Hazel Gilbert Research Department of Primary Care and Population Health UCL Medical School

1. Can we involve smokers who are unmotivated to quit in quitting activity? Hazel Gilbert Research Department of Primary Care and Population Health UCL Medical School

2. Overview • Principles of tailoring • Escape study • Baseline characteristics and follow-up assessment

3. Self-help Materials • Generic leaflets and manuals • Personalised generic • Targeted materials to particular groups • Individually Tailored Feedback • Definition: ‘intended to reach one specific person, based on characteristics unique to that person, related to the outcome of interest, and derived from an individual assessment’ • (Kreuter et al 1999)

4. Individually Tailored Feedback Personally relevant information: • greater attention • central route processing (deeper processing) • greater cognitive and behavioural change (Elaboration Likelihood Model. Petty and Cacioppo, 1981) Evidence of effectiveness ‘evidence of the effectiveness of tailoring health behaviour change messages’ (Noar, Benac and Harris 2007) (meta-analysis of 57 studies) ‘material tailored for the individualincreases quit rates over and above standard materials and untailored materials’(Lancaster and Stead 2005) 17 trials (OR 1.42)

5. Phases of development 1) Understand determinants of the behaviour Tailoring process ideally informed by established models of behaviour change • 2) Develop a framework of intervention objectives • motivation and readiness to quit • reason for quitting • dependence and self-image • cognitive expectations of the outcomes of quitting • perceived self-efficacy • offer skills and strategies to cope • social environment • encourage finding support

6. 3) Develop tailoring assessment • Design questionnaire to assess the relevant individual characteristics • 4) Create the content of the feedback • Compose a message for each possible answer • 5) Design template • Style and Format • Font • Graphics • Colour • Tone • Reading and comprehension level

7. Process Individual assessment Computer system Input Message library of persuasive texts Decision rules Individualised output Dijkstra 2008

9. General Practice Research Framework Applications of Tailored Feedback in Primary Care Eofcomputer-tailoredSmokingCessationAdvicein PrimarycarE A Randomised Controlled Trial ffectiveness Aim: To examine the effect of computer generated individually tailored feedback reports designed to help and encourage smokers to quit, on quit rates and quitting activity, when sent to smokers with varying levels of motivation and reading ability, identified from GP lists

10. NHS Smoking Cessation Service • Clinical approach: • Intensive face-to-face • Relatively high quit rates • Low participation rates • Unrepresentative • 3-6% of smokers use the services per year • Challenge for Primary Care services: • to reach the smokers who do not use clinics

11. Proactive recruitment • Contact individuals directly offering a service • Higher participation • More demographically representative • Can target specific population groups • Smokers not motivated to quit • Areas of high deprivation where smoking prevalence is higher

12. 123 general practices recruited from the MRC GPRF • Practices identified current cigarette smokers (18 to 65) from patient records using the computer system • Random sample of 500 screened by GP, and sent Smoking Behaviour Questionnaire (SBQ), together with a covering letter from GP (n=60,000) • Smokers willing to take part returned the SBQ to research team at UCL • Randomised to Intervention or Control Group • Intervention Group • Standard NHS booklet • Computer-tailored feedback report adapted to reading level and readiness to quit • Additional assessment and feedback report one month after baseline Control Group Standard NHS booklet 6-month follow-up: postal questionnaire to assess smoking status, cognitive change, perception of the feedback, economic issues

13. Baseline characteristics N=6900 Withdrawn=69 Response rate=11.75% Intervention=3404(49.8%) Control=3427(50.2%)

14. **p=.006 * p=.016

15. Respondents by readiness to quit Of those planning to quit within the next 30 days (n=890): 339 (38.1%) set a quit date Of those not planning to quit within the next 6 months (n=3203): too difficult - 45.3% / want to smoke - 44.8% / both - 4.3%

16. Readiness to quit by motivation

17. Follow-up Assessment Response Intervention Group only (N=3404) 4 weeks post baseline Sent follow-up assessment + reminder=3350(98.4%) Returns: Before reminder 968 (28.9%) After reminder 817 (24.4%) Total 1785 (53.3%) Participants planning quit in 30 days less likely to return the follow-up assessment (p=0.012)

18. Follow-up Assessment Outcome 2= 197.48, p<.0001

19. Length of abstinence by readiness Respondents not smoking 4 weeks post baseline (n=180)

20. Quit attempts by readiness Respondents still smoking 4 weeks post baseline (n=1601) 2=235.698, p<.00001

21. Conclusions • The Escape trial has met recruitment targets in terms of motivation • By reaching smokers with no plans to quit in the near future, we are able to provide them with information that they would not otherwise receive or seek out • By completing the Smoking Behaviour Questionnaire, these smokers are engaging in reflection about their smoking behaviour • Might prompt them to consider changes to their lifestyle and behaviour • Quitting activity?

22. Tailored feedback + Proactive Recruitment behavioural intervention principles of the clinical approach participation rates of public health campaigns provide personal, individually tailored self-help reports for a large population of smokers

23. General Practice Research Framework Co-investigators Irwin Nazareth, Richard Morris Department of Primary Care and Population Sciences, UCL Stephen Sutton Institute of Public Health, University of Cambridge Collaborator Christine Godfrey Department of Health Sciences, University of York Trial Co-ordinator Camille Alexis-Garsee