Internet and Telephone Treatment for Smoking Cessation Amanda L. Graham, PhD Director, Research DevelopmentThe 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
Overview Background & rationale for trial Research design and methods Major outcomes Secondary analyses currently underway Future research
Study TeamDavid Abrams, PhD BrownBeth Bock, PhD BrownCharles Neighbors, PhD, MBA BrownGeorge Papandonatos, PhD BrownRaymond Niaura, PhD BrownNathan Cobb, MD QuitNetDavid Rosenbloom, PhD QuitNetDavid Tinkelman, MD National Jewish Health
Content & Quality of Internet Cessation1. To examine the quality of smoking cessation treatment on the Internet2. To identify high-quality websites that warrant effectiveness evaluation3. To adapt PHS Clinical Practice Guideline to create an evaluation toolBock B, Graham A, et al. Smoking cessation treatment on the Internet: content, quality,and usability. Nic Tob Research, 6: 207-219, 2004. PMID: 15203794.
Why QuitNet?PARTNERS:7 US states2 CA provinces13 Counties17 employers4 HMOs
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)Cobb NK, Graham AL, et al. Initial evaluation of a real-world Internet smoking cessationsystem. Nic Tob Research, et al. (2005). NicotinePMID: 16036277. Source: Cobb, Graham 7: 207-216, 2005. and Tobacco Research.
Smoking Outcomes Least conservativeADHERENCE SAMPLE (N=223): 30.0% – Respondents onlyINTENTION TO TREAT (N=1,024): 7.0% – Counts all non-responders as smokers Most conservative
Smoking Outcomes: Secondary Analyses Least conservativeADHERENCE SAMPLE (N=223): 30.0% – Respondents only• Used site ≥ 2x (N=336): 13.1%• Used site >1x (N=488): 9.8%• Excluding bounced (N=892): 8.0%INTENTION TO TREAT (N=1,024): 7.0% – Counts all non-responders as smokers Most conservative
Utilization & Smoking Outcomes Quitters Smokers P value (N=67) (N=156) 9 2# logins, median (IQR) <.001 (1-42) (1-5) 103 33# minutes online, median (IQR) <.001 (33-339) (17-83)% 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 ***
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
Interventions: Internet + Phone• 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 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 smokingGraham AL et al. Characteristics of smokers reached and recruited to an internetsmoking 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 Consent3 explicit steps:Do you give informedconsent?Contact information“Digital signature”
Baseline Telephone AssessmentGraham AL et al. Internet- vs. telephone-administered questionnaires in a randomized trial of smokingcessation. Nic Tob Research, 8 Suppl 1: S49-57, 2006. PMID: 17491171.Graham AL & Papandonatos GD. Reliability of internet- versus telephone-administered questionnairesin a diverse sample of smokers. J Med Int Res, 10: e8, 2008. PMID: 18364345.
Follow-Up Results 3mo 6mo 12mo 18mo $25 / phone surveyBasic Internet 79.1 77.3 72.5 68.6 $15 / web surveyEnhanced Internet 76.7 74.0 72.2 69.0 (for telephone non-Enhanced Internet 73.5 72.6 69.9 67.1 responders)+ PhoneTotal 76.4 74.7 71.5 68.2 $20 bonus at end ofP‐value 0.05 0.12 0.53 0.74 study for completing all 4 surveys
25 20 Basic Internet30 day abstinence 15 Enhanced Internet 10 Enhanced Internet + Phone 5 0 3 mo 6 mo 12 mo 18 mo
20 18prevalence abstinence30 day multiple point 16 Basic Internet 14 12 Enhanced 10 Internet 8 Enhanced 6 Internet + Phone 4 2 0 3 mo 6 mo 12 mo 18 mo
Secondary Analyses1. Early advantage for Enhanced Internet + Telephone counseling2. Improvement in both Internet conditions over time3. Overall performance of the comparison condition (Why did the control group do so well?)
Social Networks & CessationTable 1. Website utilization patterns among BecomeAnEX.org members by community involvement No Community Community 3+ logins 8% 28% # days 5.0 ± 29.0 22.1 ± 59.1 website use # interactive 1.9 ± 1.6 3.4 ± 2.0 tools used
“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 & Implications1. Make sure Internet cessation program is evidence based and leverages the full functionality of the Internet2. Seamless integration of treatments each with unique advantages rather than parallel offerings3. Adherence is critical
Amanda L. Graham, PhD Phone: 202.454.5938Email: firstname.lastname@example.org