Telephone helplines

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Can we involve smokers who are unmotivated to
quit in quitting activity?
Hazel Gilbert Research Department of Primary Care
and Population Health UCL Medical School
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Overview

1. Principles of tailoring
2. Escape study
3. Baseline characteristics and follow-up assessment

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Self-help Materials

• 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)

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Individually Tailored Feedback

• Personally 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)
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Phases of development
1) Understand determinants of the
behaviour Tailoring 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

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• 3) Develop tailoring assessment
• Design questionnaire to assess the relevant
  individual characteristics
• 4) Create the content of the feedback
• Compose a message for each possible answer
• 5) Design template
• Style and Format
• Font
• Graphics
• Colour
• Tone
• Reading and comprehension level

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Process
Individual assessment
Computer system
Input
Message library of persuasive texts
Decision rules
Individualised output
Dijkstra 2008
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Applications of Tailored Feedback in Primary Care
E of computer-tailored Smoking Cessation Advice
in Primary carE A Randomised Controlled Trial
ffectiveness
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
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NHS Smoking Cessation Service

• 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

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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

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123 general practices recruited from the MRC GPRF

• 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 (n60,000)

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

• 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

Control Group Standard NHS booklet
6-month follow-up postal questionnaire to assess
smoking status, cognitive change, perception of
the feedback, economic issues
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Baseline characteristics
Demographics
Female 56.5
Mean age 44.72 (17-83)
White 96
Qualifications ltGCSE 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
N6900 Withdrawn69 Response rate11.75 Interv
ention3404(49.8) Control3427(50.2)
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Dependence I C
Non-daily smokers 5.0 5.4
Smoke lt30 minutes of waking 62.3 62.1
Previously quit gt3 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-smoker 2.5 3.04 2.48 3.02
p.006 p.016
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Respondents by readiness to quit
Of those planning to quit within the next 30 days
(n890) 339 (38.1) set a quit date Of those
not planning to quit within the next 6 months
(n3203) too difficult - 45.3 / want to smoke
- 44.8 / both - 4.3
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Readiness to quit by motivation
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Follow-up Assessment Response
Intervention Group only (N3404) 4 weeks post
baseline Sent follow-up assessment
reminder3350(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 (p0.012)
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Follow-up Assessment Outcome
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
?2 197.48, plt.0001
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Length of abstinence by readiness
Respondents not smoking 4 weeks post baseline
(n180)
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Quit attempts by readiness
Respondents still smoking 4 weeks post baseline
(n1601)
Made quit attempt 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
?2235.698, plt.00001
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Conclusions

• 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?

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Tailored feedback Proactive Recruitment
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
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Co-investigators Irwin Nazareth, Richard
Morris Department of Primary Care and Population
Sciences, UCL Stephen Sutton Institute of
Public Health, University of Cambridge Collaborat
or Christine Godfrey Department of Health
Sciences, University of York Trial
Co-ordinator Camille Alexis-Garsee