Online support for smoking cessation: a systematic review of the literature

Computer-based interventions for sexual health promotion: systematic review and meta-analyses

This systematic review was conducted to determine the effects of self-help interactive computer-based interventions (ICBIs) for sexual health promotion. We searched 40 databases for randomized controlled trials (RCTs) of computer-based interventions, defining 'interactive' as programmes that require contributions from users to produce personally relevant material. We conducted searches and analysed data using Cochrane Collaboration methods. Results of RCTs were pooled using a random-effects model with standardized mean differences for continuous outcomes and odds ratios (ORs) for binary outcomes, with heterogeneity assessed using the I(2) statistic. We identified 15 RCTs of ICBIs (3917 participants). Comparing ICBIs to minimal interventions, there were significant effects on sexual health knowledge (standardized mean difference [SMD] 0.72, 95% confidence interval [CI] 0.27-1.18); safer sex self-efficacy (SMD 0.17, 95% CI 0.05-0.29); safer-sex intentions (SMD 0.16, 95% CI 0.02-0.30); and sexual behaviour (OR 1.75, 95% CI 1.18-2.59). ICBIs had a greater impact on sexual health knowledge than face-to-face interventions did (SMD 0.36, 95% CI 0.13-0.58). ICBIs are effective tools for learning about sexual health, and show promising effects on self-efficacy, intention and sexual behaviour. More data are needed to analyse biological outcomes and cost-effectiveness.

Engagement promotes abstinence in a web-based cessation intervention: cohort study

Background

Web-based smoking cessation interventions can have a public health impact because they are both effective in promoting cessation and can reach large numbers of smokers in a cost-efficient manner. Their potential impact, however, has not been realized. It is still unclear how such interventions promote cessation, who benefits most, and how to improve their population impact.

Objective

To examine the effectiveness of a highly promoted Web-based smoking cessation intervention to promote quit behavior over time, identify the most effective features, and understand who is most likely to use those features by using unweighted and weighted analyses to estimate the impact in the broader pool of registered site users.

Methods

A sample of 1033 new adult registrants was recruited from a Web-based smoking cessation intervention by using an automated study management system. Abstinence was assessed by self-report through a mixed-mode follow-up (online survey with telephone follow-up for nonrespondents) at 1, 3, and 6 months. Software tracked respondents’ online activity. Generalized estimating equations (GEE) were used to examine predictors of website utilization and how utilization promoted abstinence using unweighted and weighted data.

Results

The 7-day point prevalence abstinence rates at 6 months ranged from 20.68% to 11.13% in the responder and intent-to-treat samples, respectively. Predictors of abstinence in unweighted analyses included number of visits to the website as well as accessing specific interactive or engaging features. In weighted analyses, only number of visits was predictive of abstinence. Motivation to quit was a key predictor of website utilization, whereas negative partner support decreased the likelihood of increasing visits or accessing engaging features.

Conclusions

Engagement is critical to promoting smoking cessation. The next generation of Web-based smoking cessation interventions needs to maximize the initial engagement of all new visitors and work to retain those smokers who proceed to register on the site.

Constructing a Theory- and Evidence-Based Treatment Rationale for Complex eHealth Interventions: Development of an Online Alcohol Intervention Using an Intervention Mapping Approach

Background

Due to limited reporting of intervention rationale, little is known about what distinguishes a good intervention from a poor one. To support improved design, there is a need for comprehensive reports on novel and complex theory-based interventions. Specifically, the emerging trend of just-in-time tailoring of content in response to change in target behavior or emotional state is promising.

Objective

The objective of this study was to give a systematic and comprehensive description of the treatment rationale of an online alcohol intervention called Balance.

Methods

We used the intervention mapping protocol to describe the treatment rationale of Balance. The intervention targets at-risk drinking, and it is delivered by email, mobile phone text messaging, and tailored interactive webpages combining text, pictures, and prerecorded audio.

Results

The rationale of the current treatment was derived from a self-regulation perspective, and the overarching idea was to support continued self-regulation throughout the behavior change process. Maintaining the change efforts over time and coping adaptively during critical moments (eg, immediately before and after a lapse) are key factors to successful behavior change. Important elements of the treatment rationale to achieving these elements were: (1) emotion regulation as an inoculation strategy against self-regulation failure, (2) avoiding lapses by adaptive coping, and (3) avoiding relapse by resuming the change efforts after a lapse. Two distinct and complementary delivery strategies were used, including a day-to-day tunnel approach in combination with just-in-time therapy. The tunnel strategy was in accordance with the need for continuous self-regulation and it functions as a platform from which just-in-time therapy was launched. Just-in-time therapy was used to support coping during critical moments, and started when the client reports either low self-efficacy or that they were drinking above target levels.

Conclusions

The descriptions of the treatment rationale for Balance, the alcohol intervention reported herein, provides an intervention blueprint that will aid in interpreting the results from future program evaluations. It will ease comparisons of program rationales across interventions, and may assist intervention development. By putting just-in-time therapy within a complete theoretical and practical context, including the tunnel delivery strategy and the self-regulation perspective, we have contributed to an understanding of how multiple delivery strategies in eHealth interventions can be combined. Additionally, this is a call for action to improve the reporting practices within eHealth research. Possible ways to achieve such improvement include using a systematic and structured approach, and for intervention reports to be published after peer-review and separately from evaluation reports.

Project Exhale: preliminary evaluation of a tailored smoking cessation treatment for HIV-positive African American smokers

This study examined the feasibility, acceptability, and outcomes of a culturally tailored smoking cessation intervention for HIV-positive African American male smokers. Eligible smokers were enrolled in a seven-session group-based treatment combined with nicotine patch. The mean age of participants was M=46 years. The majority were daily smokers (71%), smoked a mentholated brand (80%), and averaged 8.6 (standard deviation [SD]=8.1) cigarettes per day. Baseline nicotine dependency scores (M=5.8) indicated a moderate to high degree of physical dependence. Of the 31 participants enrolled, the majority completed treatment (≥3 sessions; 68%), 1-month follow-up (74%), and 3-month follow-up (87%) interviews. Program acceptability scores were strong. However, adherence to the patch was low, with 39% reporting daily patch use. The majority of participants (80%, n=24) made a quit attempt. Furthermore, over the course of the intervention, smoking urge, cigarettes smoked, nicotine dependence, withdrawal symptoms, and depression scores all significantly decreased. Follow-up quit rates at 1 and 3 months ranged from 6% to 24%, with treatment completers having better outcomes. This first of its kind intervention for HIV-positive African American male smokers was feasible, acceptable, and showed benefit for reducing smoking behaviors and depression scores. Smoking cessation outcomes were on par with other similar programs. A larger trial is needed to address limitations and to confirm benefits.

Can multiple lifestyle behaviours be improved in people with familial hypercholesterolemia? Results of a parallel randomised controlled trial

OBJECTIVE

To evaluate the efficacy of an individualised tailored lifestyle intervention on physical activity, dietary intake, smoking and compliance to statin therapy in people with Familial Hypercholesterolemia (FH).

METHODS

Adults with FH (n = 340) were randomly assigned to a usual care control group or an intervention group. The intervention consisted of web-based tailored lifestyle advice and face-to-face counselling. Physical activity, fat, fruit and vegetable intake, smoking and compliance to statin therapy were self-reported at baseline and after 12 months. Regression analyses were conducted to examine between-group differences. Intervention reach, dose and fidelity were assessed.

RESULTS

In both groups, non-significant improvements in all lifestyle behaviours were found. Post-hoc analyses showed a significant decrease in saturated fat intake among women in the intervention group (β = -1.03; CI -1.98/-0.03). In the intervention group, 95% received a log on account, of which 49% logged on and completed one module. Nearly all participants received face-to-face counselling and on average, 4.2 telephone booster calls. Intervention fidelity was low.

CONCLUSIONS

Individually tailored feedback is not superior to no intervention regarding changes in multiple lifestyle behaviours in people with FH. A higher received dose of computer-tailored interventions should be achieved by uplifting the website and reducing the burden of screening questionnaires. Counsellor training should be more extensive.

TRIAL REGISTRATION

Dutch Trial Register NTR1899.

A pilot study of StopAdvisor: a theory-based interactive internet-based smoking cessation intervention aimed across the social spectrum

BACKGROUND

This article reports a pilot study of a new smoking cessation website ('StopAdvisor'), which has been developed on the basis of PRIME theory, evidence, web-design expertise and user-testing. The aims were to i) evaluate whether cessation, website usage and satisfaction were sufficiently high to warrant a randomised controlled trial (RCT) and ii) assess whether outcomes were affected by socio-economic status.

METHODS

This was an uncontrolled pilot study. Two hundred and four adult daily smokers willing to make a serious quit attempt were included. All participants received support from 'StopAdvisor', which recommends a structured quit plan and a variety of evidence-based behaviour change techniques for smoking cessation. A series of tunnelled sessions and a variety of interactive menus provide tailored support for up to a month before quitting through until one-month post-quit (http://www.lifeguideonline.org/player/play/stopadvisordemonstration). The primary outcome was self-report of at least 1month of continuous abstinence collected at 2months post-enrolment and verified by saliva cotinine or anabasine. Usage was indexed by log-ins and page views. Satisfaction was assessed by dichotomous ratings of helpfulness, personal relevance, likelihood of recommendation and future use, which were collected using an online questionnaire at 2months post-enrolment. Outcomes according to socio-economic status were assessed.

RESULTS

At 8weeks post-enrolment, 19.6% (40/204) of participants were abstinent according to the primary outcome criteria (95% C.I.=14.1% to 25.1%). Participants viewed a mean of 133.5 pages (median=71.5) during 6.4 log-ins (median=3). A majority of respondents rated the website positively on each of the four satisfaction `ratings (range=66.7% to 75.3%). There was no evidence of an effect of socio-economic status on abstinence (OR=1.01, C.I.=0.50-2.07), usage (page-views, t(202)=0.11, p=.91; log-ins, t(202)=0.21, p=.83), or satisfaction (helpfulness, OR=1.09, C.I.=0.41-2.88; personal relevance, OR=0.55, C.I.=0.20-1.56; recommendation, OR=0.98, C.I.=0.34-2.81; use in future, OR=1.45, C.I.=0.49-4.27).

CONCLUSIONS

The systematic application of theory, evidence, web-design expertise, and user-testing has resulted in a website that shows sufficiently promising efficacy and usability to warrant evaluation in a RCT. The website appears to be similarly effective and acceptable to users across the social spectrum.

Effectiveness of web-based tailored smoking cessation advice reports (iQuit): a randomized trial

AIMS

To determine whether web-based tailored cessation advice, based on social cognitive theory and the perspectives on change model, was more effective in aiding a quit attempt than broadly similar web-based advice that was not tailored.

DESIGN

Participants were allocated randomly to one of two groups, to receive either a cessation advice report and progress report that were tailored to individual-level characteristics or a cessation advice report that presented standardized (non-tailored) content. Tailoring was based on smoking-related beliefs, personal characteristics and smoking patterns, self-efficacy and outcome expectations.

SETTING

Participant enrolment and baseline assessments were conducted remotely online via the study website, with the advice reports presented by the same website.

PARTICIPANTS

Participants (n = 1758) were visitors to the QUIT website who were based in the United Kingdom, aged 18 years or over and who smoked cigarettes or hand-rolled tobacco.

MEASUREMENTS

Follow-up assessments were made at 6 months by telephone interview. The primary outcome measure was self-reported 3 months prolonged abstinence, and secondary outcomes were 1 month prolonged abstinence, 7-day and 24-hour point prevalence abstinence.

FINDINGS

The intervention group did not differ from the control group on the primary outcome (9.1% versus 9.3%; odds ratio = 1.02 95% confidence interval 0.73-1.42) or on any of the secondary outcomes. Intervention participants gave more positive evaluations of the materials than control participants.

CONCLUSIONS

A web-based intervention that tailored content according to smoking-related beliefs, personal characteristics and smoking patterns, self-efficacy and outcome expectations, was not more effective than web-based materials presenting broadly similar non-tailored information.

Web-based cognitive behavioral self-help intervention to reduce cocaine consumption in problematic cocaine users: randomized controlled trial

BACKGROUND

Web-based self-help programs that reduce problematic substance use are able to reach hidden consumer groups in the general population. These programs are characterized by their low treatment threshold and nonrestrictive intervention settings. They are also cost effective, making them of interest to both low-income and high-income industrialized countries with ever-increasing health costs.

OBJECTIVE

To test the feasibility and effectiveness of an anonymous, fully automated, Web-based self-help intervention as an alternative to outpatient treatment services for cocaine users.

METHODS

A total of 196 cocaine-using participants were recruited through various online and offline media for a randomized controlled trial. Participants in the intervention group received interactive cognitive behavioral modules and a consumption diary to reduce cocaine use, whereas participants in the control group received online psychoeducative information modules. Web-based follow-up assessments were conducted after 4 weeks, 6 weeks, and 6 months. Treatment retention was examined and compared between the intervention and control groups. Severity of cocaine dependence was the main outcome measure. Secondary outcomes were cocaine craving, depression symptoms, and alcohol and other substance use.

RESULTS

This Web-based intervention attracted older and more educated participants than existing outpatient treatment programs for which cocaine is the primary substance of abuse. Participants in the intervention group showed greater treatment retention compared with the control group (P = .04). Low response rates at the follow-up assessments restricted the explanatory power of the analyses. At the follow-up assessments, the severity of cocaine dependence did not differ between the intervention and control groups (P = .75). Furthermore, there were no differences in cocaine craving, depression, or alcohol and other substance use. Using the consumption diaries, the average number of cocaine-free days per week did not change significantly, whereas the weekly quantity of cocaine used decreased equally in both groups (P = .009).

CONCLUSIONS

For cocaine users with low dependence severity, a fully automated Web-based cognitive behavioral self-help intervention is a feasible alternative with limited effectiveness in outpatient treatment services. However, this type of intervention may attract specific user groups that are rarely reached by existing outpatient treatment and may help them to control their cocaine consumption anonymously.

TRIAL REGISTRATION

ISRCTN93702927; http://www.controlled-trials.com/ISRCTN93702927 (Archived by WebCite at http://www.webcitation.org/6CTMM10MR).

Strategies to help a smoker who is struggling to quit

Tobacco use is the leading preventable cause of death worldwide. Stopping tobacco use benefits virtually every smoker. Most of the 19% of US residents who smoke want to quit and have tried to do so. Most individual quit attempts fail, but two-thirds of smokers use no treatment when trying to quit. Treating tobacco dependence is one of the most cost-effective actions in health care. With a brief intervention, physicians can prompt smokers to attempt to quit and connect them to evidence-based treatment that includes pharmacotherapy and behavioral support (ie, counseling). Physicians can link smokers to effective counseling support offered by a free national network of telephone quit lines. Smokers who use nicotine replacement therapy (NRT), bupropion, or varenicline when trying to quit double their odds of success. The most effective way to use NRT is to combine the long-acting nicotine patch with a shorter-acting product (lozenge, gum, inhaler, or nasal spray) and extend treatment beyond 12 weeks. Observational studies have not confirmed case reports of behavior changes associated with varenicline and bupropion, and these drugs' benefits outweigh potential risks. A chronic disease management model is effective for treating tobacco dependence, which deserves as high a priority in health care systems as treating other chronic diseases like diabetes and hypertension.

Online intervention engagement predicts smoking cessation

OBJECTIVE

Instead of focusing on individual differences as predictors of quitting ("who they are"), this study focuses on actions ("what they do"). The purpose is to predict smoking abstinence in internet users who may become involved in social activities within the virtual community.

METHODS

From March, 2009, to July, 2011, users of a web-based smoking cessation program in Germany made data available for a post-hoc evaluation study (n=13,174), including abstinence rates and online activities such as a) posting on a bulletin board after a smoke-free day, b) offering a donation, and c) posting messages throughout their course.

RESULTS

Survival analyses for 70 days of self-reported non-smoking documented higher success rates for those who made use of one or more of the virtual community activities. Moreover, the effect of making an initial bulletin board entry on 10-week abstinence was mediated by offering a donation and posting messages throughout the course (R(2)=0.125). The indirect effect via donation was 0.10 (95% CI 0.06-0.14), and the indirect effect via message posting was 0.31 (95% CI 0.25-0.38).

CONCLUSIONS

Virtual community activities predict smoking cessation. Shifting the focus from personality characteristics toward behavioral process variables such as intervention engagement might add more substance to smoking cessation studies.

Development of StopAdvisor: A theory-based interactive internet-based smoking cessation intervention

Reviews of internet-based behaviour-change interventions have shown that they can be effective but there is considerable heterogeneity and effect sizes are generally small. In order to advance science and technology in this area, it is essential to be able to build on principles and evidence of behaviour change in an incremental manner. We report the development of an interactive smoking cessation website, StopAdvisor, designed to be attractive and effective across the social spectrum. It was informed by a broad motivational theory (PRIME), empirical evidence, web-design expertise, and user-testing. The intervention was developed using an open-source web-development platform, 'LifeGuide', designed to facilitate optimisation and collaboration. We identified 19 theoretical propositions, 33 evidence- or theory-based behaviour change techniques, 26 web-design principles and nine principles from user-testing. These were synthesised to create the website, 'StopAdvisor' (see http://www.lifeguideonline.org/player/play/stopadvisordemonstration). The systematic and transparent application of theory, evidence, web-design expertise and user-testing within an open-source development platform can provide a basis for multi-phase optimisation contributing to an 'incremental technology' of behaviour change.

Preventing smoking relapse via Web-based computer-tailored feedback: a randomized controlled trial

Background

Web-based computer-tailored approaches have the potential to be successful in supporting smoking cessation. However, the potential effects of such approaches for relapse prevention and the value of incorporating action planning strategies to effectively prevent smoking relapse have not been fully explored. The Stay Quit for You (SQ4U) study compared two Web-based computer-tailored smoking relapse prevention programs with different types of planning strategies versus a control group.

Objectives

To assess the efficacy of two Web-based computer-tailored programs in preventing smoking relapse compared with a control group. The action planning (AP) program provided tailored feedback at baseline and invited respondents to do 6 preparatory and coping planning assignments (the first 3 assignments prior to quit date and the final 3 assignments after quit date). The action planning plus (AP+) program was an extended version of the AP program that also provided tailored feedback at 11 time points after the quit attempt. Respondents in the control group only filled out questionnaires. The study also assessed possible dose–response relationships between abstinence and adherence to the programs.

Methods

The study was a randomized controlled trial with three conditions: the control group, the AP program, and the AP+ program. Respondents were daily smokers (N = 2031), aged 18 to 65 years, who were motivated and willing to quit smoking within 1 month. The primary outcome was self-reported continued abstinence 12 months after baseline. Logistic regression analyses were conducted using three samples: (1) all respondents as randomly assigned, (2) a modified sample that excluded respondents who did not make a quit attempt in conformance with the program protocol, and (3) a minimum dose sample that also excluded respondents who did not adhere to at least one of the intervention elements. Observed case analyses and conservative analyses were conducted.

Results

In the observed case analysis of the randomized sample, abstinence rates were 22% (45/202) in the control group versus 33% (63/190) in the AP program and 31% (53/174) in the AP+ program. The AP program (odds ratio 1.95, P = .005) and the AP+ program (odds ratio 1.61, P = .049) were significantly more effective than the control condition. Abstinence rates and effects differed per sample. Finally, the results suggest a dose–response relationship between abstinence and the number of program elements completed by the respondents.

Conclusion

Despite the differences in results caused by the variation in our analysis approaches, we can conclude that Web-based computer-tailored programs combined with planning strategy assignments and feedback after the quit attempt can be effective in preventing relapse 12 months after baseline. However, adherence to the intervention seems critical for effectiveness. Finally, our results also suggest that more research is needed to assess the optimum intervention dose.

Trial Registration

Dutch Trial Register: NTR1892; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1892 (Archived by WebCite at http://www.webcitation.org/693S6uuPM)

Web-based interventions for behavior change and self-management: potential, pitfalls, and progress

The potential advantages of using the Internet to deliver self-care and behavior-change programs are well recognized. An aging population combined with the increasing prevalence of long-term conditions and more effective medical interventions place financial strain on all health care systems. Web-based interventions have the potential to combine the tailored approach of face-to-face interventions with the scalability of public health interventions that have low marginal costs per additional user. From a patient perspective, Web-based interventions can be highly attractive because they are convenient, easily accessible, and can maintain anonymity/privacy. Recognition of this potential has led to research in developing and evaluating Web-based interventions for self-management of long-term conditions and behavior change. Numerous systematic reviews have confirmed the effectiveness of some Web-based interventions, but a number of unanswered questions still remain. This paper reviews the progress made in developing and evaluating Web-based interventions and considers three challenging areas: equity, effectiveness, and implementation. The impact of Web-based interventions on health inequalities remains unclear. Although some have argued that such interventions can increase access to underserved communities, there is evidence to suggest that reliance on Web-based interventions may exacerbate health inequalities by excluding those on the “wrong” side of the digital divide. Although most systematic reviews have found a positive effect on outcomes of interest, effect sizes tend to be small and not all interventions are successful. Further work is needed to determine why some interventions work and others do not. This includes considering the “active ingredients” or mechanism of action of these complex interventions and the context in which they are used. Are there certain demographic, psychological, or clinical factors that promote or inhibit success? Are some behaviors or some clinical problems more amenable to change by computer-based interventions? Equally problematic is the issue of implementation and integration of such programs into routine clinical practice. Many eHealth projects end when the research is concluded and fail to become part of mainstream clinical care. One way of addressing these challenges is to apply the Medical Research Council framework for developing, evaluating, and implementing complex interventions. This includes having a strong theoretical foundation, developing a proposed mechanism or pathway of action, ensuring that the evaluation adequately reflects this proposed pathway, and considering implementation from the beginning of the development process.

Web-based smoking cessation intervention that transitions from inpatient to outpatient: study protocol for a randomized controlled trial

BACKGROUND

E-health tools are a new mechanism to expand patient care, allowing supplemental resources to usual care, including enhanced patient-provider communication. These applications to smoking cessation have yet to be tested in a hospitalized patient sample. This project aims to evaluate the effectiveness and cost-effectiveness of a tailored web-based and e-message smoking cessation program for current smokers that, upon hospital discharge, transitions the patient to continue a quit attempt when home (Decide2Quit).

DESIGN

A randomized two-arm follow-up design will test the effectiveness of an evidence- and theoretically-based smoking cessation program designed for post-hospitalization.

METHODS

A total of 1,488 patients aged 19 or older, who smoked cigarettes in the previous 30 days, are being recruited from 27 patient care areas of a large urban university hospital. Study-eligible hospitalized patients receiving usual tobacco cessation usual care are offered study referral. Trained hospital staff assist the 744 patients who are being randomized to the intervention arm with registration and orientation to the intervention website. This e-mail and web-based program offers tailored messages as well as education, self-assessment and planning aids, and social support to promote tobacco use cessation. Condition-blind study staff assess participants for tobacco use history and behaviors, tobacco use cost-related information, co-morbidities and psychosocial factors at 0, 3, 6, and 12 months. The primary outcome is self-reported 30-day tobacco abstinence at 6 months follow-up. Secondary outcomes include 7-day point prevalence quit rates at 3-, 6-, and 12-month follow-up, 30-day point prevalence quit rates at 3 and 12 months, biologically confirmed tobacco abstinence at 6-month follow-up, and multiple point-prevalence quit rates based on self-reported tobacco abstinence rates at each follow-up time period. Healthcare utilization and quality of life are assessed at baseline, and 6- and 12-month follow-up to measure program cost-effectiveness from the hospital, healthcare payer, patient, and societal perspectives.

DISCUSSION

Given the impact of tobacco use on medical resources, establishing feasible, cost-effective methods for reducing tobacco use is imperative. Given the minimal hospital staff burden and the automated transition to a post-hospitalization tailored intervention, this program could be an easily disseminated approach.

TRIAL REGISTRATION

Current Intervention Trial NCT01277250.

Understanding attrition from international Internet health interventions: a step towards global eHealth

Worldwide automated Internet health interventions have the potential to greatly reduce health disparities. High attrition from automated Internet interventions is ubiquitous, and presents a challenge in the evaluation of their effectiveness. Our objective was to evaluate variables hypothesized to be related to attrition, by modeling predictors of attrition in a secondary data analysis of two cohorts of an international, dual language (English and Spanish) Internet smoking cessation intervention. The two cohorts were identical except for the approach to follow-up (FU): one cohort employed only fully automated FU (n = 16 430), while the other cohort also used 'live' contact conditional upon initial non-response (n = 1000). Attrition rates were 48.1 and 10.8% for the automated FU and live FU cohorts, respectively. Significant attrition predictors in the automated FU cohort included higher levels of nicotine dependency, lower education, lower quitting confidence and receiving more contact emails. Participants' younger age was the sole predictor of attrition in the live FU cohort. While research on large-scale deployment of Internet interventions is at an early stage, this study demonstrates that differences in attrition from trials on this scale are (i) systematic and predictable and (ii) can largely be eliminated by live FU efforts. In fully automated trials, targeting the predictors we identify may reduce attrition, a necessary precursor to effective behavioral Internet interventions that can be accessed globally.

Effectiveness of a Web-based multiple tailored smoking cessation program: a randomized controlled trial among Dutch adult smokers

Background

Distributing a multiple computer-tailored smoking cessation intervention through the Internet has several advantages for both provider and receiver. Most important, a large audience of smokers can be reached while a highly individualized and personal form of feedback can be maintained. However, such a smoking cessation program has yet to be developed and implemented in the Netherlands.

Objective

To investigate the effects of a Web-based multiple computer-tailored smoking cessation program on smoking cessation outcomes in a sample of Dutch adult smokers.

Methods

Smokers were recruited from December 2009 to June 2010 by advertising our study in the mass media and on the Internet. Those interested and motivated to quit smoking within 6 months (N = 1123) were randomly assigned to either the experimental (n = 552) or control group (n = 571). Respondents in the experimental group received the fully automated Web-based smoking cessation program, while respondents in the control group received no intervention. After 6 weeks and after 6 months, we assessed the effect of the intervention on self-reported 24-hour point prevalence abstinence, 7-day point prevalence abstinence, and prolonged abstinence using logistic regression analyses.

Results

Of the 1123 respondents, 449 (40.0%) completed the 6-week follow-up questionnaire and 291 (25.9%) completed the 6-month follow-up questionnaire. We used a negative scenario to replace missing values. That is, we considered respondents lost to follow-up to still be smoking. The computer-tailored program appeared to have significantly increased 24-hour point prevalence abstinence (odds ratio [OR] 1.85, 95% confidence interval [CI] 1.30–2.65), 7-day point prevalence abstinence (OR 2.17, 95% CI 1.44–3.27), and prolonged abstinence (OR 1.99, 95% CI 1.28–3.09) rates reported after 6 weeks. After 6 months, however, no intervention effects could be identified. Results from complete-case analyses were similar.

Conclusions

The results presented suggest that the Web-based computer-tailored smoking cessation program had a significant effect on abstinence reported after a 6-week period. At the 6-month follow-up, however, no intervention effects could be identified. This might be explained by the replacement of missing values on the primary outcome measures due to attrition using a negative scenario. While results were similar when using a less conservative scenario (ie, complete-case analyses), the results should still be interpreted with caution. Further research should aim at identifying strategies that will prevent high attrition in the first place and, subsequently, to identify the best strategies for dealing with missing data when studies have high attrition rates.

Trial Registration

Dutch Trial Register NTR1351; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1351 (Archived by WebCite at http://www.webcitation.org/67egSTWrz)

Influence of recruitment strategy on the reach and effect of a web-based multiple tailored smoking cessation intervention among Dutch adult smokers

This study investigated the influence of two different recruitment strategies on the reach and effect of a web-based multiple tailored smoking cessation program. From May 2009 until June 2010, Dutch adult smokers were recruited via mass media or general practices. Those who completed the baseline questionnaire were followed up during 6 weeks (two follow-ups). Differences between the two samples were assessed regarding baseline characteristics, retention rates, quit attempts and 24-hour point prevalence abstinence. Smokers recruited via general practices (N = 409) were significantly lower educated, less addicted, more motivated to quit smoking and to maintain non-smoking, more often female and more often suffering from cardiovascular or respiratory diseases than mass media respondents (N = 1154). They showed higher retention rates and were more likely to report a quit attempt (64.3 versus 50.7%) and abstinence (43.3 versus 33.1%). More respondents could be recruited via mass media, while general practices respondents showed higher retention rates and were more successful in quitting smoking, though these effects became non-significant when controlling for experimental condition and baseline differences. The choice for a particular recruitment strategy appeared to determine the number and type of smokers recruited and might consequently influence the intervention's potential public health impact.

Do smoking cessation websites meet the needs of smokers with severe mental illnesses?

Many people learn about smoking cessation through information on the Internet. Whether people with severe mental illnesses, who have very high rates of smoking, are able to use currently available websites about smoking cessation is unknown. The study reported here assessed whether four smoking cessation websites met usability guidelines and whether they were usable by smokers with severe mental illnesses. Four websites that appeared first on a Google search and represented an array of sponsors were selected. First, five experts rated the websites on adequacy of content in six areas and usability in 20 areas. Second, 16 smokers with severe mental illnesses performed two search tasks on the websites with researchers observing their searches and interviewing them regarding usability. One of the websites was rated by experts as acceptable for content and usability, but most of the participants were unable to navigate this website. The only website that was navigable received poor content ratings by experts. Four easily accessible websites did not meet the needs of smokers with severe mental illnesses. Although the Internet is a promising strategy to provide education about treatments, website developers must attend to the needs and capacities of multiple user groups.

Are smokers with HIV using information and communication technology? Implications for behavioral interventions

Smoking is highly prevalent among persons living with HIV/AIDS (PLWHA) and associated with adverse outcomes including malignancy and cardiovascular disease. Information and communication technology (ICT) may be effective in disseminating cessation interventions among PLWHA. This study examines the prevalence of ICT use among 492 PLWHA attending an urban clinic and characteristics associated with ICT use. Participants completed a survey of demographics, smoking status, and ICT use. Factors associated with ICT use were examined with logistic regression. Overall, 63% of participants smoked with 73% of smokers owning their own cell phone. Use of other modalities was lower, with 48% of smokers reporting any internet use, 39% text messaging, and 31% using email. Higher education was associated with the use of all modalities. Cell phone interventions may have the broadest reach among PLWHA, though with almost half using the internet, this may also be a low-cost means of delivering cessation interventions.

Online social networks and smoking cessation: a scientific research agenda

BACKGROUND

Smoking remains one of the most pressing public health problems in the United States and internationally. The concurrent evolution of the Internet, social network science, and online communities offers a potential target for high-yield interventions capable of shifting population-level smoking rates and substantially improving public health.

OBJECTIVE

Our objective was to convene leading practitioners in relevant disciplines to develop the core of a strategic research agenda on online social networks and their use for smoking cessation, with implications for other health behaviors.

METHODS

We conducted a 100-person, 2-day, multidisciplinary workshop in Washington, DC, USA. Participants worked in small groups to formulate research questions that could move the field forward. Discussions and resulting questions were synthesized by the workshop planning committee.

RESULTS

We considered 34 questions in four categories (advancing theory, understanding fundamental mechanisms, intervention approaches, and evaluation) to be the most pressing.

CONCLUSIONS

Online social networks might facilitate smoking cessation in several ways. Identifying new theories, translating these into functional interventions, and evaluating the results will require a concerted transdisciplinary effort. This report presents a series of research questions to assist researchers, developers, and funders in the process of efficiently moving this field forward.

Effect of tailoring in an internet-based intervention for smoking cessation: randomized controlled trial

Background

Studies suggest that tailored materials are superior to nontailored materials in supporting health behavioral change. Several trials on tailored Internet-based interventions for smoking cessation have shown good effects. There have, however, been few attempts to isolate the effect of the tailoring component of an Internet-based intervention for smoking cessation and to compare it with the effectiveness of the other components.

Objective

The study aim was to isolate the effect of tailored emails in an Internet-based intervention for smoking cessation by comparing two versions of the intervention, with and without tailored content.

Methods

We conducted a two-arm, randomized controlled trial of the open and free Norwegian 12-month follow-up, fully automated Internet-based intervention for smoking cessation, slutta.no. We collected information online on demographics, smoking, self-efficacy, use of the website, and participant evaluation at enrollment and subsequently at 1, 3, and 12 months. Altogether, 2298 self-selected participants aged 16 years or older registered at the website between August 15, 2006 and December 7, 2007 and were randomly assigned to either a multicomponent, nontailored Internet-based intervention for smoking cessation (control) or a version of the same Internet-based intervention with tailored content delivered on the website and via email.

Results

Of the randomly assigned participants, 116 (of 419, response rate = 27.7%) in the intervention group and 128 (of 428, response rate = 29.9%) in the control group had participated over the 12 months and responded at the end of follow-up. The 7-day intention-to-treat abstinence rate at 1 month was 15.2% (149/982) among those receiving the tailored intervention, compared with 9.4% (94/999) among those who received the nontailored intervention (P < .001). The corresponding figures at 3 months were 13.5% (122/902) and 9.4% (84/896, P =.006) and at 12 months were 11.2% (47/419) and 11.7% (50/428, P = .91). Likewise, the intervention group had higher self-efficacy and perceived tailoring at 1 and 3 months. Self-efficacy was found to partially mediate the effect of the intervention.

Conclusion

Tailoring an Internet-based intervention for smoking cessation seems to increase the success rates in the short term, but not in the long term.

Computerized self-monitoring and technology-assisted feedback for weight loss with and without an enhanced behavioral component

OBJECTIVE

The purpose of this study was to develop and evaluate a 12-week weight management intervention involving computerized self-monitoring and technology-assisted feedback with and without an enhanced behavioral component.

METHODS

120 overweight (30.5±2.6kg/m(2)) adults (45.0±10.3 years) were randomized to one of three groups: computerized self-monitoring with Basic feedback (n=45), Enhanced behavioral feedback (n=45), or wait-list control (n=30). Intervention participants used a computer software program to record dietary and physical activity information. Weekly e-mail feedback was based on computer-generated reports, and participants attended monthly measurement visits.

RESULTS

The Basic and Enhanced groups experienced significant weight reduction (-2.7±3.3kg and -2.5±3.1kg) in comparison to the Control group (0.3±2.2; p<0.05). Waist circumference and systolic blood pressure also decreased in intervention groups compared to Control (p<0.01).

CONCLUSIONS

A program using computerized self-monitoring, technology-assisted feedback, and monthly measurement visits produced significant weight loss after 12 weeks. However, the addition of an enhanced behavioral component did not improve the effectiveness of the program.

PRACTICE IMPLICATIONS

This study suggests that healthcare professionals can effectively deliver a weight management intervention using technology-assisted strategies in a format that may complement and reduce face-to-face sessions.

Efficacy of an internet program for smoking cessation during and after inpatient rehabilitation treatment: a quasi-randomized controlled trial

OBJECTIVE

To test the feasibility and efficacy of an internet program for smoking cessation during and after inpatient treatment in rehabilitation centers.

METHODS

A total of 7574 consecutively admitted inpatients from three German rehabilitation centers were assessed for smoking status. Daily smokers or former daily smokers who regularly used the internet and e-mail were proactively invited for study participation. Out of 749 eligible patients, 477 (64%) participated in the study and were randomly assigned to an intervention or an assessment only control group based on the calendar week of admission. Patients of the intervention group had the possibility to use an internet program for smoking cessation for a period of six months. The program provided at least one but up to seven individual counseling sessions through a computer expert system, informational websites and a message board.

RESULTS

At six-months follow-up, seven-day point prevalence smoking abstinence was twice as high in the intervention group as in the control group (OR=2.0; CI 1.1-3.8; p=.02).

CONCLUSIONS

Proactive recruitment of smokers in combination with the provision of an internet program for smoking cessation allow for an inexpensive and effective smoking cessation support during and after inpatient rehabilitation treatment.

Configuring health care for systematic behavioral screening and intervention

The United States Preventive Services Task Force recommends universal screening and intervention for tobacco use, excessive drinking, and depression. These services improve health outcomes, decrease health care costs, enhance public safety, and generate substantial return on investment. Given the prevalence rates of these behavioral conditions and the time necessary for evidence-based interventions, it will be challenging to integrate behavioral screening and intervention (BSI) into busy health care settings. Therefore, consistent with the principles of the medical home and the chronic care model, the health care team must be expanded to systematically provide BSI. A 2-tiered, stepped-care model is proposed. The first tier of services-consisting of assessment, intervention, and follow-up services-would address most mild-to-moderate behavioral risks or conditions. The second tier would include various specialty-based resources, which would be conserved for patients with greatest need and potential to benefit. With slight enhancement of their training, health educators would be excellent candidates to serve as cost-efficient providers of first-tier services. The proposed model would help the United States realize improved health outcomes and cost savings as health care benefits are expanded to a greater proportion of its population.

Study protocol of a Dutch smoking cessation e-health program

BACKGROUND

The study aims to test the differential effects of a web-based text and a web-based video-driven computer-tailored approach for lower socio-economic status (LSES) and higher socio-economic status (HSES) smokers which incorporate multiple computer-tailored feedback moments. The two programs differ only in the mode of delivery (video- versus text-based messages). The paper aims to describe the development and design of the two computer-tailored programs.

METHODS/DESIGN

Respondents who smoked at the time of the study inclusion, who were motivated to quit within the following six months and who were aged 18 or older were included in the program. The study is a randomized control trial with a 2 (video/text) * 2(LSES/HSES) design. Respondents were assigned either to one of the intervention groups (text versus video tailored feedback) or to the control group (non-tailored generic advice). In all three conditions participants were asked to fill in the baseline questionnaire based on the I-Change model. The questionnaire assessed socio-demographics, attitude towards smoking, knowledge, self-efficacy, social influence, depression, level of addiction, action planning, goal actions, intention to quit smoking, seven-day point prevalence and continued abstinence. Follow-up measurements were conducted at six and twelve months after baseline.

DISCUSSION

The present paper describes the development of the two computer-tailored smoking cessation programs, their components and the design of the study. The study results reveal different working mechanisms of multiple tailored smoking cessation interventions and will help us to gain more insight into effective strategies to target different subgroups, especially smokers with a lower socio-economic status.

TRIAL REGISTRATION

Dutch Trial Register NTR3102.

Wirksamkeit internetbasierter Programme zum Tabakrauchen

Zusammenfassung. Ziel dieser systematischen Literaturübersicht ist, die Wirksamkeit internetbasierter Programme zur Förderung des Rauchausstiegs, zur Verhinderung des Raucheinstiegs und zum Schutz vor Passivrauch anhand der vorliegenden empirischen Evidenz zu beurteilen. Die Literatursuche erfolgte im Juli 2010 und umfasste die Datenbanken PubMed, MEDLINE, Web of Science, PsycINFO sowie das Cochrane Register of Controlled Trials. Randomisiert-kontrollierte Studien, die Ergebnisse zur Wirksamkeit einer Intervention im Vergleich zu einer Kontrollgruppe oder einer Standardintervention berichten, wurden eingeschlossen. Von 359 Publikationen, die in den Literaturdatenbanken recherchiert wurden, konnten 17 in diese Übersicht eingeschlossen werden. Diese beschrieben 16 Studien: 14 Studien überprüften Programme zur Förderung des Rauchausstiegs, 2 Studien überprüften kombinierte Programme zur Förderung des Ausstiegs und zur Verhinderung des Einstiegs bei Jugendlichen. Von den 14 Rauchausstiegs-Interventionen erwiesen sich sechs als wirksam zur Erhöhung der Rate Rauchabstinenter gegenüber einer Kontrollgruppe. Aufgrund der Heterogenität der Studien v.a. hinsichtlich der verwendeten Kontrollgruppen wurden keine gepoolten Effektgrößen über alle Studien hinweg berechnet. Eine separate Berechnung von Effektgrößen für Studien mit ähnlichen Kontrollgruppen, ergab eine tendenziell, aber nicht signifikant höhere Rate Rauchabstinenter bei Internetinterventionen im Vergleich zu Kontrollgruppen ohne Intervention (Relatives Risiko (RR) 1.42; 95%-Konfidenzintervall (KI) 0.85–2.37). Ein Vergleich der Internetinterventionen mit Kontrollgruppen, die eine Minimalintervention erhielten, ergab einen signifikanten Interventionseffekt (RR 1.31; KI 1.09–1.57). Beim Vergleich der Internetinterventionen mit persönlichen Beratungsinterventionen ergab sich kein signifikanter Interventionseffekt (RR 0.86; KI 0.72–1.04); tendenziell waren die persönlichen Beratungsinterventionen überlegen. Im Vergleich zu einer Standardintervention allein, erwies sich eine Standardintervention mit zusätzlichem Internetprogramm nicht als wirksamer (RR 1.27; KI 0.70–2.31). Interventionen, die ausschließlich aufhörbereite Raucher adressierten, erwiesen sich eher als erfolgversprechend als Interventionen, welche sich an alle Raucher einer bestimmten Population richteten. Die beiden kombinierten Programme zur Förderung des Ausstiegs und zur Verhinderung des Einstiegs bei Jugendlichen waren auf einzelnen, aber nicht allen Zielkriterien wirksam. Zur Förderung des Rauchausstiegs bei aufhörbereiten Rauchern liegen international bereits wirksame Programme vor, allerdings wurde keines dieser Programme im deutschsprachigen Raum überprüft. Die empirische Evidenz zu Internetprogrammen zur Verhinderung des Raucheinstiegs ist bislang sehr gering; Wirksamkeitsstudien zu Internetprogrammen zum Schutz vor Passivrauch liegen bislang keine vor.

Persuasive features in web-based alcohol and smoking interventions: a systematic review of the literature

Background

In the past decade, the use of technologies to persuade, motivate, and activate individuals’ health behavior change has been a quickly expanding field of research. The use of the Web for delivering interventions has been especially relevant. Current research tends to reveal little about the persuasive features and mechanisms embedded in Web-based interventions targeting health behavior change.

Objectives

The purpose of this systematic review was to extract and analyze persuasive system features in Web-based interventions for substance use by applying the persuasive systems design (PSD) model. In more detail, the main objective was to provide an overview of the persuasive features within current Web-based interventions for substance use.

Methods

We conducted electronic literature searches in various databases to identify randomized controlled trials of Web-based interventions for substance use published January 1, 2004, through December 31, 2009, in English. We extracted and analyzed persuasive system features of the included Web-based interventions using interpretive categorization.

Results

The primary task support components were utilized and reported relatively widely in the reviewed studies. Reduction, self-monitoring, simulation, and personalization seem to be the most used features to support accomplishing user’s primary task. This is an encouraging finding since reduction and self-monitoring can be considered key elements for supporting users to carry out their primary tasks. The utilization of tailoring was at a surprisingly low level. The lack of tailoring may imply that the interventions are targeted for too broad an audience. Leveraging reminders was the most common way to enhance the user-system dialogue. Credibility issues are crucial in website engagement as users will bind with sites they perceive credible and navigate away from those they do not find credible. Based on the textual descriptions of the interventions, we cautiously suggest that most of them were credible. The prevalence of social support in the reviewed interventions was encouraging.

Conclusions

Understanding the persuasive elements of systems supporting behavior change is important. This may help users to engage and keep motivated in their endeavors. Further research is needed to increase our understanding of how and under what conditions specific persuasive features (either in isolation or collectively) lead to positive health outcomes in Web-based health behavior change interventions across diverse health contexts and populations.

Use of the NHS Choices website for primary care consultations: results from online and general practice surveys

OBJECTIVES

To determine the effect of using the NHS Choices website on primary care consultations in England and Wales. We examined the hypothesis that using NHS Choices may reduce the frequency of primary care consultations among young, healthy users.

DESIGN

Two cross-sectional surveys of NHS Choices users.

SETTING

Survey of NHS Choices users using an online pop-up questionnaire on the NHS Choices website and a snapshot survey of patients in six general practices in London.

PARTICIPANTS

NHS Choices website users and general practice patients.

MAIN OUTCOME MEASURES

For both surveys, we measured the proportion of people using NHS Choices when considering whether to consult their GP practice and on subsequent frequency of primary care consultations.

RESULTS

Around 59% (n = 1559) of online and 8% (n = 125) of general practice survey respondents reported using NHS Choices in relation to their use of primary care services. Among these, 33% (n = 515) of online and 18% (n = 23) of general practice respondents reported reduced primary care consultations as a result of using NHS Choices. We estimated the equivalent capacity savings in primary care from reduced consultations as a result of using NHS Choices to be approximately £94 million per year.

CONCLUSIONS

NHS Choices has been shown to alter healthcare-seeking behaviour, attitudes and knowledge among its users. Using NHS Choices results in reduced demand for primary care consultations among young, healthy users for whom reduced health service use is likely to be appropriate. Reducing potentially avoidable consultations can result in considerable capacity savings in UK primary care.

On-line randomized controlled trial of an internet based psychologically enhanced intervention for people with hazardous alcohol consumption

Background

Interventions delivered via the Internet have the potential to address the problem of hazardous alcohol consumption at minimal incremental cost, with potentially major public health implications. It was hypothesised that providing access to a psychologically enhanced website would result in greater reductions in drinking and related problems than giving access to a typical alcohol website simply providing information on potential harms of alcohol. DYD-RCT Trial registration: ISRCTN 31070347.

Methodology/Principal Findings

A two-arm randomised controlled trial was conducted entirely on-line through the Down Your Drink (DYD) website. A total of 7935 individuals who screened positive for hazardous alcohol consumption were recruited and randomized. At entry to the trial, the geometric mean reported past week alcohol consumption was 46.0 (SD 31.2) units. Consumption levels reduced substantially in both groups at the principal 3 month assessment point to an average of 26.0 (SD 22.3) units. Similar changes were reported at 1 month and 12 months. There were no significant differences between the groups for either alcohol consumption at 3 months (intervention: control ratio of geometric means 1.03, 95% CI 0.97 to 1.10) or for this outcome and the main secondary outcomes at any of the assessments. The results were not materially changed following imputation of missing values, nor was there any evidence that the impact of the intervention varied with baseline measures or level of exposure to the intervention.

Conclusions/Significance

Findings did not provide support for the hypothesis that access to a psychologically enhanced website confers additional benefit over standard practice and indicate the need for further research to optimise the effectiveness of Internet-based behavioural interventions. The trial demonstrates a widespread and potentially sustainable demand for Internet based interventions for people with hazardous alcohol consumption, which could be delivered internationally.

Trial Registration

Controlled-Trials.com ISRCTN31070347

A systematic review of randomized controlled trials: Web-based interventions for smoking cessation among adolescents, college students, and adults

INTRODUCTION

Web-based treatments can deliver broad reaching, relatively inexpensive, and clinically tested methods for smoking cessation. We performed a systematic review of randomized controlled trials (RCTs) of smoking cessation to evaluate the efficacy of Web-based interventions in adults, college students, and adolescents.

METHODS

MEDLINE, EMBASE, The Cochrane Library, CINAHL, and PsycINFO were searched from January 1, 1990 through February 12, 2010 for RCTs examining the efficacy of Web-based smoking cessation programs. Paired reviewers abstracted data on study design, patient characteristics, and outcomes sequentially and did quality assessments independently.

RESULTS

Twenty-one RCTs met eligibility criteria, with 15 conducted among adults. Among adults, 2 RCTs found that a multicomponent intervention with Web and non-Web-based elements was more efficacious than a self-help manual, and one of 2 RCTs found that Web-based interventions may be more effective than no treatment. Three trials provided insufficient evidence to demonstrate whether Web-based interventions were more efficacious than counseling. By contrast, tailored Web sites in 2 RCTs and greater Web site exposure in 6 of 7 RCTs were associated with higher rates of abstinence. Among college students, evidence supporting use of Web-based interventions was insufficient because the one RCT conducted was also a multicomponent intervention. Five RCTs among adolescents demonstrated mixed results, with insufficient evidence supporting their efficacy.

CONCLUSIONS

Evidence supporting the use of Web-based interventions for smoking cessation is insufficient to moderate in adults and insufficient in college students and adolescents. These RCTs have, however, elucidated clinical, methodological, and statistical practices that are likely to improve future trial design and treatment delivery.

Preventing Relapse Following Smoking Cessation

Cigarette smoking is the leading cause of preventable deaths worldwide. Long-term smoking cessation can drastically reduce people's risk for developing smoking-related disease. The research literature points to a need for clearer operationalization and differentiation between smoking cessation and relapse prevention interventions and outcomes. That said, extensive meta-analyses and research studies have indicated that there are various efficacious smoking interventions that can both support smoking cessation and relapse prevention efforts. Specifically, behavioral treatments, relapse prevention psychotherapy, pharmacologic interventions, motivational enhancement, smoking reduction to quit, brief advice, alternative intervention modes (telephone, Internet, computer), self-help, and tailored treatments can help prepare smokers for longer-term abstinence. Although these methods vary on reach, they are relatively efficacious, particularly in combined formats.

Internet-based interventions for smoking cessation

BACKGROUND

The Internet has become a regular part of daily life for the majority of people in many parts of the world. It now offers an additional means of effecting changes to behaviour such as smoking.

OBJECTIVES

To determine the effectiveness of Internet-based interventions for smoking cessation.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE, EMBASE, CINAHL, PsycINFO, and Google Scholar. There were no restrictions placed on language of publication or publication date. The most recent search was in June 2010.

SELECTION CRITERIA

We included randomized and quasi-randomized trials. Participants were people who smoked, with no exclusions based on age, gender, ethnicity, language or health status. Any type of Internet-based intervention was eligible. The comparison condition could be a no-intervention control or a different Internet site or programme.

DATA COLLECTION AND ANALYSIS

Methodological and study quality details were extracted using a standardised form. We selected smoking cessation outcomes at short term (one to three months) and long term (6 months or more) follow up, and reported study effects as a risk ratio with 95% confidence intervals. Only limited meta-analysis was performed, as the heterogeneity of the data for populations, interventions and outcomes allowed for very little pooling.

MAIN RESULTS

Twenty trials met the inclusion criteria. There were more female than male participants. Some Internet programmes were intensive and included multiple outreach contacts with participants, whilst others relied on participants to initiate and maintain use.Ten trials compared an Internet intervention to a non-Internet based smoking cessation intervention or to a no intervention control. Six of these recruited adults, one recruited young adult university students and three recruited adolescents. Two trials of the same intensive automated intervention in populations of adult who smoked showed significantly increased cessation compared to printed self-help materials at 12 months. In one of these, all trial participants were provided with nicotine replacement therapy (NRT). Three other trials in adults did not detect significant long term effects. One of these provided access to a website as an adjunct to counselling and bupropion, one compared web-based counselling, proactive telephone-based counselling or a combination of the two as an adjunct to varenicline. The third only provided a list of Internet resources. One further short-term trial did show a significant increase in quit rates at 3 months. A trial in college students increased point prevalence abstinence after 30 weeks but had no effect on sustained abstinence. Two small trials in adolescents did not detect an effect on cessation compared to control, whilst a third small trial did detect a benefit of a web-based adjunct to a group programme amongst adolescents.Ten trials, all in adult populations, compared different Internet sites or programmes. There was some evidence that sites that were tailored and interactive might be more effective than static sites, but this was not detected in all the trials that explored this factor. One large trial did not detect differences between different Internet sites. One trial of a tailored intervention as an adjunct to NRT use showed a significant benefit but only had a 3-month follow up. One trial detected evidence of a benefit from tailored email letter compared to a non-tailored one. Trials failed to detect a benefit of including a mood management component (three trials), or an asynchronous bulletin board. Higher abstinence rates were typically reported by participants who actively engaged with the programme (as reflected by the number of log-ins).

AUTHORS' CONCLUSIONS

Results suggest that some Internet-based interventions can assist smoking cessation, especially if the information is appropriately tailored to the users and frequent automated contacts with the users are ensured, however trials did not show consistent effects.

Online social and professional support for smokers trying to quit: an exploration of first time posts from 2562 members

Background

Both intratreatment and extratreatment social support are associated with increased rates of smoking cessation. Internet-based social support groups have the capability of connecting widely dispersed groups of people trying to quit smoking, making social support available 24 hours a day, seven days a week, at minimal cost. However, to date there has been little research to guide development of this particular feature of Web-assisted tobacco interventions (WATIs).

Objective

Our objectives were to compare the characteristics of smokers who post in an online smoking cessation support group with smokers who do not post, conduct a qualitative analysis of discussion board content, and determine the time it takes for new users to receive feedback from existing members or moderators.

Methods

Data were collected from StopSmokingCenter.net version 5.0, a WATI equipped with an online social support network moderated by trained program health educators that was operational from November 6, 2004, to May 15, 2007. Demographic and smoking characteristics for both users and nonusers of the online social support network were analyzed, and qualitative analyses were conducted to explore themes in message content. Posting patterns and their frequency were also analyzed.

Results

During the study period, 16,764 individuals registered; of these, 70% (11,723) reported being American. The mean age of registrants was 38.9 years and 65% (10,965) were female. The mean number of cigarettes smoked was 20.6 per day. The mean score for the 41% (6849) of users who completed the Fagerström Test for Nicotine Dependence was 5.6. Of all registered members, 15% (2562) made at least one post in the online social support network; 25% of first posts received a response from another member within 12 minutes, 50% within 29 minutes. The most frequent first posts were from recent quitters who were struggling with their quit attempts, and most responses were from members who had quit for a month or more. Differences in demographic and smoking characteristics between members who posted on the support group board at least once and those who did not post were statistically but not clinically significant.

Conclusions

Peer responses to new users were rapid, indicating that online social support networks may be particularly beneficial to smokers requiring more immediate assistance with their cessation attempt. This function may be especially advantageous for relapse prevention. Accessing this kind of rapid in-person support from a professional would take an inordinate amount of time and money. Further research regarding the effectiveness of WATIs with online social support networks is required to better understand the contribution of this feature to cessation, for both active users (posters) and passive users (“lurkers”) alike.

The comparative effectiveness of clinic, work-site, phone, and Web-based tobacco treatment programs

INTRODUCTION

Tobacco treatment programs may be offered in clinical settings, at work-sites, via telephone helplines, or over the Internet. Little comparative data exist regarding the real-world effectiveness of these programs. This paper compares the reach, effectiveness, and costs of these different modes of cessation assistance.

METHODS

This is an observational study of cohorts of participants in Minnesota's QUITPLAN programs in 2004. Cessation assistance was provided in person at 9 treatment centers, using group counseling at 68 work-sites, via a telephone helpline, or via the Internet. The main outcomes of the study are enrollment by current smokers, self-reported 30-day abstinence, and cost per quit. Reach was calculated statewide for the helpline and Web site, regionally for the treatment centers, and for the employee population for work-site programs.

RESULTS

Enrollment was greatest for the Web site (n = 4,698), followed by the helpline (n = 2,351), treatment centers (n = 616), and work-sites (n = 479). The Web site attracted younger smokers. Smokers at treatment centers had higher levels of nicotine dependence. The helpline reached more socially disadvantaged smokers. Responder 30-day abstinence rates were higher for the helpline (29.3%), treatment centers (25.8%), and work-sites (19.6%) compared with the online program (12.5%). These differences persisted after controlling for baseline differences in participant characteristics and use of pharmacological therapy. The cost per quit was lowest for the Web site program ($291 per quit, 95% CI = $229-$372).

DISCUSSION

Treatment center, work-site, helpline, and Web site programs differ in their reach, effectiveness, and estimated cost per quit. Each program plays a part in assisting populations of tobacco users in quitting.

Using the internet to promote health behavior change: a systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy

BACKGROUND

The Internet is increasingly used as a medium for the delivery of interventions designed to promote health behavior change. However, reviews of these interventions to date have not systematically identified intervention characteristics and linked these to effectiveness.

OBJECTIVES

The present review sought to capitalize on recently published coding frames for assessing use of theory and behavior change techniques to investigate which characteristics of Internet-based interventions best promote health behavior change. In addition, we wanted to develop a novel coding scheme for assessing mode of delivery in Internet-based interventions and also to link different modes to effect sizes.

METHODS

We conducted a computerized search of the databases indexed by ISI Web of Knowledge (including BIOSIS Previews and Medline) between 2000 and 2008. Studies were included if (1) the primary components of the intervention were delivered via the Internet, (2) participants were randomly assigned to conditions, and (3) a measure of behavior related to health was taken after the intervention.

RESULTS

We found 85 studies that satisfied the inclusion criteria, providing a total sample size of 43,236 participants. On average, interventions had a statistically small but significant effect on health-related behavior (d(+) = 0.16, 95% CI 0.09 to 0.23). More extensive use of theory was associated with increases in effect size (P = .049), and, in particular, interventions based on the theory of planned behavior tended to have substantial effects on behavior (d(+) = 0.36, 95% CI 0.15 to 0.56). Interventions that incorporated more behavior change techniques also tended to have larger effects compared to interventions that incorporated fewer techniques (P < .001). Finally, the effectiveness of Internet-based interventions was enhanced by the use of additional methods of communicating with participants, especially the use of short message service (SMS), or text, messages.

CONCLUSIONS

The review provides a framework for the development of a science of Internet-based interventions, and our findings provide a rationale for investing in more intensive theory-based interventions that incorporate multiple behavior change techniques and modes of delivery.