The use of videos to inform smokers about differentnicotine replacement products

Sylvia Maya,*, Robert Westa, Peter Hajekb, Fredrik Nilssonc,Jonathan Fouldsd, Anna Meadowb

aSt. George’s Hospital Medical School, Cranmer Terrace, London SW17 ORE, UKbSt. Bartholomew’s and the Royal London Hospitals School of Medicine and Dentistry, London, UK

cPharmacia, Helsingborg, SwedendUniversity of Surrey, Guildford, UK

Received 7 February 2002; received in revised form 25 July 2002; accepted 4 September 2002

Abstract

This study examined the feasibility of using video presentations to inform smokers about nicotine replacement treatment (NRT). The study

was part of a larger trial comparing four different NRTs. Five hundred and four smokers attended a clinic on the day they stopped smoking.

They were presented with a brief video overview of the four treatments. They were then randomly allocated to a treatment and shown another

brief video describing that treatment in more detail. After 1 week of NRT use, participants rated how clearly the video described how the

treatments work, how to use them and their possible side effects. They also rated how their experience of the product compared to expectation

in terms of helpfulness, convenience and side effects. The smokers reported overwhelmingly that the videos had accurately described the

product to which they had been allocated. Video presentations can be an effective way to convey information to smokers about NRT.

# 2002 Published by Elsevier Science Ireland Ltd.

Keywords: Smoking cessation; Nicotine replacement therapy; Videos

1. Introduction

Smoking remains the leading preventable cause of death

in the developed world [1]. Nicotine replacement treatments

(NRTs) have been shown to significantly increase abstinence

rates in smokers trying to stop [2]. There are currently six

nicotine replacement treatments available on prescription

or over the counter for smokers: nicotine gum, patch, spray,

inhalator and more recently nicotine microtabs and

lozenges. With this choice available, smokers need to be

given clear and objective information about the different

products in order to make an informed decision about which

one they would like to use.

The treatments differ in that the patch is applied once a

day, while the other five treatments require that the smoker

regularly engage in a particular activity for therapeutic levels

of nicotine to be reached, e.g. chewing the gum or puffing on

an inhalator. Evidence suggests that for NRT forms where

the user controls the daily dose, consumption of higher

levels of NRT is associated with greater likelihood of

success and that users typically under-dose [3,4]. They

may also benefit from having positive but realistic expecta-

tions about the effectiveness of the product and the likely

experience of using it.

The majority of smokers who use NRT purchase it over

the counter where the opportunity to receive clear advice

about the various alternatives is very limited. It may

involve some verbal advice from the pharmacist but other-

wise is limited to manufacturer leaflets and the labelling

that comes with each product. In practice patient informa-

tion leaflets (PILs) are only read by about 35% of patients

and then only after the product has been obtained [5]. We

are not aware of any formal evaluations of PILs for NRT. In

the UK and elsewhere, healthcare professionals such as

practice nurses are being recruited to provide support to

smokers wanting to stop, including advice on medications

that may help them.

There is a need to develop a medium for presenting

information about NRT in an accessible way. Various

options exist including leaflets, audio tapes or the use of

computer technology. Another possible method of doing so

Patient Education and Counseling 51 (2003) 143–147

* Corresponding author. Tel.: þ44-20-8725-0599;

fax: þ44-20-8767-2741.

E-mail address: sivpiv@aol.com (S. May).

0738-3991/$ – see front matter # 2002 Published by Elsevier Science Ireland Ltd.

PII: S 0 7 3 8 - 3 9 9 1 ( 0 2 ) 0 0 1 9 8 - 2

would be to use videos. Videos have previously been used

for health education or as part of multi-component treatment

programmes [6–8]. The aim in these cases is to increase

cessation rates and the video component is typically not

evaluated individually [9]. Instructional videos have been

used with some success in other areas of health education

(e.g. toothbrushing [10]), however, their use has not pre-

viously been studied to instruct people on NRT. Schneider

et al. [11,12] used videos for this purpose in two studies,

however, the videos themselves were not evaluated. Man-

ufacturers of NRT products have also used videos to explain

the products but these are not directed at smokers them-

selves. Videos are a medium through which accurate and

objective information can be provided. Their use also

ensures that information is given out consistently and

important material is not forgotten. Videos could potentially

be used both in future research and in a wide variety of

health care settings such as family doctors’ surgeries and

pharmacies.

This paper reports on the findings from a study that

examined the feasibility of using brief video presentations

to provide information on different forms of NRT. This was

part of a larger study comparing 15 mg, 16 h Nicorette

Patches, Nicorette Gum, Nicorette Nasal Spray and Nicor-

ette Inhalator in terms of: withdrawal symptom relief,

efficacy in terms of 12-week abstinence rate, usage patterns,

preference, acceptability, abuse liability and dependence

potential. Results from the comparative trial and results

specific to the abuse liability and dependence potential of

the four products are reported elsewhere [13,14].

2. Methods

2.1. Participants

The study took place at two large teaching hospitals in

London. Smokers were drawn from the local populations

which included a relatively high proportion of individuals

from more deprived socio-economic groups. Participants

were 504 smokers recruited through advertisements and

referrals. Participants were eligible if they were 18 years

or older, smoked 10 or more cigarettes per day on average,

were in general good health, were not currently receiving

treatment for a psychiatric disorder, were motivated to stop

smoking, had not used NRT in the previous 3 months and for

whom none of the products were contraindicated. There

were no significant differences between the treatment groups

in terms of gender, occupation, age, cigarettes per day,

carbon monoxide level, or number of prior quit attempts

(see [14]). Participants stopped smoking at the first visit

(week 0) and were then followed up 1, 4, 12 and 15 weeks

later. Data are only presented here for the first two visits

when video presentations were assessed. Assessments were

not made at later points because by that stage attrition as a

result of relapse to smoking would have seriously biased the

sample. Participants were required to purchase their NRT at

half the usual price and were given £10 to cover travel costs

from the second visit onwards irrespective of smoking

status.

2.2. Design and procedure

Smokers were recruited through advertisements. Initial

screening for eligibility occurred over the phone and people

who were eligible were invited to attend the hospital clinic.

Participants received an information sheet and a postal

questionnaire to complete prior to their first visit. The

questionnaire included items concerning general demo-

graphic information, smoking history and previous experi-

ence of NRT. Participants were instructed to continue

smoking normally until their first clinic visit which would

be the point at which their attempt to stop smoking would

begin (their quit date).

All participants were seen individually. At their first visit

smokers provided informed consent. They were then shown

an 8 min video presenting information on the four treat-

ments. They were then randomly allocated to a product.

Participants were then shown a second video lasting 7 min

containing more detailed information about the product to

which they had been allocated. The videos recommended

that the smokers use the products according to manufacturer

instructions for up to 12 weeks. Researchers were instructed

to respond to questions and offer support as required.

However, input from the researchers was kept to a minimum.

Participants were also provided with written instructions on

the correct use of their product.

After 1 week of use, smokers were asked to rate how

clearly the video described three aspects of the treatments:

the way the treatments work, how to use them and their

possible side effects. Options for each item were ‘not clearly

enough’, ‘quite clearly’ and ‘very clearly’. (Note: in UK

English ‘quite’ is interpreted as ‘moderately’.) They were

also asked to rate how their experience of their allocated

product compared to their expectation of it in terms of its

helpfulness (less than, same as, more than expected), con-

venience (less, the same and more than expected) and side

effects (worse, same, better than expected). Participants who

did not attend the clinic were contacted within 48 h and

asked to complete the questionnaire by phone Table 1.

Of the 105 participants in the gum group who provided

data after 1 week of use, 37 had used nicotine gum before.

Of the 108 participants in the patch group who provided

data after 1 week, 43 had used a nicotine patch before; 1

smoker had used the nasal spray and none had used the

inhalator.

2.3. Materials

The videos were designed by Prof. Hajek, they cost less

than £8000 to produce and were aimed at a clients with a

minimum reading age of 14. They used a simple format with

144 S. May et al. / Patient Education and Counseling 51 (2003) 143–147

Prof. West seated behind a table explaining the rationale and

use of NRT. Bullet notes were used to highlight important

points. A smoker who recently quit smoking using NRT

demonstrated the use of products. They followed a similar

format, with wording being the same except where it was

necessary to vary it. The aim was to standardise the message

and reduce the variation in messages to that necessary to be

factually accurate. They are summarised below.

2.3.1. Video 1: general overview of NRT (8 min)

This video was in three parts.

1. The rationale behind the use of NRT.

2. Overview of the four treatments.

3. More detailed description of each of the four treatments.

2.3.2. Video 2: description of individual treatments (7 min)

Four videos were used each one describing a particular

treatment. Each video followed the same format.

1. Rationale for NRT use.

2. Setting realistic expectations.

3. How to use the treatment (including recommended

dosing regimen and showing the same patient using the

product).

4. Possible side effects of the particular form of NRT.

5. General quit tips.

3. Results

There were 504 smokers recruited to the study. Of these

35% were men, 56% were married or living with a partner,

59% were in paid employment, 44% were in or had been in

white collar job. Their mean age was 40 years (S:D: ¼ 10),

mean cigarette consumption was 25 cigarettes per day

(S:D: ¼ 9), mean expired CO level was 29 ppm (S:D: ¼12), and the average number of previous serious quit attempts

was 3 (S:D: ¼ 3). There were no significant differences

between the groups.

In total 412 participants attended the second visit of whom

254 were not smoking. A further nine completed the ques-

tionnaire over the phone. All those who completed by phone

had smoked during the week. Average daily use of NRT

among abstainers during the first week was 9.5 (S:D: ¼ 3)

pieces of gum, 1 (S:D: ¼ 0:2) patch, 24.5 (S:D: ¼ 11:8)

shots of spray and 4.3 (S:D: ¼ 1:9) inhaler cartridges.

Table 2 shows that the smokers reported overwhelmingly

that the videos had accurately described the product to which

they had been allocated. This was so whether or not they had

managed to maintain abstinence. Among the participants in

the gum group who provided data after 1 week of use, those

who had previously used the gum were more likely to rate

the video as not describing the side effects clearly enough

than those who had not: 16% versus 3% (Fisher’s exact

P ¼ 0:03). There were no other differences among prior

Table 1

Procedure, number of participants and outcome in each condition

Treatment

Gum Patch Spray Inhaler

Session 1: video presentation (N ¼ 504)

(1) Video 1 shown

(2) Randomisation

Allocation (N) Gum (127) Patch (124) Spray (126) Inhaler (127)

(3) Video 2 shown

Session 2: video evaluation

Data obtained (N) Yes (106) No (21) Yes (109) No (15) Yes (107) No (19) Yes (99) No (28)

If yes, smoking status (N) S (42) NS (64) S (41) NS (68) S (39) NS (68) S (45) NS (54)

Session 1 was followed by session 2. Where smoking status was not confirmed, participant was counted as a smoker for all relevant analyses.

Table 2

Percentages of participants who rated the videos they had seen as ‘quite’ or ‘very’ clear in describing features of NRT after 1 week of use

Treatment

Gum (N ¼ 106) Patch (N ¼ 109) Spray (N ¼ 107) Inhaler (N ¼ 99)

Smoking status NS (N ¼ 64) S (N ¼ 42) NS (N ¼ 68) S (N ¼ 41) NS (N ¼ 68) S (N ¼ 39) NS (N ¼ 54) S (N ¼ 45)

Side effects 89 88 97 98 96 92 95 85

How it works 95 100 97 100 99 97 98 98

How to use it 100 98 98 100 98 97 96 93

The log-linear analyses comparing ratings as a function of smoking status and product and examining possible interactions between these revealed no

significant differences across products nor between smokers who were abstinent and those who had relapsed.

S. May et al. / Patient Education and Counseling 51 (2003) 143–147 145

gum users and no differences at all between prior patch users

and novice patch users.

Table 3 shows that after 1 week of use a substantial

number of smokers tended to regard the product they were

using as more helpful, more convenient and as having less

severe side effects than they had expected. The exception to

this was the nasal spray where among smokers who had

relapsed to smoking, a slightly higher proportion rated the

product as less convenient and as producing worse side

effects than expected. Helpfulness ratings were significantly

greater in those who were abstinent than those who relapsed

(w2 ¼ 27:9, P < 0:001); convenience ratings were greater

for those who were abstinent than those who relapsed

(w2 ¼ 17:8) and differed across products (w2 ¼ 40:5,

P < 0:001); side effect ratings differed across products

(w2 ¼ 28:9, P < 0:001) but not according to whether the

smokers were abstinent or not (w2 ¼ 5:2, NS).

In the gum group, the abstainers who had previously used

the gum were more likely to rate it as less convenient than

expected than the novice users (16% versus 0%, w2 ¼ 8:4,

P ¼ 0:01). There were no other differences in ratings of the

products between prior users and novice users.

4. Discussion and conclusion

The results provide evidence that brief video presenta-

tions can be an effective way to convey information to

smokers about nicotine replacement products. This finding

is irrespective of treatment allocation, abstinence or pre-

vious experience with NRT. The only exception being

among people with previous experience of the gum who

were more likely to report that the video did not describe the

side effects clearly enough. The reason for this is not clear.

There was no difference in their rating of how well the video

described how the gum works or how to use it.

In addition to this, and in contrast to anecdotal reports of

smokers having unrealistic expectations and being disap-

pointed with NRT products, participants overall were plea-

santly surprised by their experience of NRT. Participants

expectations of their NRT would not be based solely on

information from the videos. Indeed many participants had

used the gum or patch before. However, the finding that

overall they were pleasantly surprised by their experience of

using NRT is of interest. It may be that future videos could be

modified to encourage more positive expectations, clearly in

a real life setting if people’s expectations are too low they

may decide against even trying the treatment. The finding

that helpfulness and convenience ratings were greater

among abstainers would be expected, as relapsers may be

seeking rationalisations for their failure. The finding that

there was no difference in the side effects ratings between

abstainers and relapsers is, therefore, particularly encoura-

ging.

4.1. Discussion

Several limitations to this study should be noted. Most

participants were recruited through advertising. This has

with implications for the generalisability of the results.

Hence, for example, the sample was 35% men while in

the population as a whole about equal proportions of men

and women smoke. Average cigarettes per day was also

higher in the trial than in the population as a whole (where it

is currently 16 cigarettes per day). This is a limitation,

however, it reflects the pattern typically seen in smokers

clinics. The videos were presented in the context of a

research trial so there was a researcher on hand to provide

further support and participants where given information

sheets to take away. The smokers’ ratings of the videos may

in part reflect this. However, the results appear sufficiently

encouraging to warrant piloting videos in more naturalistic

settings, such as at the point of purchase in pharmacies. It

also gives encouragement to their use as a convenient and

systematic way of presenting information in clinical trials. It

is possible that smokers who could not be contacted at the 1

week follow-up would have provided more negative ratings.

However, the main factor underlying non-attendance in

smoking trials is abandonment of the quit attempt and we

found no difference in the video evaluations between those

who were contacted and had versus had not maintained

abstinence. As this was part of a larger study, no control

group was used. In addition the current study only examined

smokers perceptions of the videos, it would be of value to

test participants actual knowledge before and after viewing

them. As smokers are recommended to use NRT for 3

Table 3

Percentages of participants who after 1 week of use rated their NRT product as better or worse than expected on a set of features

Treatment

Gum (N ¼ 106) Patch (N ¼ 109) Spray (N ¼ 107) Inhaler (N ¼ 99)

Status NS (N ¼ 64) S (N ¼ 42) NS (N ¼ 68) S (N ¼ 41) NS (N ¼ 68) S (N ¼ 39) NS (N ¼ 54) S (N ¼ 45)

Worse/better W B W B W B W B W B W B W B W B

Helpfulness 0 78 11 42 3 60 9 49 4 79 21 51 4 62 14 64

Convenience 5 41 16 23 0 35 5 26 12 38 21 15 11 57 32 36

Side effects 17 45 16 38 10 62 5 54 19 35 41 33 6 65 25 57

The percentages who rated the products the same as expected are not given explicitly. All w2-values are derived from log-linear analyses involving the rating,

the NRT type and the smoking status of participants (see legend to Table 1).

146 S. May et al. / Patient Education and Counseling 51 (2003) 143–147

months, it would also be of interest to examine any changes

in their perception of the videos over time. Future research

could also compare videos with other methods of informa-

tion provision (e.g. pamphlets or IT). Finally while these

particular videos may have been successful in presenting

information about NRT products, there is obviously no

guarantee that others will work as well. Overall, however,

this study provides evidence for the potential value of this

form of communication.

4.2. Practice implications

This study suggests the utility of videos as a means of

imparting information about NRT to patients. Further study

would be necessary before recommendations can be made as

to the most appropriate context for the use of such videos.

However, it may be that they would benefit patients at the

point of choice about their NRT, for example, at their local

GP practice or at the pharmacy. Videos may also be useful

for providing information systematically to research parti-

cipants.

Acknowledgements

This research was funded by Pharmacia & Upjohn.

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