Jessica A. Whiteley

Smoking cessation treatment on the Internet: Content, quality, and usability

The explosive growth in access to the Internet suggests that the Internet may be a viable channel through which we can reach and treat the large population of smokers who are unlikely to use other modes of intervention. We applied national guidelines from the U.S. Public Health Service to assess the quality of interventions for smoking cessation that are available on the Internet. The Public Health Service guidelines were codified into two instruments to record and to rate quality of the intervention contents. Usability guidelines established by the National Cancer Institute were used to develop an instrument to assess Web site usability. Of the 202 Web sites identified in searches, 77% did not provide direct intervention over the Internet and were excluded from analyses. A total of 46 Web sites were included in our review. Usability assessments showed mixed results. Web sites were visually well organized and used consistent graphical design; however, reading difficulty averaged above the 8th-grade level. Over 80% of Web sites provided no coverage of one or more of the key components of tobacco treatment recommended in the guidelines. Ironically, areas receiving the least coverage were those most amenable to the interactive capabilities of the Internet, such as providing tailored, personalized advice to quit and arranging follow-up contact. Smokers seeking quality tobacco dependence treatment on the Internet may have difficulty distinguishing among the numerous Web sites available. Web sites that provide direct treatment often fail to fully implement treatment guidelines and do not take full advantage of the interactive and tailoring capabilities of the Internet.

A Review of Web Assisted Tobacco Interventions (WATIs)

Background The Internet has great potential to provide assistance to millions of smokers who seek help with quitting smoking. Objective The goals of this study were to assess the content and the quality of smoking cessation treatments most likely to be encountered by smokers seeking treatment on the Internet and to examine differences in quality between current websites and those reviewed in 2004. Methods Internet searches for smoking cessation were designed to mimic the search patterns of most Internet users. PhD-level specialists in tobacco cessation treatments used standardized procedures to review the content of each website, assess the degree to which each site covered key components of evidence-based treatment as described in US national guidelines, determine the accuracy of information presented, and evaluate the use of website interactivity. Results of the current study were compared to results obtained in a prior review. Results Most websites retrieved in the search met exclusion criteria and were not included in the final analyses in both the current (74%, 65/88) and the prior study (77%, 156/202). In both studies, the majority of websites were excluded because they sold cessation-related products but did not provide treatment recommended by the Public Health Service guidelines. Of the 23 websites included in the current study, 26% (n = 6) provided only minimal coverage (brief mention) of key components of tobacco treatment. However, compared to the earlier study, websites included in the present study scored significantly higher in quality ratings in four areas: providing advice to quit (P = .05), practical counseling (P = .02), and enhancing motivation to quit smoking through personal relevance (P = .05) and risks (P < .001). Most Web-assisted tobacco intervention (WATI) sites (69%, 16/23) contained no inaccurate information. When observed, inaccuracies primarily occurred in content related to pharmacotherapy. The percentage of sites offering at least one interactive feature increased from 39% (18/46) in 2004 to 56% (13/23) in the present study. Despite this improvement, there was a notable underutilization of the interactive capabilities of the Internet to personalize treatment, to connect users with a virtual support system, and to provide follow-up treatment contacts. Conclusions While the quality of treatment offered in WATIs has improved since our previous review in 2004, there is substantial room for further improvement to ensure that smokers are offered high-quality, evidence-based treatments. It is not clear what degree of informational detail and interactivity is optimal for Web-based smoking cessation treatments. Additional research is needed to understand how to maximize the interactive capabilities of the Internet to produce and sustain population-based health behavior change.

MEDIATORS OF PHYSICAL ACTIVITY BEHAVIOR CHANGE: A MULTIVARIATE APPROACH

OBJECTIVE Using a multivariate extension of the Baron and Kenny (1986) mediation framework, we examined the simultaneous effect of variables hypothesized to mediate the relationship between a motivationally tailored physical activity intervention, and 6-month physical activity behavior in 239 healthy, underactive adults (M age = 47.5; 82% women). DESIGN Participants were randomly assigned to (a) print-based feedback; (b) telephone-based feedback; or (c) contact control. MAIN OUTCOME MEASURES Psychosocial variables, including self-efficacy, decisional balance, and processes of change. RESULTS All mediation criteria were satisfied for both intervention arms. A moderate indirect effect of print (0.39, 95% CI = 0.21, 0.57) was found due to increases in behavioral processes (0.54, 95% CI = 0.29, 0.80) being attenuated by decreases due to cognitive processes (-0.17, 95%CI = 0.31,-.03). A moderate indirect effect was observed for telephone (0.47, 95% CI = 0.28, 0.66), with increases due to behavioral processes (0.61, 95% CI = 0.34, 0.87) attenuated by decreases due to cognitive processes (0.15, 95% CI = -0.27, -0.02); self-efficacy and decisional balance mediational paths did not attain statistical significance. CONCLUSIONS These findings highlight the importance of studies that deconstruct the theoretical components of interventions to determine which combination produces the greatest behavior changes at the lowest cost.

Is physical activity a gateway behavior for diet? Findings from a physical activity trial

OBJECTIVE While cross-sectional research indicates physical inactivity and poor diet tend to co-occur, there are limited longitudinal data on how interventions targeting one behavior affect other behaviors. The current investigation examined cross-sectional and longitudinal relationships between health behaviors within the context of a physical activity (PA) intervention. METHODS Sedentary women (n=280; mean age=47.1; 94.6% Caucasian) were enrolled in a randomized controlled PA trial comparing the effects of print-based, individually-tailored and gender-targeted PA interventions to a wellness/control condition. Women completed baseline, month 3, and month 12 assessments that included measures of PA and dietary behaviors. RESULTS Participants in more advanced PA stages of change reported significantly greater fruits/vegetables consumption than participants in less advanced stages, although the relationships between diet and minutes of weekly activity were less pronounced. The tailored and targeted print-based PA interventions had no effect on fruit/vegetable intake, although significant reductions in fat intake were observed from baseline (M=31.24%) to month 3 (M=30.41%), p<0.03; and baseline to month 12 (M=30.36%), p<0.01. Changes in PA were not predictive of improvements in eating behaviors. CONCLUSIONS Although fat intake decreased in the context of this PA intervention, fruit/vegetable intake remained unchanged. Also, PA did not serve as a gateway behavior for dietary improvements. In fact, improvements in activity were associated with increases rather than decreases in fat intake.

The Efficacy of Stage-Matched and Standard Public Health Materials for Promoting Physical Activity in the Workplace: The Physical Activity Workplace Study (PAWS)

Purpose. To compare the effects of stage-matched and standard print materials for physical activity (PA) change. Design. Participants were randomized into (1) a stage-matched intervention group (n = 165), (2) a standard intervention group (n = 176), or (3) a no-contact control group (n = 166). The stage-matched and standard intervention groups both received materials at baseline, 3 months, and 6 months. Assessments of all three groups were conducted at baseline, 6, and 12 months. Setting. Canadian worksites. Subjects. Employees (N = 507). Interventions. Five motivationally targeted booklets were developed for the stage-matched group. The standard group received Canadas Physical Activity Guide and handbook. Measures. The main dependent variable was PA, expressed as metabolic equivalent (MET) minutes and measured using the Godin Leisure-Time Exercise Questionnaire. Demographic characteristics and stages of change for PA were also assessed. Results. At 12 months mean weekly MET minutes for combined moderate and vigorous activity increased from baseline by 223, 67, and 78 for the stage-matched, standard, and control groups, respectively; however, differences were not significant (p > .05). Women in the stage-matched group over the 12-month period significantly increased their activity by 327 weekly MET minutes whereas the standard and control groups declined their activity (F = 3.01, p < .05). Conclusion. PA stage-matched materials delivered in the workplace are efficacious for women but not men. Future interventions should explore the use of these intervention materials in conjunction with multilevel strategies, and particular attention should be paid to possible gender differences.

When, why and for whom there is a relationship between physical activity and menopause symptoms.

OBJECTIVES The relationship between enhanced physical activity and decreased menopause symptoms is equivocal. In this study we sought to better understand this relationship by examining the association of physical activity to different symptom domains and by examining mediating and moderating variables. STUDY DESIGN Women participating in a randomized control trial on physical activity were given a menopause symptom measure (MENQOL) at follow-up. Of the 280 women participating, 113 (mean age=52) reported having symptoms they attributed to menopause. Regression analyses were run to examine if change in physical activity predicted fewer symptoms. Exercise self-efficacy was examined as a mediator and depressive symptoms as a moderator. RESULTS An increase in physical activity from baseline was found to be related to reporting fewer total menopause symptoms (beta=-0.22, p=.02). When the total menopause symptoms score was examined by domain, increased physical activity was found to be related to reporting fewer general symptoms attributed to menopause (psychosocial (beta=-0.18, p=.05) and physical (beta=-0.23, p=.01)), but had no effect on specific symptoms of menopause (vasomotor and sexual). Exercise self-efficacy was found to mediate the relationship between increased physical activity and total, physical and psychosocial menopause symptoms. Finally, for individuals with high depressive symptoms, those who increased physical activity the most reported fewer sexual symptoms of menopause. CONCLUSION This study suggests that physical activity participation is associated with lower general symptom reporting as opposed to specifically impacting menopause symptoms. Further, exercise self-efficacy mediates the relationship between physical activity and general menopause symptoms, suggesting a psychological pathway.

User attitudes towards physical activity websites in a randomized controlled trial

OBJECTIVE To better understand the mixed findings regarding the efficacy of Internet-based physical activity interventions, we examined the use and usefulness of particular website components that may lead to improvements in intervention efficacy. METHOD Participants were sedentary individuals from a 12-month randomized controlled physical activity trial conducted in Providence, Rhode Island and Pittsburgh, Pennsylvania from 2003-2006. The present study included participants from the Tailored Internet arm (n=81; instantaneous web-based tailored feedback to participants) or the Standard Internet arm (n=82; websites currently available to the public). We obtained objective data via the intervention websites and subjective usefulness data via questionnaires. RESULTS The Tailored Internet arm logged onto their website significantly more times than the Standard Internet arm (median 50 vs. 38; p<.05). Among participants in the Tailored Internet arm, the self-monitoring feature (i.e., logging) followed by goal setting were rated as the most useful website components. CONCLUSION Logins in the current study were substantially higher compared to previous studies. Participants endorsed goal setting and self-monitoring as being most useful, which are critical components for health behavior change. Future studies should continue to examine these features and improve the perceived usefulness of other theory-based strategies.

Moderate Intensity Exercise as an Adjunct to Standard Smoking Cessation Treatment for Women: A Pilot Study

Previous randomized controlled trials have not supported moderate intensity exercise as an efficacious adjunct to smoking cessation treatments for women; however, compliance with exercise programs in these studies has been poor. The purpose of this pilot study was to estimate the effects of moderate intensity exercise on smoking cessation outcomes under optimal conditions for exercise program compliance. Sixty previously sedentary, healthy, female smokers were randomized to an 8-week program consisting of brief baseline smoking cessation counseling and the nicotine patch plus either 150 min/week of moderate intensity exercise or contact control. Participants attended a median of 86.4% and 95.5% of prescribed exercise/control sessions, respectively. There was a moderate, though statistically nonsignificant, effect of exercise at post-treatment for objectively verified 7-day point prevalence abstinence (48.3% vs. 23.3%; OR = 3.07, 95% CI: 0.89-11.07) and prolonged abstinence (34.5% vs. 20.0%; OR = 2.11, 95% CI: 0.56-8.32). Effects were attenuated when controlling for potential confounders, and after a 1-month, no-treatment period. The findings provide a preliminary indication that, given adequate compliance, moderate intensity exercise may enhance short-term smoking cessation outcomes for women; however, a larger trial is warranted.

Acute effects of moderate intensity aerobic exercise on affective withdrawal symptoms and cravings among women smokers

A growing number of laboratory studies have shown that acute bouts of aerobic exercise favorably impact affect and cravings among smokers. However, randomized trials have generally shown exercise to have no favorable effect on smoking cessation or withdrawal symptoms during quit attempts. The purpose of the present study was to explore this apparent contradiction by assessing acute changes in affect and cravings immediately prior to and following each exercise and contact control session during an eight-week smoking cessation trial. Sixty previously low-active, healthy, female smokers were randomized to an eight-week program consisting of brief baseline smoking cessation counseling and the nicotine patch plus either three sessions/week of moderate intensity aerobic exercise or contact control. Findings revealed a favorable impact of exercise on acute changes in positive activated affect (i.e., energy), negative deactivated affect (i.e., tiredness), and cigarette cravings relative to contact control. However, effects dissipated from session to session. Results suggest that aerobic exercise has potential as a smoking cessation treatment, but that it must be engaged in frequently and consistently over time in order to derive benefits. Thus, it is not surprising that previous randomized controlled trials-in which adherence to exercise programs has generally been poor-have been unsuccessful in showing effects of aerobic exercise on smoking cessation outcomes.

Weight gain prevention among black women in the rural community health center setting: The Shape Program

BackgroundNearly 60% of black women are obese. Despite their increased risk of obesity and associated chronic diseases, black women have been underrepresented in clinical trials of weight loss interventions, particularly those conducted in the primary care setting. Further, existing obesity treatments are less effective for this population. The promotion of weight maintenance can be achieved at lower treatment intensity than can weight loss and holds promise in reducing obesity-associated chronic disease risk. Weight gain prevention may also be more consistent with the obesity-related sociocultural perspectives of black women than are traditional weight loss approaches.Methods/DesignWe conducted an 18-month randomized controlled trial (the Shape Program) of a weight gain prevention intervention for overweight black female patients in the primary care setting. Participants include 194 premenopausal black women aged 25 to 44 years with a BMI of 25–34.9 kg/m2. Participants were randomized either to usual care or to a 12-month intervention that consisted of: tailored obesogenic behavior change goals, self-monitoring via interactive voice response phone calls, tailored skills training materials, 12 counseling calls with a registered dietitian and a 12-month YMCA membership.Participants are followed over 18 months, with study visits at baseline, 6-, 12- and 18-months. Anthropometric data, blood pressure, fasting lipids, fasting glucose, and self-administered surveys are collected at each visit. Accelerometer data is collected at baseline and 12-months.At baseline, participants were an average of 35.4 years old with a mean body mass index of 30.2 kg/m2. Participants were mostly employed and low-income. Almost half of the sample reported a diagnosis of hypertension or prehypertension and 12% reported a diagnosis of diabetes or prediabetes. Almost one-third of participants smoked and over 20% scored above the clinical threshold for depression.DiscussionThe Shape Program utilizes an innovative intervention approach to lower the risk of obesity and obesity-associated chronic disease among black women in the primary care setting. The intervention was informed by behavior change theory and aims to prevent weight gain using inexpensive mobile technologies and existing health center resources. Baseline characteristics reflect a socioeconomically disadvantaged, high-risk population sample in need of evidence-based treatment strategies.Trial registrationThe trial is registered with clinicaltrials.gov NCT00938535.