1. E of computer-tailored S moking C essation A dvice in P rimary car E ffectiveness Hazel Gilbert, Irwin Nazareth and Richard Morris Department of Primary Care and Population Sciences, UCL Stephen Sutton Institute of Public Health, University of Cambridge General Practice Research Framework Developing tailored interventions for smoking cessation in primary care: the background to the ESCAPE trial

2. To examine the effect of computer-generated individually tailored feedback reports on quit rates and quitting activity, when sent to smokers with varying levels of motivation and reading ability, identified from GP lists. ESCAPE – The Aim

3. Smoking is the leading preventable cause of disease and death Smoking is a modifiable behaviour Intensive face-to-face or group therapy most effective treatment ESCAPE – The Background

4. NHS Smoking Cessation Service Low participation rates 6% of smokers use the services per year 97% one to one / 3% groups Relatively high quit rates 52 week abstinence rate 15% 1% of smokers helped to stop long-term

5. Challenges for Primary Care *To increase success rates in clinics *Bridge the gap between clinical and public health approach *Reach the smokers who do not use clinics

6. Self help Materials Generic leaflets and manuals Targeted materials to particular groups Individually tailored feedback defined as: ‘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)

7. Feasibility of and response rates to proactive recruitment in general practice  Response from practices encouraging  Range of list sizes (6400 to 16000)  Range of levels of deprivation  % of identified smokers 8-23  Corresponds with deprivation scores  Mean response rate 8.9%  Mean 3-month follow-up response rate 66.7% Female53.8% Mean age42.1 ≥Degree level52.6% Low Literacy level23.1% Planning to quit: next 2 weeks10.3 % next 30 days 14.1 % next 6 months42.3 % not planning32.1 % Characteristics of respondents

8. Focus groups to assess perception and reaction to computer tailored feedback Females ‘Yes, if I had got one of these, something tailored to what I said on my questionnaire, I would have been quite pleased, something just for me.’ ‘They are actually bothering with me and, because I have sent in the questionnaire, you actually want me to quit. You know what I mean, I think it is pretty good.’ ‘I think the best thing is that it is aimed at an individual unlike the leaflets which are an overall thing.’

9. Males ‘There is a strong reassurance, it’s an expression of support. I like the basic concept, I like the idea of a tailored letter in response to a questionnaire, I like the idea of having that sort of personal support. ----- It looks like a chain letter even though it is trying not to be.’ ‘Yes it looks a bit like a template that’s just been printed off.’ ‘You know, once I have written a questionnaire saying I am giving up, I am giving up for health reasons, I don’t really need to be told that smoking is dangerous for you.’ ‘(If) I opened and I saw all that writing, you know I would, it would go in the bin. It needs more pictures, it needs to be more, like, more grabbing to you, so that you want to read it.’

10.  recruit 100 MRC GPRF practices, selected to represent high and low socio-economic areas  each practice select a random sample of 500 current cigarette smokers, aged between 18 and 65  selected patients (n=50,000) sent the Smoking Behaviour Questionnaire (SBQ), together with a covering letter from their GP  an estimated response rate of 15% from 2 mailings (reminder and duplicate SBQ) will secure 7250 participants ESCAPE - Recruitment

11. ESCAPE - Trial Interventions Questionnaires returned to research team at UCL Participants randomly allocated to Control Group: standard NHS ‘Giving up for life’ booklet the usual care offered by general practice Intervention Group: computer-tailored feedback report additional one month assessment and feedback report

12. ESCAPE – Outcome Measures 6 month follow-up questionnaire Primary: prolonged abstinence for 1 and 3 months Secondary: 24hr and 7 day point-prevalence abstinence quit attempts changes in motivation, intention to quit, cognitions use of NRT or Zyban contact with advice services or health professionals Process: adherence to advice perceptions of the feedback reports perceived personal relevance of feedback

13. Applications and Future Directions  Questionnaire and feedback can structure and reinforce advice given by health professionals  System can offer an efficient way of integrating smoking cessation counselling into a busy primary care practice  Internet version  Pharmacies  Dental practices  Workplaces  Opticians