Combining psychological theory and internet technology to disseminate smoking cessation programmes at population level

Jean-François E T T E RDr. polit. sci., lecturer

Institute of social and preventive medicineFaculty of Medicine

University of Geneva, Switzerland

SRNT Tuebingen, October 9, 2004

Outline

Content of websites

Tailoring using psychological theory

Effectiveness ?

Evaluation of websites

RCTs on the internet

Perspectives

Psychological support Face-to-face: effective but costly

Once a website is developed, low cost per smoker

Internet: large recruitment, available 24 / 7 / 365

Switzerland: >60% internet users

6% of U.S. internet users searched info on how to quit smoking (=

7’000’000 people)

… 18% of those with less than high schoolPew Internet & American life http://www.pewinternet.org/pdfs/PIP_Health_Report_July_2003.pdf

Reach: e.g. stop-tabac.ch

> 100'000 personal feedback reports produced

2004 = 40'000 visitors / month

Total > 1,400,000 visitors since 1997

Weekly news sent by e-mail to 10'000 people

6 languages

1st in Google, Yahoo, Altavista (in French)

Compare with clinic: ~50 clients / month

Typical content: not interactive

PULL library, PDFs fact sheets video addresses: clinics, help / support links news

PUSH general (bulk) e-mails

Website content: interactivePULL discussion groups, chat rooms personal stories tests: dependence, withdrawal, $ spent on cig FAQ quiz computer-tailored counseling

PUSH tailored e-mails, text messages on cell phones one-to-one counseling by e-mail

Number of sessions (face-to-face)

Abstinence rates

12.416.3

20.924.7

0

5

10

15

20

25

30

1 2 to 3 4 to 8 9+

1

2 to 3

4 to 8

9+

Fiore et al. Clinical practice guideline, USDHHS 2000

Internet: follow-up

Data storage, incl. e-mail addresses

- data protecion laws

Comparison with answers given on last session

- progress reports

Personalized follow-up

(e.g. more intensive just after the quit date)

Discussion forums: people come back to read answers to their

messages

- daily sessions in some people

Number of formats (face-to-face)

Abstinence rates

10.8

15.118.5

23.2

0

5

10

15

20

25

No format 1 format 2 formats 3 or 4

Formats: e.g. Self-help materials, telephone, groups...

Fiore et al. Clinical practice guideline, USDHHS 2000

Enrol smokers for: Smoking cessation clinics Telephone quitlines Tailored letters, booklets by snail mail

Statistics, Stop-tabac.ch, Aug. 200318'800

6'500 6'000 5'4003'300 3'200 3000

12000

5'000

10'000

15'000

20'00035’000 visitors

Social support

Effective, according to USDHHS guideline + meta-analysis

New + specific to the web: Discussion + Chat Not yet evaluated :

very interesting research question !

Counselor, individually - e-mail - telephone (help line) => costly

Distribution of smokers by "stageof change", U.S.A 1999

59%

33%

8%

Precont

Contempl

Prepar

Current Population SurveyWewers et al. Preventive Medicine 2003, 36, 710-20

Distribution of smokers by "stageof change", Geneva 1996

74%

22%

4%

Precont

Contempl

Prepar

Etter et al. Preventive Medicine 1997 26(4), 580-585

Smokers and EX-smokers by "stage of change", Stop-tabac.ch, 2004

1

2

2

4

16

5

2

26

35

17

32

45

35

57

55

24

7

19

9

7

0% 20% 40% 60% 80% 100%

Letters

PersoStories

Forums

Chat

PrecontContemplPreparActionMaintenance

=> How to attract Precont. + Contemplators ?Unpublished data

Develop different

pages / services

to suit the needs of

different groups

Computer-tailored counselingAssessment

(questionnaire)

Data processing

Data storage Individual counseling letter

Follow-up e-mail

Invitation to2nd assessmentprogress report

Personal page

accessedwith code

Behavior theory

Transtheoretical model of change

Ajzen+Fishbein: Theory of planned behavior

Bandura: Social learning theory (self-efficacy)

Health Belief Model

Protection Motivation Theory

PRECEDE / PROCEED model

Addiction and withdrawal (DSM-IV, ICD-10)

Tailoring variables

Demogr., have children, country of residence

Smoking status

Ex-smokers:

- quit date

- withdrawal symptoms

- use of medications (NRT, zyban)

- perceived risk

- self-efficacy (relapse situations)

Tailoring variables: smokers

Smokers:

- motivation to quit

- dependence level

- past quit attempts (date, duration)

- intention to use treatments + medications

- perceived risk / benefits of smoking / quitting

- use of self-change strategies

Preferences for frequency / type of support

Human-Computer interaction theory

Evaluation of websites

Aims of evaluations: Assess efficacy Identify most effective features Improve quality Minimize harm Promote innovation Increase confidence (in users + funding agencies) Improve competitivity (>200 websites) Are so many websites needed ?

Evaluation of smoking cessation websites

Needs of users, preferred services / pages

Which service is best suited to each category

(current / former smoker, age, sex, FTND, stage)

Time frame (e.g. more frequent after quit date)

Outcome research: RCTs

- smoking cessation

- compliance, use of treatments

- effect of interactive features, chat, discuss. forums

- incremental effect of follow-up

Bock et al. N&TR 2004;6:207-19

Review of smoking cessation websites in English Found 202 websites 46 sites included in evaluation

Criteria: Content coverage Content quality, accuracy Usability Interactivity

Bock et al. Interactive features % websites with interactive features,

among sites that cover each key component:

Advise every smoker to quit: 0-11 % Assess readiness to quit 33 % Assist with quit plan 16 % Provide practical counseling 20 % Intra-treatment social support 33 % Recommend use approved pharma 26 % Arrange follow-up contact 56 %

Bock et al. 5 best websites

Canadian Cancer Society:www. Cancer.ca/tobacco

QuitNet: www. Quitnet.com

American Lung Association: www. Lungusa.org/tobacco

University of Geneva: www. Stop-tabac.ch

Arizon Smoker’s Helpline: www. Ashline.org

Impact = efficacy * reach

Google: « quit smoking », first 3 in the list (underlined by us)

« X combines already proven effective methods of treating tobacco addiction into a powerful and effective individually controlled program that is available to anyone, anytime, anyplace »

« Y unites three independent cessation resources - motivation enhancement, a quality education, and serious group support - to form a highly effective nicotine dependency recovery tool »

Efficacy: claims

Efficacy: randomised trials Smokingzine.org vs control website, in schools, grades 9-11. In non-

smokers, decreased intention to smoke, no effect in smokers at 6 mo. (Skinner)

Committed Quitters (Strecher, Shiffman, West) Internet, tailored vs untailored, short-term- 10-week continuous abstinence, intent-to-treat- tailored 23%, untailored 18%, p<.001, OR=1.34

RCT lung cancer screening patients: booklet vs. list of websites: effect on quit attempts only (Clark)

Efficacy of other internet programs: unknown

Cochrane review: computer-tailored Computer-tailored programs, total N=17,200

on paper or PC, not on the internet

Cochrane review: OR = 1.56 (14 studies)

vs. standard materials: OR = 1.36 (10 studies)

vs. no materials: OR = 1.80 (3 studies)

Intervention: 6.1%

No treatment: 4.3%

Difference: 1.8%

NNT: 54

Why are there so few RCTs ?

Same as for other prevention programs: general lack of scientific evaluation

RCTs on the internet: specific problems

But:

This field should not distinguish itself from other fields by the absence of RCTs

RCTs are nevertheless feasible

RCTs on internet: specific problems

Control group: other websites a few clicks away

Assigned to both intervention + control group

Attrition rate (only 30% present at follow-up)

Selective dropout of those who fail to quit

Measuring exposure to the intervention

Consistency of intervention across subjects

Measuring outcome: validity issues

Identification of participants

RCTs on internet

Randomization is possible: tailored vs untailored programs + e-mail programs + control websites

E-mail interventions: effective in other fields (lower back pain)

Specific to the internet: discussion forums + chat

Forums + chats: need to evaluate their:- content (qualitative surveys)- effectiveness (RCTs)- work best for whom? (recent quitters?)

RCT: direct comparison of websites

Conclusions (1) Internet: potential for high quality information + treatments

from qualified professionals

Computer-tailored programmes: effective

Is internet effective? Too few RCTs

Evidence for efficacy from RCTs: - short-term only (10 weeks, 6 months), - at best mixed … or inexistent

Not enough research published

Incremental efficacy of specific features?- forum, chat, quit date recalls

Conclusions (2)

Interactivity = not used enough by websites

Let users contribute to the content of the website(chat, discussion forums, personal stories)

Switch from teacher centered to learner centered

Perspectives:- combine with medications (compliance)- more sophisticated, interactive interventions

Get these slides at: www.stop-tabac.ch/fr/powerpoint.html