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Integrating Psychological Theory and Internet Technology for Smoking Cessation Programs

This paper discusses the content, effectiveness, and evaluation of smoking cessation websites that combine psychological theory and internet technology to disseminate programs at a population level. It explores the benefits of using the internet for recruitment and support, as well as the potential for tailored counseling and personalized follow-up. The aim is to assess the efficacy of these websites, identify effective features, and promote innovation in smoking cessation programs.

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Integrating Psychological Theory and Internet Technology for Smoking Cessation Programs

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  1. Combining psychological theory and internet technology to disseminate smoking cessation programmes at population level Jean-François E T T E R Dr. polit. sci., lecturer Institute of social and preventive medicine Faculty of Medicine University of Geneva, Switzerland SRNT Tuebingen, October 9, 2004

  2. Outline • Content of websites • Tailoring using psychological theory • Effectiveness ? • Evaluation of websites • RCTs on the internet • Perspectives

  3. 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

  4. 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

  5. Typical content: not interactive PULL • library, PDFs • fact sheets • video • addresses: clinics, help / support • links • news PUSH • general (bulk) e-mails

  6. Website content: interactive PULL • 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

  7. Number of sessions (face-to-face) Fiore et al. Clinical practice guideline, USDHHS 2000

  8. 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

  9. Number of formats (face-to-face) Formats: e.g. Self-help materials, telephone, groups... Fiore et al. Clinical practice guideline, USDHHS 2000

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

  11. Statistics, Stop-tabac.ch, Aug. 2003 35’000 visitors

  12. 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

  13. Distribution of smokers by "stageof change", U.S.A 1999 Current Population Survey Wewers et al. Preventive Medicine 2003, 36, 710-20

  14. Distribution of smokers by "stageof change", Geneva 1996 Etter et al. Preventive Medicine 1997 26(4), 580-585

  15. Smokers and EX-smokers by "stage of change", Stop-tabac.ch, 2004 => How to attract Precont. + Contemplators ? Unpublished data

  16. Develop different pages / services to suit the needs of different groups

  17. Computer-tailored counseling Assessment (questionnaire)  Data processing  Data storage Individual counseling letter  Follow-up e-mail Personal page accessedwith code  Invitation to2nd assessment progress report

  18. 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)

  19. 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)

  20. 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

  21. 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 ?

  22. 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

  23. 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

  24. 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 %

  25. 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

  26. Impact = efficacy * reach

  27. Efficacy: claims • 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 »

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

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

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