Counselor and stimulus control enhancements of a stage-matched expert system intervention for smokers in a managed care setting

A review of research on cigarette smoking in Preventive Medicine in recognition of the journal's 50th anniversary

This report reviews the literature on cigarette smoking published in Preventive Medicine over the past 50 years. The goal is twofold. First, to acknowledge the 50th anniversary of Preventive Medicine and its role in disseminating research on cigarette smoking by providing an abridged summary of smoking research published in the journal from inception through June 23, 2022. Second, to review experimental reports to identify contributions to innovations in tobacco control and regulatory efforts to reduce cigarette smoking. We searched PubMed using the search terms cigarette/cigarettes, tobacco products, smoking, smoking cessation, Preventive Medicine. Titles and abstracts were reviewed in duplicate, excluding reports not addressing cigarette smoking. Included reports were categorized by study type (original study, commentary, review). Experimental articles were assessed for impact using iCite, a National Institutes of Health web application that provides bibliometric information for articles in defined topic areas. The review identified 1181 articles on cigarette smoking: 1018 original studies (86.2%), 107 literature reviews (9.1%), and 56 commentaries (4.7%); 166 of the 1018 original studies (16%) were experimental reports. In the iCite analysis these 166 experimental articles received 6366 total citations, a mean (standard error) citation rate/article of 38.35 (±3.21) and mean relative citation ratio of 1.85 (±0.17) which is at the 73rd percentile for NIH-funded field- and time-normalized reports. Overall, this review demonstrates an ongoing and impactful contribution of Preventive Medicine to efforts to reduce cigarette smoking, the most preventable cause of premature death.

Cross-validation of transtheoretical model smoking cessation measures in Chicago WIHS women smokers with and at risk for HIV

People with and at risk for HIV have high rates of smoking, increasing their morbidity and mortality. Effective cessation interventions are needed for this group. Transtheoretical model (TTM)-tailored interventions have demonstrated efficacy, but measures need cross-validation in this population. TTM cessation measures were evaluated in women smokers with and at risk for HIV (N = 111) from Chicago Women's Interagency HIV Study (WIHS). Confirmatory factor analyses evaluated measurement models. MANOVAs examined relationships between constructs and stage subgroups. For decisional balance, the two-factor uncorrelated model was best (χ2(20) = 13.96; comparative fit index [CFI], 1.0; root mean square error of approximation [RMSEA] = .00), with good (pros α = .78) and fair (cons α = .55) four-item alphas. The one-factor temptations model (α = .90) showed reasonable fit (χ2(18) = 80.22; CFI = .89; RMSEA = .177). Processes of change subscales had fair to good two-item alphas (α = .49-.77) and fit a 10-factor fully correlated model (χ2(125) = 222.72; CFI = .88; RMSEA = .084). MANOVAs by stage of change replicated expected patterns for the pros, overall temptations, and two process subscales with medium-sized effects (η2 = .06-.18). Contrary to expectations, no differences by stage were found for cons or temptation negative affect subscales. The structures of these TTM measures replicated with good internal and external validity, except for the cons, which needs refinement. Negative affect temptations was structurally sound, but did not vary by stage group potentially reflecting this sample's moderate depression levels and/or their reliance on smoking to deal with negative affect. Results support the use of most TTM measures in research and tailored interventions to increase smoking cessation among women smokers with and at risk for HIV and highlight the importance of managing negative affect in cessation materials targeting this group.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of telephone support to help smokers quit, including proactive or reactive counselling, or the provision of other information to smokers calling a helpline.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2018.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which offered proactive or reactive telephone counselling to smokers to assist smoking cessation.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We pooled studies using a random-effects model and assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I² statistic. In trials including smokers who did not call a quitline, we used meta-regression to investigate moderation of the effect of telephone counselling by the planned number of calls in the intervention, trial selection of participants that were motivated to quit, and the baseline support provided together with telephone counselling (either self-help only, brief face-to-face intervention, pharmacotherapy, or financial incentives).

MAIN RESULTS

We identified 104 trials including 111,653 participants that met the inclusion criteria. Participants were mostly adult smokers from the general population, but some studies included teenagers, pregnant women, and people with long-term or mental health conditions. Most trials (58.7%) were at high risk of bias, while 30.8% were at unclear risk, and only 11.5% were at low risk of bias for all domains assessed. Most studies (100/104) assessed proactive telephone counselling, as opposed to reactive forms.Among trials including smokers who contacted helplines (32,484 participants), quit rates were higher for smokers receiving multiple sessions of proactive counselling (risk ratio (RR) 1.38, 95% confidence interval (CI) 1.19 to 1.61; 14 trials, 32,484 participants; I² = 72%) compared with a control condition providing self-help materials or brief counselling in a single call. Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate.In studies that recruited smokers who did not call a helpline, the provision of telephone counselling increased quit rates (RR 1.25, 95% CI 1.15 to 1.35; 65 trials, 41,233 participants; I² = 52%). Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate. In subgroup analysis, we found no evidence that the effect of telephone counselling depended upon whether or not other interventions were provided (P = 0.21), no evidence that more intensive support was more effective than less intensive (P = 0.43), or that the effect of telephone support depended upon whether or not people were actively trying to quit smoking (P = 0.32). However, in meta-regression, telephone counselling was associated with greater effectiveness when provided as an adjunct to self-help written support (P < 0.01), or to a brief intervention from a health professional (P = 0.02); telephone counselling was less effective when provided as an adjunct to more intensive counselling. Further, telephone support was more effective for people who were motivated to try to quit smoking (P = 0.02). The findings from three additional trials of smokers who had not proactively called a helpline but were offered telephone counselling, found quit rates were higher in those offered three to five telephone calls compared to those offered just one call (RR 1.27, 95% CI 1.12 to 1.44; 2602 participants; I² = 0%).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that proactive telephone counselling aids smokers who seek help from quitlines, and moderate-certainty evidence that proactive telephone counselling increases quit rates in smokers in other settings. There is currently insufficient evidence to assess potential variations in effect from differences in the number of contacts, type or timing of telephone counselling, or when telephone counselling is provided as an adjunct to other smoking cessation therapies. Evidence was inconclusive on the effect of reactive telephone counselling, due to a limited number studies, which reflects the difficulty of studying this intervention.

Sleep quality in cigarette smokers: Associations with smoking-related outcomes and exercise

INTRODUCTION

Compared to the general population, cigarette smokers report poorer sleep quality. Poor sleep quality in cigarette smokers is associated with greater nicotine dependence. While exercise is known to improve sleep quality in the general population, less is known about how exercise effects sleep in those who smoke. The goal of this study was to explore the relationships between exercise, sleep, and smoking in cigarette smokers.

METHODS

Data on sleep quality (Insomnia Severity Index (ISI) and Pittsburgh Sleep Quality Index (PSQI)), smoking-related outcomes (e.g., cigarettes/day, Fagerstrom Test for Nicotine Dependence, Minnesota Nicotine and Withdrawal Scale, and Questionnaire of Smoking Urges) and exercise (Fitbit activity measures) were collected for 32 participants (63% female, mean age 30.3 ± 1.0 years) participating in a 12-week clinical research study. Analyses included simple linear regression models.

RESULTS

Overall, participants reported poor sleep quality at baseline (PSQI > 5). Poorer sleep quality at baseline was associated with increased withdrawal (β = 1.63 ± 0.53, p = 0.0043), craving (β = 0.51 ± 0.43, p = 0.2471), and total smoking urges (β = 1.10 ± 0.41, p = 0.0118). During follow-up (i.e., from baseline to week 12), a daily increase in exercise was associated with improved sleep quality over the same time period (PSQI: β = -0.82 ± 0.35, p = 0.0379).

CONCLUSION

Our data suggest that better sleep quality may be associated with lower levels of withdrawal, craving, and smoking urges. Further, exercise may be associated with better sleep quality in cigarette smokers. Future work should explore how increasing exercise and improving sleep quality could inform future smoking cessation interventions.

Print-based self-help interventions for smoking cessation

BACKGROUND

Many smokers give up smoking on their own, but materials that provide a structured programme for smokers to follow may increase the number who quit successfully.

OBJECTIVES

The aims of this review were to determine the effectiveness of different forms of print-based self-help materials that provide a structured programme for smokers to follow, compared with no treatment and with other minimal contact strategies, and to determine the comparative effectiveness of different components and characteristics of print-based self-help, such as computer-generated feedback, additional materials, tailoring of materials to individuals, and targeting of materials at specific groups.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Trials Register, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The date of the most recent search was March 2018.

SELECTION CRITERIA

We included randomised trials of smoking cessation with follow-up of at least six months, where at least one arm tested print-based materials providing self-help compared with minimal print-based self-help (such as a short leaflet) or a lower-intensity control. We defined 'self-help' as structured programming for smokers trying to quit without intensive contact with a therapist.

DATA COLLECTION AND ANALYSIS

We extracted data in accordance with standard methodological procedures set out by Cochrane. The main outcome measure was abstinence from smoking after at least six months' follow-up in people smoking at baseline. We used the most rigorous definition of abstinence in each study and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a random-effects model.

MAIN RESULTS

We identified 75 studies that met our inclusion criteria. Many study reports did not include sufficient detail to allow judgement of risk of bias for some domains. We judged 30 studies (40%) to be at high risk of bias for one or more domains.Thirty-five studies evaluated the effects of standard, non-tailored self-help materials. Eleven studies compared self-help materials alone with no intervention and found a small effect in favour of the intervention (n = 13,241; risk ratio (RR) 1.19, 95% confidence interval (CI) 1.03 to 1.37; I² = 0%). We judged the evidence to be of moderate certainty in accordance with GRADE, downgraded for indirect relevance to populations in low- and middle-income countries because evidence for this comparison came from studies conducted solely in high-income countries and there is reason to believe the intervention might work differently in low- and middle-income countries. This analysis excluded two studies by the same author team with strongly positive outcomes that were clear outliers and introduced significant heterogeneity. Six further studies of structured self-help compared with brief leaflets did not show evidence of an effect of self-help materials on smoking cessation (n = 7023; RR 0.87, 95% CI 0.71 to 1.07; I² = 21%). We found evidence of benefit from standard self-help materials when there was brief contact that did not include smoking cessation advice (4 studies; n = 2822; RR 1.39, 95% CI 1.03 to 1.88; I² = 0%), but not when self-help was provided as an adjunct to face-to-face smoking cessation advice for all participants (11 studies; n = 5365; RR 0.99, 95% CI 0.76 to 1.28; I² = 32%).Thirty-two studies tested materials tailored for the characteristics of individual smokers, with controls receiving no materials, or stage-matched or non-tailored materials. Most of these studies used more than one mailing. Pooling studies that compared tailored self-help with no self-help, either on its own or compared with advice, or as an adjunct to advice, showed a benefit of providing tailored self-help interventions (12 studies; n = 19,190; RR 1.34, 95% CI 1.20 to 1.49; I² = 0%) with little evidence of difference between subgroups (10 studies compared tailored with no materials, n = 14,359; RR 1.34, 95% CI 1.19 to 1.51; I² = 0%; two studies compared tailored materials with brief advice, n = 2992; RR 1.13, 95% CI 0.86 to 1.49; I² = 0%; and two studies evaluated tailored materials as an adjunct to brief advice, n = 1839; RR 1.72, 95% CI 1.17 to 2.53; I² = 10%). When studies compared tailored self-help with non-tailored self-help, results favoured tailored interventions when the tailored interventions involved more mailings than the non-tailored interventions (9 studies; n = 14,166; RR 1.42, 95% CI 1.20 to 1.68; I² = 0%), but not when the two conditions were contact-matched (10 studies; n = 11,024; RR 1.07, 95% CI 0.89 to 1.30; I² = 50%). We judged the evidence to be of moderate certainty in accordance with GRADE, downgraded for risk of bias.Five studies evaluated self-help materials as an adjunct to nicotine replacement therapy; pooling three of these provided no evidence of additional benefit (n = 1769; RR 1.05, 95% CI 0.86 to 1.30; I² = 0%). Four studies evaluating additional written materials favoured the intervention, but the lower confidence interval crossed the line of no effect (RR 1.20, 95% CI 0.91 to 1.58; I² = 73%). A small number of other studies did not detect benefit from using targeted materials, or find differences between different self-help programmes.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that when no other support is available, written self-help materials help more people to stop smoking than no intervention. When people receive advice from a health professional or are using nicotine replacement therapy, there is no evidence that self-help materials add to their effect. However, small benefits cannot be excluded. Moderate-certainty evidence shows that self-help materials that use data from participants to tailor the nature of the advice or support given are more effective than no intervention. However, when tailored self-help materials, which typically involve repeated assessment and mailing, were compared with untailored materials delivered similarly, there was no evidence of benefit.Available evidence tested self-help interventions in high-income countries, where more intensive support is often available. Further research is needed to investigate effects of these interventions in low- and middle-income countries, where more intensive support may not be available.

Which eHealth interventions are most effective for smoking cessation? A systematic review

PURPOSE

To synthesize evidence of the effects and potential effect modifiers of different electronic health (eHealth) interventions to help people quit smoking.

METHODS

Four databases (MEDLINE, PsycINFO, Embase, and The Cochrane Library) were searched in March 2017 using terms that included "smoking cessation", "eHealth/mHealth" and "electronic technology" to find relevant studies. Meta-analysis and meta-regression analyses were performed using Mantel-Haenszel test for fixed-effect risk ratio (RR) and restricted maximum-likelihood technique, respectively. Protocol Registration Number: CRD42017072560.

RESULTS

The review included 108 studies and 110,372 participants. Compared to nonactive control groups (eg, usual care), smoking cessation interventions using web-based and mobile health (mHealth) platform resulted in significantly greater smoking abstinence, RR 2.03 (95% CI 1.7-2.03), and RR 1.71 (95% CI 1.35-2.16), respectively. Similarly, smoking cessation trials using tailored text messages (RR 1.80, 95% CI 1.54-2.10) and web-based information and conjunctive nicotine replacement therapy (RR 1.29, 95% CI 1.17-1.43) may also increase cessation. In contrast, little or no benefit for smoking abstinence was found for computer-assisted interventions (RR 1.31, 95% CI 1.11-1.53). The magnitude of effect sizes from mHealth smoking cessation interventions was likely to be greater if the trial was conducted in the USA or Europe and when the intervention included individually tailored text messages. In contrast, high frequency of texts (daily) was less effective than weekly texts.

CONCLUSIONS

There was consistent evidence that web-based and mHealth smoking cessation interventions may increase abstinence moderately. Methodologic quality of trials and the intervention characteristics (tailored vs untailored) are critical effect modifiers among eHealth smoking cessation interventions, especially for web-based and text messaging trials. Future smoking cessation intervention should take advantages of web-based and mHealth engagement to improve prolonged abstinence.

The Equity Impact of Proactive Outreach to Smokers: Analysis of a Randomized Trial

INTRODUCTION

Population-based smoking-cessation services tend to preferentially benefit high-SES smokers, potentially exacerbating disparities. Interventions that include proactive outreach, telephone counseling, and free or low-cost cessation medications may be more likely to help low-SES smokers quit. This analysis evaluated the role of SES in smokers' response to a population-based proactive smoking-cessation intervention.

METHODS

This study, conducted in 2016 and 2017, was a secondary analysis of the Veterans Victory Over Tobacco Study, a multicenter pragmatic RCT of a proactive smoking-cessation intervention conducted from 2009 to 2011. Logistic regression modeling was used to test the effect of income or education level on 6-month prolonged abstinence at 1-year follow-up.

RESULTS

Of the 5,123 eligible, randomized participants, 2,565 (50%) reported their education level and 2,430 (47%) reported their income level. The interactions between education (p=0.07) or income (p=0.74) X treatment arm were not statistically significant at the 0.05 level. The largest effect sizes for the intervention were found among smokers in the lowest education category (≤11th grade), with a quit rate of 17.3% as compared with 5.7% in usual care (OR=3.5, 95% CI=1.4, 8.6) and in the lowest income range (<$10,000), with a quit rate of 18.7% as compared with 9.4% in usual care (OR=2.2, 95% CI=1.2, 4.0).

CONCLUSIONS

In a large, multicenter smoking-cessation trial, proactive outreach was associated with higher rates of prolonged abstinence among smokers at all SES levels. Proactive outreach interventions that integrate telephone-based care and facilitated cessation medication access have the potential to reduce socioeconomic disparities in quitting.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT00608426.

A randomized controlled evaluation of the tobacco status project, a Facebook intervention for young adults

AIMS

To test the efficacy of the Tobacco Status Project (TSP) Facebook smoking cessation intervention for young adults relative to referral to an on-line program on biochemically verified 7-day abstinence from smoking.

DESIGN

Two-group parallel randomized controlled trial, comparing TSP (n = 251) to on-line control (n = 249) with follow-up to 12 months.

SETTING

On-line, throughout the United States.

PARTICIPANTS

Young adult cigarette smokers (mean age 21 years; 73% white, 55% female, 87% daily smokers).

INTERVENTIONS AND COMPARATOR

TSP provided private Facebook groups tailored to stage of change to quit smoking, daily contacts, weekly live counseling sessions, and for those ready to quit, six cognitive behavioral therapy counseling sessions. Some TSP groups were assigned randomly to receive a monetary incentive for engagement. Control provided referral to the National Cancer Institute Smokefree.gov website.

MEASUREMENTS

PRIMARY OUTCOME: Biochemically verified 7-day abstinence over 12 months.

SECONDARY OUTCOMES

Post-treatment (3-month) abstinence; reported abstinence, quit attempt, reduction in smoking, readiness to quit smoking over 12 months.

FINDINGS

Verified 7-day abstinence was not significantly different for intervention compared with control over 1 year: month 3 (8.3 versus 3.2%), 6 (6.2 versus 6.0%), and 12 (5.9 versus 10.0%); odds ratio (OR) = 1.07; 95% confidence interval (CI) = 0.23, 4.97; retention = 71%. There was an effect at 3 months (OR = 2.52; CI = 1.56, 4.04; P < 0.0001). There were no 12-month treatment effects for reported abstinence (P = 0.746), reduction in smoking by 50% or more (P = 0.533), likelihood of having made a quit attempt (P = 0.387) or stage of change over time (0.968). Participants in TSP engaged more and rated the intervention more favorably than those in the control condition.

CONCLUSIONS

Compared with referral to a smoking cessation website, a novel USA-focused Facebook smoking cessation intervention did not improve abstinence from smoking over 1 year, but increased abstinence at the end of treatment and was engaging to participants.

High-intensity Interval Training and Continuous Aerobic Exercise Interventions to Promote Self-initiated Quit Attempts in Young Adults Who Smoke: Feasibility, Acceptability, and Lessons Learned From a Randomized Pilot Trial

OBJECTIVES

While exercise significantly reduces craving for cigarettes, the effect of exercise on self-initiation of quit attempts is less known. Therefore, this randomized pilot study explored the effect of starting an exercise program on self-initiated quit attempts, and also the feasibility and acceptability of a novel exercise intervention, high-intensity interval training (HIIT), as compared with a more traditional continuous aerobic (CA) exercise intervention.

METHODS

Participants smoked (≥5 cigarettes/d), were aged 18 to 40 years, and wanted to increase their exercise. Participants were randomized into 1 of 3 groups: HIIT, CA, and delayed control. All participants attended follow-up visits at weeks 4, 8, and 12. Outcomes included measures of feasibility (eg, visit attendance) and acceptability (eg, satisfaction), and also changes in smoking behavior (eg, quit attempts during follow-up) and proxies to quit attempts (eg, positive affect).

RESULTS

Overall, there were no differences in terms of feasibility and acceptability between the HITT (n = 12) and CA (n = 9) groups. Based on both self-report and objective measurement, the exercise groups (HIIT and CA) increased their physical activity as compared with the delayed treatment group (n = 11). Compared with HIIT and delayed control, CA (n = 9) had significant favorable changes in positive affect (eg, at week 8, HIIT: +0.25 ± 2.21, delayed control: -5.11 ± 2.23, CA: +5.50 ± 2.23; P = 0.0153).

CONCLUSIONS

These observations suggest that HIIT is as feasible and acceptable as CA, though CA may have a more favorable effect on proxies to quit attempts (eg, positive affect). Fully powered studies are needed to examine the effect of HIIT versus CA on quit attempts.

Internet-based interventions for smoking cessation

BACKGROUND

Tobacco use is estimated to kill 7 million people a year. Nicotine is highly addictive, but surveys indicate that almost 70% of US and UK smokers would like to stop smoking. Although many smokers attempt to give up on their own, advice from a health professional increases the chances of quitting. As of 2016 there were 3.5 billion Internet users worldwide, making the Internet a potential platform to help people quit smoking.

OBJECTIVES

To determine the effectiveness of Internet-based interventions for smoking cessation, whether intervention effectiveness is altered by tailoring or interactive features, and if there is a difference in effectiveness between adolescents, young adults, and adults.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, which included searches of MEDLINE, Embase and PsycINFO (through OVID). There were no restrictions placed on language, publication status or publication date. The most recent search was conducted in August 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs). Participants were people who smoked, with no exclusions based on age, gender, ethnicity, language or health status. Any type of Internet intervention was eligible. The comparison condition could be a no-intervention control, a different Internet intervention, or a non-Internet intervention. To be included, studies must have measured smoking cessation at four weeks or longer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed and extracted data. We extracted and, where appropriate, pooled smoking cessation outcomes of six-month follow-up or more, reporting short-term outcomes narratively where longer-term outcomes were not available. We reported study effects as a risk ratio (RR) with a 95% confidence interval (CI).We grouped studies according to whether they (1) compared an Internet intervention with a non-active control arm (e.g. printed self-help guides), (2) compared an Internet intervention with an active control arm (e.g. face-to-face counselling), (3) evaluated the addition of behavioural support to an Internet programme, or (4) compared one Internet intervention with another. Where appropriate we grouped studies by age.

MAIN RESULTS

We identified 67 RCTs, including data from over 110,000 participants. We pooled data from 35,969 participants.There were only four RCTs conducted in adolescence or young adults that were eligible for meta-analysis.Results for trials in adults: Eight trials compared a tailored and interactive Internet intervention to a non-active control. Pooled results demonstrated an effect in favour of the intervention (RR 1.15, 95% CI 1.01 to 1.30, n = 6786). However, statistical heterogeneity was high (I2 = 58%) and was unexplained, and the overall quality of evidence was low according to GRADE. Five trials compared an Internet intervention to an active control. The pooled effect estimate favoured the control group, but crossed the null (RR 0.92, 95% CI 0.78 to 1.09, n = 3806, I2 = 0%); GRADE quality rating was moderate. Five studies evaluated an Internet programme plus behavioural support compared to a non-active control (n = 2334). Pooled, these studies indicated a positive effect of the intervention (RR 1.69, 95% CI 1.30 to 2.18). Although statistical heterogeneity was substantial (I2 = 60%) and was unexplained, the GRADE rating was moderate. Four studies evaluated the Internet plus behavioural support compared to active control. None of the studies detected a difference between trial arms (RR 1.00, 95% CI 0.84 to 1.18, n = 2769, I2 = 0%); GRADE rating was moderate. Seven studies compared an interactive or tailored Internet intervention, or both, to an Internet intervention that was not tailored/interactive. Pooled results favoured the interactive or tailored programme, but the estimate crossed the null (RR 1.10, 95% CI 0.99 to 1.22, n = 14,623, I2 = 0%); GRADE rating was moderate. Three studies compared tailored with non-tailored Internet-based messages, compared to non-tailored messages. The tailored messages produced higher cessation rates compared to control, but the estimate was not precise (RR 1.17, 95% CI 0.97 to 1.41, n = 4040), and there was evidence of unexplained substantial statistical heterogeneity (I2 = 57%); GRADE rating was low.Results should be interpreted with caution as we judged some of the included studies to be at high risk of bias.

AUTHORS' CONCLUSIONS

The evidence from trials in adults suggests that interactive and tailored Internet-based interventions with or without additional behavioural support are moderately more effective than non-active controls at six months or longer, but there was no evidence that these interventions were better than other active smoking treatments. However some of the studies were at high risk of bias, and there was evidence of substantial statistical heterogeneity. Treatment effectiveness in younger people is unknown.

Health Evaluation and Referral Assistant: A Randomized Controlled Trial of a Web-Based Screening, Brief Intervention, and Referral to Treatment System to Reduce Risky Alcohol Use Among Emergency Department Patients

Background

Computer technologies hold promise for implementing alcohol screening, brief intervention, and referral to treatment (SBIRT). Questions concerning the most effective and appropriate SBIRT model remain.

Objective

The aim of this study was to evaluate the impact of a computerized SBIRT system called the Health Evaluation and Referral Assistant (HERA) on risky alcohol use treatment initiation.

Methods

Alcohol users (N=319) presenting to an emergency department (ED) were considered for enrollment. Those enrolled (n=212) were randomly assigned to the HERA, to complete a patient-administered assessment using a tablet computer, or a minimal-treatment control, and were followed for 3 months. Analyses compared alcohol treatment provider contact, treatment initiation, treatment completion, and alcohol use across condition using univariate comparisons, generalized estimating equations (GEEs), and post hoc chi-square analyses.

Results

HERA participants (n=212; control=115; intervention=97) did not differ between conditions on initial contact with an alcohol treatment provider, treatment initiation, treatment completion, or change in risky alcohol use behavior. Subanalyses indicated that HERA participants, who accepted a faxed referral, were more likely to initiate contact with a treatment provider and initiate treatment for risky alcohol use, but were not more likely to continue engaging in treatment, or to complete treatment and change risky alcohol use behavior over the 3-month period following the ED visit.

Conclusions

The HERA promoted initial contact with an alcohol treatment provider and initiation of treatment for those who accepted the faxed referral, but it did not lead to reduced risky alcohol use behavior. Factors which may have limited the HERA’s impact include lack of support for the intervention by clinical staff, the low intensity of the brief and stand-alone design of the intervention, and barriers related to patient follow-through, (eg, a lack of transportation or childcare, fees for services, or schedule conflicts).

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): NCT01153373; https://clinicaltrials.gov/ct2/show/NCT01153373 (Archived by WebCite at http://www.webcitation.org/6pHQEpuIF)

Brief intervention to promote smoking cessation and improve glycemic control in smokers with type 2 diabetes: a randomized controlled trial

The aim of the study was to examine the effects of a brief stage-matched smoking cessation intervention group compared with a control group (with usual care) in type 2 diabetes mellitus patients who smoked by randomized controlled trial. There were 557 patients, randomized either into the intervention group (n = 283) who received brief (20- minute) individualized face-to-face counseling by trained nurses and a diabetes mellitus-specific leaflet, or a control group (n = 274) who received standard care. Patient follow-ups were at 1 week, 1 month, 3 months, 6 months, and 12 months via telephone, and assessment of smoking status from 2012 to 2014. Patients smoked an average of 14 cigarettes per day for more than 37 years, and more than 70% were in the precontemplation stage of quitting. The primary outcome showed that both the intervention and control groups had similar 7-day point-prevalence smoking abstinence (9.2% vs. 13.9%; p = 0.08). The secondary outcome showed that HbA1c levels with 7.95% [63 mmol/mol] vs. 8.05% [64 mmol/mol], p = 0.49 at 12 months, respectively. There was no evidence for effectiveness in promoting the brief stage-matched smoking cessation or improving glycemic control in smokers with type 2 diabetes mellitus, particularly those in the pre-contemplation stage.

Automated telephone communication systems for preventive healthcare and management of long-term conditions

BACKGROUND

Automated telephone communication systems (ATCS) can deliver voice messages and collect health-related information from patients using either their telephone's touch-tone keypad or voice recognition software. ATCS can supplement or replace telephone contact between health professionals and patients. There are four different types of ATCS: unidirectional (one-way, non-interactive voice communication), interactive voice response (IVR) systems, ATCS with additional functions such as access to an expert to request advice (ATCS Plus) and multimodal ATCS, where the calls are delivered as part of a multicomponent intervention.

OBJECTIVES

To assess the effects of ATCS for preventing disease and managing long-term conditions on behavioural change, clinical, process, cognitive, patient-centred and adverse outcomes.

SEARCH METHODS

We searched 10 electronic databases (the Cochrane Central Register of Controlled Trials; MEDLINE; Embase; PsycINFO; CINAHL; Global Health; WHOLIS; LILACS; Web of Science; and ASSIA); three grey literature sources (Dissertation Abstracts, Index to Theses, Australasian Digital Theses); and two trial registries (www.controlled-trials.com; www.clinicaltrials.gov) for papers published between 1980 and June 2015.

SELECTION CRITERIA

Randomised, cluster- and quasi-randomised trials, interrupted time series and controlled before-and-after studies comparing ATCS interventions, with any control or another ATCS type were eligible for inclusion. Studies in all settings, for all consumers/carers, in any preventive healthcare or long term condition management role were eligible.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods to select and extract data and to appraise eligible studies.

MAIN RESULTS

We included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty-one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long-term conditions, and seven studies for appointment reminders. We downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. We judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. We considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear.For preventive healthcare, ATCS (ATCS Plus, IVR, unidirectional) probably increase immunisation uptake in children (risk ratio (RR) 1.25, 95% confidence interval (CI) 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty).For screening, multimodal ATCS increase uptake of screening for breast cancer (RR 2.17, 95% CI 1.55 to 3.04; 2 studies, N = 462; high certainty) and colorectal cancer (CRC) (RR 2.19, 95% CI 1.88 to 2.55; 3 studies, N = 1013; high certainty) versus usual care. It may also increase osteoporosis screening. ATCS Plus interventions probably slightly increase cervical cancer screening (moderate certainty), but effects on osteoporosis screening are uncertain. IVR systems probably increase CRC screening at 6 months (RR 1.36, 95% CI 1.25 to 1.48; 2 studies, N = 16,915; moderate certainty) but not at 9 to 12 months, with probably little or no effect of IVR (RR 1.05, 95% CI 0.99, 1.11; 2 studies, 2599 participants; moderate certainty) or unidirectional ATCS on breast cancer screening.Appointment reminders delivered through IVR or unidirectional ATCS may improve attendance rates compared with no calls (low certainty). For long-term management, medication or laboratory test adherence provided the most general evidence across conditions (25 studies, data not combined). Multimodal ATCS versus usual care showed conflicting effects (positive and uncertain) on medication adherence. ATCS Plus probably slightly (versus control; moderate certainty) or probably (versus usual care; moderate certainty) improves medication adherence but may have little effect on adherence to tests (versus control). IVR probably slightly improves medication adherence versus control (moderate certainty). Compared with usual care, IVR probably improves test adherence and slightly increases medication adherence up to six months but has little or no effect at longer time points (moderate certainty). Unidirectional ATCS, compared with control, may have little effect or slightly improve medication adherence (low certainty). The evidence suggested little or no consistent effect of any ATCS type on clinical outcomes (blood pressure control, blood lipids, asthma control, therapeutic coverage) related to adherence, but only a small number of studies contributed clinical outcome data.The above results focus on areas with the most general findings across conditions. In condition-specific areas, the effects of ATCS varied, including by the type of ATCS intervention in use.Multimodal ATCS probably decrease both cancer pain and chronic pain as well as depression (moderate certainty), but other ATCS types were less effective. Depending on the type of intervention, ATCS may have small effects on outcomes for physical activity, weight management, alcohol consumption, and diabetes mellitus. ATCS have little or no effect on outcomes related to heart failure, hypertension, mental health or smoking cessation, and there is insufficient evidence to determine their effects for preventing alcohol/substance misuse or managing illicit drug addiction, asthma, chronic obstructive pulmonary disease, HIV/AIDS, hypercholesterolaemia, obstructive sleep apnoea, spinal cord dysfunction or psychological stress in carers.Only four trials (3%) reported adverse events, and it was unclear whether these were related to the interventions.

AUTHORS' CONCLUSIONS

ATCS interventions can change patients' health behaviours, improve clinical outcomes and increase healthcare uptake with positive effects in several important areas including immunisation, screening, appointment attendance, and adherence to medications or tests. The decision to integrate ATCS interventions in routine healthcare delivery should reflect variations in the certainty of the evidence available and the size of effects across different conditions, together with the varied nature of ATCS interventions assessed. Future research should investigate both the content of ATCS interventions and the mode of delivery; users' experiences, particularly with regard to acceptability; and clarify which ATCS types are most effective and cost-effective.

Results of the PAS Study: A Randomized Controlled Trial Evaluating the Effectiveness of a Web-Based Multiple Tailored Smoking Cessation Program Combined With Tailored Counseling by Practice Nurses

This study investigated the effects of Web-based multiple computer tailoring and counseling by a practice nurse (MTC) compared with computer tailoring without counseling (MT) and usual care (UC) on smoking cessation rates, via a randomized controlled trial with 414 Dutch adult smokers, recruited by 91 practice nurses from May 2009 to June 2010. Logistic multilevel regression analyses were conducted with 24-hour point prevalence, 7-day point prevalence, and prolonged abstinence after 6 and 12 months as dependent variables and experimental condition as the independent variable. After 6 and 12 months, 38% and 56% of respondents were followed up, respectively. At both follow-ups, no main effects of the interventions could be identified when comparing them with care as usual and with each other-neither in analyses using available data nor in analyses using a negative scenario in which respondents lost to follow-up were considered to still be smoking. A Web-based multiple computer-tailored smoking cessation program combined with a single face-to-face counseling session by a practice nurse may not be more effective than this computer-tailored program alone or than usual smoking cessation care in the general practice setting. Yet before concluding that the addition of counseling to Web-based computer tailoring cannot be successful, more research needs to be conducted to identify the optimal number of counseling sessions to be combined with the Web-based program and to how to best attune the two modalities.

Applying the Transtheoretical Model to Tobacco Cessation and Prevention: A Review of Literature

Objective.

To comprehensively review all published, peer-reviewed research on the Transtheoretical Model (TTM) and tobacco cessation and prevention by exploring the validity of its constructs, the evidence for use of interventions based on the TTM, the description of populations using TTM constructs, and the identification of areas for further research. The three research questions answered were: “How is the validity of the TTM as applied to tobacco supported by research?” “How does the TTM describe special populations regarding tobacco use?” “What is the nature of evidence supporting the use of stage-matched tobacco interventions?”

Data Source.

Computer Database search (PsychInfo, Medline, Current Contents, ERIC, CINAHL-Allied Health, and Pro-Quest Nursing) and manual journal search.

Inclusion/Exclusion Criteria.

All English, original, research articles on the TTM as it relates to tobacco use published in peer-reviewed journals prior to March 1, 2001, were included. Commentaries, editorials, and books were not included.

Data Extraction and Synthesis.

Articles were categorized as TTM construct validation, population descriptions using TTM constructs, or intervention evaluation using TTM constructs. Summary tables including study design, research rating, purpose, methods, findings, and implications were created. Articles were further divided into groups according to their purpose. Considering both the findings and research quality of each, the three research questions were addressed.

Results.

The 148 articles reviewed included 54 validation studies, 73 population studies, and 37 interventions (some articles fit two categories). Overall, the evidence in support of the TTM as applied to tobacco use was strong, with supportive studies being more numerous and of a better design than nonsupportive studies. Using established criteria, we rated the construct validity of the entire body of literature as good; however, notable concerns exist about the staging construct. A majority of stage-matched intervention studies provided positive results and were of a better quality than those not supportive of stage-matched interventions; thus, we rated the body of literature using stage-matched tobacco interventions as acceptable and the body of literature using non–stage-matched interventions as suggestive. Population studies indicated that TTM constructs are applicable to a wide variety of general and special populations both in and outside of the United States, although a few exceptions exist.

Conclusions.

Evidence for the validity of the TTM as it applies to tobacco use is strong and growing; however, it is not conclusive. Eight different staging mechanisms were identified, raising the question of which are most valid and reliable. Interventions tailored to a smoker's stage were successful more often than nontailored interventions in promoting forward stage movement. Stage distribution is well-documented for U.S. populations; however, more research is needed for non-U.S. populations, for special populations, and on other TTM constructs.

Population Treatment for Addictions

Addictive behaviors are major causes of chronic disease, premature death, and high health care costs. Such behaviors have not been treated seriously by health care systems, and this is a major reason why such systems face an unhealthy future. Treating addictions seriously requires complementing a traditional individual-patient paradigm with a population paradigm, an action paradigm with a stage paradigm, clinic practices with home-based practices, a clinician paradigm with a computer paradigm, and programs that focus on changing single behaviors with programs that focus on changing multiple behaviors.

Treating Tobacco Dependence at the Intersection of Diversity, Poverty, and Mental Illness: A Randomized Feasibility and Replication Trial

INTRODUCTION

In an ethnically-diverse, uninsured psychiatric sample with co-occurring drug/alcohol addiction, we evaluated the feasibility and reproducibility of a tobacco treatment intervention. The intervention previously demonstrated efficacy in insured psychiatric and nonpsychiatric samples with 20.0%-25.0% abstinence at 18 months.

METHODS

Daily smokers, recruited in 2009-2010 from psychiatric units at an urban public hospital, were randomized to usual care (on-unit nicotine replacement plus quit advice) or intervention, which added a Transtheoretical-model tailored, computer-assisted intervention, stage-matched manual, brief counseling, and 10-week post-hospitalization nicotine replacement.

RESULTS

The sample (N = 100, 69% recruitment rate, age M = 40) was 56% racial/ethnic minority, 65% male, 79% unemployed, and 48% unstably housed, diagnosed with unipolar (54%) and bipolar (14%) depression and psychotic disorders (46%); 77% reported past-month illicit drug use. Prior to hospitalization, participants averaged 19 (SD = 11) cigarettes/day for 23 (SD = 13) years; 80% smoked within 30 minutes of awakening; 25% were preparing to quit. Encouraging and comparable to effects in the general population, 7-day point prevalence abstinence for intervention versus control was 12.5% versus 7.3% at 3 months, 17.5% versus 8.5% at 6 months, and 26.2% versus 16.7% at 12 months. Retention exceeded 80% over 12 months. The odds of abstinence increased over time, predicted by higher self-efficacy, greater perceived social status, and diagnosis of psychotic disorder compared to unipolar depression.

CONCLUSIONS

Findings indicate uninsured smokers with serious mental illness can engage in tobacco treatment research with quit rates comparable to the general population. A larger investigation is warranted. Inclusion of diverse smokers with mental illness in clinical trials is supported and encouraged.

Health evaluation and referral assistant: a randomized controlled trial to improve smoking cessation among emergency department patients

BACKGROUND

Computer technologies hold promise for implementing tobacco screening, brief intervention, and referral to treatment (SBIRT). This study aims to evaluate a computerized tobacco SBIRT system called the Health Evaluation and Referral Assistant (HERA).

METHODS

Smokers (n = 421) presenting to an emergency department were randomly assigned to the HERA or a minimal-treatment Control and were followed for 3 months. Analyses compared smoking cessation treatment provider contact, treatment initiation, treatment completion, and smoking behavior across condition using univariable comparisons, generalized estimating equations (GEE), and post hoc Chi square analyses.

RESULTS

HERA participants were more likely to initiate contact with a treatment provider but did not differ on treatment initiation, quit attempts, or sustained abstinence. Subanalyses revealed HERA participants who accepted a faxed referral were more likely to initiate treatment but were not more likely to stop smoking.

CONCLUSIONS

The HERA promoted initial contact with a smoking cessation provider and the faxed referral further promoted treatment initiation, but it did not lead to improved abstinence.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT01153373.

The Tobacco Status Project (TSP): Study protocol for a randomized controlled trial of a Facebook smoking cessation intervention for young adults

BACKGROUND

Tobacco use remains the leading cause of premature morbidity and mortality in the United States. Young adults are less successful at quitting, use cessation treatment less often than smokers of other ages, and can be a challenge to retain in treatment. Social media, integrated into the lives of many young adults, represents a promising strategy to deliver evidence-based smoking cessation treatment to a large, diverse audience. The goal of this trial is to test the efficacy of a stage-based smoking cessation intervention on Facebook for young adults age 18 to 25 on smoking abstinence, reduction in cigarettes smoked, and thoughts about smoking abstinence.

METHODS/DESIGN

This is a randomized controlled trial. Young adult smokers throughout the United States are recruited online and randomized to either the 3 month Tobacco Status Project intervention on Facebook or a referral to a smoking cessation website. The intervention consists of assignment to a secret Facebook group tailored to readiness to quit smoking (precontemplation, contemplation, preparation), daily Facebook contacts tailored to readiness to quit smoking, weekly live counseling sessions, and for those in preparation, weekly Cognitive Behavioral Therapy counseling sessions on Facebook. Primary outcome measure is biochemically-verified 7-day point prevalence abstinence from smoking at posttreatment (3 months), 6, and 12 months. Secondary outcome measures are reduction of 50 % or more in cigarettes smoked, 24 h quit attempts, and commitment to abstinence at each time point. A secondary aim is to test, within the TSP condition, the effect of a monetary incentive at increasing engagement in the intervention.

DISCUSSION

This randomized controlled trial is testing a novel Facebook intervention for treating young adults' tobacco use. If efficacious, the social media intervention could be disseminated widely and expanded to address additional health risks.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02207036 , May 13, 2014.

How Smart are Smartphone Apps for Smoking Cessation? A Content Analysis

INTRODUCTION

Smartphone technology is ideally suited to provide tailored smoking cessation support, yet it is unclear to what extent currently existing smartphone "apps" use tailoring, and if tailoring is related to app popularity and user-rated quality.

METHODS

We conducted a content analysis of Android smoking cessation apps (n = 225), downloaded between October 1, 2013 to May 31, 2014. We recorded app popularity (>10,000 downloads) and user-rated quality (number of stars) from Google Play, and coded the existence of tailoring features in the apps within the context of using the 5As ("ask," "advise," "assess," "assist," and "arrange follow-up"), as recommended by national clinical practice guidelines.

RESULTS

Apps largely provided simplistic tools (eg, calculators, trackers), and used tailoring sparingly: on average, apps addressed 2.1 ± 0.9 of the 5As and used tailoring for 0.7 ± 0.9 of the 5As. Tailoring was positively related to app popularity and user-rated quality: apps that used two-way interactions (odds ratio [OR] = 5.56 [2.45-12.62]), proactive alerts (OR = 3.80 [1.54-9.38]), responsiveness to quit status (OR = 5.28 [2.18-12.79]), addressed more of the 5As (OR = 1.53 [1.10-2.14]), used tailoring for more As (OR = 1.67 [1.21-2.30]), and/or used more ways of tailoring 5As content (OR = 1.35 [1.13-1.62]) were more likely to be frequently downloaded. Higher star ratings were associated with a higher number of 5As addressed (b = 0.16 [0.03-0.30]), a higher number of 5As with any level of tailoring (b = 0.14 [0.01-0.27]), and a higher number of ways of tailoring 5As content (b = 0.08 [0.002-0.15]).

CONCLUSIONS

Publically available smartphone smoking cessation apps are not particularly "smart": they commonly fall short of providing tailored feedback, despite users' preference for these features.

Print-based self-help interventions for smoking cessation

BACKGROUND

Many smokers give up smoking on their own, but materials giving advice and information may help them and increase the number who quit successfully.

OBJECTIVES

The aims of this review were to determine: the effectiveness of different forms of print-based self-help materials, compared with no treatment and with other minimal contact strategies; the effectiveness of adjuncts to print-based self help, such as computer-generated feedback, telephone hotlines and pharmacotherapy; and the effectiveness of approaches tailored to the individual compared with non-tailored materials.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register. Date of the most recent search April 2014.

SELECTION CRITERIA

We included randomized trials of smoking cessation with follow-up of at least six months, where at least one arm tested a print-based self-help intervention. We defined self help as structured programming for smokers trying to quit without intensive contact with a therapist.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the participants, the nature of the self-help materials, the amount of face-to-face contact given to intervention and to control conditions, outcome measures, method of randomization, and completeness of follow-up.The main outcome measure was abstinence from smoking after at least six months follow-up in people smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a fixed-effect model.

MAIN RESULTS

We identified 74 trials which met the inclusion criteria. Many study reports did not include sufficient detail to judge risk of bias for some domains. Twenty-eight studies (38%) were judged at high risk of bias for one or more domains but the overall risk of bias across all included studies was judged to be moderate, and unlikely to alter the conclusions.Thirty-four trials evaluated the effect of standard, non-tailored self-help materials. Pooling 11 of these trials in which there was no face-to-face contact and provision of structured self-help materials was compared to no intervention gave an estimate of benefit that just reached statistical significance (n = 13,241, risk ratio [RR] 1.19, 95% confidence interval [CI] 1.04 to 1.37). This analysis excluded two trials with strongly positive outcomes that introduced significant heterogeneity. Six further trials without face-to-face contact in which the control group received alternative written materials did not show evidence for an effect of the smoking self-help materials (n = 7023, RR 0.88, 95% CI 0.74 to 1.04). When these two subgroups were pooled, there was no longer evidence for a benefit of standard structured materials (n = 20,264, RR 1.06, 95% CI 0.95 to 1.18). We failed to find evidence of benefit from providing standard self-help materials when there was brief contact with all participants (5 trials, n = 3866, RR 1.17, 95% CI 0.96 to 1.42), or face-to-face advice for all participants (11 trials, n = 5365, RR 0.97, 95% CI 0.80 to 1.18).Thirty-one trials offered materials tailored for the characteristics of individual smokers, with controls receiving either no materials, or stage matched or non-tailored materials. Most of the trials used more than one mailing. Pooling these showed a benefit of tailored materials (n = 40,890, RR 1.28, 95% CI 1.18 to 1.37) with moderate heterogeneity (I² = 32%). The evidence is strongest for the subgroup of nine trials in which tailored materials were compared to no intervention (n = 13,437, RR 1.35, 95% CI 1.19 to 1.53), but also supports tailored materials as more helpful than standard materials. Part of this effect could be due to the additional contact or assessment required to obtain individual data, since the subgroup of 10 trials where the number of contacts was matched did not detect an effect (n = 11,024, RR 1.06, 95% CI 0.94 to 1.20). In two trials including a direct comparison between tailored materials and brief advice from a health care provider, there was no evidence of a difference, but confidence intervals were wide (n = 2992, RR 1.13, 95% CI 0.86 to 1.49).Only four studies evaluated self-help materials as an adjunct to nicotine replacement therapy, with no evidence of additional benefit (n = 2291, RR 1.05, 95% CI 0.88 to 1.25). A small number of other trials failed to detect benefits from using additional materials or targeted materials, or to find differences between different self-help programmes.

AUTHORS' CONCLUSIONS

Standard, print-based self-help materials increase quit rates compared to no intervention, but the effect is likely to be small. We did not find evidence that they have an additional benefit when used alongside other interventions such as advice from a healthcare professional, or nicotine replacement therapy. There is evidence that materials that are tailored for individual smokers are more effective than non-tailored materials, although the absolute size of effect is still small. Available evidence tested self-help interventions in high income countries; further research is needed to investigate their effect in contexts where more intensive support is not available.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of proactive and reactive telephone support via helplines and in other settings to help smokers quit.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2013.

SELECTION CRITERIA

randomized or quasi-randomised controlled trials in which proactive or reactive telephone counselling to assist smoking cessation was offered to smokers or recent quitters.

DATA COLLECTION AND ANALYSIS

One author identified and data extracted trials, and a second author checked them. The main outcome measure was the risk ratio for abstinence from smoking after at least six months follow-up. We selected the strictest measure of abstinence, using biochemically validated rates where available. We considered participants lost to follow-up to be continuing smokers. Where trials had more than one arm with a less intensive intervention we used only the most similar intervention without the telephone component as the control group in the primary analysis. We assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I² statistic. We considered trials recruiting callers to quitlines separately from studies recruiting in other settings. Where appropriate, we pooled studies using a fixed-effect model. We used a meta-regression to investigate the effect of differences in planned number of calls, selection for motivation, and the nature of the control condition (self help only, minimal intervention, pharmacotherapy) in the group of studies recruiting in non-quitline settings.

MAIN RESULTS

Seventy-seven trials met the inclusion criteria. Some trials were judged to be at risk of bias in some domains but overall we did not judge the results to be at high risk of bias. Among smokers who contacted helplines, quit rates were higher for groups randomized to receive multiple sessions of proactive counselling (nine studies, > 24,000 participants, risk ratio (RR) for cessation at longest follow-up 1.37, 95% confidence interval (CI) 1.26 to 1.50). There was mixed evidence about whether increasing the number of calls altered quit rates but most trials used more than two calls. Three studies comparing different counselling approaches during a single quitline contact did not detect significant differences. Of three studies that tested the provision of access to a hotline two detected a significant benefit and one did not.Telephone counselling not initiated by calls to helplines also increased quitting (51 studies, > 30,000 participants, RR 1.27; 95% CI 1.20 to 1.36). In a meta-regression controlling for other factors the effect was estimated to be slightly larger if more calls were offered, and in trials that specifically recruited smokers motivated to try to quit. The relative extra benefit of counselling was smaller when it was provided in addition to pharmacotherapy (usually nicotine replacement therapy) than when the control group only received self-help material or a brief intervention.A further eight studies were too diverse to contribute to meta-analyses and are discussed separately. Two compared different intensities of counselling, both of which detected a dose response; one of these detected a benefit of multiple counselling sessions over a single call for people prescribed bupropion. The others tested a variety of interventions largely involving offering telephone counselling as part of a referral or systems change and none detected evidence of effect.

AUTHORS' CONCLUSIONS

Proactive telephone counselling aids smokers who seek help from quitlines. Telephone quitlines provide an important route of access to support for smokers, and call-back counselling enhances their usefulness. There is limited evidence about the optimal number of calls. Proactive telephone counselling also helps people who receive it in other settings. There is some evidence of a dose response; one or two brief calls are less likely to provide a measurable benefit. Three or more calls increase the chances of quitting compared to a minimal intervention such as providing standard self-help materials, or brief advice, or compared to pharmacotherapy alone.

Internet-based interventions for smoking cessation

BACKGROUND

The Internet is now an indispensable part of daily life for the majority of people in many parts of the world. It 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 METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register. There were no restrictions placed on language of publication or publication date. The most recent search was conducted in April 2013.

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 intervention was eligible. The comparison condition could be a no-intervention control, a different Internet intervention, or a non-Internet intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed and extracted data. Methodological and study quality details were extracted using a standardized form. We extracted smoking cessation outcomes of six months follow-up or more, reporting short-term outcomes where longer-term outcomes were not available. We reported study effects as a risk ratio (RR) with a 95% confidence interval (CI). Clinical and statistical heterogeneity limited our ability to pool studies.

MAIN RESULTS

This updated review includes a total of 28 studies with over 45,000 participants. Some Internet programmes were intensive and included multiple outreach contacts with participants, whilst others relied on participants to initiate and maintain use.Fifteen trials compared an Internet intervention to a non-Internet-based smoking cessation intervention or to a no-intervention control. Ten of these recruited adults, one recruited young adult university students and two recruited adolescents. Seven of the trials in adults had follow-up at six months or longer and compared an Internet intervention to usual care or printed self help. In a post hoc subgroup analysis, pooled results from three trials that compared interactive and individually tailored interventions to usual care or written self help detected a statistically significant effect in favour of the intervention (RR 1.48, 95% CI 1.11 to 2.78). However all three trials were judged to be at high risk of bias in one domain and high statistical heterogeneity was detected (I² = 53%), with no obvious clinical explanation. Pooled results from two studies of an interactive, tailored intervention involving the Internet and automated phone contacts also detected a significant effect (RR 2.05, 95% CI 1.42 to 2.97, I² = 42%). Results from a sixth study comparing an interactive but non-tailored intervention to control did not detect a significant effect, nor did the seventh study, which compared a non-interactive, non-tailored intervention to control. Three trials comparing Internet interventions to face-to-face or phone counselling also did not detect evidence of an effect, nor did two trials evaluating Internet interventions as adjuncts to other behavioural interventions. 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.Fourteen trials, all in adult populations, compared different Internet sites or programmes. Pooled estimates from three trials that compared tailored and/or interactive Internet programmes with non-tailored, non-interactive Internet programmes did not detect evidence of an effect (RR 1.12, 95% CI 0.95 to 1.32, I² = 0%). One trial detected evidence of a benefit from a tailored email compared to a non-tailored one, whereas a second trial comparing tailored messages to a non-tailored message did not detect evidence of an effect. Trials failed to detect a benefit of including a mood management component (three trials), or an asynchronous bulletin board.

AUTHORS' CONCLUSIONS

Results suggest that some Internet-based interventions can assist smoking cessation at six months or longer, particularly those which are interactive and tailored to individuals. However, the trials that compared Internet interventions with usual care or self help did not show consistent effects and were at risk of bias. Further research is needed despite 28 studies on the subject. Future studies should carefully consider optimising the interventions which promise most effect such as tailoring and interactivity.

Testing the transtheoretical model in predicting smoking relapse among Malaysian adult smokers receiving assistance in quitting

The role of The Transtheoretical Model (TTM) in predicting relapse is limited. We aimed to assess whether this model can be utilised to predict relapse during the action stage. The participants included 120 smokers who had abstained from smoking for at least 24 hours following two Malaysian universities' smoking cessation programme. The smokers who relapsed perceived significantly greater advantages related to smoking and increasing doubt in their ability to quit. In contrast, former smokers with greater self-liberation and determination to abstain were less likely to relapse. The findings suggest that TTM can be used to predict relapse among quitting smokers.

A randomized clinical trial of the health evaluation and referral assistant (HERA): research methods

The Health Evaluation and Referral Assistant (HERA) is a web-based program designed to facilitate screening, brief intervention, and referral to treatment (SBIRT) for tobacco, alcohol, and drug abuse. After the patient completes a computerized substance abuse assessment, the HERA produces a summary report with evidence-based recommended clinical actions for the healthcare provider (the Healthcare Provider Report) and a report for the patient (the Patient Feedback Report) that provides education regarding the consequences of use, personally tailored motivational messages, and a tailored substance abuse treatment referral list. For those who provide authorization, the HERA faxes the individual's contact information to a substance abuse treatment provider matched to the individual's substance use severity and personal characteristics, like insurance and location of residence (dynamic referral). This paper summarizes the methods used for a randomized controlled trial to evaluate the HERA's efficacy in leading to increased treatment initiation and reduced substance use. The study was performed in four emergency departments. Individual patients were randomized into one of two conditions: the HERA or assessment only. A total of 4269 patients were screened and 1006 participants enrolled. The sample was comprised of 427 tobacco users, 212 risky alcohol users, and 367 illicit drug users. Forty-two percent used more than one substance class. The enrolled sample was similar to the eligible patient population. The study should enhance understanding of whether computer-facilitated SBIRT can impact process of care variables, such as promoting substance abuse treatment initiation, as well as its effect on subsequent substance abuse and related outcomes.

Testing 40 Predictions From the Transtheoretical Model Again, With Confidence

Testing Theory-based Quantitative Predictions (TTQP) represents an alternative to traditional Null Hypothesis Significance Testing (NHST) procedures and is more appropriate for theory testing. The theory generates explicit effect size predictions and these effect size estimates, with related confidence intervals, are used to test the predictions. The focus of a study is shifted to a quantitative approach in contrast to the NHST dyadic decision centered on testing a prediction not based on the theory. This article describes the TTQP as an alternative approach by replicating and extending a test of 40 a priori predictions based on the Transtheoretical Model (TTM). Specific quantitative predictions were made about the magnitude of the effect size (ω(2)). The predictions involved movement from 1 of 3 initial stages (Precontemplation, Contemplation, and Preparation) to stage membership 12 months later. In the initial study, 36 of the 40 predictions were confirmed. The same 40 predictions are evaluated on a sample (N = 3,923) of smokers recruited from a large New England HMO for a smoking cessation study. The predictions were recalibrated based on the first study and 99% confidence intervals were employed to test the predictions. Thirty-two of the 40 predictions were confirmed. Of the 8 failures, 4 were judged to reflect a need for further recalibration, 1 was attributed to sampling fluctuation, and 3 suggested revisions of the theory are needed. The results provide overall support for the TTM. The study also illustrates some of the challenges of testing quantitative predictions.

Outcomes of cluster profiles within stages of change for sun protection behavior

OBJECTIVE

Predictive and external validity was studied among cluster profiles for sun protection behavior within stages from Transtheoretical Model of behavior change using follow-up data.

METHODS

Data from participants in a home-based expert system were analyzed. Longitudinal patterns of clusters on the precontemplation, contemplation, and preparation stages of change were assessed. Differences between clusters on membership in action/maintenance stages and scores on the Sun Protection Behavior Scale (SPBS) were measured at 12 and 24 months after intervention.

RESULTS

Differences between clusters on stage progression and on scores from the SPBS were found at 12 and 24 months after intervention at all stages.

DISCUSSION

Predictive and external validity of sun protection subtypes was established using sun protection variables after a stage-matched intervention. Results provide information to improve interventions for sun protection.

Results of a transtheoretical model-based alcohol, tobacco and other drug intervention in middle schools

BACKGROUND

Early use of alcohol, tobacco, and other drugs threatens the physical and mental well-being of students and continued use negatively affects many areas of development. An internet-based, tailored intervention based on the Transtheoretical Model of Behavior Change was delivered to middle school students to reduce alcohol, tobacco, and other drug use. This internet-based approach requires very little faculty and staff time, which is efficient given curricular demands.

METHODS

Twenty-two middle schools in the United States were matched and randomly assigned to either the intervention or control conditions (N=1590 students who had ever used substances). Participants received one pre-test assessment, three thirty-minute intervention sessions over three months, and two post-test assessments (3 and 14 months after pre-test, respectively).

RESULTS

Random effects logistic models showed significant treatment effects for the intervention group when compared to the control group at the 3-month post-test.

CONCLUSIONS

This program has the potential to be applied as stand-alone practice or as part of more intensive interventions to promote substance use cessation.

Questions about quitting (Q2): design and methods of a Multiphase Optimization Strategy (MOST) randomized screening experiment for an online, motivational smoking cessation intervention

Effective interventions are needed to improve smokers' motivation for quitting, treatment utilization, and abstinence rates. The Internet provides an ideal modality for delivering such interventions, given the low cost, broad reach, and capacity to individually tailor content, but important methodological questions remain about how to best design and deliver an online, motivational intervention to smokers. The current paper reports on the intervention, study design and research methods of a randomized trial (called Questions about Quitting) designed to address some of these questions. Using a Multi-phase Optimization Strategy (MOST) screening experiment, the trial has two key aims: to examine the impact of four experimental intervention factors (each evaluated on two levels) on smokers' subsequent treatment utilization and abstinence, and to examine select moderators of each sub-factor's effectiveness. The experimental factors of interest are: navigation autonomy (content viewing order is dictated based on stage of change or not), use of self-efficacy based testimonials (yes vs. no), proactive outreach (reminder emails vs. no emails), and decisional framework (prescriptive vs. motivational tone). To our knowledge, this is the first application of the MOST methodology to explore these factors or to explore the optimal design for a motivational intervention targeting smokers not actively trying to quit smoking. The rationale for the experimental factor choice, intervention design, and trial methods are discussed. Outcome data are currently being collected and are not presented, but recruitment data confirm the feasibility of enrolling smokers at varying stages of readiness to quit.

Use of smoking reduction strategies among U.S. tobacco quitlines

INTRODUCTION

Tobacco quitlines (QLs) are efficacious and have assisted many smokers in achieving tobacco abstinence. However, most smokers are not able to achieve tobacco abstinence with QL services. QL counseling interventions for smokers who do not quit on their target quit date (TQD) and decline to set a new TQD after missing their TQD have not been systematically evaluated.

METHODS

A telephone survey of tobacco QLs in the United States (US) was conducted to examine systematic approaches used with smokers who do not quit on their TQD and decline to set a new TQD. Tobacco QLs service providers were identified through the North American Quitline Consortium (NAQC).

RESULTS

Fourteen service providers managing QLs of all 50 US states were identified and completed the voluntary survey. All providers recommended setting a new quit TQD if smokers did not achieve smoking cessation by their initial TQD. Six percent of US state QLs used brief motivational interviewing utilizing the "5R's" (relevance, risk, rewards, roadblocks, repetition). However, 90% of QLs had intervention protocols emphasizing smoking rate reduction.

CONCLUSION

Although some US QLs utilized the "5Rs," the majority provided smoking reduction interventions for smokers not achieving tobacco cessation by their initial TQD and declining to set a new TQD. Research is needed to evaluate the efficacy of smoking rate reduction methods implemented through QLs for increasing smoking abstinence rates.

Cluster subtypes appropriate for preventing postpartum smoking relapse

OBJECTIVE

While the majority of women quit smoking either before or during pregnancy, 60 to 80% relapse in the postpartum period. The objective of this research was to examine postpartum women who quit smoking during their pregnancies and to determine the predictive factors for relapse in the postpartum period by identifying different subgroups that predict risk of relapse.

METHOD

One hundred forty four postpartum women who were abstinent at the time of delivery were recruited. Data regarding the Acquisition Stage of Change, Decisional Balance and Situational Temptations to Smoke were assessed in the immediate postpartum period. Based on their intention to remain abstinent, 121 women identified in the acquisition-Precontemplation (aPC) group comprised the study sample. Smoking status was assessed again at 2 months postpartum.

RESULTS

A cluster analysis was performed to identify subgroups of the acquisition-Precontemplation (aPC) group. Four subgroups were identified and were labeled Most Protected, Ambivalent, Risk Denial, and High Risk. Logistic regression was performed to establish external validity of the clusters. The clusters and exclusive breastfeeding were the only statistically significant variables associated with relapse at 2 months postpartum.

CONCLUSIONS

The results confirmed the clusters identified in previous prevention research with both adolescents and postpartum women, The cluster profiles can serve to guide the development of a tailored intervention program.

Enhancing multiple domains of well-being by decreasing multiple health risk behaviors: a randomized clinical trial

Tailored behavior change programs have proven effective at decreasing health risk factors, but the impact of such programs on participant well-being has not been tested. This randomized trial evaluated the impact of tailored telephone coaching and Internet interventions on health risk behaviors and individual well-being. Exercise and stress management were the primary health risks of interest; improvements in other health risk behaviors were secondary outcomes. A sample of 3391 individuals who reported health risk in the areas of exercise and stress management were randomly assigned to 3 groups: telephonic coaching that applied Transtheoretical Model (TTM) tailoring for exercise and minimal tailoring (stage of change) for stress management; an Internet program that applied TTM tailoring for stress management and minimal tailoring for exercise; or a control group that received an assessment only. Participants were administered the Well-Being Assessment and, at baseline, had relatively low well-being scores (mean, 60.9 out of 100 across all groups). At 6 months, a significantly higher percentage of both treatment groups progressed to the Action stage for exercise, stress management, healthy diet, and total number of health risks, compared to the control group. Both treatment groups also demonstrated significantly greater improvements on overall well-being and the domains of emotional health, physical health, life evaluation, and healthy behaviors. There were no differences between the groups for 2 well-being domains: basic access to needs and work environment. These results indicate that scalable, tailored behavior change programs can effectively reduce health risk and accrue to improved well-being for participants.

Cluster subtypes within the precontemplation stage of change for sun protection behavior

The aim of this study is to identify replicable cluster subtypes within the precontemplation stage of change for sun protection. Secondary data analysis of baseline data from a sample of participants in a home-based expert system intervention was performed. Three random samples were selected from participants in the precontemplation stage (N = 570). Cluster analyses were performed using the scales of pros, cons, and self-efficacy. Interpretability of pattern, pseudo F-test, and dendograms were used to determine the number of clusters. A four-cluster solution replicated across subsamples. Significant differences between clusters on the nine processes of change and on behavioral measures were found. Cluster solutions were robust, interpretable and with good initial external validity. They replicated patterns found for other behaviors, demonstrating long-term predictability and providing basis for tailored interventions.

A computerized, tailored intervention to address behaviors associated with PTSD in veterans: rationale and design of STR(2)IVE

Combat exposure among military personnel results in increased risk of posttraumatic stress disorder (PTSD), major depression, substance use, and related health risks. PTSD symptoms require innovative approaches to promote effective coping postdeployment. PTSD's nature and scope requires an approach capable of integrating multiple health risks while reaching large populations. This article provides the rationale and approach to adapt and evaluate a Pro-Change computerized tailored intervention (CTI) targeted at behavioral sequelae (i.e., smoking, stress, and depression) for veterans with or at risk for PTSD. The three-phase approach includes: 1) focus groups to review and, subsequently, adapt content of the existing CTI programs; 2) usability testing; and 3) feasibility testing using a three-month pre-postdesign. Effective, theory-based, real-time, multiple behavior interventions targeting veterans' readiness to quit smoking, manage stress, and depression are warranted to provide potential health impact, opportunities for learning veteran-specific issues, and advance multiple health behavior change knowledge.

Smoking, stages of change and decisional balance in Iceland and Sweden

INTRODUCTION

Smoking remains a significant health problem. Smoking interventions are important but selection of successful quitters can be difficult.

OBJECTIVE

To characterise smokers with emphasis on two constructs of the transtheoretical model, the stages of change and decisional balance.

METHODS

A random sample from adults aged 40 and over in Reykjavik, Iceland, and Uppsala, Sweden. Smokers were defined as being in the stage of pre-contemplation (not thinking of quitting within the next 6 months), contemplation (thinking of quitting within the next 6 months) or preparation (thinking of quitting within the next 30 days, having managed to quit for at least 24 h within the last 12 months).

RESULTS

A total of 226 participants were smokers: 72 (32%) were in the pre-contemplation stage, 126 (56%) in the contemplation stage and 28 (12%) in the preparation stage. A younger age, higher body mass index (BMI) and higher educational level were significantly related to being in a more advanced stage. A significant association was observed between decisional balance and stages of change such that decreased importance of the positive aspects of smoking and increased importance of the negative aspects of smoking were independently associated with an increased readiness to quit.

CONCLUSION

The motivated smoker is likely to be young and educated with an above average BMI. A smoker in the contemplation stage is likely to maintain the negative aspects of smoking at a high level. Decreasing the value of the pros of smoking may facilitate the shift towards the stage of preparation.

Proactive telephone counseling for smoking cessation: meta-analyses by recruitment channel and methodological quality

BACKGROUND

Systematic reviews demonstrated that proactive telephone counseling increases smoking cessation rates. However, these reviews did not differentiate studies by recruitment channel, did not adequately assess methodological quality, and combined different measures of abstinence.

METHODS

Twenty-four randomized controlled trials published before December 31, 2008, included seven of active recruitment, 16 of passive recruitment, and one of mixed recruitment. We rated methodological quality on selection bias, study design, confounders, blinding, data collection methods, withdrawals, and dropouts, according to the Quality Assessment Tool for Quantitative Studies. We conducted random effects meta-analysis to pool the results according to abstinence type and follow-up time for studies overall and segregated by recruitment channel, and methodological quality. The level of statistical heterogeneity was quantified by I(2). All statistical tests were two-sided.

RESULTS

Methodological quality ratings indicated two strong, 10 moderate, and 12 weak studies. Overall, compared with self-help materials or no intervention control groups, proactive telephone counseling had a statistically significantly greater effect on point prevalence abstinence (nonsmoking at follow-up or abstinent for at least 24 hours, 7 days before follow-up) at 6-9 months (relative risk [RR] = 1.26, 95% confidence interval [CI] = 1.11 to 1.43, P < .001, I(2) = 21.4%) but not at 12-15 months after recruitment. This pattern also emerged when studies were segregated by recruitment channel (active, passive) or methodological quality (strong/moderate, weak). Overall, the positive effect on prolonged/continuous abstinence (abstinent for 3 months or longer before follow-up) was also statistically significantly greater at 6-9 months (RR = 1.58, CI = 1.26 to 1.98, P < .001, I(2) = 49.1%) and 12-18 months after recruitment (RR = 1.40, CI = 1.23 to 1.60, P < .001, I(2) = 18.5%).

CONCLUSIONS

With the exception of point prevalence abstinence in the long term, these data support previous results showing that proactive telephone counseling has a positive impact on smoking cessation. Proactive telephone counseling increased prolonged/continuous abstinence long term for both actively and passively recruited smokers.

Stage-based interventions for smoking cessation

BACKGROUND

The transtheoretical model is the most widely known of several stage-based theories of behaviour. It proposes that smokers move through a discrete series of motivational stages before they quit successfully. These are precontemplation (no thoughts of quitting), contemplation (thinking about quitting), preparation (planning to quit in the next 30 days), action (quitting successfully for up to six months), and maintenance (no smoking for more than six months). According to this influential model, interventions which help people to stop smoking should be tailored to their stage of readiness to quit, and are designed to move them forward through subsequent stages to eventual success. People in the preparation and action stages of quitting would require different types of support from those in precontemplation or contemplation.

OBJECTIVES

Our primary objective was to test the effectiveness of stage-based interventions in helping smokers to quit.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group's specialised register for trials, using the terms ('stage* of change', 'transtheoretical model*', 'trans-theoretical model*, 'precaution adoption model*', 'health action model', 'processes of change questionnaire*', 'readiness to change', 'tailor*') and 'smoking' in the title or abstract, or as keywords. The latest search was in August 2010.

SELECTION CRITERIA

We included randomized controlled trials, which compared stage-based interventions with non-stage-based controls, with 'usual care' or with assessment only. We excluded trials which did not report a minimum follow-up period of six months from start of treatment, and those which measured stage of change but did not modify their intervention in the light of it.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the participants, the dose and duration of intervention, the outcome measures, the randomization procedure, concealment of allocation, and completeness of follow up.The main outcome was abstinence from smoking for at least six months. We used the most rigorous definition of abstinence, and preferred biochemically validated rates where reported. Where appropriate we performed meta-analysis to estimate a pooled risk ratio, using the Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We found 41 trials (>33,000 participants) which met our inclusion criteria. Four trials, which directly compared the same intervention in stage-based and standard versions, found no clear advantage for the staging component. Stage-based versus standard self-help materials (two trials) gave a relative risk (RR) of 0.93 (95% CI 0.62 to 1.39). Stage-based versus standard counselling (two trials) gave a relative risk of 1.00 (95% CI 0.82 to 1.22). Six trials of stage-based self-help systems versus any standard self-help support demonstrated a benefit for the staged groups, with an RR of 1.27 (95% CI 1.01 to 1.59). Twelve trials comparing stage-based self help with 'usual care' or assessment-only gave an RR of 1.32 (95% CI 1.17 to 1.48). Thirteen trials of stage-based individual counselling versus any control condition gave an RR of 1.24 (95% CI 1.08 to 1.42). These findings are consistent with the proven effectiveness of these interventions in their non-stage-based versions. The evidence was unclear for telephone counselling, interactive computer programmes or training of doctors or lay supporters. This uncertainty may be due in part to smaller numbers of trials.

AUTHORS' CONCLUSIONS

Based on four trials using direct comparisons, stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling were neither more nor less effective than their non-stage-based equivalents. Thirty-one trials of stage-based self help or counselling interventions versus any control condition demonstrated levels of effectiveness which were comparable with their non-stage-based counterparts. Providing these forms of practical support to those trying to quit appears to be more productive than not intervening. However, the additional value of adapting the intervention to the smoker's stage of change is uncertain. The evidence is not clear for other types of staged intervention, including telephone counselling, interactive computer programmes and training of physicians or lay supporters. The evidence does not support the restriction of quitting advice and encouragement only to those smokers perceived to be in the preparation and action stages.

A randomised controlled trial of proactive telephone counselling on cold-called smokers' cessation rates

Objectives

Active telephone recruitment (‘cold calling’) can enrol almost 45 times more smokers to cessation services than media. However, the effectiveness of proactive telephone counselling with cold-called smokers from the broader community is unknown. This study examined whether proactive telephone counselling improved abstinence, quit attempts and reduced cigarette consumption among cold-called smokers.

Methods

From 48 014 randomly selected electronic telephone directory numbers, 3008 eligible smokers were identified and 1562 (51.9%) smokers recruited into the randomised controlled trial. Of these, 769 smokers were randomly allocated to proactive telephone counselling and 793 to the control (ie, mailed self-help) conditions. Six counselling calls were offered to intervention smokers willing to quit within a month and four to those not ready to quit. The 4-month, 7-month and 13-month follow-up interviews were completed by 1369 (87.6%), 1278 (81.8%) and 1245 (79.9%) participants, respectively.

Results

Proactive telephone counselling participants were significantly more likely than controls to achieve 7-day point prevalence abstinence at 4 months (13.8% vs 9.6%, p=0.005) and 7 months (14.3% vs 11.0%, p=0.02) but not at 13 months. There was a significant impact of telephone counselling on prolonged abstinence at 4 months (3.4% vs 1.8%, p=0.02) and at 7 months (2.2% vs 0.9%, p=0.02). At 4 months post recruitment, telephone counselling participants were significantly more likely than controls to have made a quit attempt (48.6% vs 42.9%, p=0.01) and reduced cigarette consumption (16.9% vs 9.0%, p=0.0002).

Conclusions

Proactive telephone counselling initially increased abstinence and quitting behaviours among cold-called smokers. Given its superior reach, quitlines should consider active telephone recruitment, provided relapse can be reduced.

Trial registration

Australian New Zealand Clinical Trial Registry; ACTRN012606000221550.

A meta-analysis of computer-tailored interventions for health behavior change

OBJECTIVE

Computer-tailored interventions have become increasingly common for facilitating improvement in behaviors related to chronic disease and health promotion. A sufficient number of outcome studies from these interventions are now available to facilitate the quantitative analysis of effect sizes, permitting moderator analyses that were not possible with previous systematic reviews.

METHOD

The present study employs meta-analytic techniques to assess the mean effect for 88 computer-tailored interventions published between 1988 and 2009 focusing on four health behaviors: smoking cessation, physical activity, eating a healthy diet, and receiving regular mammography screening. Effect sizes were calculated using Hedges g. Study, tailoring, and demographic moderators were examined by analyzing between-group variance and meta-regression.

RESULTS

Clinically and statistically significant overall effect sizes were found across each of the four behaviors. While effect sizes decreased after intervention completion, dynamically tailored interventions were found to have increased efficacy over time as compared with tailored interventions based on one assessment only. Study effects did not differ across communication channels nor decline when up to three behaviors were identified for intervention simultaneously.

CONCLUSION

This study demonstrates that computer-tailored interventions have the potential to improve health behaviors and suggests strategies that may lead to greater effectiveness of these techniques.

Motivating the unmotivated for health behavior change: a randomized trial of cessation induction for smokers

BACKGROUND

Many smokers remain unwilling or unable to make a quit attempt. For these smokers, novel strategies to induce quit attempts are necessary to achieve further reductions in smoking prevalence.

PURPOSE

This article describes the design and methods of an ongoing nationwide telephone-based clinical trial for cessation induction, the principal aim of which is to test the hypothesis that samples of nicotine replacement therapy (NRT), can induce quit attempts among smokers otherwise unmotivated to quit.

METHODS

Smokers are recruited proactively through online channels. A 'behavioral filter' is used to identify and separate motivated versus unmotivated smokers, the latter of whom (N = 750) are formally entered into the clinical trial. Participants are randomized to one of two treatment conditions designed to promote self-efficacy and motivation to quit: (1) practice quit attempt (PQA) or (2) PQA plus NRT sampling. The primary outcome measure tested over a 6-month follow-up is the incidence of additional quit attempts as well as hypothesized mediators of treatment effects.

RESULTS

This study details the challenges of identifying and treating smokers who are unmotivated to quit. Strengths include a novel treatment approach, tested among a group of proactively recruited smokers nationwide, with a unique method of identifying cessation-resistant smokers.

LIMITATIONS

The omission of a true control group, testing the effect of the PQA itself, is an inherent limitation to the study design. Online recruitment presents additional study challenges, all of which are discussed in detail.

CONCLUSIONS

The study has translational potential to guide both clinical and policy recommendations for cessation induction. Further, while the focus is on smoking, this trial may serve as an example to researchers and clinicians who focus on other health behaviors, and who themselves are challenged with motivating people who are unmotivated for change.

Predictors and moderators of outcome in different brief interventions for smoking cessation in general medical practice

OBJECTIVE

To explore demographic-, health-, and smoking-related predictors and moderators of outcome in smokers who participated in two different brief smoking cessation interventions.

METHODS

Data were acquired using a quasi-randomized controlled trial that tested the efficacy of computer-generated tailored letters and physician-delivered brief advice against assessment only. Daily smokers (n=1499) were recruited from 34 general medical practices. We used Generalized Estimating Equation analyses to investigate the relationship between 6-month prolonged smoking abstinence assessed at 12-, 18-, and 24-month follow-ups and potential predictors and moderators.

RESULTS

Female gender (OR=1.49, 95% CI=1.01-2.19), higher level of education (OR=1.82, 95% CI=1.18-2.82), intention to quit smoking (OR=1.66, 95% CI=1.16-2.38), and smoking cessation self-efficacy (OR=1.30, 95% CI=1.03-1.64) were positively, nicotine dependence (OR=0.84, 95% CI=0.76-0.94) and the presence of a smoking partner (OR=0.60, 95% CI=0.42-0.85) were negatively associated with smoking abstinence. Compared to assessment only, physician advice was less effective for people without an intention to quit smoking and for unemployed.

CONCLUSION

Smoking cessation interventions might be improved by tailoring them to demographic- and smoking-related variables which were identified as predictors in this study.

PRACTICE IMPLICATIONS

The results suggest that tailored letters are a more universally applicable brief intervention in general medical practice than physician advice.

Decision making in the transtheoretical model of behavior change

Decision making is an integral part of the transtheoretical model of behavior change. Stage of change represents a temporal dimension for behavior change and has been the key dimension for integrating principles and processes of change from across leading theories of psychotherapy and behavior change. The decision-making variables representing the pros and cons of changing have been found to have systematic relationships across the stages of change for 50 health-related behaviors. Implications of these patterns of relationships are discussed in the context of helping patients make more effective decisions to decrease health risk behaviors and increase health-enhancing behaviors.

Theory Testing Using Quantitative Predictions of Effect Size

Traditional Null Hypothesis Testing procedures are poorly adapted to theory testing. The methodology can mislead researchers in several ways, including: (a) a lack of power can result in an erroneous rejection of the theory; (b) the focus on directionality (ordinal tests) rather than more precise quantitative predictions limits the information gained; and (c) the misuse of probability values to indicate effect size. An alternative approach is proposed which involves employing the theory to generate explicit effect size predictions that are compared to the effect size estimates and related confidence intervals to test the theoretical predictions. This procedure is illustrated employing the Transtheoretical Model. Data from a sample (N = 3,967) of smokers from a large New England HMO system were used to test the model. There were a total of 15 predictions evaluated, each involving the relation between Stage of Change and one of the other 15 Transtheoretical Model variables. For each variable, omega-squared and the related confidence interval were calculated and compared to the predicted effect sizes. Eleven of the 15 predictions were confirmed, providing support for the theoretical model. Quantitative predictions represent a much more direct, informative, and strong test of a theory than the traditional test of significance.

Educator and participant perceptions and cost analysis of stage-tailored educational telephone calls

OBJECTIVE

To identify strengths and weaknesses of nutrition education via telephone calls as part of a larger stage-of-change tailored intervention with mailed materials.

DESIGN

Evaluative feedback was elicited from educators who placed the calls and respondents who received the calls.

SETTING

An internet and telephone survey of 10 states in the midwestern United States.

PARTICIPANTS

21 educators in 10 states reached via the internet and 50 young adults reached via telephone. VARIABLES MEASURED AND ANALYSIS: Rankings of intervention components, ratings of key aspects of educational calls, and cost data (as provided by a lead researcher in each state) were summarized via descriptive statistics. RESULTS, CONCLUSIONS, AND IMPLICATIONS: Educational calls used 6 to 17 minutes of preparation time, required 8 to 15 minutes of contact time, and had a mean estimated cost of $5.82 per call. Low-income young adults favored print materials over educational calls. However, the calls were reported to have positive effects on motivating participants to set goals. Educators who use educational telephone calls to reach young adults, a highly mobile target audience, may require a robust and flexible contact plan.