students, both smokers and non smokers; (ii) an individual consultation with a tobacco addiction specialist for smokers; (iii) then 4 group sessions of follow-up and cognitive-behavioural therapy for smokers. The program is implemented within the institution during school hours. Consultations with tobacco addiction specialists and the group sessions are free, as are any substances that may be prescribed and dispensed as nicotine replacements.
The program was designed to be implemented within a particularly vulnerable population: vocational trainees. It was meant to enhance equity by reducing inequality in the access to health education programmes. Vocational trainees generally come from the least privileged socio-economic groups. Their health behaviour is often unfavourable, and their access to treatment is more difficult than for students of the same age who are enrolled in general school or university education .
However, before expanding such programs, their efficacy must be assessed. Therefore, we implemented this evaluation study among the vocational training centers (VTCs) of the Lorraine region, north-east France. The objective of this paper is to present the TABADO study protocol.