Exploring the "active ingredients" of an online smoking intervention: a randomized factorial trial

A Novel mHealth App for Smokers Living With HIV Who Are Ambivalent About Quitting Smoking: Formative Research and Randomized Feasibility Study

BACKGROUND

More people who smoke and are living with HIV now die from tobacco-related diseases than HIV itself. Most people are ambivalent about quitting smoking and want to quit someday but not yet. Scalable, effective interventions are needed to motivate and support smoking cessation among people ambivalent about quitting smoking (PAQS) who are living with HIV.

OBJECTIVE

This study aims to develop an app-based intervention for PAQS who are living with HIV and assess its feasibility, acceptability, and potential impact. Results of this study will inform plans for future research and development.

METHODS

In phase 1, PAQS living with HIV (n=8) participated in user-centered design interviews to inform the final intervention app design and recruitment plan for a subsequent randomized pilot study. In phase 2, PAQS living with HIV were randomized to either a standard care control app or a similar experimental app with additional content tailored for PAQS and those with HIV. Participants were followed for 3 months. Feasibility focused on recruitment, retention, and participants' willingness to install the app. The study was not powered for statistical significance. Indices of acceptability (satisfaction and use) and impact (smoking behavior change and treatment uptake) were assessed via automated data and self-report among those who installed and used the app (n=19).

RESULTS

Recruitment for both study phases was a challenge, particularly via web-based and social media platforms. Enrollment success was greater among people living with HIV recruited from a health care provider and research registry. Once enrolled, retention for the phase 2 randomized study was good; 74% (14/19) of the participants completed the 3-month follow-up. Phase 1 findings suggested that PAQS living with HIV were receptive to using an app-based intervention to help them decide whether, when, and how to stop smoking, despite not being ready to quit smoking. Phase 2 findings further supported this conclusion based on feedback from people who agreed to use an app, but group differences were observed. Indices of acceptability favored the experimental arm, including a descriptively higher mean number of sessions and utilization badges. Similarly, indices of potential impact were descriptively higher in the experimental arm (proportion reducing smoking, making a quit attempt, or calling free tobacco quitline). No participants in either arm quit smoking at the 3-month follow-up.

CONCLUSIONS

On the basis of this formative work, PAQS living with HIV may be receptive to using a mobile health-based app intervention to help them decide whether, when, or how to stop using tobacco. Indices of acceptability and impact indicate that additional research and development are warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05339659; https://clinicaltrials.gov/study/NCT05339659.

Feasibility, Acceptability, and Potential Impact of a Novel mHealth App for Smokers Ambivalent About Quitting: Randomized Pilot Study

BACKGROUND

Most smokers are ambivalent about quitting-they want to quit someday, but not now. Interventions are needed that can engage ambivalent smokers, build their motivation for quitting, and support future quit attempts. Mobile health (mHealth) apps offer a cost-effective platform for such interventions, but research is needed to inform their optimal design and assess their acceptability, feasibility, and potential effectiveness.

OBJECTIVE

This study aims to assess the feasibility, acceptability, and potential impact of a novel mHealth app for smokers who want to quit smoking someday but are ambivalent about quitting in the near term.

METHODS

We enrolled adults across the United States who smoked more than 10 cigarettes a day and were ambivalent about quitting (n=60). Participants were randomly assigned to 1 of 2 versions of the GEMS app: standard care (SC) versus enhanced care (EC). Both had a similar design and identical evidence-based, best-practice smoking cessation advice and resources, including the ability to earn free nicotine patches. EC also included a series of exercises called experiments designed to help ambivalent smokers clarify their goals, strengthen their motivation, and learn important behavioral skills for changing smoking behavior without making a commitment to quit. Outcomes were analyzed using automated app data and self-reported surveys at 1 and 3 months post enrollment.

RESULTS

Participants who installed the app (57/60, 95%) were largely female, White, socioeconomically disadvantaged, and highly nicotine dependent. As expected, key outcomes trended in favor of the EC group. Compared to SC users, EC participants had greater engagement (mean sessions 19.9 for EC vs 7.3 for SC). An intentional quit attempt was reported by 39.3% (11/28) of EC users and 37.9% (11/29) of SC users. Seven-day point prevalence smoking abstinence at the 3-month follow-up was reported by 14.7% (4/28) of EC users and 6.9% (2/29) of SC users. Among participants who earned a free trial of nicotine replacement therapy based on their app usage, 36.4% (8/22) of EC participants and 11.1% (2/18) of SC participants requested the treatment. A total of 17.9% (5/28) of EC and 3.4% (1/29) of SC participants used an in-app feature to access a free tobacco quitline. Other metrics were also promising. EC participants completed an average of 6.9 (SD 3.1) out of 9 experiments. Median helpfulness ratings for completed experiments ranged from 3 to 4 on a 5-point scale. Finally, satisfaction with both app versions was very good (mean 4.1 on a 5-point Likert scale) and 95.3% (41/43) of all respondents would recommend their app version to others.

CONCLUSIONS

Ambivalent smokers were receptive to the app-based intervention, but the EC version, which combined best-practice cessation advice with self-paced, experiential exercises, was associated with greater use and evidence of behavior change. Further development and evaluation of the EC program is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04560868; https://clinicaltrials.gov/ct2/show/NCT04560868.

One view of the next decade of research on behavioral and biobehavioral approaches to cancer prevention and control: intervention optimization

As a new decade begins, we propose that the time is right to reexamine current methods and procedures and look for opportunities to accelerate progress in cancer prevention and control. In this article we offer our view of the next decade of research on behavioral and biobehavioral interventions for cancer prevention and control. We begin by discussing and questioning several implicit conventions. We then briefly introduce an alternative research framework: the multiphase optimization strategy (MOST). MOST, a principled framework for intervention development, optimization, and evaluation, stresses not only intervention effectiveness, but also intervention affordability, scalability, and efficiency. We review some current limitations of MOST along with future directions for methodological work in this area, and suggest some changes in the scientific environment we believe would permit wider adoption of intervention optimization. We propose that wider adoption of intervention optimization would have a positive impact on development and successful implementation of interventions for cancer prevention and control and on intervention science more broadly, including accumulation of a coherent base of knowledge about what works and what does not; establishment of an empirical basis for adaptation of interventions to different settings with different levels and types of resources; and, in the long run, acceleration of progress from Stage 0 to Stage V in the National Institutes of Health Model of Stages of Intervention Development.

The preparation phase in the multiphase optimization strategy (MOST): a systematic review and introduction of a reporting checklist

Multicomponent behavioral interventions developed using the multiphase optimization strategy (MOST) framework offer important advantages over alternative intervention development models by focusing on outcomes within constraints relevant for effective dissemination. MOST consists of three phases: preparation, optimization, and evaluation. The preparation phase is critical to establishing the foundation for the optimization and evaluation phases; thus, detailed reporting is critical to enhancing rigor and reproducibility. A systematic review of published research using the MOST framework was conducted. A structured framework was used to describe and summarize the use of MOST terminology (i.e., preparation phase and optimization objective) and the presentation of preparation work, the conceptual model, and the optimization. Fifty-eight articles were reviewed and the majority focused on either describing the methodology or presenting results of an optimization trial (n = 38, 66%). Although almost all articles identified intervention components (96%), there was considerable variability in the degree to which authors fully described other elements of MOST. In particular, there was less consistency in use of MOST terminology. Reporting on the MOST preparation phase is varied, and there is a need for increased focus on explicit articulation of key design elements and rationale of the preparation phase. The proposed checklist for reporting MOST studies would significantly advance the use of this emerging methodology and improve implementation and dissemination of MOST. Accurate reporting is essential to reproducibility and rigor of scientific trials as it ensures future research fully understands not only the methodology, but the rationale for intervention and optimization decisions.

Barriers to Building More Effective Treatments: Negative Interactions Amongst Smoking Intervention Components

Meaningfully improved mental and behavioral health treatment is an unrealized dream. Across three factorial experiments, inferential tests in prior studies showed a pattern of negative interactions suggesting that better clinical outcomes are obtained when participants receive fewer rather than more intervention components. Further, relatively few significant main effects were found in these experiments. Modeling suggested that negative interactions amongst components may account for these patterns. This paper evaluates factors that may contribute to such declining benefit: increased attentional or effort burden; components that produce their effects via the same capacity limited mechanisms, making their effects subadditive; and a tipping point phenomenon in which those near a hypothesized "tipping point" for change will benefit markedly from weak intervention while those far from the tipping point will benefit little from even strong intervention. New research should explore factors that cause negative interactions amongst components and constrain the development of more effective treatments.

Smoking Treatment: A Report Card on Progress and Challenges

The impact of tobacco smoking treatment is determined by its reach into the smoking population and the effectiveness of its interventions. This review evaluates the reach and effectiveness of pharmacotherapy and psychosocial interventions for smoking. Historically, the reach of smoking treatment has been low, and therefore its impact has been limited, but new reach strategies such as digital interventions and health care system changes offer great promise. Pharmacotherapy tends to be more effective than psychosocial intervention when used clinically, and newer pharmacotherapy strategies hold great promise of further enhancing effectiveness. However, new approaches are needed to advance psychosocial interventions; progress has stagnated because research and dissemination efforts have focused too narrowly on skill training despite evidence that its core content may be inconsequential and the fact that its mechanisms are either unknown or inconsistent with supporting theory. Identifying effective psychosocial content and its mechanisms of action could greatly enhance the effectiveness of counseling, digital, and web interventions.

The association between frequency of e-cigarette use and long-term smoking cessation outcomes among treatment-seeking smokers receiving a behavioral intervention

INTRODUCTION

A growing body of literature suggests daily, but not non-daily, e-cigarette use is associated with greater odds of quitting combustible cigarettes in the general adult population. However, it is unknown if these findings generalize to treatment-seeking smokers who are receiving a behavioral intervention. Our primary aim was to examine whether frequency of e-cigarette use was associated with subsequent cessation among treatment-seeking smokers who are receiving a behavioral smoking cessation intervention.

METHODS

Participants (N = 2637) enrolled in a RCT of web-based smoking treatments reported their use of e-cigarettes at baseline, 3-, and 6-months. Three groups were created based on e-cigarette use: (1) non-users, (2) intermittent users, and (3) daily users. The primary outcome was complete-case, self-reported 30-day point prevalence abstinence at 12 months.

RESULTS

Compared to non-users, daily e-cigarette users were significantly less likely to be abstinent (21.39 % vs. 29.68 %; p = .006). Quit rates for intermittent users (24.56 %) were not significantly different from non-users (p = .092). Nicotine dependence moderated the results such that among smokers with low nicotine dependence, those who used e-cigarettes (intermittently or daily) were less likely to quit than non-users; these differences were not significant among those with high nicotine dependence. Post hoc analyses indicated that initiating daily e-cigarette use after baseline, but not daily e-cigarette use at baseline, was associated with lower odds of cessation.

CONCLUSIONS

Daily e-cig use may be associated with lower odds of quitting smoking among treatment-seeking smokers, particularly among those with lower nicotine dependence and who initiate daily use after beginning an intervention.

How to optimise public health interventions: a scoping review of guidance from optimisation process frameworks

Background

Optimisation processes have the potential to rapidly improve the impact of health interventions. Optimisation can be defined as a deliberate, iterative and data-driven process to improve a health intervention and/or its implementation to meet stakeholder-defined public health impacts within resource constraints. This study aimed to identify frameworks used to optimise the impact of health interventions and/or their implementation, and characterise the key concepts, steps or processes of identified frameworks.

Methods

A scoping review of MEDLINE, CINAL, PsycINFO, and ProQuest Nursing & Allied Health Source databases was undertaken. Two reviewers independently coded the key concepts, steps or processes involved in each frameworks, and identified if it was a framework aimed to optimise interventions or their implementation. Two review authors then identified the common steps across included frameworks.

Results

Twenty optimisation frameworks were identified. Eight frameworks were for optimising interventions, 11 for optimising implementation and one covered both intervention and implementation optimisation. The mean number of steps within the frameworks was six (range 3–9). Almost half (n = 8) could be classified as both linear and cyclic frameworks, indicating that some steps may occur multiple times in a single framework. Two meta-frameworks are proposed, one for intervention optimisation and one for implementation strategy optimisation. Steps for intervention optimisation are: Problem identification; Preparation; Theoretical/Literature base; Pilot/Feasibility testing; Optimisation; Evaluation; and Long-term implementation. Steps for implementation strategy optimisation are: Problem identification; Collaborate; Plan/design; Pilot; Do/change; Study/evaluate/check; Act; Sustain/endure; and Disseminate/extend.

Conclusions

This review provides a useful summary of the common steps followed to optimise a public health intervention or its implementation according to established frameworks. Further opportunities to study and/or validate such frameworks and their impact on improving outcomes exist.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09950-5.

Does the structure (tunneled vs. free-roam) and content (if-then plans vs. choosing strategies) of a brief online alcohol intervention effect engagement and effectiveness? A randomized controlled trial

Despite the potential of brief online interventions for reducing alcohol consumption, their effectiveness may be compromised by low levels of engagement and the inclusion of ineffective behavior change techniques. To test whether (i) a tunneled version of an intervention (where the content is delivered in a prespecified order) leads to greater engagement and greater reductions in alcohol consumption than a free-roam version (where the content can be viewed in any order) and (ii) forming if-then plans linking strategies to cut down with high-risk situations leads to greater reductions in alcohol consumption than only choosing strategies to cut down. Participants (N = 286 university staff and students) were randomly allocated to one of four versions of a brief online alcohol intervention in a 2 (structure: tunneled vs. free-roam) by 2 (planning: strategies vs. if-then plans) factorial design. Engagement (pages visited, time) was recorded automatically. Alcohol consumption (weekly units) was assessed at baseline and 1- and 6-month follow-up. Participants who received the tunneled version viewed significantly more pages and spent significantly more time on the website than those who received the free-roam version. Significant reductions in alcohol consumption were observed at follow-up; however, neither the structure of the intervention nor planning had a significant effect on reductions in alcohol consumption. Tunneled online interventions can increase engagement, but this may not translate into greater changes in behavior. Further experimental research using factorial designs is needed to identify the key behavior change techniques to include in brief online interventions.

Development of a Mobile Health Intervention with Personal Experiments for Smokers Who Are Ambivalent About Quitting: Formative Design and Testing

Background

The majority of cigarette smokers want to quit someday but are not ready to commit to long-term abstinence. However, available smoking cessation treatments are not well-suited to meet the needs of these ambivalent smokers. Low-cost, high-reach mobile health (mHealth) interventions may be a cost-efficient means of offering assistance to ambivalent smokers, yet there are currently no evidence-based options available for this group.

Objective

The aim of this study was to develop and preliminarily evaluate the core content for an mHealth program targeting adult smokers who are ambivalent about quitting. The core content consisted of a series of “personal experiments” similar to those tested as part of a counseling intervention in prior work, including brief cognitive or behavioral tasks designed to boost readiness for changing smoking behavior.

Methods

We conducted individual user interviews (N=3) to refine program content, and then conducted a one-arm pilot study (N=25) to assess user receptivity and the potential impact of the experiments on motivation and self-efficacy to quit or reduce smoking.

Results

In user interviews, participants liked the concept of the personal experiments. Participants in the pilot study found a medium-fidelity prototype to be highly acceptable. After watching a brief orientation video that explained how the program works, most participants (80%, 20/25) indicated that it sounded interesting, primarily because it did not require any commitment to quit. All participants (100%, 25/25) completed all 7 experiments, including a 24-hour quit attempt, although not all were able to refrain from smoking for a full day based on qualitative feedback on the experiment. The mean rating of usefulness of the overall program was 4.12 (SD 1.09) out of 5, and the average rating of the difficulty of the experiments was 2.16 (SD 1.18) out of 5. At the last assessment point, 92% (23/25) of the participants indicated that they were more interested in either quitting or cutting back than when they began the program, and 72% (18/25) said that if the program had included a free trial of nicotine replacement therapy, they would have used it to try to quit smoking.

Conclusions

This formative work confirmed that ambivalent smokers are willing to use and will remain engaged with an mHealth intervention that employs the novel concept of personal experiments to enhance their motivation for and ability to quit smoking. The addition of action-oriented treatment (self-help and free nicotine replacement therapy, quitline referral) could further support users’ efforts to stop smoking and remain quit.

Optimizing Text Messages to Promote Engagement With Internet Smoking Cessation Treatment: Results From a Factorial Screening Experiment

BACKGROUND

Smoking remains a leading cause of preventable death and illness. Internet interventions for smoking cessation have the potential to significantly impact public health, given their broad reach and proven effectiveness. Given the dose-response association between engagement and behavior change, identifying strategies to promote engagement is a priority across digital health interventions. Text messaging is a proven smoking cessation treatment modality and a powerful strategy to increase intervention engagement in other areas of health, but it has not been tested as an engagement strategy for a digital cessation intervention.

OBJECTIVE

This study examined the impact of 4 experimental text message design factors on adult smokers' engagement with an internet smoking cessation program.

METHODS

We conducted a 2×2×2×2 full factorial screening experiment wherein 864 participants were randomized to 1 of 16 experimental conditions after registering with a free internet smoking cessation program and enrolling in its automated text message program. Experimental factors were personalization (on/off), integration between the web and text message platforms (on/off), dynamic tailoring of intervention content based on user engagement (on/off), and message intensity (tapered vs abrupt drop-off). Primary outcomes were 3-month measures of engagement (ie, page views, time on site, and return visits to the website) as well as use of 6 interactive features of the internet program. All metrics were automatically tracked; there were no missing data.

RESULTS

Main effects were detected for integration and dynamic tailoring. Integration significantly increased interactive feature use by participants, whereas dynamic tailoring increased the number of features used and page views. No main effects were found for message intensity or personalization alone, although several synergistic interactions with other experimental features were observed. Synergistic effects, when all experimental factors were active, resulted in the highest rates of interactive feature use and the greatest proportion of participants at high levels of engagement. Measured in terms of standardized mean differences (SMDs), effects on interactive feature use were highest for Build Support System (SMD 0.56; 95% CI 0.27 to 0.81), Choose Quit Smoking Aid (SMD 0.38; 95% CI 0.10 to 0.66), and Track Smoking Triggers (SMD 0.33; 95% CI 0.05 to 0.61). Among the engagement metrics, the largest effects were on overall feature utilization (SMD 0.33; 95% CI 0.06 to 0.59) and time on site (SMD 0.29; 95% CI 0.01 to 0.57). As no SMD >0.30 was observed for main effects on any outcome, results suggest that for some outcomes, the combined intervention was stronger than individual factors alone.

CONCLUSIONS

This factorial experiment demonstrates the effectiveness of text messaging as a strategy to increase engagement with an internet smoking cessation intervention, resulting in greater overall intervention dose and greater exposure to the core components of tobacco dependence treatment that can promote abstinence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02585206; https://clinicaltrials.gov/ct2/show/NCT02585206.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2015-010687.

Improving Adherence to Smoking Cessation Treatment: Smoking Outcomes in a Web-based Randomized Trial

Background

Partial adherence in Internet smoking cessation interventions presents treatment and evaluation challenges. Increasing adherence may improve outcomes.

Purpose

To present smoking outcomes from an Internet randomized trial of two strategies to encourage adherence to tobacco dependence treatment components: (i) a social network (SN) strategy to integrate smokers into an online community and (ii) free nicotine replacement therapy (NRT). In addition to intent-to-treat analyses, we used novel statistical methods to distinguish the impact of treatment assignment from treatment utilization.

Methods

A total of 5,290 current smokers on a cessation website (WEB) were randomized to WEB, WEB + SN, WEB + NRT, or WEB + SN + NRT. The main outcome was 30-day point prevalence abstinence at 3 and 9 months post-randomization. Adherence measures included self-reported medication use (meds), and website metrics of skills training (sk) and community use (comm). Inverse Probability of Retention Weighting and Inverse Probability of Treatment Weighting jointly addressed dropout and treatment selection. Propensity weights were used to calculate Average Treatment effects on the Treated.

Results

Treatment assignment analyses showed no effects on abstinence for either adherence strategy. Abstinence rates were 25.7%-32.2% among participants that used all three treatment components (sk+comm +meds).Treatment utilization analyses revealed that among such participants, sk+comm+meds yielded large percentage point increases in 3-month abstinence rates over sk alone across arms: WEB = 20.6 (95% CI = 10.8, 30.4), WEB + SN = 19.2 (95% CI = 11.1, 27.3), WEB + NRT = 13.1 (95% CI = 4.1, 22.0), and WEB + SN + NRT = 20.0 (95% CI = 12.2, 27.7).

Conclusions

Novel propensity weighting approaches can serve as a model for establishing efficacy of Internet interventions and yield important insights about mechanisms.

Clinical Trials.gov

NCT01544153.

Measuring Acceptability and Engagement of The Keep It Up! Internet-Based HIV Prevention Randomized Controlled Trial for Young Men Who Have Sex With Men

HIV disproportionately impacts young men of color who have sex with men. Keep It Up! (KIU!) is an online intervention that addresses the needs of this population. The study objective was to examine intervention acceptability and engagement. Outcomes of interests were qualitative and quantitative acceptability and engagement measures, content ratings, and paradata. On average, participants rated content (4 out of 5 stars) and acceptability (3.5 out of 4) highly. Compared to White participants, Black participants found KIU! more useful, engaging, and acceptable; Latino participants found KIU! more engaging; and other non-White participants found KIU! more engaging and acceptable. Participants with high school or less education found KIU! more useful, engaging, acceptable, and deserving of five stars than college graduates (p values = .047, <.001, .002, .01) and graduate degree holders (p values = .04, .001, <.001, .004). KIU! is a promising prevention tool for highest risk populations.

Collecting outcome data of a text messaging smoking cessation intervention with in-program text assessments: How reliable are the results?

BACKGROUND

Text messaging interventions have shown promise in helping people quit smoking. Texting programs periodically survey participants about their smoking status. This study examined the consistency of participant self-reported smoking between external surveys and internal program text message assessments.

METHODS

Participants in Text2Quit program were surveyed about their past 7-day smoking at one, three, and six months post-enrollment using different survey modes (external surveys and internal program text message assessments) and responses were compared for consistency. The first set of analyses was conducted for participants responding on both modes (n = 45 at one month; n = 50 at three months; n = 42 at six months). Additional analyses, assuming missing = smoking, were conducted with the full sample of 262 smokers (68.7% female, mean age = 35.8 years) and compared to saliva-confirmed abstinence rates.

RESULTS

Participants responding to both modes consistently reported smoking status at one (88.9%), three (88.0%) and six (88.1%) months post-enrollment, with fair to substantial levels of agreement (one month: κ = 0.24; three months: κ = 0.63; six months: κ = 0.66). Participants responding to both modes reported high rates of abstinence. In missing = smoking analyses, significant differences in abstinence rates reported across modes were detected at each timepoint (one month: external = 30.5%, internal = 16.4%; three months: external = 33.2%, internal = 16.0%; six months: external = 31.7%, internal = 12.2%; all p < .001). Moderate levels of agreement were found between the two modes. At 6 months, abstinence rates obtained via internal data were closer to those biochemically verified (15.7%) compared to external surveys.

CONCLUSIONS

Results provide initial support for the use of internal program assessments in text messaging programs with missing = smoking assumptions in order to gather outcome data on smoking behavior.

A Randomized Controlled Trial of an Optimized Smoking Treatment Delivered in Primary Care

Background

The effectiveness of smoking cessation treatment is limited in real-world use, perhaps because we have not selected the components of such treatments optimally nor have treatments typically been developed for and evaluated in real-world clinical settings.

Purpose

To validate an optimized smoking cessation treatment package that comprises intervention components identified as effective in factorial screening experiments conducted as per the Multiphase Optimization Strategy (MOST).

Methods

Adult smokers motivated to quit were recruited from primary care clinics (N = 623). Participants were randomized to receive either recommended usual care (R-UC; 10 min of in-person counseling, 8 weeks of nicotine patch, and referral to quitline services) or abstinence-optimized treatment (A-OT; 3 weeks of prequit mini-lozenges, 26 weeks of nicotine patch + mini-lozenges, three in-person and eight phone counseling sessions, and 7-11 automated calls to prompt medication use). The key outcomes were self-reported and biochemically confirmed (carbon monoxide, CO <6 ppm) 7-day point-prevalence abstinence.

Results

A-OT participants had significantly higher self-reported abstinence rates than R-UC participants at 4, 8, 16, and 26 weeks (ORs: 1.91-3.05; p <. 001). The biochemically confirmed 26-week abstinence rates were lower than the self-reported 26-week rates, but revealed a similar treatment effect size (OR = 2.94, p < .001). There was no moderation of treatment effects on 26-week abstinence by demographic, psychiatric, or nicotine dependence variables. A-OT had an incremental cost-effectiveness ratio for 26-week CO-confirmed abstinence of $7,800.

Conclusions

A smoking cessation treatment that is optimized via MOST development meaningfully enhances cessation rates beyond R-UC smoking treatment in smokers seen in primary care.

Clinical Trial Registration

NCT02301403.

A Multimedia Support Skills Intervention for Female Partners of Male Smokeless Tobacco Users: Use and Perceived Acceptability

Background

UCare is a new multimedia (website+booklet) intervention for women who want their male partner to quit their use of smokeless tobacco. The intervention is based on research showing that perceived partner responsiveness to social support is highest when the supporter conveys respect, understanding, and caring in their actions. The website included both didactic and interactive features, with optional video components, and special activities to help women develop empathy for nicotine addiction. The booklet reinforced the website content, encouraged women to use the website, and served both as a physical reminder of the intervention and a convenient way to share the information with her partner.

Objective

The objective of this study was to describe the utilization and acceptability of a multimedia intervention among women seeking to support their partner in quitting smokeless tobacco. Lessons learned with respect to design considerations for online interventions are also summarized.

Methods

We present the evaluation of the intervention components' use and usefulness in a randomized trial.

Results

In the randomized clinical trial, more than 250,000 visits were made to the website in a 2-year period, with the vast majority from mobile devices. Of the 552 women randomized to receive the intervention, 96.9% (535/552) visited the website at least once, and 30.8% (170/552) completed the core website component, "The Basics." About half of the women (287/552) used the interactive "Take Notes" feature, and 37% (204/552) used the checklists. Few women used the post-Basics features. At 6 weeks, 40.7% (116/285) reported reading the printed and mailed booklet. Website and booklet use were uncorrelated. User ratings for the website and booklet were positive overall.

Conclusions

Intervention website designers should consider that many users will access the program only once or twice, and many will not complete it. It is also important to distinguish between core and supplemental features and to consider whether the primary purpose is training or support. Furthermore, printed materials still have value.

Trial Registration

ClinicalTrials.gov NCT01885221; https://clinicaltrials.gov/ct2/show/NCT01885221 (Archived by WebCite at http://www.webcitation.org/6zdIgGGtx).

Customized recommendations and reminder text messages for automated, computer-based treatment during methadone

The Recovery Line is an automated, computer-based intervention based on cognitive behavioral therapy (CBT) designed to provide real-time assistance by phone for patients in methadone maintenance. Preliminary efficacy findings were promising, however, as with other computer-based systems for substance use disorder, patient system use was less than recommended. Development and evaluation of system functions to increase patient engagement and use is needed. Thus, we conducted two randomized trials to evaluate system functions designed to increase patient use of the Recovery Line among methadone-maintained patients with continued illicit drug use. In Trial 1 (n = 60), patients received customized, system use recommendations or no recommendations on each Recovery Line call. Ratings of system usability were higher for customized recommendations (CR), but number of calls and total call time did not differ by condition. Trial 2 evaluated characteristics of reminder messages (message frame and reminder latency). Participants (N = 67) received gain- and loss-frame reminder messages, and were randomly assigned to immediate, short, or long term message latency. Although message framing had no effect, gender interacted with latency condition such that females did not differ by message latency, while males had significantly greater total contact time in the short latency conditions. Number of calls differed by condition over time such that the shorter latencies led to greater calls initially, but dissipated over time. Overall the study indicates that computer-based self-management systems can be adapted to increase patient engagement and use. (PsycINFO Database Record

The effect of programme testimonials on registrations for an online cognitive behaviour therapy intervention: a randomised trial

Objective

Suboptimal visit-to-registration rates limit the reach and potential impact of online health interventions. In this study, we examined whether testimonials presented during a new-user registration process could increase the uptake rates of MoodGYM, an open-access automated intervention designed to reduce the symptoms of depression.

Methods

We conducted a three-armed parallel randomised controlled trial on the MoodGYM website involving variations of the first page of the registration process. Spontaneous visitors saw either the current pre-registration content, the current content supplemented by a first-person past user testimonial or the current content accompanied by a testimonial from a third-party health professional. The primary outcome measure was the proportion of visitors seeing each version who completed registration.

Results

A total of 14,267 visits were recorded across the three conditions. The past user, health professional and control condition registration rates were 45.6%, 45.5% and 45.5% respectively, indicating that there was no effect of registration content on registration rate. (p > 0.05)

Conclusions

There may be limited use for testimonials in well-established interventions that have programme benefits clearly stated and presented in other forms. However, we cannot exclude the possibility that testimonial effects might be moderated by positioning or other elements within the registration flow or by visitor source. Further research is required to examine these factors and, more broadly, assess whether modifications to other aspects of the registration process can improve visit-to-registration rates.

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.

A prospective examination of online social network dynamics and smoking cessation

Introduction

Use of online social networks for smoking cessation has been associated with abstinence. Little is known about the mechanisms through which the formation of social ties in an online network may influence smoking behavior. Using dynamic social network analysis, we investigated how temporal changes of an individual’s number of social network ties are prospectively related to abstinence in an online social network for cessation. In a network where quitting is normative and is the focus of communications among members, we predicted that an increasing number of ties would be positively associated with abstinence.

Method

Participants were N = 2,657 adult smokers recruited to a randomized cessation treatment trial following enrollment on BecomeAnEX.org, a longstanding Internet cessation program with a large and mature online social network. At 3-months post-randomization, 30-day point prevalence abstinence was assessed and website engagement metrics were extracted. The social network was constructed with clickstream data to capture the flow of information among members. Two network centrality metrics were calculated at weekly intervals over 3 months: 1) in-degree, defined as the number of members whose posts a participant read; and 2) out-degree-aware, defined as the number of members who read a participant’s post and commented, which was subsequently viewed by the participant. Three groups of users were identified based on social network engagement patterns: non-users (N = 1,362), passive users (N = 812), and active users (N = 483). Logistic regression modeled 3-month abstinence by group as a function of baseline variables, website utilization, and network centrality metrics.

Results

Abstinence rates varied by group (non-users = 7.7%, passive users = 10.7%, active users = 20.7%). Significant baseline predictors of abstinence were age, nicotine dependence, confidence to quit, and smoking temptations in social situations among passive users (ps < .05); age and confidence to quit among active users. Among centrality metrics, positive associations with abstinence were observed for in-degree increases from Week 2 to Week 12 among passive and active users, and for out-degree-aware increases from Week 2 to Week 12 among active users (ps < .05).

Conclusions

This study is the first to demonstrate that increased tie formation among members of an online social network for smoking cessation is prospectively associated with abstinence. It also highlights the value of using individuals’ activities in online social networks to predict their offline health behaviors.

Linking smokers to a quitline: randomized controlled effectiveness trial of a support person intervention that targets non-smokers

Evidence-based treatments (e.g. quitlines) are greatly underutilized by smokers limiting their public health impact. A three-session phone intervention for nonsmoking family members and friends (i.e. support persons) was successful for increasing smoker quitline enrollment. To enhance the intervention's potential translatability, in this study, we delivered treatment for the non-smoker within ongoing quitline services and compared the efficacy of the three-call intervention to a streamlined version (one call). A total of 704 adult non-smokers (85% female, 95% White) wanting to help a smoker quit and recruited statewide in Minnesota participated in this randomized controlled trial with parallel groups. Non-smokers received mailed written materials and were randomly assigned to a control condition (no additional treatment, n = 235), or to a one- (n = 233) or three-call (n = 236) intervention delivered by quitline coaches. The main outcome was smoker quitline enrollment through 7-month follow-up. Smoker quitline enrollment was similar for those linked to non-smokers in the one- and three-call interventions (14.6% [34/233] and 14.8% [35/236]), and higher than for smokers linked to control participants (6.4% [15/235]), P = 0.006. Just one quitline coaching call delivered to non-smokers increased treatment enrollment among smokers. The reach of quitlines could be enhanced by targeting the social support network of smokers.

Targeting hardcore smokers: The effects of an online tailored intervention, based on motivational interviewing techniques

OBJECTIVES

Hardcore smokers have smoked for many years and do not intend to quit. They also seem unreceptive to information about smoking cessation. We developed a 30-min, tailored web-based intervention that includes motivational interviewing principles. It aims to increase hardcore smokers' intention to quit and their receptivity to information about smoking cessation.

DESIGN

In a two-arm experiment, we compared outcome scores of the experimental intervention (n = 346) with those of a control intervention (n = 411).

METHODS

Our main outcomes were receptivity to information about quitting, intention to quit, quitting self-efficacy, and interest in a subsequent online intervention. Our secondary outcomes were cigarettes smoked per day and quit attempts. All outcomes were measured directly post-experiment (t₁ ), after 2 weeks (t₂ ), and after 2 months (t₃ ).

RESULTS

At t₁ , hardcore smokers in the intervention condition were more receptive to information about quitting than controls. At both t₂ and t₃ , those in the experimental group had reduced the number of cigarettes more than those in the control group. At t₂ , but not t₃ , more participants in the experimental group had reduced their cigarette consumption by at least 50% than among controls. We found no significant differences in intention to quit, quitting self-efficacy, interest in a subsequent online quitting intervention, and number of quit attempts.

CONCLUSIONS

The intervention increased hardcore smokers' receptivity to information about smoking cessation and decreased their cigarette consumption by about 1 cigarette per day. Although the results are positive, the clinical relevance may be limited. We recommend further developing this intervention for practical use in health care settings. Statement of contribution What is already known on this subject? Hardcore smokers have smoked for many years and do not intend to quit. There are currently no online interventions for hardcore smokers. What does this study add? This study tested an online intervention for hardcore smokers. The intervention increased hardcore smokers' receptivity to information about quitting. It also helped to reduce the number of cigarettes per day.

Implementing Clinical Research Using Factorial Designs: A Primer

Factorial experiments have rarely been used in the development or evaluation of clinical interventions. However, factorial designs offer advantages over randomized controlled trial designs, the latter being much more frequently used in such research. Factorial designs are highly efficient (permitting evaluation of multiple intervention components with good statistical power) and present the opportunity to detect interactions amongst intervention components. Such advantages have led methodologists to advocate for the greater use of factorial designs in research on clinical interventions (Collins, Dziak, & Li, 2009). However, researchers considering the use of such designs in clinical research face a series of choices that have consequential implications for the interpretability and value of the experimental results. These choices include: whether to use a factorial design, selection of the number and type of factors to include, how to address the compatibility of the different factors included, whether and how to avoid confounds between the type and number of interventions a participant receives, and how to interpret interactions. The use of factorial designs in clinical intervention research poses choices that differ from those typically considered in randomized clinical trial designs. However, the great information yield of the former encourages clinical researchers' increased and careful execution of such designs.

Treatment seeking as a mechanism of change in a randomized controlled trial of a mobile health intervention to support recovery from alcohol use disorders

BACKGROUND

We estimated the efficacy of the Addiction-Comprehensive Health Enhancement Support System (A-CHESS) in increasing the use of services for addiction and examined the extent to which this use of services mediated the effects of A-CHESS on risky drinking days and abstinence from drinking.

METHODS

We conducted secondary data analyses of the A-CHESS randomized controlled trial. Recruitment occurred in five residential treatment programs operated by two addiction treatment organizations. Participants were 349 adults with alcohol use disorders recruited two weeks before discharge from residential treatment. We provided intervention arm participants with a smartphone, the A-CHESS application, and an 8-month service plan. Control arm participants received treatment as usual. Telephone interviews at 4, 8, and 12-month follow-ups assessed past-month risky drinking days, past-month abstinence, and post-discharge service utilization (past-month outpatient addiction treatment and past-week mutual help including Alcoholics Anonymous and Narcotics Anonymous). Using mixed effects latent variable models, we estimated the indirect effects of A-CHESS on drinking outcomes, as mediated by post-discharge service utilization.

RESULTS

Approximately 50.5% of participants reported outpatient addiction treatment and 75.5% reported mutual help at any follow-up interview in the year following randomization. Assignment to the A-CHESS intervention was associated with an increased odds of outpatient addiction treatment across follow-ups, but not mutual help. This use of outpatient addiction treatment mediated the effect of A-CHESS on risky drinking days, but not abstinence. The effect of A-CHESS through outpatient addiction treatment appeared to reduce the expected number of risky drinking days across follow-ups by 11%.

CONCLUSIONS

The mobile health (mHealth) intervention promoted the use of outpatient addiction treatment, which appeared to contribute to its efficacy in reducing risky drinking. Future research should investigate how mHealth interventions could link patients to needed treatment services and promote the sustained use of these services.

Design Considerations for mHealth Programs Targeting Smokers Not Yet Ready to Quit: Results of a Sequential Mixed-Methods Study

Background

Mobile health (mHealth) smoking cessation programs are typically designed for smokers who are ready to quit smoking. In contrast, most smokers want to quit someday but are not yet ready to quit. If mHealth apps were designed for these smokers, they could potentially encourage and assist more people to quit smoking. No prior studies have specifically examined the design considerations of mHealth apps targeting smokers who are not yet ready to quit.

Objective

To inform the user-centered design of mHealth apps for smokers who were not yet ready to quit by assessing (1) whether these smokers were interested in using mHealth tools to change their smoking behavior; (2) their preferred features, functionality, and content of mHealth programs addressing smoking; and (3) considerations for marketing or distributing these programs to promote their uptake.

Methods

We conducted a sequential exploratory, mixed-methods study. Qualitative interviews (phase 1, n=15) were completed with a demographically diverse group of smokers who were smartphone owners and wanted to quit smoking someday, but not yet. Findings informed a Web-based survey of smokers from across the United States (phase 2, n=116). Data were collected from April to September, 2016.

Results

Findings confirmed that although smokers not yet ready to quit are not actively seeking treatment or using cessation apps, most would be interested in using these programs to help them reduce or change their smoking behavior. Among phase 2 survey respondents, the app features, functions, and content rated most highly were (1) security of personal information; (2) the ability to track smoking, spending, and savings; (3) content that adaptively changes with one’s needs; (4) the ability to request support as needed; (5) the ability to earn and redeem awards for program use; (6) guidance on how to quit smoking; and (7) content specifically addressing management of nicotine withdrawal, stress, depression, and anxiety. Results generally did not vary by stage of change for quitting smoking (precontemplation vs contemplation). The least popular feature was the ability to share progress via social media. Relevant to future marketing or distribution considerations, smokers were price-sensitive and valued empirically validated programs. Program source, expert recommendations, and user ratings were also important considerations.

Conclusions

Smokers who are not yet ready to quit represent an important target group for intervention. Study findings suggest that many of these individuals are receptive to using mHealth tools to reduce or quit smoking, despite not having made a commitment to quit yet. The preferences for specific mHealth intervention features, functionality, and content outlined in this paper can aid addiction treatment experts, design specialists, and software developers interested in creating engaging interventions for smokers who want to quit in the future but are not yet committed to this important health goal.

Improving Adherence to Smoking Cessation Treatment: Intervention Effects in a Web-Based Randomized Trial

BACKGROUND

Web-based smoking cessation interventions can deliver evidence-based treatments to a wide swath of the population, but effectiveness is often limited by insufficient adherence to proven treatment components. This study evaluated the impact of a social network (SN) intervention and free nicotine replacement therapy (NRT) on adherence to evidence-based components of smoking cessation treatment in the context of a Web-based intervention.

METHODS

A sample of adult U.S. smokers (N = 5290) was recruited via BecomeAnEX.org, a free smoking cessation Web site. Smokers were randomized to one of four arms: (1) an interactive, evidence-based smoking cessation Web site (WEB) alone; (2) WEB in conjunction with an SN intervention designed to integrate participants into the online community (WEB+SN); (3) WEB plus free NRT (WEB+NRT); and (4) the combination of all treatments (WEB+SN+NRT). Adherence outcomes assessed at 3-month follow-up were as follows: Web site utilization metrics, use of skills training components, intratreatment social support, and pharmacotherapy use.

RESULTS

WEB+SN+NRT outperformed all others on Web site utilization metrics, use of practical counseling tools, intratreatment social support, and NRT use. It was the only intervention to promote the sending of private messages and the viewing of community pages over WEB alone. Both social network arms outperformed WEB on most metrics of online community engagement. Both NRT arms showed higher medication use compared to WEB alone.

CONCLUSIONS

This study demonstrated the effectiveness of two approaches for improving adherence to evidence-based components of smoking cessation treatment. Integrated approaches to medication provision and social network engagement can enhance adherence to components known to improve cessation.

IMPLICATIONS

This study demonstrated that an integrated approach to medication provision and social network integration, when delivered through an online program, can enhance adherence across all three recommended components of an evidence-based smoking cessation program (skills training, social support, and pharmacotherapy use). Nicotine replacement therapy-when provided as part of an integrated program-increases adherence to other program elements, which in turn augment its own therapeutic effects. An explicit focus on approaches to improve treatment adherence is an important first step to identifying leverage points for optimizing intervention effectiveness.

Differential prevalence of established risk factors for poor cessation outcomes among smokers by level of social anxiety

BACKGROUND AND OBJECTIVES

Despite clear associations between social anxiety (SA), high prevalence of smoking, and cessation failure, little is known about factors contributing to these relationships. Moreover, the extent to which smokers with moderate SA represent an at-risk group of smokers is also unknown. This study examined the extent to which established risk factors for poor cessation (eg, sociodemographic, smoking history, mental health comorbidity) are prevalent among smokers with low, moderate, and high levels of SA.

METHODS

Participants (N = 2,637) were adult smokers from a web-based smoking cessation trial. Nineteen characteristics considered risk factors for poor cessation outcomes were assessed at baseline. Those associated with social anxiety were subsequently compared by SA level.

RESULTS

Regression models indicated that 10/19 risk factors were associated with SA. Compared to smokers with low SA, those with moderate and high SA endorsed 4/10 and 10/10 risk factors as more prevalent or severe, respectively. Compared to smokers with low SA, High SA was associated with greater sociodemographic risk factors, while both moderate and high SA was associated with more severe mental health symptoms.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Smokers with moderate and high levels of SA endorse more risk factors for poor cessation outcomes than those with low levels of SA, particularly mental health symptoms. These factors may help explain the differential smoking outcomes of socially anxious smokers. Results suggest that smokers with both moderate and high levels of SA would likely benefit from cessation interventions that address and consider these risk factors. (Am J Addict 2017;26:176-182).

Systematic review and meta-analysis of Internet interventions for smoking cessation among adults

BACKGROUND

The aim of this systematic review was to determine the effectiveness of Internet interventions in promoting smoking cessation among adult tobacco users relative to other forms of intervention recommended in treatment guidelines.

METHODS

This review followed Cochrane Collaboration guidelines for systematic reviews. Combinations of "Internet," "web-based," and "smoking cessation intervention" and related keywords were used in both automated and manual searches. We included randomized trials published from January 1990 through to April 2015. A modified version of the Cochrane risk of bias assessment tool was used. We calculated risk ratios (RRs) for each study. Meta-analysis was conducted using random-effects method to pool RRs. Presentation of results follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

Forty randomized trials involving 98,530 participants were included. Most trials had a low risk of bias in most domains. Pooled results comparing Internet interventions to assessment-only/waitlist control were significant (RR 1.60, 95% confidence interval [CI] 1.15-2.21, I (2)=51.7%; four studies). Pooled results of largely static Internet interventions compared to print materials were not significant (RR 0.83, 95% CI 0.63-1.10, I (2)=0%; two studies), whereas comparisons of interactive Internet interventions to print materials were significant (RR 2.10, 95% CI 1.25-3.52, I (2)=41.6%; two studies). No significant effects were observed in pooled results of Internet interventions compared to face-to-face counseling (RR 1.35, 95% CI 0.97-1.87, I (2)=0%; four studies) or to telephone counseling (RR 0.95, 95% CI 0.79-1.13, I (2)=0%; two studies). The majority of trials compared different Internet interventions; pooled results from 15 such trials (24 comparisons) found a significant effect in favor of experimental Internet interventions (RR 1.16, 95% CI 1.03-1.31, I (2)=76.7%).

CONCLUSION

Internet interventions are superior to other broad reach cessation interventions (ie, print materials), equivalent to other currently recommended treatment modes (telephone and in-person counseling), and they have an important role to play in the arsenal of tobacco-dependence treatments.

Online smoking cessation program for Korean Americans: Randomized trial to test effects of incentives for program completion and interim surveys

INTRODUCTION

Smoking is prevalent among Korean American men. Quitting is Winning, an Internet-based, cognitive-behavioral smoking cessation program, was developed using community-based participatory research principles.

METHODS

A randomized controlled trial was used to evaluate whether participants were more likely to complete the program and quit smoking at 6-months of follow-up with additional reinforcement. The main outcomes were the proportion of participants who completed the online program and the proportion who quit smoking for at least 30days, 26weeks after enrollment, among those randomized into the high-reinforcement (HR) condition compared with those in the low-reinforcement (LR) condition.

RESULTS

The study achieved a final enrollment of 403 participants including 56 women. Program completion was greater for the HR as compared to the LR condition (17% vs. 10%, p=.035). There was no significant difference in 30-day smoking cessation (intent-to-treat [ITT]) between the HR and LR conditions (9% vs. 8%, ns). Smoking cessation was greater among program completers as compared to those who did not complete the program (28% vs. 5%, p<.001).

CONCLUSIONS

The addition of interim surveys and financial incentives for interim survey completion and program completion significantly increased the likelihood of program completion. Moreover, program completers were significantly more likely to quit smoking. Although smoking cessation rates did not significantly differ between the HR and LR conditions, the results suggest that future studies should explore the efficacy of larger financial incentives for program completion (Clinical Trial #NCT02584127).

Technology-delivered adaptations of motivational interviewing for health-related behaviors: A systematic review of the current research

OBJECTIVES

The aims of this paper were to describe and evaluate the methods and efficacy of technology-delivered motivational interviewing interventions (TAMIs), discuss the challenges and opportunities of TAMIs, and provide a framework for future research.

METHODS

We reviewed studies that reported using motivational interviewing (MI) based components delivered via technology and conducted ratings on technology description, comprehensiveness of MI, and study methods.

RESULTS

The majority of studies were fully-automated and included at least one form of media rich technology to deliver the TAMI. Few studies provided complete descriptions of how MI components were delivered via technology. Of the studies that isolated the TAMI effects, positive changes were reported.

CONCLUSION

Researchers have used a range of technologies to deliver TAMIs suggesting feasibility of these methods. However, there are limited data regarding their efficacy, and strategies to deliver relational components remain a challenge. Future research should better characterize the components of TAMIs, empirically test the efficacy of TAMIs with randomized controlled trials, and incorporate fidelity measures.

PRACTICE IMPLICATIONS

TAMIs are feasible to implement and well accepted. These approaches offer considerable potential to reduce costs, minimize therapist and training burden, and expand the range of clients that may benefit from adaptations of MI.

Enhancing the effectiveness of smoking treatment research: conceptual bases and progress

BACKGROUND AND AIMS

A chronic care strategy could potentially enhance the reach and effectiveness of smoking treatment by providing effective interventions for all smokers, including those who are initially unwilling to quit. This paper describes the conceptual bases of a National Cancer Institute-funded research program designed to develop an optimized, comprehensive, chronic care smoking treatment.

METHODS

This research is grounded in three methodological approaches: (1) the Phase-Based Model, which guides the selection of intervention components to be experimentally evaluated for the different phases of smoking treatment (motivation, preparation, cessation, and maintenance); (2) the Multiphase Optimization Strategy (MOST), which guides the screening of intervention components via efficient experimental designs and, ultimately, the assembly of promising components into an optimized treatment package; and (3) pragmatic research methods, such as electronic health record recruitment, that facilitate the efficient translation of research findings into clinical practice. Using this foundation and working in primary care clinics, we conducted three factorial experiments (reported in three accompanying papers) to screen 15 motivation, preparation, cessation and maintenance phase intervention components for possible inclusion in a chronic care smoking treatment program.

RESULTS

This research identified intervention components with relatively strong evidence of effectiveness at particular phases of smoking treatment and it demonstrated the efficiency of the MOST approach in terms both of the number of intervention components tested and of the richness of the information yielded.

CONCLUSIONS

A new, synthesized research approach efficiently evaluates multiple intervention components to identify promising components for every phase of smoking treatment. Many intervention components interact with one another, supporting the use of factorial experiments in smoking treatment development.

Posting behaviour patterns in an online smoking cessation social network: implications for intervention design and development

Objectives

Online Cessation Support Networks (OCSNs) are associated with increased quit success rates, but few studies have examined their use over time. We identified usage patterns in New Zealand's largest OCSN over two years and explored implications for OCSN intervention design and evaluation.

Methods

We analysed metadata relating to 133,096 OCSN interactions during 2011 and 2012. Metrics covered aggregate network activity, user posting activity and longevity, and between-user commenting. Binary logistic regression models were estimated to investigate the feasibility of predicting low user engagement using early interaction data.

Results

Repeating periodic peaks and troughs in aggregate activity related not only to seasonality (e.g., New Year), but also to day of the week. Out of 2,062 unique users, 69 Highly Engaged Users (180+ interactions each) contributed 69% of all OCSN interactions in 2012 compared to 1.3% contributed by 864 Minimally Engaged Users (< = 2 items each). The proportion of Highly Engaged Users increased with network growth between 2011 and 2012 (with marginal significance), but the proportion of Minimally Engaged Users did not decline substantively. First week interaction data enabled identification of Minimally Engaged Users with high specificity and sensitivity (AUROC  = 0.94).

Implications

Results suggest future research should develop and test interventions that promote activity, and hence cessation support, amongst specific user groups or at key time points. For example, early usage information could help identify Minimally Engaged Users for tests of targeted messaging designed to improve their integration into, or re-engagement with, the OCSN. Furthermore, although we observed strong growth over time on varied metrics including posts and comments, this change did not coincide with large gains in first-time user persistence. Researchers assessing intervention effects should therefore examine multiple measures when evaluating changes in network dynamics over time.