Utilization of a Web-based vs integrated phone/Web cessation program among 140,000 tobacco users: an evaluation across 10 free state quitlines

Digital Smoking Cessation Intervention for Cancer Survivors: Analysis of Predictors and Moderators of Engagement and Outcome Alongside a Randomized Controlled Trial

BACKGROUND

Recent studies have shown positive, though small, clinical effects of digital smoking cessation (SC) interventions for cancer survivors. However, research on associations among participant characteristics, intervention engagement, and outcomes is limited.

OBJECTIVE

This study aimed to explore the predictors and moderators of engagement and outcome of MyCourse-Quit Smoking (in Dutch: "MijnKoers-Stoppen met Roken"), a digital minimally guided intervention for cancer survivors.

METHODS

A secondary analysis of data from the randomized controlled trial was performed. The number of cigarettes smoked in the past 7 days at 6-month follow-up was the primary outcome measure. We analyzed interactions among participant characteristics (11 variables), intervention engagement (3 variables), and outcome using robust linear (mixed) modeling.

RESULTS

In total, 165 participants were included in this study. Female participants accessed the intervention less often than male participants (B=-11.12; P=.004). A higher Alcohol Use Disorders Identification Test score at baseline was associated with a significantly higher number of logins (B=1.10; P<.001) and diary registrations (B=1.29; P<.001). A higher Fagerström Test for Nicotine Dependence score at baseline in the intervention group was associated with a significantly larger reduction in tobacco use after 6 months (B=-9.86; P=.002). No other associations and no moderating effects were found.

CONCLUSIONS

Overall, a limited number of associations was found between participant characteristics, engagement, and outcome, except for gender, problematic alcohol use, and nicotine dependence. Future studies are needed to shed light on how this knowledge can be used to improve the effects of digital SC programs for cancer survivors.

TRIAL REGISTRATION

Netherlands Trial register NTR6011/NL5434; https://onderzoekmetmensen.nl/nl/trial/22832.

Baseline characteristics and the factors influencing successful smoking cessation: A comparison between a WeChat smoking cessation mini-program and an offline smoking cessation clinic

INTRODUCTION

Smoking cessation (SC) clinics are a professional SC services in China. However, studies comparing the characteristics and SC rates of smoking populations in SC clinics with those using mobile SC programs are limited. We compared smokers' characteristics, 3-month SC rates, and the factors influencing 3-month SC success, between a large hospital SC clinic and a WeChat SC mini-program.

METHODS

Between January and November 2021, 384 participants voluntarily enrolled in either the hospital SC clinic (Group A: n=243) or the WeChat SC mini-program (Group B: n=141). Both groups underwent a 3-month SC intervention, and their SC status was monitored at 24 hours, 1 week, 1 month, and 3 months after quitting. SC rate was defined as the self-reported rate of continuous SC.

RESULTS

The 3-month SC rate was higher in Group A (42.4%) than in Group B (24.8%). Participants with middle school education had a lower likelihood of SC success than those with primary school or lower (p=0.014). Employees in the enterprise/business/services industries were more likely to have SC success than farmers (p=0.013). Participants with SC difficulty scores of 0-60 were more successful than those with scores >60 (p=0.001, p=0.000, respectively). Participants who quit smoking due to their illness, or other reasons, had a higher likelihood of SC success than those who quit due to concerns about their own and their family's health (p=0.006, p=0.098, respectively). While the likelihood of SC success was lower in those who quit because of the influence of their environment than in those who quit due to concerns about their own and their family's health (p=0.057).

CONCLUSIONS

Both SC clinics and WeChat SC mini-programs achieved satisfactory SC rates. The high accessibility of mobile SC platforms, which save time spent on transportation and medical visits, renders them worth promoting and publicizing as additional SC options for smokers, particularly young smokers.

Identifying adolescents' gaming preferences for a tobacco prevention social game: A qualitative study

INTRODUCTION

Considering the dangers of adolescent tobacco use, the successful design of behavioral programs is crucial for tobacco prevention. According to preliminary research, social game interventions can improve adolescent tobacco outcomes. The current qualitative study aims to (1) uncover the gaming elements that adolescents deem important for a positive learning experience, and (2) confirm these gaming elements with adolescents who are presented with a tobacco prevention game concept that applies these elements.

METHODS

Findings from this study are drawn from two phases. Phase 1 involved in-person focus group discussions (n = 15) and Phase 2 included three online focus groups and a paired interview with another set of adolescents (n = 15). The study was conducted under a project that aimed to design and test a social game-based tobacco prevention program for adolescents (Storm-Heroes). With open coding and thematic analysis, two research team members identified repeated topics and relevant quotes to organize them into themes. The themes evolved as new content was identified during the process. This process was repeated until thematic saturation was reached.

RESULTS

Thematic analysis across Phase 1 and Phase 2 revealed four major themes: 1) Balance during gaming challenges, 2) Healthy social interaction, 3) Performance and creative freedom, and 4) Fictional world and game mechanics for tobacco prevention.

CONCLUSION

This study identified specific intervention features that best fit the needs of adolescents in the context of a social game for tobacco prevention. For future research, we will use a participatory approach to allow adolescents to take part in the design process, improve Storm-Heroes, and develop health promotional messages that can be incorporated into the program. Ultimately, a board game for tobacco prevention is expected to bring adolescents together to create lasting memories that nudge them away from tobacco use and the harm it can cause.

Analysis of Demographic Characteristics of Users of a Free Tobacco Cessation Smartphone App: Observational Study

Background

Tobacco use continues to be the leading preventable cause of death, disease, and disability in the United States. Since 2000, Washington state has offered free tobacco “quitline” services to help its residents stop using tobacco. In 2015, the state began offering free access to a tobacco cessation smartphone app to absorb excess quitline demand. Since most publicly funded tobacco cessation programs are designed to provide access to populations disproportionately impacted by tobacco use, it is important to consider who these public health interventions reach.

Objective

The aim of this study is to understand who used a free cessation app and the extent to which users represented populations disproportionately impacted by tobacco use.

Methods

This is an observational study of 1280 adult Washington state residents who registered for and activated the cessation app. Demographic data were collected as part of the sign-up process, examined using standard descriptive measures, and assessed against state-level surveillance data for representativeness.

Results

Participants were primarily non-Hispanic White (978/1218, 80.3%), identified as female (780/1236, 63.1%), were between ages 25-54 years (903/1186, 76.1%), had at least some college education (836/1222, 68.4%), and reported a household income under US $50,000 (742/1055, 70.3%). Fewer respondents were from rural counties (359/1220, 29.4%); identified as lesbian, gay, bisexual, pansexual, queer, questioning, or asexual (LGBQA; 153/1222, 12.5%); were uninsured (147/1206, 12.2%); or were currently pregnant, planning pregnancy, or breastfeeding (42/624, 6.7%). However, relative to available state data for tobacco users, there was high representation of women, 35- to 54-year-olds, college graduates, and LGBQA individuals, as well as individuals with low household income, poor mental health, Medicaid insurance, and those residing in rural counties.

Conclusions

A diverse population of tobacco users will use a free cessation app, including some demographic groups disproportionately impacted by tobacco use. With high reach and high efficacy, it is possible to address health disparities associated with tobacco use and dependence treatment among certain underserved and at-risk groups.

Understanding health disparities affecting utilization of tobacco treatment in low-income patients in an urban health center in Southern California

Tobacco use disproportionately affects low-income communities. Prevalence among patients in Federally Qualified Health Centers (FQHCs) is higher (29.3%) than the general population (20%). Little is known about the rates of referrals to cessation services and cessation pharmacotherapy practices in FQHCs. This study will examine referral and prescribing patterns based on patient characteristics at a large FQHC in Southern California. We conducted a retrospective analysis of EHR data from 2019. Patients who were ≥ 18 years old and had "tobacco use" as an active problem were included in analyses. We characterized the proportion of 1) those who were referred to California Smokers' Helpline (CSH), 2) referred to smoking cessation counseling (SCC) at the FQHC clinic, or 3) received pharmacotherapy. Associations of demographic characteristics and comorbidities with referral types and uptake of services were evaluated using mixed-effects multinomial and logistic regressions. Of the 20,119 tobacco users identified, 87% had some cessation intervention: 66% were advised to quit and given information to contact CSH, while 21% were referred to SCC. Patients were least likely to get referred to cessation services if they had more medical, psychiatric, or substance use comorbidities, were in the lowest income group, were uninsured or were Hispanic. Although EHR systems have enhanced the ease of screening, most patients do not receive more than brief advice to quit during a PCP visit. Most (70%) low-income smokers see their PCPs at least once a year, making FQHCs excellent settings to promote smoking cessation initiatives in low-income populations.

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.

What Works Best to Engage Participants in Mobile App Interventions and e-Health: A Scoping Review

Background:

Despite the growing popularity of mobile app interventions, specific engagement components of mobile apps have not been well studied.

Methods:

The objectives of this scoping review are to determine which components of mobile health intervention apps encouraged or hindered engagement, and examine how studies measured engagement.

Results:

A PubMed search on March 5, 2020 yielded 239 articles that featured the terms engagement, mobile app/mobile health, and adult. After applying exclusion criteria, only 54 studies were included in the final analysis.

Discussion:

Common app components associated with increased engagement included: personalized content/feedback, data visualization, reminders/push notifications, educational information/material, logging/self-monitoring functions, and goal-setting features. On the other hand, social media integration, social forums, poor app navigation, and technical difficulties appeared to contribute to lower engagement rates or decreased usage. Notably, the review revealed a great variability in how engagement with mobile health apps is measured due to lack of established processes.

Conclusion:

There is a critical need for controlled studies to provide guidelines and standards to help facilitate engagement and its measurement in research and clinical trial work using mobile health intervention apps.

Impact of a novel oral health promotion program on routine oral hygiene among socioeconomically disadvantaged smokers: results from a randomized semi-pragmatic trial

Smokers are at high risk of oral disease and report sub-optimal oral hygiene. Improving smokers’ oral hygiene could reduce their future disease risk. The purpose of this study is to assess the effects of a novel, multi-modal oral health promotion program (Oral Health 4 Life; OH4L) targeted to socioeconomically disadvantaged smokers and delivered through state-funded tobacco quitlines. Smokers (n = 718) were randomized to standard quitline care or standard care plus OH4L. OH4L recipients received a comprehensive behavioral intervention and were advised of the benefits of routine oral hygiene, encouraged to brush and floss daily (for better oral health and to manage cigarette cravings), and provided a toothbrush and floss. Participants were followed for 6 months to assess the intervention effects on routine oral hygiene (brushing and flossing) and changes in motivation and self-efficacy. Data were collected between 2015 and 2017. At 2-month follow-up, OH4L participants were more likely to meet the American Dental Association (ADA) recommendations for brushing twice daily (adjusted RR = 1.15 [1.04, 1.27], p = .006), flossing daily (adjusted RR = 1.20 [1.03, 1.39], p = .02), and for both brushing and flossing (adjusted RR = 1.33 [1.10, 1.61], p = .003). Daily flossing was more likely at 6-month follow-up (adjusted RR = 1.21 [1.04, 1.42], p = .02) among OH4L participants. The change in self-efficacy and motivation for daily flossing from baseline to 2 months was significantly greater among OH4L participants and mediated the intervention effect on flossing at 6 months. Integrating oral hygiene promotion with standard tobacco quitline services improved oral health self-care.

CDC's Flu on Call Simulation: Testing a National Helpline for Use During an Influenza Pandemic

During an influenza pandemic, healthcare facilities are likely to be filled to capacity, leading to delays in seeing a provider and obtaining treatment. Flu on Call is a collaborative effort between the US Centers for Disease Control and Prevention and partners to develop a toll-free telephone helpline to reduce the burden on healthcare facilities and improve access to antivirals for people who are ill during an influenza pandemic. This study tested the feasibility of Flu on Call during a 1-day simulation using a severe pandemic scenario. Trained volunteer actors placed calls to the helpline using prepared scripts that were precoded for an expected outcome ("disposition") of the call. Scripts represented callers who were ill, those calling for someone else who was ill, and callers who were only seeking information. Information specialists and medical professionals managed the calls. Results demonstrated that Flu on Call may effectively assist callers during a pandemic, increase access to antiviral prescriptions, and direct patients to the appropriate level of care. Overall, 84% of calls exactly matched the expected call disposition; few calls (2%) were undermanaged (eg, the caller was ill but not transferred to a medical professional or received advice from the medical professional that was less intensive than what was warranted). Callers indicated a high level of satisfaction (83% reported their needs were met). Because of the high volume of calls that may be received during a severe pandemic, the Flu on Call platform should evolve to include additional triage channels (eg, through internet, chat, and/or text access).

Online Versus Telephone Registration: Differences in Quitline Participant Characteristics

INTRODUCTION

Although 72% of Internet users have searched for health information, online quitline registration is not universally available. In 2014, QUITPLAN Services (Minnesota's quitline) added options (Individual Services: 2-week nicotine-replacement therapy starter kit, text messaging, e-mail messaging, quit guide) to the existing Helpline (telephone counseling, nicotine-replacement therapy, integrated e-mails and texts, quit guide) and online registration for all programs. Demographic and quit outcome differences by registration mode (online versus telephone) and program type (Individual Services versus Helpline) were examined.

METHODS

A total of 4 years (March 2014-February 2018) of participants' registration and utilization data (N=55,817) were examined. Data were also studied from subsets of participants who completed the outcome evaluations conducted in 2014 (n=1,127) and 2017 (n=872). Select demographic and program use characteristics and quit outcomes were analyzed by registration method and stratified by program type. Associations between registration mode and quit outcomes were examined within program and adjusted for available covariates using 2017 outcome study data. Data were analyzed in 2019.

RESULTS

Overall, 65.8% of participants enrolled online, and 34.2% enrolled by telephone. Helpline participants were more likely to enroll by telephone than Individual Services participants (85.8% vs 25.3%). Younger adults were more likely to enroll online for either program type than older adults (p<0.001). No differences were found in 30-day point prevalence abstinence by registration mode within program after adjusting for covariates.

CONCLUSIONS

Online quitline registration has multiple benefits, including engaging younger tobacco users. Moreover, abstinence rates do not differ. Online registration may be particularly appropriate for nontelephone quitline services. Quitlines may wish to add online registration to capitalize on Internet use.

Vaping and E-Cigarettes Within the Evolving Tobacco Quitline Landscape

This article summarizes the vaping research literature as it pertains to tobacco quitlines and describes vaping assessment, treatment, and evaluation quitline practices. It also presents 2014-2018 registration data (vaping in the past 30 days, number of use days, use for quitting smoking, and intentions to quit vaping) from 24 public quitlines (23 states and District of Columbia) and 110,295 enrollees to employer-sponsored quitlines. Trends in vaping rates over time, by state, and by age group are described. Approximately 57,000 adult public quitline enrollees in the U.S. reported vaping at registration in 2018 (14.7% of enrollees). Most quitline participants who vape also smoke cigarettes and contact the quitline for smoking cessation support. Rates of reporting vaping and no combustible or smokeless tobacco use in the past 30 days are 0.5% of all public quitline participants (<3% of public quitline vaping product users). Data are not systematically available regarding the number of quitline participants who are seeking help quitting vaping and only vape (do not use combustible or smokeless tobacco). Few quitline participants (<1%) are youth aged <18 years, but more than a third (35%) report vaping. This paper outlines research and evaluation priorities to inform the future quitline treatment landscape with respect to vaping. The quitline community is positioned to increase the likelihood that vaping has a positive impact for adults who smoke through harm reduction or supporting cessation and has opportunities to expand impacts on youth and young adult vaping prevention and cessation.

Using Digital Technologies to Reach Tobacco Users Who Want to Quit: Evidence From the National Cancer Institute's Smokefree.gov Initiative

The rapid growth of smartphone ownership and broadband access has created new opportunities to reach smokers with cessation information and support using digital technologies. These technologies can both complement and be integrated with traditional support modalities such as telephone quitlines and 1-on-1 clinical cessation counseling. The National Cancer Institute's Smokefree.gov Initiative provides free, evidence-based cessation support to the public through a multimodal suite of digital interventions, including several mobile-optimized websites, text messaging programs, and 2 mobile applications. In addition to digital resources directed at the general population, the Smokefree.gov Initiative includes population-specific resources targeted to adolescents, women, military veterans, Spanish speakers, older adults, and other populations. This paper describes the reach and use of the Smokefree.gov Initiative's resources over a 5-year period between 2014 and 2018, including how users interact with the program's digital content in ways that facilitate engagement with live counseling support. Use of Smokefree.gov Initiative resources has grown steadily over time; in 2018 alone, approximately 7-8 million people accessed Smokefree.gov Initiative web- and mobile-based resources. Smokefree.gov Initiative utilization data show that people take advantage of the full range of technology tools and options offered as part of the Smokefree.gov Initiative's multiplatform intervention. The Smokefree.gov Initiative experience suggests that offering different, complementary technology options to meet the needs and preferences of smokers has the potential to meaningfully expand the reach of cessation treatment.

Feasibility of a Smartphone-Based Tobacco Treatment for HIV-Infected Smokers

BACKGROUND

Cigarette smoking is common among persons living with HIV (PLWH) in the United States. It is the leading cause of mortality in this group, and efforts to promote cessation have been largely unsuccessful.

METHODS

From 2015 to 2017, we performed a randomized controlled trial of Positively Smoke Free-Mobile (PSF-M) versus standard care. PSF-M is a mobile Web site that offers a 42-day text message-based quit-smoking program with smartphone features including quit-day selection/calendar, educational/motivational videos, and HELP button for cravings.

RESULTS

One hundred individuals enrolled, 48 were randomized to PSF-M (mean age = 45 years, 54% male, 81% black, 31% Latino) and 52 to the standard care condition. All participants were offered a 3-month supply of nicotine patches. Participants randomized to the mobile intervention visited the PSF-M home page a mean of 83 times, viewed 5.6/8 videos, logged in on 13 of 42 possible days, and received 131 texts. Among them, 77% tapped HELP for cravings, and craving response options were used by the following proportions: phone-a-friend, 58%; play-a-game, 29%; play-a-song, 4%. Older age and nonblack race were both associated with higher levels of engagement with the site. Of participants, 61% rated PSF-M very or extremely helpful, and 98% would recommend PSF-M to PLWH family or friends. Abstinence at 3 months, quit attempts, and daily cigarette intake all favored PSF-M over standard care but did not achieve statistical significance in our pilot sample.

CONCLUSIONS

Smartphone-based tobacco treatment for PLWH was feasible and achieved moderate-high rates of engagement and satisfaction in a middle-aged, ethnic or racial minority group in the poorest urban community in the United States.

IMPLICATIONS

Cigarette smoking has emerged as the leading killer of PLWH. Behavioral interventions have achieved only limited success in promoting cessation in this population. In this study, we explore the feasibility and preliminary efficacy of a multimodal, Web-based, quit-smoking intervention delivered to PLWH smokers via their smartphones.

Revealing users' experience and social interaction outcomes following a web-based smoking prevention intervention for adolescents: A qualitative study

BACKGROUND

Tobacco smoking remains a public health problem among adolescents in the United States. While Web-based interventions for smoking prevention have been successful at the individual level, there is still an urgent need to understand their engagement capabilities and their effects at the social level. In the current study, we aimed to (1) learn about adolescents' subjective experience with a Web-based program called a smoking prevention interactive experience (ASPIRE), (2) obtain suggestions for improvement in ASPIRE content, (3) identify psychological outcomes of ASPIRE, and (4) explore outcomes of social interaction.

MATERIALS AND METHODS

After a randomized controlled trial with 110 adolescents, 20 adolescent users of ASPIRE, aged 11-18, were randomly selected to participate in one-on-one interviews at four after-school programs in Houston, Texas. Interviews involved questions concerning adolescents' experience with the intervention. Qualitative data were coded and analyzed using a constant comparison approach for the generation of themes.

RESULTS

Describing their experience with ASPIRE, participants expressed comfort in material that is tailored to their demographic and preferred interactive activities over entertaining videos. Presenting suggestions for improvement, participants mainly reported the need to include gaming features into ASPIRE. Presenting psychological outcomes, they expressed emotional engagement in the program, shifts in attitudes and beliefs, and unwillingness to smoke. Finally, as outcomes of social interaction, participants reported engagement with others in discussions about tobacco and their need to hold smokers accountable for their actions.

CONCLUSIONS

Adolescents' reports moved from their individual experience with ASPIRE to their active interactions with family members and friends and their attempt to persuade others to quit smoking. Future Web-based programs for adolescents may be designed with tailoring and game play in mind, in order to provide mobilization skills and foster social interactions against smoking.

A cross sectional survey of internet use among a highly socially disadvantaged population of tobacco smokers

Background

Tobacco smoking is highest among population groups which are the most socially disadvantaged. Internet-based smoking cessation programs have been found to be effective, though rates of internet access are not well known in these groups. This study describes the rates of internet use and types of technology used to access the internet by a population of socially disadvantaged smokers. The study also examined relationships between sociodemographic and smoking behaviours with amount of internet use and type of device used.

Methods

A cross-sectional survey of 369 clients (response rate 77%) from two non-government community service organisations in metropolitan New South Wales, Australia was conducted using touchscreen computers. Descriptive statistics and logistic regressions were used to examine results.

Results

Eligible participants ranged from 19 to 88 years old current tobacco users. Over half (58%) of the participants reported weekly or more frequent use of the internet with less than a third (28%) not having any access. The odds of using the internet at least weekly decreased with age and as heaviness of smoking increased (OR = 0.94, p < 0.001; OR = 0.81, p = 0.022, respectively). Odds of internet use were higher as income increased (OR = 2.74, p < 0.001 for individuals earning $201–$400 per week; OR = 2.83, p = 0.006 for individuals earning > $400 per week). Device use differed for age and income.

Conclusions

Internet-based interventions appear to reach the majority of socially disadvantaged populations. It is expected that this reach will continue to grow, making internet-based interventions a potential platform for providing care to low socioeconomic individuals who smoke, however inequalities may be exacerbated for those individual without internet access.

Implications

Internet use among socially disadvantaged tobacco users is moderate (58%). An internet-based smoking cessation intervention for socially disadvantaged tobacco users may be an effective intervention however, older, heavier tobacco users may not benefit as easily due to limited internet access and therefore acknowledging these limitations when developing an intervention can help to acknowledge limitation of intervention reach.

Web-Based Tobacco Cessation Interventions and Digital Inequality across US Racial/Ethnic Groups

Introduction

Internet-based tobacco cessation programs have increased in use and popularity in recent years. To examine evidence for racial/ethnic digital inequality in web-only tobacco cessation services offered by US tobacco quitlines, we conducted an analysis of quitline enrollees in five states. We hypothesized that racial/ethnic minorities would demonstrate lower enrollment and utilization of a web-only tobacco cessation program.

Methods

The sample includes enrollees into five state quitlines whose service options included a web-only program in 2015 (N=32,989). Outcomes included web-entry into the quitline, web-only enrollment, establishment of a web account, and the number of times users logged into the program. Regression models tested associations with race/ethnicity.

Results

Compared with Whites, African Americans, Hispanics, American Indians/Alaska Natives, and "others" were less likely to enter the quitline via the web (Ps<.01) and enroll in a web-only (vs counseling) program (Ps<.01). Among web-only program enrollees, all racial/ethnic minority groups were significantly less likely than Whites to establish an online account (Ps<.03), and African Americans were less likely than Whites to log in to the web-only service (P<.01).

Conclusions

This study suggests that digital inequalities exist in web-based tobacco cessation services. Findings have implications for the development and implementation of digital tobacco interventions for racial/ethnic minority communities. The proliferation of digital tobacco interventions could increase disparities, as members of racial/ethnic minority groups may not engage in these interventions.

Implications

The proliferation of digital interventions has the potential to increase tobacco-related disparities, as members of racial/ethnic minority groups may not enroll in, or engage in, such interventions. As the field moves to digitize tobacco interventions, we must remain cognizant of persistent digital inequalities and the potential for widening racial/ethnic tobacco cessation disparities.

User characteristics of national smoking cessation services in Korea: who chooses each type of tobacco cessation program?

BACKGROUND

Relatively little is known about which characteristics of smokers are related to choosing a specific type of smoking cessation service. The user characteristics of different smoking cessation services were compared to determine the service preferred by user characteristics.

METHODS

The characteristics of adult smokers from Korea National Health and Nutrition Examination Survey (3762) and registered users of national smoking cessation services operated through the web (14,762), at Public Health Center-based Smoking Cessation Clinics (PHC-based SCCs) (335,532), and by telephone (Quitline) (2983) were compared.

RESULTS

Females and younger aged were more in web and telephone-based cessation service users, while aged 50 years or older were more in PHC-based SCCs users. Although manufacturing and production workers were the most prevalent among smokers in the general population, office workers and others including housewives and unemployed were most prevalent among the users of Quitline and PHC-based SCCs, respectively. The number of cigarettes smoked per day was twice as high among cessation service users as in general population. Smokers with greater nicotine dependency were most prevalent in the web-based service. Overseas users were in the web-based cessation service.

CONCLUSION

Identifying user-specific characteristics by the type of cessation services looks necessary to develop and offer appropriate cessation services.

A randomized clinical trial of the Recovery Line among methadone treatment patients with ongoing illicit drug use

BACKGROUND

Relapse, drug use, and treatment dropout are common challenges facing patients receiving methadone. Though effective, multiple barriers to face-to-face counseling exist. The Recovery Line (RL), an automated, self-management system based on Cognitive Behavioral Therapy, is a phone-based adjunctive treatment that provides low cost, consistent delivery and immediate therapeutic availability 24 h a day.

METHODS

The current study was a 12-week randomized clinical efficacy trial of treatment-as-usual (TAU) only or RL + TAU for methadone treatment patients with continued illicit drug use (N = 82). Previous small trial phases evaluated methods to increase participant engagement and use of the RL and were incorporated into the current RL version. Primary outcomes were days of self-reported illicit drug abstinence and urine screens negative for illicit drugs.

RESULTS

Days of self-reported illicit drug abstinence improved for patients in RL + TAU but not in TAU. Percent of urine screens negative for illicit drugs, coping skills efficacy, and retention in methadone treatment did not differ by condition. Patients in RL + TAU attended more substance use disorder treatment and self-help group sessions during treatment than those in TAU. RL system use was generally low and more system use was correlated with abstinence outcomes.

CONCLUSIONS

Although the RL did not impact urine screen outcomes, it increases self-reported abstinence. Additional methods to increase patient engagement with automated, self-management systems for substance use disorder are needed.

Factors associated with future dental care utilization among low-income smokers overdue for dental visits

BACKGROUND

Smokers are at increased risk of oral disease. While routine dental care can help prevent and treat oral health problems, smokers have far lower rates of dental care utilization compared with non-smokers. We sought to better understand which factors may facilitate or hinder dental care utilization among low-income smokers participating in a randomized intervention trial in order to inform future intervention planning.

METHODS

This is a secondary analysis of data collected between 2015 and 2017 as part of the OralHealth4Life trial. Participants were eligible callers to the Louisiana, Nebraska, and Oregon state tobacco quitlines who had no dental appointment in the prior or upcoming six months. We examined the association between participants' baseline characteristics and their receiving professional dental care between baseline and the 6-month follow-up survey.

RESULTS

Participants were racially diverse (42% non-White) and two-thirds had an annual household income under $20,000. Most (86.7%) had not had a dental cleaning in more than one year. Commonly cited barriers to dental care included cost (83.7%) and no dental insurance (78.1%). Those with dental insurance were more likely to see a dentist at follow-up (RR 1.66). Similarly, those reporting a dental insurance barrier to care were less likely to see a dentist at follow-up (RR 0.69); however, there was no significant utilization difference between those reporting a cost barrier vs. those who did not. After controlling for these financial factors, the following baseline characteristics were significantly associated with a higher likelihood of dental care utilization at 6 months: higher motivation (RR 2.16) and self-efficacy (RR 1.80) to visit the dentist, having a disability (RR 1.63), having a higher education level (RR 1.52), and having perceived gum disease (RR 1.49). Factors significantly associated with a lower likelihood of dental care utilization included being married (RR 0.68) and not having a last dental cleaning within the past year (RR 0.47).

CONCLUSIONS

Our findings provide important insight into factors that may facilitate or deter use of professional dental care among low-income smokers. This information could inform the development of future interventions to promote dental care utilization.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT02347124 ; registered 27 January 2015.

Retrospective reports of former smokers: Receiving doctor's advice to quit smoking and using behavioral interventions for smoking cessation in the United States

The study investigated the over-time changes and racial/ethnic disparities in the quality of health care services for cigarette smoking cessation in the U.S. from 2007 to 2015. The primary measures included receiving a doctor's advice to quit smoking in the year before smoking cessation and using behavioral interventions for smoking cessation (telephone helplines and web-based interventions) while trying to quit smoking. The study was conducted from January to July 2018. We used merged data from the 2010-11 and 2014-15 Tobacco Use Supplement to the Current Population Survey. The sample sizes were 7011 and 12,025, respectively, for the analyses corresponding to two primary measures. The rate of receiving a doctor's advice to quit increased significantly from 66% (SE = 2%) in 2007 to 73% (SE = 4%) in 2015. The rate of usage of telephone helplines or web-based interventions for smoking cessation increased only from 3% (SE = 1%) in 2007 to 5% (SE = 1%) in 2015. These positive trends remained even after adjusting for several important factors. For both measures, the rates were consistently lower among Hispanic smokers than Non-Hispanic Black/African American and White smokers. Despite the availability of states' behavioral interventions for cessation of tobacco use, utilization of these interventions remains very low, indicating that smokers may not be aware of these free resources, may have misconceptions about these interventions being evidence-based, or there are barriers for using these interventions.

Good intentions are not enough: how informatics interventions can worsen inequality

Health informatics interventions are designed to help people avoid, recover from, or cope with disease and disability, or to improve the quality and safety of healthcare. Unfortunately, they pose a risk of producing intervention-generated inequalities (IGI) by disproportionately benefiting more advantaged people. In this perspective paper, we discuss characteristics of health-related interventions known to produce IGI, explain why health informatics interventions are particularly vulnerable to this phenomenon, and describe safeguards that can be implemented to improve health equity. We provide examples in which health informatics interventions produced inequality because they were more accessible to, heavily used by, adhered to, or effective for those from socioeconomically advantaged groups. We provide a brief outline of precautions that intervention developers and implementers can take to guard against creating or worsening inequality through health informatics. We conclude by discussing evaluation approaches that will ensure that IGIs are recognized and studied.

Simultaneous vs. sequential treatment for smoking and weight management in tobacco quitlines: 6 and 12 month outcomes from a randomized trial

BACKGROUND

Smoking cessation often results in weight gain which discourages many smokers from quitting and can increase health risks. Treatments to reduce cessation-related weight gain have been tested in highly controlled trials of in-person treatment, but have never been tested in a real-world setting, which has inhibited dissemination.

METHODS

The Best Quit Study (BQS) is a replication and "real world" translation using telephone delivery of a prior in-person efficacy trial.

DESIGN

randomized control trial in a quitline setting. Eligible smokers (n = 2540) were randomized to the standard 5-call quitline intervention or quitline plus simultaneous or sequential weight management. Regression analyses tested effectiveness of treatments on self-reported smoking abstinence and weight change at 6 and 12 months.

RESULTS

Study enrollees were from 10 commercial employer groups and three state quitlines. Participants were between ages 18-72, 65.8% female, 68.2% white; 23.0% Medicaid-insured, and 76.3% overweight/obese. The follow-up response rate was lower in the simultaneous group than the control group at 6 months (p = 0.01). While a completers analysis of 30-day point prevalence abstinence detected no differences among groups at 6 or 12 months, multiply imputed abstinence showed quit rate differences at 6 months for:simultaneous (40.3%) vs. sequential (48.3%), p = 0.034 and simultaneous vs. control (44.9%), p = 0.043. At 12 months, multiply imputed abstinence, was significantly lower for the simultaneous group (40.7%) vs. control (46.0%), p < 0.05 and vs. sequential (46.3%), p < 0.05. Weight gain at 6 and 12 months was minimal and not different among treatment groups. The sequential group completed fewer total calls (3.75) vs. control (4.16) and vs. simultaneous group (3.83), p = 0.01, and fewer weight calls (0.94) than simultaneous (2.33), p < 0.0001. The number of calls completed predicted 30-day abstinence, p < 0.001, but not weight outcomes.

DISCUSSION

This study offers a model for evaluating population-level public health interventions conducted in partnership with tobacco quitlines.

CONCLUSIONS

Simultaneous (vs. sequential) delivery of phone/web weight management with cessation treatment in the quitline setting may adversely affect quit rate. Neither a simultaneous nor sequential approach to addressing weight produced any benefit on suppressing weight gain. This study highlights the need and the challenges of testing intensive interventions in real-world settings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01867983 . Registered: May 30, 2013.

The Development and Evaluation of Online Smoking Cessation Services: A Narrative Literature Review

Introduction:The use of quitlines for smoking cessation has contracted, with service providers adapting through the development of comprehensive interactive online smoking cessation services. The primary aim of this review is to investigate the continuum of online cessation services, innovations in design and service components, measures used in formative, process and outcome evaluations, as well as evidence of effectiveness.

Methods:This review includes the peer-reviewed literature, scholarly articles and the grey literature material. Databases searched included: PubMed, Google Scholar, SCOPUS and the Cochrane Collaboration.

Results/findings:56 academic journal articles and the 5 grey literature reports met the inclusion criteria for this review. Developmental stages of online/combination services included: static websites, tailored feedback, email and text services, interactive components, social media, pharmacological offers; as well as social and professional support mechanisms. Innovations in online smoking cessation include: chat rooms, new recruitment strategies, mobile apps, service tailoring and messaging support groups. Online cessation services were significantly cheaper and more popular than quitlines; however, abstinence rates appear higher amongst quitline users.

Conclusions:Three likely catalysts for the shift from quitlines to online services are the rapid development of technology, increased internet access and the general movement of the goods and services sector to digital channels. The challenge for online cessation service providers is to leverage their comparative cost advantage and develop strategies that keep pace, engage users and increase service effectiveness.

Implications:Our paper synthesises a wide-range of the literature that evaluates the effectiveness and scope of online smoking cessation programs. Through applying this literature to the stages of evaluation framework, we also provide one of the first detailed roadmaps towards developing comprehensive evaluation methodology for online smoking cessation services.

The failure to increase social support: it just might be time to stop intervening (and start rigorously observing)

In 1986, Lichtenstein et al. (Behav Ther. 17(5):607-19, 1986) presented the results of five studies focused on enhancing social support for smoking cessation in community-based clinic and worksite interventions. The manuscript was titled Social Support in Smoking Cessation: In Search of Effective Interventions and its main conclusion was that "attempts to both increase social support and to enhance treatment effectiveness have not been successful." Thirty years later, the paper by Cutrona et al. (Transl Behav Med. 6(4):546-57, 2016) draws a similar conclusion from a study focused on providing social support through an online social network for smoking cessation. In reviewing these findings - and based on our knowledge of the extensive literature on social support interventions that has been published over the past 30+ years - we believe there is a need for a fundamental shift in research on social support. Our focus here is largely on smoking cessation, but our comments are applicable to other areas of behavior change.

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

Weekly enrollment and usage patterns in an Internet smoking cessation intervention

BACKGROUND

Previous analyses of Google search queries identified circaseptan (weekly) rhythms in smoking cessation information seeking, with Google searches for "quit" and "smoking" peaking early in the week. Similar patterns were observed for smoking cessation treatment seeking, such as calls to quitlines. These findings suggest that smoking cessation behaviors may have a weekly rhythm that could be leveraged to improve smoking cessation efforts.

AIMS

To assess whether weekly enrollment and usage patterns exist for an Internet smoking cessation intervention.

METHODS

We used process data from a large, longstanding Internet smoking cessation intervention (www.becomeanex.org). Pearson's chi-squared tests were performed to identify day-of-the week differences in enrollment, first visit to site community pages, and quit date. Differences were considered statistically significant at the 1% level if p < 0.00167 due to multiple comparisons. Regression analysis was used to examine differences in engagement activity based on the day of the week a user enrolled.

RESULTS

Website users (n = 69,237) were more likely to enroll on the site at the beginning of the week (Mondays and Tuesdays) (p < 0.0001). Current smokers who selected quit dates (n = 5574) preferred quit dates that came early in the week (Sundays and Mondays) compared to other weekdays (p < 0.0001). Generally, there were no significant differences in overall website utilization metrics by day of enrollment, but there were some exceptions. Use of interactive features to select quit dates, track cigarette use, and record coping strategies was generally lower for Friday/Saturday enrollees.

CONCLUSIONS

Consistent with prior research, the beginning of the week appears to be a time when individuals are more likely to enroll in an Internet smoking cessation intervention and engage with its core features. Emphasizing marketing and promotional efforts during the beginning of the week could result in greater reach of Internet smoking cessation interventions.

Who is More Likely to Use the Internet for Health Behavior Change? A Cross-Sectional Survey of Internet Use Among Smokers and Nonsmokers Who Are Orthopedic Trauma Patients

BACKGROUND

eHealth presents opportunities to provide population groups with accessible health interventions, although knowledge about Internet access, peoples' interest in using the Internet for health, and users' characteristics are required prior to eHealth program development.

OBJECTIVE

This study surveyed hospital patients to examine rates of Internet use, interest in using the Internet for health, and respondent characteristics related to Internet use and interest in using the Internet for health. For patients who smoke, preferences for types of smoking cessation programs for use at home and while in hospital were also examined.

METHODS

An online cross-sectional survey was used to survey 819 orthopedic trauma patients (response rate: 72.61%, 819/1128) from two public hospitals in New South Wales, Australia. Logistic regressions were used to examine associations between variables.

RESULTS

A total of 72.7% (574/790) of respondents had at least weekly Internet access and more than half (56.6%, 357/631) reported interest in using the Internet for health. Odds of at least weekly Internet usage were higher if the individual was born overseas (OR 2.21, 95% CI 1.27-3.82, P=.005), had a tertiary education (OR 3.75, 95% CI 2.41-5.84, P<.001), or was a nonsmoker (OR 3.75, 95% CI 2.41-5.84, P<.001). Interest in using the Internet for health increased with high school (OR 1.85, 95% CI 1.09-3.15, P=.02) or tertiary education (OR 2.48, 95% CI 1.66-3.70, P<.001), and if household incomes were more than AUS $100,000 (OR 2.5, 95% CI 1.25-4.97, P=.009). Older individuals were less interested in using the Internet for health (OR 0.98, 95% CI 0.97-0.99, P<.001).

CONCLUSIONS

Online interventions may be a potential tool for health care in this hospitalized population.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12614001147673; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366829&isReview=true (Archived by WebCite at http://www.webcitation.org/6qg26u3En).

Electronic nicotine delivery system (ENDS) use during smoking cessation: a qualitative study of 40 Oklahoma quitline callers

OBJECTIVES

Approximately 10% (40 000) of US quitline enrollees who smoke cigarettes report current use of electronic nicotine delivery systems (ENDS); however, little is known about callers' ENDS use. Our aim was to describe why and how quitline callers use ENDS, their beliefs about ENDS and the impact of ENDS use on callers' quit processes and use of FDA-approved cessation medications.

DESIGN

Qualitative interviews conducted 1-month postregistration. Interviews were recorded, transcribed, double-coded and analysed to identify themes.

SETTING

Oklahoma Tobacco Helpline.

PARTICIPANTS

40 callers aged ≥18 who were seeking help to quit smoking were using ENDS at registration and completed ≥1 programme calls.

RESULTS

At 1-month postregistration interview, 80% of callers had smoked cigarettes in the last 7 days, almost two-thirds were using ENDS, and half were using cessation medications. Nearly all believed ENDS helped them quit or cut down on smoking; however, participants were split on whether they would recommend cessation medications, ENDS or both together for quitting. Confusion and misinformation about potential harms of ENDS and cessation medications were reported. Participants reported using ENDS in potentially adaptive ways (eg, using ENDS to cut down and nicotine replacement therapy to quit, and stepping down nicotine in ENDS to wean off ENDS after quitting) and maladaptive ways (eg, frequent automatic ENDS use, using ENDS in situations they did not previously smoke, cutting down on smoking using ENDS without a schedule or plan to quit), which could impact the likelihood of quitting smoking or continuing ENDS use.

CONCLUSIONS

These qualitative findings suggest quitline callers who use ENDS experience confusion and misinformation about ENDS and FDA-approved cessation medications. Callers also use ENDS in ways that may not facilitate quitting smoking. Opportunities exist for quitlines to educate ENDS users and help them create a coordinated plan most likely to result in completely quitting combustible tobacco.

Impact of a Temporary NRT Enhancement in a State Quitline and Web-Based Program

Purpose:

To examine the impact of a nicotine replacement therapy (NRT) enhancement on quit outcomes.

Design:

Observational study using an intent to treat as treated analysis.

Setting:

Not available.

Participants:

A total of 4022 Idaho tobacco users aged ≥18 years who received services from the Idaho Tobacco Quitline or Idaho’s web-based program.

Intervention:

One-call phone or web-based participants were sent a single 4- or 8-week NRT shipment. Multiple-call participants were sent NRT in a single 4-week shipment or two 4-week shipments (second shipment sent only to those completing a second coaching call).

Measures:

North American Quitline Consortium recommended Minimal Data Set items collected at registration and follow-up. Thirty-day point prevalence quit rates were assessed at 7-month follow-up.

Analysis:

Multiple logistic regression models were used to examine the effects of program type and amount of NRT sent to participants while controlling for demographic and tobacco use characteristics.

Results:

Abstinence rates were significantly higher among 8-week versus 4-week NRT recipients (42.5% vs 33.3%). The effect was only significant between multiple-call program participants who received both 4-week NRT shipments versus only the first of 2 possible 4-week shipments (51.1% vs 31.1%). Costs per quit were lowest among web-based participants who received 4 weeks of NRT (US$183 per quit) and highest among multiple-call participants who received only 1 of 2 possible NRT shipments (US$557 per quit).

Conclusion:

To better balance cost with clinical effectiveness, funders of state-based tobacco cessation services may want to consider (1) allowing tobacco users to choose between phone- and web-based programs while (2) limiting longer NRT benefits only to multiple-call program participants.

Web-Based Intervention for Transitioning Smokers From Inpatient to Outpatient Care: An RCT

INTRODUCTION

Smoking-cessation follow-up care after hospitalization is known to be effective. Cost-effective and disseminable interventions adoptable by hospitals are needed.

DESIGN

RCT.

SETTING/PARTICIPANTS

Fourteen hundred eighty-eight current smokers recruited during a tertiary care hospital stay were randomly assigned to Usual Care (UC) or Usual Care plus Web-Based Intervention (WI). Data were collected in 2011-2013 and analyzed in 2014-2015.

INTERVENTION

UC provided brief bedside advice to quit, a quit plan template, and quitline contact information. WI included access to a website with asynchronous e-message communication with a tobacco counselor, use of interactive self-assessments, helpful cessation information, and access to additional web resources, as well as automated e-mail messages tailored for health concern and readiness to quit.

MAIN OUTCOME MEASURES

Self-reported 30-day abstinence at 6 months was the primary outcome; a subset was verified by saliva cotinine.

RESULTS

Six-month follow-up was completed by 83% of participants. No difference was found between study arms for self-reported abstinence rates in intent-to-treat (25.4% WI vs 26.8% UC) and complete case (31.3% WI vs 31.4% UC) analyses. Reduced smoking was reported by 45.5% (WI, n=276) and 47% (UC, n=296) of non-abstinent responders (p=0.59). Using a 10-ng/mL cotinine cut off, abstinence was verified in 52.1% of WI and 62.5% of UC (p=0.11). Significant covariates associated with abstinence at 6 months were being male, not smoking during hospitalization, being very confident in quitting, planning to quit/stay quit, smoking fewer days in the past 30 days, fewer years of smoking, and having cerebrovascular or connective tissue rheumatic disease as primary hospital diagnosis.

CONCLUSIONS

Lack of difference between treatment arms suggests a strong effect for UC, WI was not effective, or both. Low intervention engagement may be partially responsible. Self-reported abstinence rates were relatively high in both arms, although the biochemically verified rates indicate over-reporting of abstinence. These findings suggest brief bedside counseling for all hospitalized smokers is beneficial.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01277250.

Increasing reach by offering choices: Results from an innovative model for statewide services for smoking cessation

Although state quitlines provide free telephone counseling and often include nicotine replacement therapy (NRT), reach remains limited (1-2% in most states). More needs to be done to engage all smokers in the quitting process. A possible strategy is to offer choices of cessation services through quitlines and to reduce registration barriers. In March 2014, ClearWay Minnesota^SM implemented a new model for QUITPLAN® Services, the state's population-wide cessation services. Tobacco users could choose the QUITPLAN® Helpline or one or more Individual QUITPLAN® Services (NRT starter kit, text messaging, email program, or quit guide). The program website was redesigned, online enrollment was added, and a new advertising campaign was created and launched. In 2014-2015, we evaluated whether these changes increased reach. We also assessed quit attempts, quit outcomes, predictors of 30-day abstinence, and average cost per quit via a seven-month follow-up survey. Between March 2014-February 2015, 15,861 unique tobacco users registered, which was a 169% increase over calendar year 2013. The majority of participants made a quit attempt (83.7%). Thirty-day point prevalence abstinence rates (responder rates) were 26.1% for QUITPLAN Services overall, 29.6% for the QUITPLAN Helpline, and 25.5% for Individual QUITPLAN Services. Several variables predicted quit outcomes, including receiving only one call from the Helpline and using both the Helpline and the NRT starter kit. Providing greater choice of cessation services and reducing registration barriers have the potential to engage more tobacco users, foster more quit attempts, and ultimately lead to long-term cessation and reductions in prevalence.

Young Adult Utilization of a Smoking Cessation Website: An Observational Study Comparing Young and Older Adult Patterns of Use

Background

There is little research on how young adults or young adult subgroups utilize and engage with Web-based cessation interventions when trying to quit smoking. Addressing this knowledge gap is important to identify opportunities to optimize the effectiveness of online cessation programs across diverse young adult users.

Objective

This study examines utilization of the BecomeAnEX.org smoking cessation website among young adults and young adult subgroups compared with older adults to identify patterns of use by age, gender, and race/ethnicity.

Methods

Study participants were 5983 new registered users on a free smoking cessation website who were aged 18 to 70 years. Website utilization was tracked for 6 months; metrics of use included website visits, pages per visit, length of visit, and interaction with specific website features. Differences in website use by age were examined via bivariate analyses and multivariate logistic regression adjusted for age, gender, and race/ethnicity. Interactions were examined to determine differences by gender and race/ethnicity within young (18- to 24-year-olds and 25- to 34-year-olds) and older (35 years and older) adult segments.

Results

A greater percentage of young adults aged 18 to 34 years visited the site only once compared with older adults aged 35 years and older (72.05% vs 56.59%, respectively; P<.001). Young adults also spent less time on the site and viewed fewer pages than older adults. In adjusted analyses, young adults were significantly less likely than older adults to visit the site more than once (18-24 years: adjusted odds ratio [AOR] 0.58, 95% CI 0.49-0.68, P<.001; 25-34 years: AOR 0.56, 95% CI 0.50-0.64, P<.001), spend more than 3 minutes on the site (18-24 years: AOR 0.67, 95% CI 0.57-0.79, P<.001; 25-34 years: AOR 0.56, 95% CI 0.49-0.64, P<.001), view 12 or more pages (18-24 years: AOR 0.72, 95% CI 0.61-0.83; P<.001; 25-34 years: AOR 0.67, 95% CI 0.59-0.76, P<.001), utilize the BecomeAnEX.org community (18-24 years: AOR 0.61, 95% CI 0.48-0.79, P<.001; 25-34 years: AOR 0.73, 95% CI 0.60-0.88, P<.001), or utilize Separation Exercises (18-24 years: AOR 0.68, 95% CI 0.51-0.89, P<.01; 25-34 years: AOR 0.77, 95% CI 0.63-0.94, P<.01). Gender differences in utilization were more pronounced among young adults compared with older adults, with lower levels of utilization among young men than young women. For all age groups, utilization was higher among whites and African Americans than among Hispanics and other racial minorities, with one exception—BecomeAnEX.org community utilization was significantly higher among Hispanic young adults compared with white and African American young adults.

Conclusions

Results point to important areas of inquiry for future research and development efforts. Research should focus on enhancing demand and increasing engagement among younger adults and men, examining strategies for capitalizing on young adult developmental needs, and increasing utilization of effective site features among diverse young adult users.

Engagement and attrition in Internet smoking cessation interventions: Insights from a cross-sectional survey of "one-hit-wonders"

INTRODUCTION

Internet interventions can reach large numbers of individuals. However, low levels of engagement and high rates of follow-up attrition are common, presenting major challenges to evaluation. This study investigated why registrants of an Internet smoking cessation intervention did not return after joining ("one hit wonders"), and explored the impact of graduated incentives on survey response rates and responder characteristics.

METHODS

A sample of "one hit wonders" that registered on a free smoking cessation website between 2014 and 2015 were surveyed. The initial invitation contained no incentive. Subsequent invitations were sent to random subsamples of non-responders from each previous wave offering $25 and $50 respectively. Descriptive statistics characterized respondents on demographic characteristics, reasons for not returning, and length of time since last visit. Differences were investigated with Fisher's Exact tests, Kruskal-Wallis, and logistic regression.

RESULTS

Of 8779 users who received the initial invitation, 132 completed the survey (1.5%). Among those subsequently offered a $25 incentive, 127 (3.7%) responded. Among those offered a $50 incentive, 97 responded (5.7%). The most common reasons endorsed for not returning were being unable to quit (51%), not having enough time (33%), having forgotten about the website (28%), and not being ready to quit (21%). Notably, however, 23% reported not returning because they had successfully quit smoking. Paid incentives yielded a higher proportion of individuals who were still smoking than the $0 incentive (72% vs. 61%). Among $0 and $25 responders, likelihood of survey response decreased with time since registration; the $50 incentive removed the negative effect of time-since-registration on probability of response.

CONCLUSIONS

One third of participants that had disengaged from an Internet intervention reported abstinence at follow-up, suggesting that low levels of engagement are not synonymous with treatment failure in all cases. Paid incentives above $25 may be needed to elicit survey responses, especially among those with longer intervals of disengagement from an intervention.

Mobile health solutions for the aging population: A systematic narrative analysis

Introduction The ubiquitous nature of mobile technology coupled with the acceptance of mobile health (mHealth) among the elderly offers an opportunity to augment the existing medical workforce in long-term care. The objective of this review and narrative analysis is to identify and analyse facilitators and barriers to adoption of mHealth for the elderly. Methods Studies over the last year were identified in multiple database indices, and three reviewers examined abstracts ( k = 0.82) and analysed articles for themes which were tallied in affinity diagrams to identify frequency of occurrence in the literature (n = 36). Results The three facilitators mentioned most often were independence (18%), understanding (13%), and visibility (13%). The three barriers mentioned most often were complexity (21%), limited by users (12%) and ineffective (12%). Discussion and conclusions The reviewers concluded that the work done so far illustrates that mHealth enables a perception of independence. Future research should focus on the barriers of complexity of technology and improving existing medical literacy in order to facilitate further adoption.

Feasibility and Quit Rates of the Tobacco Status Project: A Facebook Smoking Cessation Intervention for Young Adults

Background

Young adult smokers are a challenging group to engage in smoking cessation interventions. With wide reach and engagement among users, Facebook offers opportunity to engage young people in socially supportive communities for quitting smoking and sustaining abstinence.

Objective

We developed and tested initial efficacy, engagement, and acceptability of the Tobacco Status Project, a smoking cessation intervention for young adults delivered within Facebook.

Methods

The intervention was based on the US Public Health Service Clinical Practice Guidelines and the Transtheoretical Model and enrolled participants into study-run 3-month secret Facebook groups matched on readiness to quit smoking. Cigarette smokers (N=79) aged 18-25, who used Facebook on most days, were recruited via Facebook. All participants received the intervention and were randomized to one of three monetary incentive groups tied to engagement (commenting in groups). Assessments were completed at baseline, 3-, 6-, and 12-months follow-up. Analyses examined retention, smoking outcomes over 12 months (7-day point prevalence abstinence, ≥50% reduction in cigarettes smoked, quit attempts and strategies used, readiness to quit), engagement, and satisfaction with the intervention.

Results

Retention was 82% (65/79) at 6 months and 72% (57/79) at 12 months. From baseline to 12-months follow-up, there was a significant increase in the proportion prepared to quit (10/79, 13%; 36/79, 46%, P<.001). Over a third (28/79, 35%) reduced their cigarette consumption by 50% or greater, and 66% (52/79) made at least one 24-hour quit attempt during the study. In an intent-to-treat analysis, 13% (10/79) self-reported 7-day abstinence (6/79, 8% verified biochemically) at 12-months follow-up. In their quit attempts, 11% (9/79) used a nicotine replacement therapy approved by the Food and Drug Administration, while 18% (14/79) used an electronic nicotine delivery system to quit (eg, electronic cigarette). A majority (48/79, 61%) commented on at least one Facebook post, with more commenting among those with biochemically verified abstinence at 3 months (P=.036) and those randomized to receive a personal monetary incentive (P=.015). Over a third of participants (28/79, 35%) reported reading most or all of the Facebook posts. Highest acceptability ratings of the intervention were for post ease (57/79, 72%) and thinking about what they read (52/79, 66%); 71% (56/79) recommended the program to others. Only 5 participants attended the optional cognitive-behavioral counseling sessions, though their attendance was high (6/7 sessions overall) and the sessions were rated as easy to understand, useful, and helpful (all 90-100% agreed).

Conclusions

A Facebook quit smoking intervention is attractive and feasible to deliver, and early efficacy data are encouraging. However, the 1.5-fold greater use of electronic cigarettes over nicotine replacement products for quitting is concerning.

Smoking cessation outcomes of referral to a specialist hospital outpatient clinic

BACKGROUND AND OBJECTIVES

Hospital visits are an opportunity to engage smokers in tobacco treatment. However, little is known about engagement in follow-up referrals. The purpose of this study is to report the rates of program engagement and smoking cessation outcomes of patients referred to a specialist outpatient tobacco treatment program after a hospital visit or other referral.

METHODS

A retrospective chart review was used to examine the outcomes of 486 participants referred to a hospital-based smoking cessation clinic provided by tobacco treatment specialists. Referral sources, demographics and smoking, medical, psychiatric, and substance use history were obtained. The main outcomes of interest were engagement in the program and 7-day point-prevalence of smoking abstinence.

RESULTS

Sixty-eight percent of participants who were referred to the program were considered "engaged," of which 70% were from hospitals, 4% from community programs, 11% were from general practitioners, and 16% were self-referrals. Thirty-percent (98/331) of engagers were abstinent by time of chart review (30% from the hospital, 8% from community programs, 19% from general practitioners, and 39% of self-referrals). Having quit for 1 month or longer at the past quit attempt, greater confidence in quitting smoking, lower expired carbon monoxide levels at baseline, and greater duration in the program were significant predictors of successful smoking cessation.

DISCUSSION AND CONCLUSION

Providing tobacco treatment follow-up and referral for smokers after a hospital visit is important to enhance smoking cessation efforts.

SCIENTIFIC SIGNIFICANCE

Referral to evidence-based tobacco treatment after hospital visits is effective. Models of tobacco treatment based on sources of referral should further be explored.

Cessation Outcomes Among Quitline Callers in Three States During a National Tobacco Education Campaign

Introduction

Antismoking mass media campaigns, such as the Centers for Disease Control and Prevention’s Tips from Former Smokers (Tips) campaign, increase the number of tobacco users calling tobacco quitlines. Few studies have investigated long-term tobacco use cessation for callers during antismoking media campaigns. Studies have suggested that callers during campaigns may be less committed to quitting and have lower quit rates. This study examines tobacco user cessation outcomes 7 months after quitline enrollment during the 2012 Tips campaign (March 19 through June 10, 2012).

Methods

We analyzed data for 715 tobacco users who enrolled in the Nebraska, North Carolina, or Texas state quitline multiple-call programs during the 2012 Tips campaign and responded to a 7-month postenrollment survey (38.5% survey response rate). We used multivariable logistic regression analyses to determine whether 7-day and 30-day point prevalence abstinence rates 7 months after enrollment were related to level of exposure to the campaign.

Results

In multivariable models, only lower nicotine dependence and higher call completion were associated with higher odds of 7-day and 30-day abstinence 7 months after enrollment. Tips campaign exposure was not associated with abstinence.

Conclusion

Once enrolled in quitline counseling, quitline callers achieved similar outcomes regardless of Tips campaign exposure levels. While the campaign did not appear to directly affect odds of tobacco abstinence through quitlines, antismoking mass media campaigns such as Tips are valuable in increasing tobacco users’ exposure to quitlines and thus increasing their likelihood of making a quit attempt and eventually achieving tobacco abstinence.