randomized controlled trial of a web-based youth smoking intervention oonagh maley, cameron norman...
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Randomized Controlled Trial of a
Web-based Youth Smoking Intervention
Oonagh Maley, Cameron Norman & Harvey SkinnerDepartment of Public Health Sciences
University of Toronto
FUNDED BY:
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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
December 10, 2003NCTH Boston, MA
www.smokingzine.org
The Smoking Zine
Tobacco & Youth: Challenges and Opportunities
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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”
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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.
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Smoking Initiation in Canada
Begin - 8 years
Increase – 11 years
Peak – 16 years
Smoke free at 19 years – Little chance of ever starting
Age of Initiation to Smoking
Source: FNIRHS, 1997. (FNIRHS data based on population expansion weighted proportion)
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Age
0
1
2
3
4
5
6
7
% s
tart
ing
Female Male
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Stages of Change of Canadian Smokers
19
28 27
2117
20
3034
22
149
25
1511
5 3
41
4
49
13
19
42
62
0
10
20
30
40
50
60
Precontemplation Contemplation Preparation Action Maintenance
ALL 15-19 20-24 25-44 45+
Source: CTUMS, 2001
December 10, 2003NCTH Boston, MA
www.smokingzine.org
The Challenge is Large….but not Insurmountable
Why the Internet?
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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)
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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!
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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
The TeenNet Project
Based at:
Department of Public Health Sciences
Faculty of Medicine
University of Toronto
Toronto, Ontario Canada
December 10, 2003NCTH Boston, MA
www.smokingzine.org
TeenNet Research Project
Established in 1995Lead by Dr. Harvey SkinnerBased in the Department of Public
Health Sciences in the Faculty of Medicine, University of Toronto
http://www.teennetproject.org
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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 building locally, nationally and internationally
Disseminate best practices and models for knowledge translation and sustainability .
December 10, 2003NCTH Boston, MA
www.smokingzine.org
TechnologyOptions
Dissemination
Utilization
RapidPrototyping
Feasibility
Do
Ownership
Community Capacity
Engagement
Relevance
Study
Plan
Listen/Dialogue
DevelopmentCycles
CommunityInvolvement
TeenNet Action Research Model
Act
December 10, 2003NCTH Boston, MA
www.smokingzine.org
TeenNet’s Guiding Principles
Participatory Relevant to Youth Autonomy Supporting Active Learning and Fun Accessible
‘Youth in Action’ Approach
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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
December 10, 2003NCTH Boston, MA
www.smokingzine.org
TeenNet Research Projects
Adolescent Gambling
Community Capacity
Global Youth Voices
Positive Youth Project
Smoking Zine Evaluation
Youth, Technology and Access
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Diverse Youth
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Randomized Controlled Trial: Overview
Principal Investigator: Harvey Skinner
Co-Investigators: Eudice Goldberg
Cameron Norman
Program Manager: Oonagh Maley
Funded by:
December 10, 2003NCTH Boston, MA
www.smokingzine.org
What was this study?
Population: Adolescents (grades 9-11)Issue: Smoking & eHealth LiteracyProgram: Web & Face-to-face Setting: SchoolDesired Effect: Population impact
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Community Partners
Toronto Public Health (Tobacco Team)YMCA Youth Substance Abuse
Program, Toronto
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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
December 10, 2003NCTH Boston, MA
www.smokingzine.org
TeenNet Support
Sherry Biscope, MHScShawn Chirrey, MHScJennifer Elliott Sarah Flicker, MPHVero MichelliMeg Morrison, MEdMabel Soo
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Study Design
Zine vs.Control?
Lifestyle &Technology
ProfilePretest
WebsiteEvaluation
SmokingZine
Post-test3-month
Follow-up6-month
Follow-up
END
3-months 6-months45-minutes
MotivationalInterview
MotivationalInterview
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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’?
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Study Timeline (Administrative)
2000: Focused partnership with local Public Health Department develops
2001: Consultations with School Administrators & curriculum consultants
2001: Collaboration with YMCA-YSAP2001-2: Relationship building with
individual schools2002: Active & Passive Consent Process
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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 ResultsSchool by Grade by Sex by Smoking Status interaction
e.g. decreased tobacco use for grade 9 boys
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Study Procedures
1. Complete baseline instruments
2. Zine or Web Evaluation (Control) Task with booklet in class
3. 10-minute MI Group with booklet
4. Complete Post-test measures
5. CO Monitor
6. Tailored email messages between follow-ups
7. Complete follow-up assessments (3 & 6 mo.)
The Interventions
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Intervention: Smoking Zine
Zine vs.Control?
Lifestyle &Technology
ProfilePretest
WebsiteEvaluation
SmokingZine
Post-test3-month
Follow-up6-month
Follow-up
END
3-months 6-months45-minutes
MotivationalInterview
MotivationalInterview
December 10, 2003NCTH Boston, MA
www.smokingzine.org
The Smoking Zine
Launched May 2000Based on multiple theoretical
approachesYouth empowerment & Harm Reduction
approach to tobacco use‘Youth in Action” approach to
development and evaluationMultilingual (English, French, Chinese)
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Self - Determination Theory Deci and Ryan (1985)
Motivated BehaviorAutonomous Controlled
self determined pressured
"want to do it"
"should do""have to"
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Maintenance
Action
Preparation
Contemplation
Precontemplation
Processes of Change
Relapse Prevention
Motivational Interviewing
BehavioralCognitive/Experiential
Build Motivation Strengthen Commitment
December 10, 2003NCTH Boston, MA
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Readiness For Change
DecidedNot ToChange
Not ThinkingAboutChange
Soon, Next30 Days
Now
NOTREADY UNSURE READY
1 2 3 4 5
Undecided
Skinner (2002)
Meet the Smoking Zine
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Control Condition: Website Evaluation
Zine vs.Control?
Lifestyle &Technology
ProfilePretest
WebsiteEvaluation
SmokingZine
Post-test3-month
Follow-up6-month
Follow-up
END
3-months 6-months45-minutes
MotivationalInterview
MotivationalInterview
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Control Condition: Web Evaluation
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Control Task: Website Evaluation
Developed with youth health consumers Includes both ‘professional’ and consumer-
oriented criteria Focus on both knowledge and skill
development
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Booklets
Zine vs.Control?
Lifestyle &Technology
ProfilePretest
WebsiteEvaluation
SmokingZine
Post-test3-month
Follow-up6-month
Follow-up
END
3-months 6-months45-minutes
MotivationalInterview
MotivationalInterview
December 10, 2003NCTH Boston, MA
www.smokingzine.org
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
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Smoking Zine Booklet
December 10, 2003NCTH Boston, MA
www.smokingzine.org
CyberHealthLiteracy Booklet
Created to allow youth to review websites and calculate a rating based on five criteria
Wallet card with cyberliteracy url
Used in MI discussions May be taken home and
re-used as needed
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Booklet: Web Evaluation
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Motivational Interview
Zine vs.Control?
Lifestyle &Technology
ProfilePretest
WebsiteEvaluation
SmokingZine
Post-test3-month
Follow-up6-month
Follow-up
END
3-months 6-months45-minutes
MotivationalInterview
MotivationalInterview
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Motivational Interviewing
An approach to fostering change through enhancement of a client’s readiness and intrinsic motivation
Motivational interviewing is “a client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002)
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Motivational Interviewing: Adaptation for Group Setting
Uses a single-session model Brief format (~10 minutes in duration) Few known attempts at adapting to group
form: no known outcome studies No single-session group models Focus on the Decision Balance (pros and
cons) and exploring ambivalence about change
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Sample Discussion Questions
Smoking Zine (Smoker)Group:
Smoking Zine (Non-Smoker)Group:
What were your reasons for changing your smoking behaviour?
What were some of your reasons not to change?
How did your scores balance out?
How can this information help you make decisions about what to do next?
What were your reasons for being smoke free?
What concerns do you have about remaining smoke-free?
How did your scores balance out?
How can this information help you make decisions about what to do next?
Randomized Controlled Trial:Outcome Measures
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Measurement Points
Zine vs.Control?
Lifestyle &Technology
ProfilePretest
WebsiteEvaluation
SmokingZine
Post-test3-month
Follow-up6-month
Follow-up
END
3-months 6-months45-minutes
MotivationalInterview
MotivationalInterview
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Smoker Definition (Mills et al., 1994)
Q1: Which of the following statements best describes your use of tobacco in your lifetime?
Q2: During the past 30 days, on how many days did you smoke cigarettes?
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Lifestyle & Technology Profile
30-item questionnaire on:Risk behaviors
e.g., Substance use, diet & exerciseTechnology use
e.g., email, World Wide Web, Wireless phonesDemographics
e.g., age, grade, cultural affiliation
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Measures of Change:Likelihood of Action Scale & eHEALS
23-item scale based on the five major behavior change theories used to guide the Smoking Zine (Skinner, 2002)
Pilot tested with youth in community, school and clinical settings over 3 years
Scale items obtained through tobacco survey databases, published scales and partnership with other researchers in the area of adolescent health
eHEALS: eHealth Literacy Scale
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Likelihood of Action Index
Likelihood ofAction Index
TranstheoreticalModel
Theory ofReasoned Action
/ PlannedBehaviour
Social CognitiveTheory
Self-Determination
Theory
Health BeliefModel
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Data Collection
Measures Baseline Post Test 3 Month 6 Month
1. Resistance
to InitiationX X X X
2. Behavioral
IntentionX X X X
3. Smoking
BehaviorX X X
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Follow-up
Zine vs.Control?
Lifestyle &Technology
ProfilePretest
WebsiteEvaluation
SmokingZine
Post-test3-month
Follow-up6-month
Follow-up
END
3-months 6-months45-minutes
MotivationalInterview
MotivationalInterview
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Follow-up
Response Rates: 89% (3-months); 87% (6-months)
Participants complete survey in class 25% randomly chosen to complete CO
monitoring ** not at 6-month due to SARS outbreak
Tailored email support follows until 6-months Participants complete survey in class All participants are informed of the Zine and
Web Evaluation resources
December 10, 2003NCTH Boston, MA
www.smokingzine.org
CO Monitoring
Validates smoking self-report
Potential for bogus pipeline
Opportunity to engage youth and reinforce the message
Data Analysis and Results
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Study Demographics
N=1410 760 Boys 650 Girls 214 smokers at baseline (15% of total)
14 urban high schools: Public & Catholic districts
83 classes Grades 9-11 Passive and Active Parental Consent Active Youth Consent
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Key Findings
Smoking Zine’s greatest potential impact with: Grade 9 students (cessation and prevention) Boys Smokers (Zine as treatment) ‘High-risk’ schools
eHealth Literacy Main effect
Small intervention effect with great potential cumulative effect on a population level
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Planned Analysis & Results
I. Psychometric Assessment Item (reliability) analysisConfirmatory factor analysis
II. Impact AssessmentDoubly-repeated Measures MANOVA
(SPSS v11.5)Structural Equation Modeling (Mplus, v2.14)Hierarchical Linear Modeling (MLwiN v1.1)
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Analysis:Three Approaches
MANOVA: Multivariate Analysis of Variance Intervention X Smoker X Grade X Sex interaction
HLM: Hierarchical Linear Modeling School and Grade level effects Multiple Rs ranging from .88 (post) to .40 (6-month)
SEM: Structural Equation Modeling I. Measurement model: three factor (latent variables) II. Path Model
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Outcome Measures
Three Key Scales:Resistance to smoking Intentions to smokeCigarette consumption
Smoking StatusSatisfaction with Intervention
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Cigarette Use ScaleItem Item-Scale
Correlation
1. . Cigarette Use: Lifetime .75
2. Cigarette Use: Past 30 Days .83
3. Cigarette Use: Daily .78
Internal Consistency Reliability (alpha)
.85
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Behavioral Intention Scale
Item Item-Scale Correlation
1. Intent to smoke: I year .83
2. Intent to smoke: 6-months .84
3. Intent to smoke: 30-days .59
Internal Consistency Reliability (alpha)
.82
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Resistance to Smoking Scale
Item Item-Scale Correlation
1. Affect .54
2. Efficacy .77
3. Willingness .70
4. Decision Balance .41
5. Self Determination .52
6. Importance .63
7. Readiness to Change .64
Internal Consistency Reliability (alpha) .83
Resistanceto Smoking
Affect
Self-efficacy
Self-Determination
DecisionBalance
Readiness
Willingness
BehaviouralIntention
Cigarette Use
Intent(6 months)
Intent(3 months)
Intent(daily)
Importance
Lifetime
Last 30 Days
Daily
E6
E1
E2
E3
E7
E5
E4
E13
E12
E11
E10
E9
E8
Study Impact
Interaction effects indicate strongest effect for grade 9’s for both prevention and cessation
Most noticeable effects with smokers (cessation)
Smoking Cessation
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Resistance to Smoking (p < .05)
Grade Grade by Sex
* Most noticeable influence on grade 9 boys
December 10, 2003NCTH Boston, MA
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Behavior Intention (p < .05)
Grade Group by GradeGroup by Smoker by Grade Group by Smoker by Grade by SexSmoker by Grade by Sex
* Most noticeable influence on smokers (boys) in grade 9
December 10, 2003NCTH Boston, MA
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Cigarette Use (p < .05)
GradeGroup by Smoker by Sex Grade by SexSmoker by GradeSmoker by Grade by Sex
* Most noticeable influence on smokers (boys) in grade 9
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Key Findings
Smoking Zine’s greatest potential impact with: Grade 9 students (cessation and prevention) Boys Smokers (Zine as treatment) ‘High-risk’ schools
eHealth Literacy Main effect
Small intervention effect with great potential cumulative effect on a population level
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Multi-level Modelling
December 10, 2003NCTH Boston, MA
www.smokingzine.org
In Progress: Multi-level Model
Supra-level
Base Level
Context:
School, Grade, Class
Individual:
Sex, Smoker, Intervention
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Preliminary findings
Significant effect for Grade 9 students for both smoking cessation and prevention of smoking acting on behavior intention
Effect most noticeable with boysNo class effects
Lessons Learned
- Study Process - Web-based Interventions- The Team - Working with Schools- Working with Youth
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Lessons Learned 1: Study Process
Pilot..pilot..pilot Build solid community partnershipsCommunicate with your partnersHire administrative supportDebrief and improve processThings always take longer!No two days are alike
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Lessons Learned 2: The Team
Identify a clear chain of commandHire staff to complement each otherEnsure a range of experience with youth Select staff with leadership skillsCross train staff on all study rolesHave back-up staff available and trained
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Lessons Learned 3: Web-based Interventions
Youth and adult testing Onsite technology assessments Quality of access is an issue Literacy is an issue ESL and Special needs are an issue On-call technical support is critical Establish back-up procedures in advance Upfront development costs extensive
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Lessons Learned 4: Working With Schools
Create partnerships earlyPersistence is keyConsult with educators & administratorsReflect school realities in your studyOutline school roles and responsibilitiesProvide value to schools, teachers &
students
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Lessons Learned 4: Working With Schools
Identify fit with existing activities & curriculum
School level compensationIdentify and support a championProvide ongoing feedback Changing routine is difficultDon’t assume support structures
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Lessons Learned 5: Working With Youth
Communicate with respectProvide clear concise instructionsThey are interested in researchGet back to them with resultsGrade 9 is not Grade 10 is not Grade 11
Future Directions
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Next Steps:
Follow-up studies examining the interaction effects Boys, Lower grades, High-Risk Schools
Whole-school approach (including parents and community)
Smoking Zine in primary care settings International Applications
China Brazil Middle East
Take Home Message
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Take Home Messages
Ensure authentic youth involvement in all phases:design,implementation,evaluation
Pilot test the intervention in stages (iterative development)
Build partnerships that respect and recognize their needs and challenges
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Designing Effective Interventions
Accessible Individualized Remote & Group Counselling Provide opportunities for assisted self-help Strengthen social support networks Use biomarker feedback Must be efficient (& realistic):
Population X Reach X Efficacy
Thank you
December 10, 2003NCTH Boston, MA
www.smokingzine.org
Contact Us
Oonagh Maley
oonagh.maley@utoronto.ca
416.978.7543
Cameron Norman
cameron.norman@utoronto.ca
416.209.6740
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