Comparative and Cost Effectiveness of Telemedicine Versus Telephone Counseling for Smoking Cessation

BackgroundIn rural America, cigarette smoking is prevalent and health care providers lack the time and resources to help smokers quit. Telephone quitlines are important avenues for cessation services in rural areas, but they are poorly integrated with local health care resources.ObjectiveThe intent of the study was to assess the comparative effectiveness and cost effectiveness of two models for delivering expert tobacco treatment at a distance: telemedicine counseling that was integrated into smokers’ primary care clinics (Integrated Telemedicine—ITM) versus telephone counseling, similar to telephone quitline counseling, delivered to smokers in their homes (Phone).MethodsSmokers (n=566) were recruited offline from 20 primary care and safety net clinics across Kansas. They were randomly assigned to receive 4 sessions of ITM or 4 sessions of Phone counseling. Patients in ITM received real-time video counseling, similar to Skype, delivered by computer/webcams in clinic exam rooms. Three full-time equivalent trained counselors delivered the counseling. The counseling duration and content was the same in both groups and was available in Spanish or English. Both groups also received identical materials and assistance in selecting and obtaining cessation medications. The primary outcome was verified 7-day point prevalence smoking abstinence at month 12, using an intent-to-treat analysis.ResultsThere were no significant baseline differences between groups, and the trial achieved 88% follow-up at 12 months. Verified abstinence at 12 months did not significantly differ between ITM or Phone (9.8%, 27/280 vs 12%, 34/286; P=.406). Phone participants completed somewhat more counseling sessions than ITM (mean 2.6, SD 1.5 vs mean 2.4, SD 1.5; P=.0837); however, participants in ITM were significantly more likely to use cessation medications than participants in Phone (55.9%, 128/280 vs 46.1%, 107/286; P=.03). Compared to Phone participants, ITM participants were significantly more likely to recommend the program to a family member or friend (P=.0075). From the combined provider plus participant (societal) perspective, Phone was significantly less costly than ITM. Participants in ITM had to incur time and mileage costs to travel to clinics for ITM sessions. From the provider perspective, counseling costs were similar between ITM (US $45.46, SD 31.50) and Phone (US $49.58, SD 33.35); however, total provider costs varied widely depending on how the clinic space for delivering ITM was valued.ConclusionsFindings did not support the superiority of ITM over telephone counseling for helping rural patients quit smoking. ITM increased utilization of cessation pharmacotherapy and produced higher participant satisfaction, but Phone counseling was significantly less expensive. Future interventions could combine elements of both approaches to optimize pharmacotherapy utilization, counseling adherence, and satisfaction. Such an approach could commence with a telemedicine-delivered clinic office visit for pharmacotherapy guidance, and continue with telephone or real-time video counseling delivered via mobile phones to flexibly deliver behavioral support to patients where they most need it—in their homes and communities.

Trial Registration

Clinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00843505","term_id":"NCT00843505"}}NCT00843505; http://clinicaltrials.gov/ct2/show/{"type":"clinical-trial","attrs":{"text":"NCT00843505","term_id":"NCT00843505"}}NCT00843505 (Archived by WebCite at http://www.webcitation.org/6YKSinVZ9).     

Effects of a Guided Web-Based Smoking Cessation Program With Telephone Counseling: A Cluster Randomized Controlled Trial

Background

Preliminary findings suggest that Web-based interventions may be effective in achieving significant smoking cessation. To date, very few findings are available for primary care patients, and especially for the involvement of general practitioners.

Objective

Our goal was to examine the short-term effectiveness of a fully automated Web-based coaching program in combination with accompanied telephone counseling in smoking cessation in a primary care setting.

Methods

The study was an unblinded cluster-randomized trial with an observation period of 12 weeks. Individuals recruited by general practitioners randomized to the intervention group participated in a Web-based coaching program based on education, motivation, exercise guidance, daily short message service (SMS) reminding, weekly feedback through Internet, and active monitoring by general practitioners. All components of the program are fully automated. Participants in the control group received usual care and advice from their practitioner without the Web-based coaching program. The main outcome was the biochemically confirmed smoking status after 12 weeks.

Results

We recruited 168 participants (86 intervention group, 82 control group) into the study. For 51 participants from the intervention group and 70 participants from the control group, follow-up data were available both at baseline and 12 weeks. Very few patients (9.8%, 5/51) from the intervention group and from the control group (8.6%, 6/70) successfully managed smoking cessation (OR 0.86, 95% CI 0.25-3.0; P=.816). Similar results were found within the intent-to-treat analysis: 5.8% (5/86) of the intervention group and 7.3% (6/82) of the control group (OR 1.28, 95% CI 0.38-4.36; P=.694). The number of smoked cigarettes per day decreased on average by 9.3 in the intervention group and by 6.6 in the control group (2.7 mean difference; 95% CI -5.33 to -0.58; P=.045). After adjustment for the baseline value, age, gender, and height, this significance decreases (mean difference 2.2; 95% CI -4.7 to 0.3; P=.080).

Conclusions

This trial did not show that the tested Web-based intervention was effective for achieving smoking cessation compared to usual care. The limited statistical power and the high drop-out rate may have reduced the study’s ability to detect significant differences between the groups. Further randomized controlled trials are needed in larger populations and to investigate the long-term outcome.

Trial Registration

German Register for Clinical Trials, registration number DRKS00003067; http://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ ID=DRKS00003067 (Archived by WebCite at http://www.webcitation.org/6Sff1YZpx).     

Partnership for Health-2, A Web-Based Versus Print Smoking Cessation Intervention for Childhood and Young Adult Cancer Survivors: Randomized Comparative Effectiveness Study

Background

Smoking among cancer survivors increases the risk of late effects and second cancers. This article reports on Partnership for Health-2 (PFH-2)—an effort to develop an effective and scalable version of Partnership for Health (PFH), which was a previously tested peer-delivered telephone counseling program that doubled smoking cessation rates among childhood cancer survivors who smoke.

Objective

This paper presents results from a randomized controlled trial evaluating the effectiveness of PFH-2 in targeted and tailored Web-based versus print formats. The overall goal was to determine whether the intervention outcomes in these self-guided scalable formats approximate what was found in a more intensive telephone counseling program.

Methods

This study was a randomized controlled trial with a 15-month follow-up that included 374 smokers who were survivors of childhood or young adult cancers, recruited from five survivorship clinics. Participants were randomly assigned to a Web-based or print format of the PFH intervention; all had access to free pharmacotherapy. The website was designed to provide new content at each log-on, and a peer counselor moderated a forum/chat feature. The primary outcome was smoking status at 15 months post randomization.

Results

In total, 58.3% (77/132) of Web participants logged on at least once (mean visits 3.25). Using multiple imputation methods for missing data, there were similar rates of cessation in the two arms (print: 20/128, 15.6%; Web: 33/201, 6.4%), and no differences in quit attempts or readiness to quit. The quit rates were equivalent to those found in our previous telephone counseling intervention. There were high rates of satisfaction with both of the PFH-2 interventions.

Conclusions

The print and Web formats yielded equivalent levels of success to those found with our telephone-delivered intervention and are comparable to other Internet treatment studies. This study provides important options for survivorship programs that may not have resources for interpersonal forms of cessation counseling. Efforts to increase patient use of the interventions may result in higher cessation rates.

Trial Registration

Clinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00588107","term_id":"NCT00588107"}}NCT00588107; http://clinicaltrials.gov/ct2/show/{"type":"clinical-trial","attrs":{"text":"NCT00588107","term_id":"NCT00588107"}}NCT00588107 (Archived by WebCite at http://www.webcitation.org/6K1gJtFEC).     

Smoking Cessation: Significance and Implications for Children

A number of people in the USA who are still current smokers remain a staggering figure. Although this number continues to decrease, there is still a considerable amount of second-hand smoke. More importantly and for the purpose of this review, the detrimental effects of passive smoke in children is significant. We will not review the specific health effects of passive smoke, but for pediatricians, in particular, it is important to place in perspective programs that are available to influence the parents of children to stop smoking. Indeed, approximately 25% of all children aged 3–11 live in a household with at least one smoker. Despite the increasing number of communities in the states that have instituted restrictions or complete bans on smoking in the workplace and in many public areas, the principal site of smoking remains the home.     

Smoking Cessation Apps for Smartphones: Content Analysis With the Self-Determination Theory

Background

Smartphones are increasingly receiving attention from public health scholars and practitioners as a means to assist individuals’ health management. A number of smartphone apps for smoking cessation are also available; however, little effort has been made to evaluate the content and functions of these apps employing a theoretical framework.

Objective

The present study aims to analyze and evaluate the contents of smoking cessation apps available in South Korea employing the self-determination theory (SDT) as a theoretical framework for analysis. This study analyzes the extent to which smoking cessation apps have features that satisfy the basic needs identified in the SDT, which stimulate autonomous motivation. The type of motivational goal content manifested in the apps and how the goal content was framed are also explored. By assessing the features of smoking cessation apps based on the SDT, this study aims to offer direction for improvement for these apps.

Methods

Out of 309 apps identified from the iTunes store and Google Play (excluding 27 duplications), 175 apps were randomly drawn and analyzed. The coding scheme was drafted by the authors based on the SDT and gain/loss framing theory and was further finely tuned through the process of coder training and by establishing intercoder reliability. Once the intercoder reliability was established, the coders divided up the rest of the sample and coded them independently.

Results

The analysis revealed that most apps (94.3%, 165/175) had at least one feature that tapped at least 1 of the 3 basic needs. Only 18 of 175 apps (10.3%) addressed all 3 basic needs. For goal content, money (53.7%, 94/175) showed the highest frequency, followed by health (32.0%, 56/175), time (7.4%, 13/175), and appearance (1.1%, 2/175), suggesting that extrinsic goals are more dominantly presented in smoking cessation apps. For the framing of goal content, gain framing appeared more frequently (41.7%, 73/175).

Conclusions

The results suggest that these smoking cessation apps may not sufficiently stimulate autonomous motivation; a small number of apps addressed all 3 basic needs suggested by the SDT (ie, autonomy, competence, and relatedness). The apps also tended to present extrinsic goal content (primarily in terms of money) over intrinsic ones (ie, health) by primarily adopting gain framing. Implications of these findings for public health practitioners and consumers are discussed.     

Comparison of Text and Video Computer-Tailored Interventions for Smoking Cessation: Randomized Controlled Trial

Background

A wide range of effective smoking cessation interventions have been developed to help smokers to quit. Smoking rates remain high, especially among people with a lower level of education. Multiple tailoring adapted to the individual’s readiness to quit and the use of visual messaging may increase smoking cessation.

Objective

The results of video and text computer tailoring were compared with the results of a control condition. Main effects and differential effects for subgroups with different educational levels and different levels of readiness to quit were assessed.

Methods

During a blind randomized controlled trial, smokers willing to quit within 6 months were assigned to a video computer tailoring group with video messages (n=670), a text computer tailoring group with text messages (n=708), or to a control condition with short generic text advice (n=721). After 6 months, effects on 7-day point prevalence abstinence and prolonged abstinence were assessed using logistic regression analyses. Analyses were conducted in 2 samples: (1) respondents (as randomly assigned) who filled in the baseline questionnaire and completed the first session of the program, and (2) a subsample of sample 1, excluding respondents who did not adhere to at least one further intervention session. In primary analyses, we used a negative scenario in which respondents lost to follow-up were classified as smokers. Complete case analysis and multiple imputation analyses were considered as secondary analyses.

Results

In sample 1, the negative scenario analyses revealed that video computer tailoring was more effective in increasing 7-day point prevalence abstinence than the control condition (OR 1.45, 95% CI 1.09-1.94, P=.01). Video computer tailoring also resulted in significantly higher prolonged abstinence rates than controls among smokers with a low (ready to quit within 4-6 months) readiness to quit (OR 5.13, 95% CI 1.76-14.92, P=.003). Analyses of sample 2 showed similar results, although text computer tailoring was also more effective than control in realizing 7-day point prevalence abstinence. No differential effects were found for level of education. Complete case analyses and multiple imputation yielded similar results.

Conclusions

In all analyses, video computer tailoring was effective in realizing smoking cessation. Furthermore, video computer tailoring was especially successful for smokers with a low readiness to quit smoking. Text computer tailoring was only effective for sample 2. Results suggest that video-based messages with personalized feedback adapted to the smoker’s motivation to quit might be effective in increasing abstinence rates for smokers with diverse educational levels.

Trial Registration

Netherlands Trial Register: NTR3102; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3102 (Archived by WebCite at http://www.webcitation.org/6NS8xhzUV).     

Perception of Computer-tailored Feedback for Smoking Cessation: Qualitative Findings from Focus Groups

Tobacco smoking continues to be a major public health problem. Few smokers present themselves for treatment, and it is important to offer a range of interventions that appeal to different individual needs and preferences. Computer-tailored feedback can fill the gap between generic self-help and intensive clinical therapy. Using focus groups, we investigated smokers' perceptions of generic self-help materials and computer-generated individually tailored feedback reports. Participants recognized the generic nature of self-help material and welcomed the concept of personal support, but were concerned about some aspects of the material. Findings supported the continuation of the development and delivery of computer-tailored feedback, but more research is warranted to optimize the content and style of the feedback for individual perceptions and expectations.     

Smoking and HIV: Prevalence, Health Risks, and Cessation Strategies

Health hazards due to smoking may undermine benefits of HIV treatment on morbidity and mortality. Over 40% of persons with HIV are current smokers. Health risks of smoking include increases in some HIV-associated infections, cardiovascular disease, some cancers, bacterial pneumonia and other lung disease, and overall mortality. Proven strategies for smoking cessation include various counseling approaches, nicotine replacement therapy and other pharmacotherapy; approaches may need to be individualized to address specific client needs and comorbidities. HIV clinicians and other service providers can have an influential role in screening their patients for smoking and promoting cessation programs to improve health.     

A Text Messaging-Based Smoking Cessation Program for Adult Smokers: Randomized Controlled Trial

BackgroundDespite promising data in Western countries, there is a dearth of research into the efficacy of text messaging-based smoking cessation programs in other settings, including the Middle East, where smoking prevalence rates are higher.ObjectiveThis paper reports cessation rates observed in SMS Turkey, a text messaging-based smoking cessation program for adult smokers in Ankara, Turkey.MethodsThis study was a small-scale, parallel-group randomized controlled trial (RCT) conducted in Ankara, Turkey. Participants were adult daily smokers who were seriously thinking about quitting in the next 15 days and living in Ankara, Turkey. The text messaging intervention, SMS Turkey, provided 6 weeks of daily messages aimed at giving participants skills to help them quit smoking. Messages were sent in an automated fashion, except 2 days and 7 days after the initial quit day. On days 2 and 7, the research assistant manually assigned participants to content “paths” based on whether they were still not smoking or had relapsed. The control arm received a brochure that provided similar information about smoking cessation. The main outcome measure was self-reported 3-month sustained abstinence, verified by carbon monoxide (CO) readings. Neither participants nor researchers were blinded to arm assignment.ResultsThe 151 participants were randomly assigned to 1 of 2 groups: 76 to the SMS Turkey intervention group and 75 to the brochure control group. Using intention to treat, all 151 participants were included in analyses. Three-month cessation trends were not significantly higher in the intervention group: 11% intervention vs 5% control had quit (χ² ₁=1.4, P=.24; R²=2.0, 95% CI 0.62-6.3). When the sample was stratified by sex, female intervention participants (14%, n=5) were significantly more likely to have quit at 3 months than female control participants (0%, n=0; χ² ₁=3.7, P=.05). Among light smokers (ie, those smoking less than 20 cigarettes per day), intervention participants (17%, n=5) also were significantly more likely to have quit compared to control participants (0%, n=0; χ² ₁=5.3, P=.02). We noted no difference in cessation rates for males or heavy smokers. Participants experienced significant technology problems during the study. Some participants received duplicate text messages at least once during the trial; others failed to receive some program messages. Neither receiving duplicate messages (χ² ₁=0.12, P=.73), or missing 5 or more program messages (χ² ₁=0.75, P=.39) negatively affected quitting rates.ConclusionsAlthough the study was not powered to detect statistically significant differences, as the primary aim was to provide estimates of effect size that could be used to better inform a power analysis for a larger trial, findings provide optimism that SMS Turkey may be able to affect quitting rates in environments with high smoking prevalence, such as Ankara, Turkey. The SMS Turkey software program did not work as well as it did 2 years previous. The system will need to be updated to maintain software compatibility with ongoing technology evolution.

Trial Registration

Clinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00912795","term_id":"NCT00912795"}}NCT00912795 http://clinicaltrials.gov/ct2/show/{"type":"clinical-trial","attrs":{"text":"NCT00912795","term_id":"NCT00912795"}}NCT00912795 (Archived by WebCite at http://www.webcitation.org/6Ch1cIA8l).     

Facebook Apps for Smoking Cessation: A Review of Content and Adherence to Evidence-Based Guidelines

Background

Facebook is the most popular social network site, with over 1 billion users globally. There are millions of apps available within Facebook, many of which address health and health behavior change. Facebook may represent a promising channel to reach smokers with cessation interventions via apps. To date, there have been no published reports about Facebook apps for smoking cessation.

Objective

The purpose of this study was to review the features and functionality of Facebook apps for smoking cessation and to determine the extent to which they adhere to evidence-based guidelines for tobacco dependence treatment.

Methods

In August 2013, we searched Facebook and three top Internet search engines using smoking cessation keywords to identify relevant Facebook apps. Resultant apps were screened for eligibility (smoking cessation-related, English language, and functioning). Eligible apps were reviewed by 2 independent coders using a standardized coding scheme. Coding included content features (interactive, informational, and social) and adherence to an established 20-item index (possible score 0-40) derived from the US Public Health Service’s Clinical Practice Guidelines for Treating Tobacco Use and Dependence.

Results

We screened 22 apps for eligibility; of these, 12 underwent full coding. Only 9 apps were available on Facebook. Facebook apps fell into three broad categories: public pledge to quit (n=3), quit-date–based calculator/tracker (n=4), or a multicomponent quit smoking program (n=2). All apps incorporated interactive, informational, and social features except for two quit-date–based calculator/trackers apps (lacked informational component). All apps allowed app-related posting within Facebook (ie, on self/other Facebook profile), and four had a within-app “community” feature to enable app users to communicate with each other. Adherence index summary scores among Facebook apps were low overall (mean 15.1, SD 7.8, range 7-30), with multicomponent apps scoring the highest.

Conclusions

There are few smoking cessation apps available within Facebook. Among those available, adherence to cessation treatment guidelines was low. Smoking cessation interventions provided via the Facebook platform are a unique and as yet untapped treatment strategy that can harness existing social support and social networks for quitting. Research is needed to examine whether apps that adhere to clinical practice guidelines for tobacco dependence treatment are more effective in promoting cessation than those that do not.     

Efficacy of Team-Based Financial Incentives for Smoking Cessation in the Workplace

Worksite smoking cessation programs offer accessibility of the target population, availability of occupational health support, and the potential for peer pressure and peer support. The purpose of this study was to identify the efficacy of the financial incentives given to various teams in the workplace. St. Paul''s Hospital''s employees were enrolled. Each team of employees consisted of smoking participants and non-smoking fellow workers from the same department. The financial incentive of 50000 won (about $45) was rewarded to the team for each successful participant-not to individual members-after the first week and then after one month. If the smokers in the team remained abstinent for a longer time period, the team was given an incentive of 100000 won for each successful participant after 3 and 6 months. A total 28 smoking participants and 6 teams were enrolled. Self-reported abstinence rates validated by urinary cotinine test at 3, 6, and 12 months after the initial cessation were 61%, 54%, and 50%, respectively. Smokers with high nicotine dependence scores or those who began participation 1 month after enrollment initiation had a lower abstinence rate at 3 months, but not at 6 and 12 months. Participants who succeeded at smoking cessation at 12 months were more likely to be older and have a longer smoking duration history. The financial incentives given to teams could be promising and effective to improve long-term rates of smoking cessation. This approach could use peer pressure and peer support in the workplace over a longer period.     

Acculturation and Cigarette Smoking Among African Americans: Replication and Implications for Prevention and Cessation Programs

We report a replication of a 1996 study on the role of acculturation in smoking among African American adults. Results with the current sample were nearly identical to the prior ones: smokers tended to be traditional and nonsmokers acculturated, with nearly 70% of Black smokers in both studies being highly traditional in their cultural orientation. Given that coming from a highly traditional Black family was a strong predictor of smoking in both studies, we suggest that new smoking prevention and cessation programs might be culturally tailored for Blacks by focusing on smoking as a familywide issue.