Richard Windsor

A randomized trial of Text2Quit: a text messaging program for smoking cessation.

BACKGROUND Text messaging programs on mobile phones have shown some promise in helping people quit smoking. Text2Quit is an automated, personalized, interactive mobile health program that sends text messages to offer advice, support, and reminders about quitting smoking. PURPOSE To evaluate the effect of Text2Quit on biochemically confirmed repeated point prevalence abstinence in the context of an RCT conducted in the U.S. METHODS Participants (n=503) were recruited on the Internet and randomized to receive Text2Quit or self-help material. Between 2011 and 2013, participants were surveyed at baseline and at 1, 3, and 6 months post-enrollment to assess smoking status. Saliva was collected from participants who reported not smoking in the past 7 days at the 6-month follow-up. An intent to treat analysis was used, and those lost to follow-up were categorized as smokers. All analyses were completed in 2013. RESULTS Biochemically confirmed repeated point prevalence abstinence favored the intervention group, with 11.1% abstinent compared to 5.0% of the control group (relative risk=2.22, 95% CI=1.16, 4.26, p<0.05). Similarly, self-reported repeated point prevalence abstinence was higher in the intervention group (19.9%) than in the control group (10.0%) (p<0.01). Effects were found to be uniform across the analyzed demographic subgroups, although suggestive of a larger effect for non-whites than whites. CONCLUSIONS These results provide initial support for the relative efficacy of the Text2Quit program.

Text2Quit: results from a pilot test of a personalized, interactive mobile health smoking cessation program.

Text messaging programs on mobile phones have shown some promise in helping people quit smoking. Text2Quit is an automated, personalized, and interactive mobile health program that sends text messages and e-mails timed around a participants quit date over the course of 3 months. The text messages include pre- and post-quit educational messages, peer ex-smoker messages, medication reminders and relapse messages, and multiple opportunities for interaction. Study participants were university students (N = ;23) enrolled in the Text2Quit program. Participants were surveyed at baseline and at 2 and 4 weeks after enrollment. The majority of participants agreed that they liked the program at 2 and 4 weeks after enrollment (90.5% and 82.3%, respectively). Support for text messages was found to be moderate and higher than that of the e-mail and web components. Of participants, 75% reported reading most or all of the texts. On average, users made 11.8 responses to the texts over a 4-week period, although responses declined after the quit date. The interactive feature for tracking cigarettes was the most used interactive feature, followed by the craving trivia game. This pilot test provides some support for the Text2Quit program. A future iteration of the program will include additional tracking features in both the pre-quit and post-quit protocols and an easier entry into the not-quit protocol. Future studies are recommended that identify the value of the interactive and personalized features that characterize this program.

The accuracy of self-reported smoking status assessed by cotinine test strips

We evaluated a new cotinine test strip to assess smoking status. Urine cotinine was measured using cotinine test strips and also by gas chromatographic techniques (GC) (as the reference criterion). Smoking status was assessed with a self-administered questionnaire. The cotinine test strip identified smokers with a very high level of agreement (97.3% using 100 ng/ml and 97.1% using 250 ng/ml for the cutoff point) and non-smokers with a fair-to-moderate level of agreement (74.5% using 100 ng/ml and 86.4% using 250 ng/ml for the cutoff point). These data suggest that the cotinine test strip appears to provide a reasonably accurate measure of smoking status. Since this was the first study to evaluate the cotinine test strip using the test strip prototype, larger clinical trials are needed to evaluate the validity of the cotinine test strip compared to GC measurements to confirm smoking status.

Feasibility of a tobacco cessation intervention for pregnant Alaska Native women.

BACKGROUND Among Alaska Native women residing in the Yukon-Kuskokwim (Y-K) Delta region of Western Alaska, about 79% smoke cigarettes or use smokeless tobacco during pregnancy. Treatment methods developed and evaluated among Alaska Native pregnant tobacco users do not exist. This pilot study used a randomized two-group design to assess the feasibility and acceptability of a targeted cessation intervention for Alaska Native pregnant women. METHODS Recruitment occurred over an 8-month period. Enrolled participants were randomly assigned to the control group (n = 18; brief face-to-face counseling at the first visit and written materials) or to the intervention group (n = 17) consisting of face-to-face counseling at the first visit, four telephone calls, a video highlighting personal stories, and a cessation guide. Interview-based assessments were conducted at baseline and follow-up during pregnancy (>or=60 days postrandomization). Feasibility was determined by the recruitment and retention rates. RESULTS The participation rate was very low with only 12% of eligible women (35/293) enrolled. Among enrolled participants, the study retention rates were high in both the intervention (71%) and control (94%) groups. The biochemically confirmed abstinence rates at follow-up were 0% and 6% for the intervention and control groups, respectively. DISCUSSION The low enrollment rate suggests that the program was not feasible or acceptable. Alternative approaches are needed to improve the reach and efficacy of cessation interventions for Alaska Native women.

Feasibility, cost, and cost-effectiveness of a telephone-based motivational intervention for underserved pregnant smokers.

This study reports on the evaluation of the feasibility, cost, and cost-effectiveness of a proactively provided telephone-based motivational smoking cessation intervention to an underserved population of pregnant smokers who may or may not receive ongoing prenatal care. As part of the New England SCRIPT randomized clinical trial comparing the efficacy of three types of smoking cessation interventions for pregnant smokers, one-third of the women (n = 358) received a motivational telephone counseling intervention (MI) delivered by trained counselors using a semistructured protocol. Although this population was very mobile, the MI counselors were able to reach 86% of the women with at least one call and 46% received all three calls. The group receiving three MI calls had a cotinine-confirmed quit rate of 23%. Cost-effectiveness analyses for those women receiving telephone counseling supported the net benefit in favor of the three phone calls compared with the women who did not receive any telephone calls, with an effectiveness to cost ratio of 1:US dollars 84. Our results suggest that telephone-based motivational smoking cessation counseling may be a feasible and cost-effective method for low-income pregnant smokers enrolled in prenatal care.

Getting young adults to quit smoking: a formative evaluation of the X-Pack Program.

The lack of promising smoking cessation interventions targeting young adults is a recognized public health problem. This study was designed to determine the feasibility of a young-adult-oriented program, the X-Pack Program, when administered to college student smokers, and to estimate its effect on smoking cessation. Participants (N = 83) were randomized after enrollment to receive either a moderately intensive, E-mail-based, young-adult intervention (the X-Pack group) or a less-intensive program aimed at a general adult audience (the Clearing the Air group). Participants were assessed at baseline and at 3 and 6 months after enrollment. Participants in the X-Pack group rated their treatment more favorably overall, were more engaged in program activities, and quit for more consecutive days at the 3- and 6-month follow-ups, compared with the Clearing the Air group. Differences in quit rates favored the X-Pack group at the two follow-ups, but the differences were not significant. These findings offer some support for the X-Pack Program when administered to college smokers.

Evaluation of the Immediate Impact of the Washington, D.C., Smoke-Free Indoor Air Policy on Bar Employee Environmental Tobacco Smoke Exposure

Objective. On January 2, 2007, the Washington, D.C., City Council banned smoking in restaurants and bars. We sought to determine the immediate impact of the ban on cotinine-confirmed environmental tobacco smoke (ETS) levels and respiratory symptom reports of a random sample of bar employees. Methods. We conducted an assessment of 66 employees from 41 randomly selected bars in December 2006, a month before the ban went into effect. After analyses of baseline data, 52 employees were eligible and 49 of them (94%) had a post-ban assessment in February 2007. Three participants were excluded due to high cotinine levels at the post-ban assessment, yielding a final sample size of 46 bar employees. ETS exposure levels were documented using saliva cotinine analyses by tandem liquid chromatography and mass spectrometry. Employee respiratory and sensory symptoms reports were assessed by a standardized, validated form: the International Union Against Tuberculosis and Lung Disease Bronchial Symptoms Questionnaire. Employee ETS exposure reports at work were eliminated after the ban. Results. Sensory symptoms reports (at ≤4 weeks) declined significantly by 70% to 100% (p=0.0016); respiratory symptoms results were inconclusive due to a lack of data. Saliva cotinine medians declined significantly by 70% (p<0.0001), from a pre-ban mean of 2.11 nanograms per millileter (ng/mL) to a post-ban mean of 0.29 ng/mL, confirming reports of no ETS exposure at work. Conclusion. We concluded that the indoor air law was effective, eliminating employee ETS exposure reports, dramatically reducing their cotinine levels, and almost eliminating reports of sensory symptoms.

A formative evaluation in maternal and child health practice: the Partners for Life Nutrition Education Program for pregnant women.

Objectives: This paper describes the formative evaluation of the Partners For Life Program that was developed to change dietary behavior of low income pregnant women in the Mississippi Delta region. Methods: A diverse group of nutrition/health professionals, adapted the Expanded Food and Nutrition Education Programs (EFNEP) methodology for pregnant patients in the local Women, Infants, and Children program who were receiving maternity care at the county health department. Formative evaluation activities included gathering data to determine 1) whether a new nutrition curriculum, modeled after EFNEP could be created, 2) whether peer educators could be recruited and trained to deliver the intervention, 3) whether pregnant women could be recruited to participate in the new program, 4) whether a pilot test of the new intervention would produce short-term impact in nutrition knowledge and dietary behavior, and 5) reactions of pregnant women on the usability of the new program. Data were gathered through use of the Program Implementation Index, focus groups, and a retrospective record review. Pilot test assessments included tests of nutrition knowledge and self-reported changes in dietary behavior. Results: The formative evaluation demonstrated both positive and negative outcomes. Positive data included 1) successful recruitment and training of the peer educators to deliver the intervention; 2) successful recruitment of the targeted population for the pilot study; 3) complete information on project questionnaires and measuring forms; and 4) among those who completed the program, a statistically significant improvement in nutrition knowledge and dietary behavior. Two negative aspects in this formative study were 1) the Program Implementation Index quantitatively showed that the program experienced problems retaining participants it recruited and 2) deviation of the timeframe for intervention delivery. Program length was identified as the primary reason for participant attrition. Conclusions: It is important for program developers to use results from formative evaluations to make changes in problem areas prior to implementation of a full-scale impact evaluation.

Motivational interviewing versus prescriptive advice for smokers who are not ready to quit

OBJECTIVE Smokers who are not ready to quit are a very difficult group to treat. Physicians, nurses, and nurse practitioners are in a unique position to encourage patients to quit smoking. However, the best approach to do so is not clear. METHODS A two-group randomized controlled trial with 218 pack-a-day precontemplative and contemplative smokers recruited from the community. The laboratory-based study was designed to simulate outpatient visits to general practitioners. Participants were randomized to a 15-min intervention to compare the effectiveness of brief motivational or prescriptive counseling by a health professional. Thirteen outcome variables included intentions to quit and verbal reports at 1 and 6 months with biological verification. A composite outcome measure was constructed to provide greater power to detect study differences. RESULTS Approximately 33% of the sample reported at least one 24-h quit period during the 6 months they were followed after the trial. Results suggest that while neither treatment was superior, there were subgroup differences. Participants in the motivational condition were also more likely to respond to follow-up calls. CONCLUSIONS AND PRACTICE IMPLICATIONS Motivational interviewing and prescriptive advice were equally effective for precontemplative and contemplative smokers. Practitioners should use the method that appeals to them.

Effectiveness of Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Methods in Medicaid-Supported Prenatal Care Trial III

This two-phase evaluation documented the delivery and effectiveness of evidence-based health education methods by regular staff to pregnant smokers. During Phase 1, a total of 436 Medicaid patients were screened and 416 (95%) gave consent: 334 nonsmokers and 102 smokers. This historical Comparison (C) group was assessed to document the “normal” pretrial smoking prevalence, patient nondisclosure (deception), and cessation rates at the first prenatal visit and during care. After this study, a formative evaluation of SCRIPT methods was conducted among 139 experimental group patients and 126 control group patients. During Phase 2, a total of 6,514 patients were screened over a 36-month period: 1,736 (27%) were smokers and 1,340 (77%) gave consent. After randomization, 247 became ineligible. The remaining 1,093 smokers received brief routine advice to quit. The experimental group (n = 544) also received a Commit to Quit video, A Pregnant Woman’s Guide to Quit Smoking, and counseling. Self-reports and saliva were collected at baseline, ≥60 days, and ≤90 days postpartum for cotinine analyses to document cessation and significant reduction (SR) rates. The Phase 1 formative evaluation documented a 24% nondisclosure rate at the onset of care. It also confirmed a significantly higher experimental (17.3%) versus control group (8.8%) cessation rate and experimental versus control group SR rates of 22% and 16%. During Phase 2, unplanned policy changes, and delivery of experimental group counseling procedures to 15% to 20% of control group patients, resulted in a final experimental group cessation rate of 12% and a control group rate of 10%. The experimental group SR rate of 18%, however, was significantly higher than the control group SR rate of 13%. Effectiveness varied by the stability of clinic infrastructure, and degree of fidelity of staff performance of assessment and intervention procedures. The methods and results of this study will assist future health education programs for pregnant smokers to plan and conduct process and impact evaluations in prenatal care.