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

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

 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) Self-help Materials

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)

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 Phases of development

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

Individual assessment Input Decision rules Message library of persuasive texts Individualised output Computer system Dijkstra 2008 Process

E of computer-tailored S moking C essation A dvice in P rimary car E A Randomised Controlled Trial ffectiveness General Practice Research Framework 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 Applications of Tailored Feedback in Primary Care

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 NHS Smoking Cessation Service

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

Smokers willing to take part returned the SBQ to research team at UCL Randomised to Intervention or Control Group 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 (n=60,000) 123 general practices recruited from the MRC GPRF Control Group Standard NHS booklet 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 6-month follow-up: postal questionnaire to assess smoking status, cognitive change, perception of the feedback, economic issues

Baseline characteristics Demographics: Female56.5% Mean age44.72 (17-83) White96% Qualifications <=GCSE62.1% Married/living with partner58.8% In paid employment65.2% Live with smoker50.2% Children under % Children % Pregnant1.2% N=6900 Withdrawn=69 Response rate=11.75% Intervention=3404(49.8%) Control=3427(50.2%)

Dependence:IC Non-daily smokers5.0%5.4% Smoke <30 minutes of waking62.3%62.1% Previously quit >3 months49.1%48.7% Mean age started smoking Mean cigarettes per day How much do you want to quit (scale 1-5) ** How determined are you to quit for good (scale 1-5) * Think of self as addicted (scale 1-5)4.03 Image (scale 1-5): smoking is part of who I am see self as non-smoker **p=.006 * p=.016

Respondents by readiness to quit Of those planning to quit within the next 30 days (n=890): 339 (38.1%) set a quit date Of those not planning to quit within the next 6 months (n=3203): too difficult % / want to smoke % / both - 4.3%

Readiness to quit by motivation

Intervention Group only (N=3404) 4 weeks post baseline Sent follow-up assessment + reminder=3350(98.4%) Returns:Before reminder 968 (28.9%) After reminder 817 (24.4%) Total1785 (53.3%) Participants planning quit in 30 days less likely to return the follow-up assessment (p=0.012) Follow-up Assessment Response

Plan to quitAbstinent (%)Not abstinent (%) Total Within 2 weeks43 (23.5)61 (76.5)183 Within 30 days36 (13.5)84 (86.5)267 Within 6 months66 (4.8)661 (95.2)1384 Not planning35 (2.3)800 (97.7)1516 Total180 (5.4)3170 (94.6)3350 Follow-up Assessment Outcome  2 = , p<.0001

Length of abstinence by readiness Respondents not smoking 4 weeks post baseline (n=180)

Made quit attempt Plan to quitYes(%)No (%)Total within 2 weeks49(81.7)11(18.3)60 within 30 days52(61.9)32(38.1)84 within 6 months171(25.9)489(74.1)660 not within 6 months102(12.8)695(87.2)797 Total374(23.4)1227(76.6)1601 Quit attempts by readiness  2 = , p< Respondents still smoking 4 weeks post baseline (n=1601)

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? Conclusions

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 Tailored feedback + Proactive Recruitment

Co-investigators Irwin Nazareth, Richard Morris Department of Primary Care and Population Sciences, UCL Stephen Sutton Institute of Public Health, University of Cambridge Collaborator Christine Godfrey Department of Health Sciences, University of York Trial Co-ordinator Camille Alexis-Garsee General Practice Research Framework