Hazel GilbertResearch Department of Primary Care and Population

Health UCL Medical School

Can we involve smokers Can we involve smokers who are unmotivated to who are unmotivated to quit in quitting activity?quit in quitting activity?

1) Principles of tailoring

2) Escape study

3) Baseline characteristics and follow-up assessment

Overview

Generic leaflets and manuals

Personalised generic

Targeted materials to particular groups

Individually Tailored Feedback

Definition: ‘intended to reach one specific person, based on characteristics unique to that person, related to the outcome of interest, and derived from an individual assessment’

(Kreuter et al 1999)

Self-help Materials

Individually Tailored FeedbackPersonally relevant information:

→ greater attention

→ central route processing (deeper processing)

→ greater cognitive and behavioural change (Elaboration Likelihood Model. Petty and Cacioppo, 1981)

Evidence of effectiveness

‘evidence of the effectiveness of tailoring health behaviour change messages’ (Noar, Benac and Harris 2007) (meta-analysis of 57 studies)

‘material tailored for the individual increases quit rates over and above standard materials and untailored materials’ (Lancaster and Stead 2005) 17 trials (OR 1.42)

1) Understand determinants of the behaviourTailoring process ideally informed by established models of behaviour change

2) Develop a framework of intervention objectives • motivation and readiness to quit• reason for quitting• dependence and self-image• cognitive expectations of the outcomes of quitting• perceived self-efficacy • offer skills and strategies to cope• social environment • encourage finding support

Phases of development

3) Develop tailoring assessmentDesign questionnaire to assess the relevant individual characteristics

4) Create the content of the feedbackCompose a message for each possible answer

5) Design templateStyle and Format • Font• Graphics• Colour• Tone• Reading and comprehension level

Individual assessment

Input

Decision rulesMessage library of persuasive texts

Individualised output

Computer system

Dijkstra 2008

Process

E of computer-tailored Smoking Cessation Advice in

Primary carE A Randomised Controlled Trial

ffectiveness

General PracticeResearchFramework

Aim: To examine the effect of computer generated individually tailored feedback reports designed to help and encourage smokers to quit, on quit rates and quitting activity, when sent to smokers with varying levels of motivation and reading ability, identified from GP lists

Applications of Tailored Feedback in Primary Care

Clinical approach: Intensive face-to-face Relatively high quit rates

Low participation rates Unrepresentative

3-6% of smokers use the services per year

Challenge for Primary Care services:

to reach the smokers who do not use clinics

NHS Smoking Cessation Service

Proactive recruitment

Contact individuals directly offering a service

Higher participation

More demographically representative

Can target specific population groups

• Smokers not motivated to quit

• Areas of high deprivation where smoking prevalence is higher

• Smokers willing to take part returned the SBQ to research team at UCL• Randomised to Intervention or Control Group

• Practices identified current cigarette smokers (18 to 65) from patient records using the computer system

• Random sample of 500 screened by GP, and sent Smoking Behaviour Questionnaire (SBQ), together with a covering letter from GP (n=60,000)

123 general practices recruited from the MRC GPRF

Control GroupStandard NHS booklet

Intervention Group• Standard NHS booklet• Computer-tailored feedback report

adapted to reading level and readiness to quit

• Additional assessment and feedback report one month after baseline

6-month follow-up: postal questionnaire to assess smoking status, cognitive change, perception of the feedback, economic issues

Baseline characteristics

Demographics:

Female 56.5%

Mean age 44.72 (17-83)

White 96%

Qualifications <=GCSE 62.1%

Married/living with partner 58.8%

In paid employment 65.2%

Live with smoker 50.2%

Children under 10 18.9%

Children 10-18 24.4%

Pregnant 1.2%

N=6900

Withdrawn=69

Response rate=11.75%

Intervention=3404(49.8%)

Control=3427(50.2%)

Dependence: I C

Non-daily smokers 5.0% 5.4%

Smoke <30 minutes of waking 62.3% 62.1%

Previously quit >3 months 49.1% 48.7%

Mean age started smoking 16.19 16.24

Mean cigarettes per day 17.82 17.7

How much do you want to quit (scale 1-5)

3.33 3.25**

How determined are you to quit for good (scale 1-5)

3.26 3.19*

Think of self as addicted (scale 1-5) 4.03 4.03

Image (scale 1-5):smoking is part of who I am

see self as non-smoker2.5

3.042.483.02

**p=.006 * p=.016

Respondents by readiness to quit

5.70% 7.80%

40.10%

46.90%

0%

10%

20%

30%

40%

50%

w ithin 2 w eeks w ithin 30 days w ithin 6 months not w ithin 6 months

planning to quit

Of those planning to quit within the next 30 days (n=890): 339 (38.1%) set a quit date

Of those not planning to quit within the next 6 months (n=3203):too difficult - 45.3% / want to smoke - 44.8% / both - 4.3%

Readiness to quit by motivation

1

2

3

4

5

w ithin 2 w eeks w ithin 30 day s w ithin 6 months not planning

Planning to quit

mea

n sc

ore

w ant to quit

determined to quit

think self addicted

image 'w ho I am'

image 'non-smoker'

Intervention Group only (N=3404)4 weeks post baseline

Sent follow-up assessment + reminder=3350(98.4%)

Returns: Before reminder 968 (28.9%)After reminder 817 (24.4%)

Total 1785 (53.3%)

Participants planning quit in 30 days less likely to return the follow-up assessment (p=0.012)

Follow-up Assessment Response

Plan to quit Abstinent (%) Not abstinent (%)

Total

Within 2 weeks 43 (23.5) 61 (76.5) 183

Within 30 days 36 (13.5) 84 (86.5) 267

Within 6 months 66 (4.8) 661 (95.2) 1384

Not planning 35 (2.3) 800 (97.7) 1516

Total 180 (5.4) 3170 (94.6) 3350

Follow-up Assessment Outcome

2 = 197.48, p<.0001

0

10

20

30

40

50

60

1-6 days ago 7-14 days ago 2-4 weeks ago >4 weeks ago

last smoked

%

within 2 weeks

within 30 days

within 6 months

not within 6 months

Length of abstinence by readiness

Respondents not smoking 4 weeks post baseline (n=180)

Made quit attempt

Plan to quit Yes(%) No (%) Total

within 2 weeks 49(81.7) 11(18.3) 60

within 30 days 52(61.9) 32(38.1) 84

within 6 months 171(25.9) 489(74.1) 660

not within 6 months 102(12.8) 695(87.2) 797

Total 374(23.4) 1227(76.6) 1601

Quit attempts by readiness

2=235.698, p<.00001

Respondents still smoking 4 weeks post baseline (n=1601)

The Escape trial has met recruitment targets in terms of motivation

By reaching smokers with no plans to quit in the near future, we are able to provide them with information that they would not otherwise receive or seek out

By completing the Smoking Behaviour Questionnaire, these smokers are engaging in reflection about their smoking behaviour

Might prompt them to consider changes to their lifestyle and behaviour

Quitting activity?

Conclusions

participation rates of

public health campaigns

behavioural intervention principles of the clinical approach

provide personal, individually tailored self-help reports for a large population of smokers

Tailored feedback + Proactive Recruitment

Co-investigatorsIrwin Nazareth, Richard MorrisDepartment of Primary Care and Population Sciences, UCL

Stephen SuttonInstitute of Public Health, University of Cambridge

CollaboratorChristine GodfreyDepartment of Health Sciences, University of York

Trial Co-ordinatorCamille Alexis-Garsee

General PracticeResearchFramework