internet and telephone treatment for smoking cessation
TRANSCRIPT
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
