internet and telephone treatment for smoking cessation

Internet and Telephone Treatment for Smoking Cessation

Amanda L. Graham, PhDDirector, Research Development

The Steven A. Schroeder Institute for Tobacco Research & Policy Studies

Associate Professor (Adjunct)Georgetown University / Lombardi Comprehensive Cancer Center

PRESENTED AT:NORTH AMERICAN QUITLINE CONSORTIUM 2011 WEBINAR SERIES

“ARE INNOVATIONS IN WEB AND PHONE TECHNOLOGY INCREASING OUR EFFECTIVENESS WITH TOBACCO USERS?”FEBRUARY 9 & 11, 2011

National Cancer InstituteR01 CA104836

Background & rationale for trial

Research design and methods

Major outcomes

Secondary analyses currently underway

Future research

Overview

David Abrams, PhD Brown

Beth Bock, PhD Brown

Charles Neighbors, PhD, MBA Brown

George Papandonatos, PhD Brown

Raymond Niaura, PhD Brown

Nathan Cobb, MD QuitNet

David Rosenbloom, PhD QuitNet

David Tinkelman, MD National Jewish Health

Study Team

Content & Quality of Internet Cessation

1. To examine the quality of smoking cessation treatment on the Internet

2. To identify high-quality websitesthat warrant effectivenessevaluation

3. To adapt PHS Clinical PracticeGuideline to create anevaluation tool

Bock B, Graham A, et al. Smoking cessation treatment on the Internet: content, quality, and usability. Nic Tob Research, 6: 207-219, 2004. PMID: 15203794.

Content & Quality of Internet Cessation

PARTNERS:

7 US states

2 CA provinces

13 Counties

17 employers

4 HMOs

Why QuitNet?

Initial Evaluation of QuitNet

• Observational study in December 2002

• Total # surveyed = 1,501

– Bounced email: 12.3%

• Incentives

– 2 days after initial email: $20

– 6 days after initial email: $40

• Responders: 25.6% (N=385)

Source: Cobb, Graham et al. (2005). Nicotine and Tobacco Research.Cobb NK, Graham AL, et al. Initial evaluation of a real-world Internet smoking cessation system. Nic Tob Research, 7: 207-216, 2005. PMID: 16036277.

Smoking Outcomes

Least conservative

Most conservative

ADHERENCE SAMPLE (N=223): 30.0%– Respondents only

INTENTION TO TREAT (N=1,024): 7.0%– Counts all non-responders as smokers

Smoking Outcomes: Secondary Analyses

Least conservative

Most conservative

ADHERENCE SAMPLE (N=223): 30.0%– Respondents only

INTENTION TO TREAT (N=1,024): 7.0%– Counts all non-responders as smokers

• Used site ≥ 2x (N=336): 13.1%

• Used site >1x (N=488): 9.8%

• Excluding bounced (N=892): 8.0%

Utilization & Smoking Outcomes

Quitters(N=67)

Smokers(N=156) P value

# logins, median (IQR) 9(1-42)

2(1-5) <.001

# minutes online, median (IQR) 103(33-339)

33(17-83) <.001

% posting in forums 19.4% 4.5% <.001

% with buddy 19.4% 9.6% <.05

% sent Qmail 25.4% 9.0% <.01

% received Qmail 41.8% 20.5% <.001

Utilization & Smoking Outcomes

• Community participation & smoking outcomes: 7-day pp. abstinence: OR=3.24 ***

2-month continuous abstinence: OR=4.03 ***

• Intensity of website use & smoking outcomes: 7-day pp. abstinence: OR=2.34 ***

2-month continuous abstinence: OR=6.07 ***

Study Design

Interventions: Control Condition

Static site designed by research team

“look and feel” of QuitNet

Extracted content from QuitNet

No interactive features

No online community

Interventions: Enhanced Internet

Premium service

Membership fee paid for by grant

6 month access

• Strong evidence base for telephone counseling– 2003 Cochrane review included 27 trials

• Broad reach of telephone counseling– 38 states had quitlines

– Feb 3, 2004: 1-800-QUITNOW

• Web + phone offering on the horizon

Interventions: Internet + Phone

Interventions: Internet + Phone

Non-profit, non-sectarian

World-recognized academic medical and research center for over 110 Years

#1 Respiratory hospital since 1998

Call center operations for more than 35 years Quit Line Weight Management Disease Management Lung Line and Physician Line

Interventions: Internet + Phone

Intake call

Entry call

Preparation call

2 support calls after quit date

Additional support calls as needed

Motivational interviewing approach (e.g., roll with resistance, support self efficacy, listen reflectively, clarify and summarize)

Use of QuitNet encouraged & reinforced

Recruitment Approach

“Active User Interception Sampling”

Google, AOL, MSN, Yahoo!

Quit smoking Stop smoking Quitting smoking Stopping smoking

Graham AL et al. Characteristics of smokers reached and recruited to an internet smoking cessation trial: a case of denominators. Nic Tob Research, 8: S43-48, 2006. PMID: 17491170.

Eligibility Screening

Smoking rate (5+ cpd)

• Time to first cig.

• Quits past year

• Age 1st puff

Current age (18+ years)

• Gender

• Race

• Education

• Zip code

Prior use QuitNet (none)

Informed Consent

3 explicit steps:

“Digital signature”

Contact information

Do you give informed consent?

Baseline Telephone Assessment

Graham AL et al. Internet- vs. telephone-administered questionnaires in a randomized trial of smoking cessation. Nic Tob Research, 8 Suppl 1: S49-57, 2006. PMID: 17491171.

Graham AL & Papandonatos GD. Reliability of internet- versus telephone-administered questionnaires in a diverse sample of smokers. J Med Int Res, 10: e8, 2008. PMID: 18364345.

Recruitment Results

Participants

3mo 6mo 12mo 18mo

Basic Internet 79.1 77.3 72.5 68.6

Enhanced Internet 76.7 74.0 72.2 69.0

Enhanced Internet+ Phone 73.5 72.6 69.9 67.1

Total 76.4 74.7 71.5 68.2

P‐value 0.05 0.12 0.53 0.74

Follow-Up Results

$25 / phone survey

$15 / web survey (for telephone non-responders)

$20 bonus at end of study for completing all 4 surveys

0

5

10

15

20

25

3 mo 6 mo 12 mo 18 mo

Basic Internet

EnhancedInternet

EnhancedInternet + Phone30

 day abstin

ence

02468

101214161820

3 mo 6 mo 12 mo 18 mo

Basic Internet

EnhancedInternetEnhancedInternet + Phone

30 day m

ultip

le point 

prevalen

ce abstin

ence

Secondary Analyses

1.Early advantage for Enhanced Internet + Telephone counseling

2. Improvement in both Internet conditions over time

3.Overall performance of the comparison condition (Why did the control group do so well?)

Telephone Counseling Utilization Data (0-3 months)

N=675

# calls completed, M (SD) 3.6 (3.3)

0 calls 26.7%

1 call 2.5%

2 calls 14.5%

3 calls 11.1%

4 calls 8.3%

5+ calls 36.9%

Secondary Analyses: Utilization Data

Website UtilizationData (0-3 months)

N=675

# logins, median (IQR) 3.0 (9.0)

0 logins 24.1%

1 login 15.9%

2 login 11.4%

3 login 7.3%

4 login 4.4%

5+ logins 36.9%

Secondary Analyses: Utilization Data

Compared to no treatment:

5+ logins were 2.3x more likely to quit (95% CI 1.31 – 4.13, p<.01)

5+ calls were 3.4x more likely to quit (1.82 – 6.44, p<.001)

Additive effect, not multiplicative

0 Logins

1‐4 logins

5+logins

0 calls 13.8% 12.5% 21.1%

1‐4 calls 17.6% 8.7% 25.8%

5+ calls 31.6% 26.2% 44.5%

Responder only full sample (ITT): 25.9%

Population Impact

EFFICACY x REACH = IMPACT

(% abstinent) (# using method annually) (total # quitters)

None (unaided) 3% 16,000,000 480,000 Rx NRT (1995) 14% 2,500,000 350,000 OTC NRT (1996) 14% 6,300,000 882,000 Internet + Phone (3mo ITT) 19.0% 320,000** 60,800 Internet + Phone (3mo hi adh) 45.5% 320,000** 145,600 Behavioral counseling 24% 395,000 94,800 Inpatient treatment 32% 500 160

** US quitlines receive calls from 320,000 smokers annually (Source: NAQC, 2008)Adapted from Shiffman et al. (1998), Annual Review of Public Health .

Utilization & 18 Month Outcomes

< 90 min

0 min

Social Networks & Cessation

Table 1. Website utilization patterns among BecomeAnEX.org members by community involvement

No Community Community

3+ logins 8% 28%

# days website use 5.0 ± 29.0 22.1 ± 59.1

# interactive tools used 1.9 ± 1.6 3.4 ± 2.0

“Integrator” Pilot Study

• N=244 randomized to EX vs. EX + SN• Intervention feasible & well received

– High ratings on positive adjectives (encouraging, welcoming, supportive)

– Low ratings on negative adjectives (annoying, intrusive, irrelevant)

– More satisfied with website

– Greater perceived helpfulness of website

• 1.7x more likely to return to the website 3+ times• 2.3x more likely to be abstinent at 30 days

Summary & Implications

1.Make sure Internet cessation program is evidence based and leverages the full functionality of the Internet

2.Seamless integration of treatments each with unique advantages rather than parallel offerings

3.Adherence is critical

Amanda L. Graham, PhD

Phone: 202.454.5938Email: agraham@legacyforhealth.org