Improving quit rates of web-delivered interventions for smoking cessation: full-scale randomized trial of WebQuit.org versus Smokefree.gov

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Abstract

<div class="section"> <a class="named-anchor" id="S1">  </a> <h5 class="section-title" id="d3298248e145">Background and aims</h5> <p id="P1">Millions of people worldwide use websites to help them quit smoking, but effectiveness trials have an average 34% follow-up data retention rate and an average 9% quit rate. We compared the quit rates of a website using a new behavioral approach called Acceptance and Commitment Therapy (ACT; WebQuit.org) with the current standard of the National Cancer Institute’s (NCI) Smokefree.gov website. </p> </div><div class="section"> <a class="named-anchor" id="S2">  </a> <h5 class="section-title" id="d3298248e156">Design</h5> <p id="P2">A two-arm stratified double-blind individually randomized trial (n = 1319 for WebQuit; n = 1318 for Smokefree.gov) with 12-month follow-up. </p> </div><div class="section"> <a class="named-anchor" id="S3">  </a> <h5 class="section-title" id="d3298248e164">Setting</h5> <p id="P3">USA.</p> </div><div class="section"> <a class="named-anchor" id="S4">  </a> <h5 class="section-title" id="d3298248e169">Participants</h5> <p id="P4">Adults (N = 2637) who currently smoked at least 5 cigarettes per day were recruited from March 2014 to August 2015. At baseline, participants were mean (SD) age of 46.2 (13.4), 79% women, and 73% white. </p> </div><div class="section"> <a class="named-anchor" id="S5">  </a> <h5 class="section-title" id="d3298248e174">Interventions</h5> <p id="P5"> WebQuit.org website (experimental) provided ACT for smoking cessation; Smokefree.gov website (comparison) followed US Clinical Practice Guidelines for smoking cessation. </p> </div><div class="section"> <a class="named-anchor" id="S6">  </a> <h5 class="section-title" id="d3298248e185">Measurements</h5> <p id="P6">The primary outcome was self-reported 30-day point prevalence abstinence at 12 months.</p> </div><div class="section"> <a class="named-anchor" id="S7">  </a> <h5 class="section-title" id="d3298248e190">Findings</h5> <p id="P7">The 12-month follow-up data retention rate was 88% (2309/2637). The 30-day point prevalence abstinence rates at the 12-month follow-up were 24% (278/1141) for WebQuit.org and 26% (305/1168) for Smokefree.gov (OR = 0.91; 95% CI = 0.76, 1.10); p = 0.334) in the a priori complete case analysis. Abstinence rates were 21% (278/1319) for WebQuit.org and 23% (305/1318) for Smokefree.gov (OR = 0.89 (0.74, 1.07); p = 0.200) when missing cases were imputed as smokers. The Bayes Factor comparing the primary abstinence outcome was 0.17, indicating “substantial” evidence of no difference between groups. </p> </div><div class="section"> <a class="named-anchor" id="S8">  </a> <h5 class="section-title" id="d3298248e207">Conclusions</h5> <p id="P8"> WebQuit.org and Smokefree.gov had similar 30-day point prevalence abstinence rates at 12 months that were descriptively higher than those of prior published website-delivered interventions and telephone counselor-delivered interventions. </p> </div>

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Acceptance and commitment therapy and contextual behavioral science: examining the progress of a distinctive model of behavioral and cognitive therapy.

Steven C. Hayes, Michael E Levin, Jennifer Plumb-Vilardaga … (2013)

A number of recent authors have compared acceptance and commitment therapy (ACT) and traditional cognitive behavior therapy (CBT). The present article describes ACT as a distinct and unified model of behavior change, linked to a specific strategy of scientific development, which we term "contextual behavioral science." We outline the empirical progress of ACT and describe its distinctive development strategy. A contextual behavioral science approach is an inductive attempt to build more adequate psychological systems based on philosophical clarity; the development of basic principles and theories; the development of applied theories linked to basic ones; techniques and components linked to these processes and principles; measurement of theoretically key processes; an emphasis on mediation and moderation in the analysis of applied impact; an interest in effectiveness, dissemination, and training; empirical testing of the research program across a broad range of areas and levels of analysis; and the creation of a more effective scientific and clinical community. We argue that this is a reasonable approach, focused on long-term progress, and that in broad terms it seems to be working. ACT is not hostile to traditional CBT, and is not directly buoyed by whatever weaknesses traditional CBT may have. ACT should be measured at least in part against its own goals as specified by its own developmental strategy.

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Internet-based interventions for smoking cessation

Gemma M. J. Taylor, Michael N Dalili, Monika Semwal … (2017)

Tobacco use is estimated to kill 7 million people a year. Nicotine is highly addictive, but surveys indicate that almost 70% of US and UK smokers would like to stop smoking. Although many smokers attempt to give up on their own, advice from a health professional increases the chances of quitting. As of 2016 there were 3.5 billion Internet users worldwide, making the Internet a potential platform to help people quit smoking. To determine the effectiveness of Internet‐based interventions for smoking cessation, whether intervention effectiveness is altered by tailoring or interactive features, and if there is a difference in effectiveness between adolescents, young adults, and adults. We searched the Cochrane Tobacco Addiction Group Specialised Register, which included searches of MEDLINE, Embase and PsycINFO (through OVID). There were no restrictions placed on language, publication status or publication date. The most recent search was conducted in August 2016. We included randomised controlled trials (RCTs). Participants were people who smoked, with no exclusions based on age, gender, ethnicity, language or health status. Any type of Internet intervention was eligible. The comparison condition could be a no‐intervention control, a different Internet intervention, or a non‐Internet intervention. To be included, studies must have measured smoking cessation at four weeks or longer. Two review authors independently assessed and extracted data. We extracted and, where appropriate, pooled smoking cessation outcomes of six‐month follow‐up or more, reporting short‐term outcomes narratively where longer‐term outcomes were not available. We reported study effects as a risk ratio (RR) with a 95% confidence interval (CI). We grouped studies according to whether they (1) compared an Internet intervention with a non‐active control arm (e.g. printed self‐help guides), (2) compared an Internet intervention with an active control arm (e.g. face‐to‐face counselling), (3) evaluated the addition of behavioural support to an Internet programme, or (4) compared one Internet intervention with another. Where appropriate we grouped studies by age. We identified 67 RCTs, including data from over 110,000 participants. We pooled data from 35,969 participants. There were only four RCTs conducted in adolescence or young adults that were eligible for meta‐analysis. Results for trials in adults: Eight trials compared a tailored and interactive Internet intervention to a non‐active control. Pooled results demonstrated an effect in favour of the intervention (RR 1.15, 95% CI 1.01 to 1.30, n = 6786). However, statistical heterogeneity was high (I 2 = 58%) and was unexplained, and the overall quality of evidence was low according to GRADE. Five trials compared an Internet intervention to an active control. The pooled effect estimate favoured the control group, but crossed the null (RR 0.92, 95% CI 0.78 to 1.09, n = 3806, I 2 = 0%); GRADE quality rating was moderate. Five studies evaluated an Internet programme plus behavioural support compared to a non‐active control (n = 2334). Pooled, these studies indicated a positive effect of the intervention (RR 1.69, 95% CI 1.30 to 2.18). Although statistical heterogeneity was substantial (I 2 = 60%) and was unexplained, the GRADE rating was moderate. Four studies evaluated the Internet plus behavioural support compared to active control. None of the studies detected a difference between trial arms (RR 1.00, 95% CI 0.84 to 1.18, n = 2769, I 2 = 0%); GRADE rating was moderate. Seven studies compared an interactive or tailored Internet intervention, or both, to an Internet intervention that was not tailored/interactive. Pooled results favoured the interactive or tailored programme, but the estimate crossed the null (RR 1.10, 95% CI 0.99 to 1.22, n = 14,623, I 2 = 0%); GRADE rating was moderate. Three studies compared tailored with non‐tailored Internet‐based messages, compared to non‐tailored messages. The tailored messages produced higher cessation rates compared to control, but the estimate was not precise (RR 1.17, 95% CI 0.97 to 1.41, n = 4040), and there was evidence of unexplained substantial statistical heterogeneity (I 2 = 57%); GRADE rating was low. Results should be interpreted with caution as we judged some of the included studies to be at high risk of bias. The evidence from trials in adults suggests that interactive and tailored Internet‐based interventions with or without additional behavioural support are moderately more effective than non‐active controls at six months or longer, but there was no evidence that these interventions were better than other active smoking treatments. However some of the studies were at high risk of bias, and there was evidence of substantial statistical heterogeneity. Treatment effectiveness in younger people is unknown. Can Internet‐based interventions help people to stop smoking? Background Tobacco use is estimated to kill 7 million people a year. Nicotine is highly addictive, but surveys indicate that almost 70% of US and UK smokers would like to stop smoking. Although many smokers attempt to give up on their own, advice from a health professional increases the chances of quitting. As of 2016 there were 3.5 billion Internet users worldwide. The Internet is an attractive platform to help people quit smoking because of low costs per user, and it has potential to reach smokers who might not access support because of limited health care availability or stigmatisation. Internet‐based interventions could also be used to target young people who smoke, or others who may not seek traditional methods of smoking treatment. Study Characteristics Up to August 2016, this review found 67 trials, including data from over 110,000 participants. Smoking cessation data after six months or more were available for 35,969 participants. We examined a range of Internet interventions, from a low intensity intervention, for example providing participants with a list of websites for smoking cessation, to intensive interventions consisting of Internet‐, email‐ and mobile phone‐delivered components. We classed interventions as tailored or interactive, or both. Tailored Internet interventions differed in the amount of tailoring, from multimedia components to personalised message sources. Some interventions also included Internet‐based counselling or support from nurses, peer coaches or tobacco treatment specialists. Recent trials incorporated online social networks, such as Facebook, Twitter, and other online forums. Key results In combined results, Internet programmes that were interactive and tailored to individual responses led to higher quit rates than usual care or written self‐help at six months or longer. Quality of evidence There were not many trials conducted in younger people. More trials are needed to determine the effect on Internet‐based methods to aid quitting in youth and young adults. Results should be interpreted with caution, as we rated some of the included studies at high risk of bias, and for most outcomes the quality of evidence was moderate or low.

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The effectiveness and cost effectiveness of telephone counselling and the nicotine patch in a state tobacco quitline.

Jack F Hollis, Timothy A. McAfee, Michael Stark … (2007)

State and national tobacco quitlines have expanded rapidly and offer a range of services. We examined the effectiveness and cost effectiveness of offering callers single session versus multisession counselling, with or without free nicotine patches. This 3x2 randomised trial included 4614 Oregon tobacco quitline callers and compared brief (one 15-minute call), moderate (one 30-minute call and a follow-up call) and intensive (five proactive calls) intervention protocols, with or without offers of free nicotine patches (nicotine replacement therapy, NRT). Blinded staff assessed tobacco use by phone at 12 months. Abstinence odds ratios were significant for moderate (OR = 1.22, CI = 1.01 to 1.48) and intensive (OR = 1.29, CI = 1.07 to 1.56) intervention, and for NRT (OR = 1.58, CI = 1.35 to 1.85). Intent to treat quit rates were as follows: brief no NRT (12%); brief NRT (17%); moderate no NRT (14%); moderate NRT (20%); intensive no NRT (14%); and intensive NRT (21%). Relative to brief no NRT, the added costs for each additional quit was $2467 for brief NRT, $1912 for moderate no NRT, $2109 for moderate NRT, $2641 for intensive no NRT, and $2112 for intensive NRT. Offering free NRT and multisession telephone support within a state tobacco quitline led to higher quit rates, and similar costs per incremental quit, than less intensive protocols.