Randomized Controlled Trial of a Web-based Youth Smoking Intervention

1. Randomized Controlled Trial of a Web-based Youth Smoking Intervention Oonagh Maley, Cameron Norman & Harvey Skinner Department of Public Health Sciences University of Toronto FUNDED BY:

2. Learning Objectives • Describe key elements for effective engagement of adolescents using a web-based smoking cessation and prevention intervention • Identify strategies for implementing a web-based randomized control study in a school setting • Recognize challenges inherent in conducting smoking cessation research in schools and using web-based resources www.smokingzine.org

3. Presentation Overview • Introduce the Smoking Zine website • Examine challenges of working with youth about tobacco • Highlight innovative opportunities of eHealth for tobacco control • Provide an overview of the TeenNet Project • Describe the randomized trial & initial results • Review Lesson’s Learned www.smokingzine.org

4. The Smoking Zine www.smokingzine.org

5. Tobacco & Youth: Challenges and Opportunities

6. The High Cost of Smoking • The lifetime medical costs of cigarette smokers are approximately 1/3 higher than non-smokers • Harvard Report (1996) concluded that nearly two-thirds of cancer deaths (US) are linked to preventable risk behaviors: 30% smoking       30% adult diet and obesity 5% physical activity level • Law and Tang (1995) estimate a cost of $1,500 (US) for saving a life through routine 5-minute advice to all smokers to stop: “Few procedures in medicine carry so small a cost of saving a life” www.smokingzine.org

7. Tobacco’s Impact on Children & Youth • Direct Effects: 250 million children alive today will be killed by tobacco in the future if current consumption patterns continue • Indirect Effects: Nearly 700 million children (almost half world’s population) breath air polluted by second hand smoke • World Health Organization (2001). Tobacco and the Rights of the Child. Geneva. www.smokingzine.org

8. Smoking Initiation in Canada • Begin - 8 years • Increase – 11 years • Peak – 16 years • Smoke free at 19 years – Little chance of ever starting www.smokingzine.org

9. Stages of Change of Canadian Smokers Source: CTUMS, 2001 www.smokingzine.org

10. The Challenge is Large….but not Insurmountable www.smokingzine.org

11. Why the Internet?

12. Youth Online • United States: 73% of youth online, 57% of general population using the Internet for health information1 • Canada: 99% of youth online, 52% have used the Internet for health information2 1 PEW Internet & American Life Project (2001) 2 Environics / Media Awareness (2001) www.smokingzine.org

13. Key Reasons for Using the Internet for Youth Tobacco Control • Reaches youth where they are • Interventions are not bound by time or space • Interactivity and active learning; media combinations • Potential for tailoring to users • Easy to update and modify • Minimal cost for maximum reach • Because the tobacco industry is already there! www.smokingzine.org

14. Designing Effective Interventions • Accessible • Individualized • Remote (e.g.,telephone) & Group Counselling • Provide opportunities for assisted self-help • Strengthen social support networks • Use biomarker feedback • Must be efficient (& realistic): • Population X Reach X Efficacy • See Niaura & Abrams, 2002 www.smokingzine.org

15. The TeenNet Project Based at: Department of Public Health Sciences Faculty of Medicine University of Toronto Toronto, Ontario Canada

16. TeenNet Research Project • Established in 1995 • Lead by Dr. Harvey Skinner • Based in the Department of Public Health Sciences in the Faculty of Medicine, University of Toronto • http://www.teennetproject.org www.smokingzine.org

17. TeenNet Project Goals • Generate new knowledge and practical tools for engaging youth in health promotion • Evaluate innovative models for using Interactive Communication Technology for health promotion • Collaborate for research and capacity buildinglocally, nationally and internationally • Disseminate best practices andmodels for knowledge translation and sustainability. www.smokingzine.org

18. www.smokingzine.org

19. TeenNet’s Guiding Principles • Participatory • Relevant to Youth • Autonomy Supporting • Active Learning and Fun • Accessible ‘Youth in Action’ Approach www.smokingzine.org

20. Youth in Action Approach Initial needs identification • Focus groups with youth • Brain storming sessions with youth Concept development and assessment • Youth working groups • Youth forums • Reality checks with youth • Professional advisors and/or advisory groups Prototype development and assessment • Youth employees • Reality checks with youth and practitioners • Quality review committee (for website links) • Ongoing feedback through website and discussion boards www.smokingzine.org

21. TeenNet Research Projects • Adolescent Gambling • Community Capacity • Global Youth Voices • Positive Youth Project • Smoking Zine Evaluation • Youth, Technology and Access www.smokingzine.org

22. Diverse Youth www.smokingzine.org

23. www.smokingzine.org

24. Randomized Controlled Trial: Overview Principal Investigator: Harvey Skinner Co-Investigators: Eudice Goldberg Cameron Norman Program Manager: Oonagh Maley Funded by:

25. What was this study? • Population: Adolescents (grades 9-11) • Issue: Smoking & eHealth Literacy • Program: Web & Face-to-face • Setting: School • Desired Effect: Population impact www.smokingzine.org

26. Community Partners • Toronto Public Health (Tobacco Team) • YMCA Youth Substance Abuse Program, Toronto www.smokingzine.org

27. The Team • Team Leaders • Oonagh Maley, MISt • Cameron Norman, MA • Public Health Nurses • Mary-Anne McBean • Sue St John • Sarah Newham • Voula Varsamidou • Youth Counsellors & Research Assistants • Lisa Ennis, MSW--RSW • Celeste Le Duigou, MSW--RSW • Jennifer Moses, MSW • Jennifer Reynolds, MEd • Bohdan Turok, MEd CCC, CHt www.smokingzine.org

28. TeenNet Support • Sherry Biscope, MHSc • Shawn Chirrey, MHSc • Jennifer Elliott • Sarah Flicker, MPH • Vero Michelli • Meg Morrison, MEd • Mabel Soo www.smokingzine.org

29. Initial Research • Spring 2000: Instrument Development • Summer-Fall 2000: Community-based trial • Winter-Spring 2001: Instrument re-development • Summer 2002: Community-based pilot tests • 1995-2003 • Ongoing ‘reality checks’ • Test groups www.smokingzine.org

30. Study Design www.smokingzine.org

31. Study Overview • A two-group randomized trial • Major Research Questions: • Does the Smoking Zine Intervention promote behaviour change in youth smokers? • Does the Smoking Zine enhance resistance to smoking among non-smokers? • Does exposing adolescents to critical appraisal tools assist them in building ‘e-Health literacy’? www.smokingzine.org

32. Study Timeline (Administrative) • 2000: Focused partnership with local Public Health Department develops • 2001: Consultations with School Administrators & curriculum consultants • 2001: Collaboration with YMCA-YSAP • 2001-2: Relationship building with individual schools • 2002: Active & Passive Consent Process www.smokingzine.org

33. Study Overview 1. Smoking Zine Website Intervention – including motivational counseling, virtual group support, feedback 2. Control Condition: website evaluation task Measures: Pre – Post intervention, 3 & 6 month follow-up a) Resistance to Smoking b) Intentions to Smoke c) Smoking Behavior Initial Results School by Grade by Sex by Smoking Status interaction e.g. decreased tobacco use for grade 9 boys www.smokingzine.org

34. Study Procedures • Complete baseline instruments • Zine or Web Evaluation (Control) Task with booklet in class • 10-minute MI Group with booklet • Complete Post-test measures • CO Monitor • Tailored email messages between follow-ups • Complete follow-up assessments (3 & 6 mo.) www.smokingzine.org

35. The Interventions

36. Intervention • Intervention: The Smoking Zine including access to online discussion forum for peer support and mutual aid • Control: Modified website evaluation checklist applied to three non-health websites • Group-based motivational interview • Booklet • Follow-up tailored emails www.smokingzine.org

37. Intervention: Smoking Zine www.smokingzine.org

38. The Smoking Zine • Launched May 2000 • Based on multiple theoretical approaches • Youth empowerment & Harm Reduction approach to tobacco use • ‘Youth in Action” approach to development and evaluation • Multilingual (English, French, Chinese) www.smokingzine.org

39. The Smoking Zine • Five stages • Self-assessments, games, discussion forum, personalized quit plans • Builds motivation through: • Building on readiness for change • Enhancing self-efficacy • Fostering self-determination • Connecting with community/peers • Identifying discrepancies between goals and behaviour • Personal forecasting www.smokingzine.org

40. Linking Theory & Evidence Health Behaviour Models (individual level) • Self-Determination Theory • Social Cognitive Theory (Self-Efficacy) • Transtheoretical Model (Readiness for Change) • Motivational Interviewing (Decision Balance) • Theory of Reasoned Action & Planned Behavior • Health Belief Model Multisystems - multilevel integration • Health Promotion five coordinated actions (1986 WHO Ottawa Charter) • Community Capacity Building and Mobilization www.smokingzine.org

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44. Meet the Smoking Zine

45. Control Condition: Website Evaluation www.smokingzine.org

46. Control Condition: Web Evaluation www.smokingzine.org

47. Control Task: Website Evaluation • Developed with youth health consumers • Includes both ‘professional’ and consumer-oriented criteria • Focus on both knowledge and skill development www.smokingzine.org

48. Booklets www.smokingzine.org

49. Smoking Zine Booklet • Created to allow youth to record results from the Zine without printing • Wallet card with login information • Used in MI discussions • May be taken home and re-used as needed www.smokingzine.org

50. Smoking Zine Booklet www.smokingzine.org