Internet and Telephone Treatment for         Smoking Cessation             Amanda L. Graham, PhD                   Directo...
National Cancer Institute     R01 CA104836
Overview Background & rationale for trial Research design and methods Major outcomes Secondary analyses currently unde...
Study TeamDavid Abrams, PhD                            BrownBeth Bock, PhD                               BrownCharles Neig...
Content & Quality of                                                   Internet Cessation1. To examine the quality of smok...
Content & Quality of  Internet Cessation
Why QuitNet?PARTNERS:7 US states2 CA provinces13 Counties17 employers4 HMOs
Initial Evaluation of                                                           QuitNet• Observational study in December 2...
Smoking Outcomes                                  Least conservativeADHERENCE SAMPLE (N=223):               30.0%  – Respo...
Smoking Outcomes:                            Secondary Analyses                                  Least conservativeADHEREN...
Utilization &                                   Smoking Outcomes                                 Quitters   Smokers       ...
Utilization &                              Smoking Outcomes• Community participation & smoking outcomes:    7-day pp. abs...
Study Design
Interventions:Control Condition  Static site designed   by research team  “look and feel” of   QuitNet  Extracted conte...
Interventions:Enhanced Internet Premium service Membership fee  paid for by grant 6 month access
Interventions:                              Internet + Phone• Strong evidence base for telephone  counseling  – 2003 Cochr...
Interventions:                                      Internet + Phone Non-profit, non-sectarian World-recognized  academi...
Interventions:  Internet + Phone Intake call Entry call Preparation call 2 support calls after quit date Additional s...
Recruitment                                                                Approach                                       ...
Eligibility Screening Smoking rate (5+ cpd)• Time to first cig.• Quits past year• Age 1st puff Current age (18+ years)• ...
Informed Consent3 explicit steps:Do you give informedconsent?Contact information“Digital signature”
Baseline Telephone                                                             AssessmentGraham AL et al. Internet- vs. te...
Recruitment    Results
Participants
Follow-Up Results                    3mo    6mo    12mo 18mo     $25 / phone surveyBasic Internet      79.1   77.3   72.5 ...
25                    20                               Basic Internet30 day abstinence                    15              ...
20                         18prevalence abstinence30 day multiple point                          16                       ...
Secondary Analyses1. Early advantage for Enhanced Internet +   Telephone counseling2. Improvement in both Internet conditi...
Secondary Analyses:                                            Utilization DataTelephone Counseling Utilization           ...
Secondary Analyses:                                              Utilization DataResponder only full sample (ITT): 25.9%  ...
Population Impact                                      EFFICACY         x      REACH          =       IMPACT              ...
Utilization &        18 Month Outcomes        0       min< 90min
Social Networks &                  CessationTable 1. Website utilization patterns among BecomeAnEX.org members by communit...
“Integrator” Pilot                                              Study• N=244 randomized to EX vs. EX + SN• Intervention fe...
Summary &                                     Implications1. Make sure Internet cessation program is   evidence based and ...
Amanda L. Graham, PhD       Phone: 202.454.5938Email: agraham@legacyforhealth.org
Internet and telephone treatment for smoking cessation
Upcoming SlideShare
Loading in …5
×

Internet and telephone treatment for smoking cessation

326 views

Published on

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Internet and telephone treatment for smoking cessation

  1. 1. 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
  2. 2. National Cancer Institute R01 CA104836
  3. 3. Overview Background & rationale for trial Research design and methods Major outcomes Secondary analyses currently underway Future research
  4. 4. 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
  5. 5. 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.
  6. 6. Content & Quality of Internet Cessation
  7. 7. Why QuitNet?PARTNERS:7 US states2 CA provinces13 Counties17 employers4 HMOs
  8. 8. 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.
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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 ***
  13. 13. Study Design
  14. 14. Interventions:Control Condition  Static site designed by research team  “look and feel” of QuitNet  Extracted content from QuitNet  No interactive features  No online community
  15. 15. Interventions:Enhanced Internet Premium service Membership fee paid for by grant 6 month access
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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.
  20. 20. 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)
  21. 21. Informed Consent3 explicit steps:Do you give informedconsent?Contact information“Digital signature”
  22. 22. 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.
  23. 23. Recruitment Results
  24. 24. Participants
  25. 25. 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
  26. 26. 25 20 Basic Internet30 day abstinence 15 Enhanced Internet 10 Enhanced Internet + Phone 5 0 3 mo 6 mo 12 mo 18 mo
  27. 27. 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
  28. 28. 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?)
  29. 29. Secondary Analyses: Utilization DataTelephone Counseling Utilization Website Utilization Data (0-3 months) Data (0-3 months) N=675 N=675# calls completed, M (SD) 3.6 (3.3) # logins, median (IQR) 3.0 (9.0)0 calls 26.7% 0 logins 24.1%1 call 2.5% 1 login 15.9%2 calls 14.5% 2 login 11.4%3 calls 11.1% 3 login 7.3%4 calls 8.3% 4 login 4.4%5+ calls 36.9% 5+ logins 36.9%
  30. 30. Secondary Analyses: Utilization DataResponder only full sample (ITT): 25.9% Compared to no treatment: 0  1‐4  5+ Logins logins logins  5+ logins were 2.3x more likely to quit (95% CI 0 calls 13.8% 12.5% 21.1% 1.31 – 4.13, p<.01)  5+ calls were 3.4x more 1‐4 calls 17.6% 8.7% 25.8% likely to quit (1.82 – 6.44, p<.001) 5+ calls 31.6% 26.2% 44.5%  Additive effect, not multiplicative
  31. 31. Population Impact EFFICACY x REACH = IMPACT (# using method (% abstinent) (total # quitters) annually)None (unaided) 3% 16,000,000 480,000Rx NRT (1995) 14% 2,500,000 350,000OTC NRT (1996) 14% 6,300,000 882,000Internet + Phone (3mo ITT) 19.0% 320,000** 60,800Internet + Phone (3mo hi adh) 45.5% 320,000** 145,600Behavioral counseling 24% 395,000 94,800Inpatient 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 .
  32. 32. Utilization & 18 Month Outcomes 0 min< 90min
  33. 33. 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
  34. 34. “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
  35. 35. 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
  36. 36. Amanda L. Graham, PhD Phone: 202.454.5938Email: agraham@legacyforhealth.org

×