Written Advice Given by African American Smokers to Their Peers: Qualitative Study of Motivational Messages.

BACKGROUND: Although African Americans have the lowest rates of smoking onset and progression to daily smoking, they are less likely to achieve long-term cessation. Interventions tailored to promote use of cessation resources in African American individuals who smoke are needed. In our past work, we demonstrated the effectiveness of a technology-assisted peer-written message intervention for increasing smoking cessation in non-Hispanic White smokers. In this formative study, we have adapted this intervention to be specific for African American smokers. OBJECTIVE: We aimed to report on the qualitative analysis of messages written by African American current and former smokers for their peers in response to hypothetical scenarios of smokers facing cessation challenges. METHODS: We recruited African American adult current and former smokers (n=41) via ResearchMatch between April 2017 and November 2017. We asked participants to write motivational messages for their peers in response to smoking-related hypothetical scenarios. We also collected data on sociodemographic factors and smoking characteristics. Thematic analysis was conducted to identify cessation strategies suggested by the study participants. RESULTS: Among the study participants, 60% (25/41) were female. Additionally, more than half (23/41, 56%) were thinking about quitting, 29% (12/41) had set a quit date, and 27% (11/41) had used electronic cigarettes in the past 30 days. Themes derived from the qualitative analysis of peer-written messages were (1) behavioral strategies, (2) seeking help, (3) improvements in quality of life, (4) attitudes and expectations, and (5) mindfulness/religious or spiritual practices. Under the behavioral strategies theme, distraction strategies were the most frequently suggested strategies (referenced 84 times in the 318 messages), followed by use of evidence-based treatments/cessation strategies. Within the seeking help theme, subthemes included seeking help or support from family/friends or close social networks (referenced 56 times) and health care professionals (referenced 22 times). The most frequent subthemes that emerged from improvements in the quality of life theme included improving one's health (referenced 22 times) and quality of life (referenced 21 times). Subthemes that emerged from the attitude and expectations theme included practicing positive self-talk (referenced 27 times), autonomy/independence from the smoking habit (referenced six times), and financial cost of smoking (referenced five times). The two subthemes that emerged from the mindfulness/religious or spiritual practices theme were use of self-awareness techniques (referenced 36 times) and religious or spiritual practices to cope (referenced 13 times). CONCLUSIONS: Our approach to adapt a prior peer-message intervention to African American smokers yielded a set of evidence-based messages that may be suitable for smokers at all phases of motivation to quit (ready to quit or not ready to quit). In future research, we plan to assess the impact of texting these messages to African American smokers in a smoking cessation trial.

Secure Asynchronous Communication Between Smokers and Tobacco Treatment Specialists: Secondary Analysis of a Web-Assisted Tobacco Intervention in the QUIT-PRIMO and National Dental PBRN Networks.

BACKGROUND: Within a web-assisted tobacco intervention, we provided a function for smokers to asynchronously communicate with a trained tobacco treatment specialist (TTS). Previous studies have not attempted to isolate the effect of asynchronous counseling on smoking cessation. OBJECTIVE: This study aimed to conduct a semiquantitative analysis of TTS-smoker communication and evaluate its association with smoking cessation. METHODS: We conducted a secondary analysis of data on secure asynchronous communication between trained TTSs and a cohort of smokers during a 6-month period. Smokers were able to select their preferred TTS and message them using a secure web-based form. To evaluate whether the TTS used evidence-based practices, we coded messages using the Motivational Interviewing Self-Evaluation Checklist and Smoking Cessation Counseling (SCC) Scale. We assessed the content of messages initiated by the smokers by creating topical content codes. At 6 months, we assessed the association between smoking cessation and the amount of TTS use and created a multivariable model adjusting for demographic characteristics and smoking characteristics at baseline. RESULTS: Of the 725 smokers offered asynchronous counseling support, 33.8% (245/725) messaged the TTS at least once. A total of 1082 messages (TTSs: 565; smokers 517) were exchanged between the smokers and TTSs. The majority of motivational interviewing codes were those that supported client strengths (280/517, 54.1%) and promoted engagement (280/517, 54.1%). SCC code analysis showed that the TTS provided assistance to smokers if they were willing to quit (247/517, 47.8%) and helped smokers prepare to quit (206/517, 39.8%) and anticipate barriers (197/517, 38.1%). The majority of smokers' messages discussed motivations to quit (234/565, 41.4%) and current and past treatments (talking about their previous use of nicotine replacement therapy and medications; 201/565, 35.6%). The majority of TTS messages used behavioral strategies (233/517, 45.1%), offered advice on treatments (189/517, 36.5%), and highlighted motivations to quit (171/517, 33.1%). There was no association between the amount of TTS use and cessation. In the multivariable model, after adjusting for gender, age, race, education, readiness at baseline, number of cigarettes smoked per day at baseline, and the selected TTS, smokers messaging the TTS one or two times had a smoking cessation odds ratio (OR) of 0.8 (95% CI 0.4-1.4), and those that messaged the TTS more than two times had a smoking cessation OR of 1.0 (95% CI 0.4-2.3). CONCLUSIONS: Our study demonstrated the feasibility of using asynchronous counseling to deliver evidence-based counseling. Low participant engagement or a lack of power could be potential explanations for the nonassociation with smoking cessation. Future trials should explore approaches to increase participant engagement and test asynchronous counseling in combination with other approaches for improving the rates of smoking cessation.

Exploring Online Asynchronous Counseling With Tobacco Treatment Specialists in the QUIT-PRIMO and National Dental PBRN HI-QUIT Studies: Who Uses It and What Do They Say?

PURPOSE: To describe the content of messages sent by smokers through asynchronous counseling within a Web-based smoking cessation intervention. DESIGN: Qualitative. SETTING: National community-based setting of patients who had been engaged by the medical or dental practices at which they attended or via Google advertisements. PARTICIPANTS: Adults older than 19 years who were current smokers and interested in quitting. Participants throughout the United States referred to a Web-based cessation intervention by their medical or dental provider or by clicking on a Google advertisement. METHODS: We conducted a qualitative review of 742 asynchronous counseling messages sent by 270 Web site users. Messages were reviewed, analyzed, and organized into qualitative themes by the investigative team. RESULTS: The asynchronous counseling feature of the intervention was used most frequently by smokers who were white (87%), female (67%), aged 45 to 54 (32%), and who had at least some college-level education (70%). Qualitative analysis yielded 7 basic themes-Talk about the Process of Quitting, Barriers to Quitting, Reasons to Quit, Quit History, Support and Strategies for Quitting, Quitting with Medication, and Quit Progress. The most common theme was Support and Strategies for Quitting with 255 references among all messages. CONCLUSION: We found rich communication across the spectrum of the quit process, from persons preparing to quit to those who had successfully quit. Asynchronous smoking cessation counseling provides a promising means of social support for smokers during the quit process.

Narratives to enhance smoking cessation interventions among African-American smokers, the ACCE project.

BACKGROUND: Low-income, African-American smokers are less likely to have resources to aid in quitting smoking. Narrative communication may provide an enhancement to traditional smoking cessation interventions like NRT, medications, or behavioral treatments for this audience. After extensive pilot testing of stories and personal experiences with smoking cessation from African-Americans from a low-income community, we conducted a randomized control trial using stories to augment routine inpatient treatment among African-Americans at an urban Southern hospital (N = 300). RESULTS: Differences in smoking cessation outcomes between the intervention (stories DVD + routine clinical treatment) and control (routine clinical treatment) arms were compared using self-report and carbon monoxide measurement at 6-months. Compared to control, individuals who viewed the intervention stories DVD reported greater intentions to quit. Although continuous quitting marginally favored the intervention, our main result did not reach statistical significance (p = 0.16). CONCLUSION: Narrative communication via storytelling to promote smoking cessation among African-Americans in the South is one method to communicate smoking cessation. Results suggest this may not be sufficient as a stand-alone augmentation of routine clinical treatment for continuous smoking cessation. Smoking cessation efforts need to continually assess different means of communicating to smokers about quitting. CLINICAL TRIALS REGISTRATION: The ClinicalTrials.gov Identifier is NCT00101491. This trial was registered January 10, 2005.

Smoking-cessation e-referrals: a national dental practice-based research network randomized controlled trial.

BACKGROUND: Tobacco use is still the leading preventable cause of death and morbidity in the U.S. Web-assisted tobacco interventions are an effective but underutilized tool in assisting smokers with quitting. The dental visit is an excellent opportunity to assist smokers in quitting by referring them to these tobacco-cessation online programs. PURPOSE: The study purpose was to test two patient referral methods-paper referrals (information prescriptions) versus paper plus e-referrals-to a web-assisted smoking-cessation induction system. DESIGN: RCT that used implementation research methods. PARTICIPANTS/SETTING: A total of 100 community-based dental practices were enrolled and 1814 smokers were referred to the web-assisted tobacco induction system. INTERVENTION: The study intervention was a proactive e-referral of smokers to a web-assisted tobacco induction system called Decide2Quit.org, and the control group used paper referrals (information prescriptions) to refer smokers to the Decide2Quit.org. MAIN OUTCOME MEASUREMENTS: The outcome measurements were the referral numbers, Decide2Quit registration numbers, and the smokers' quit rate. Data were collected in 2010-2011 and analyses were completed in 2012. RESULTS: Although total referrals from intervention practices was lower than control, subsequent proportions of registrations among smokers referred to Decide2Quit.org were nearly fourfold higher (adjusted mean percentages: 29.5% vs 7.6%, p<0.01) in intervention compared with control practices. Subsequent rates of cessation among referred smokers were threefold higher (adjusted mean percentages: 3.0% vs 0.8%, p=0.03) in intervention practices as compared with control. CONCLUSIONS: Intervention practices using the e-referral system had higher smoker registration numbers and higher quit smoking rates than the control practices. This study finds that e-referrals are effective in getting smokers to the web-assisted smoking-cessation induction system and in assisting with quitting that more than compensates for any additional effort that e-referrals require on the part of the practitioner. CLINICAL TRIAL REGISTRATION: DPBRN Hygienists Internet Quality Improvement in Tobacco Cessation (HiQuit); NCT01108432.

Implementing point of care "e-referrals" in 137 clinics to increase access to a quit smoking internet system: the Quit-Primo and National Dental PBRN HI-QUIT Studies.

Integrating electronic referral systems into clinical practices may increase use of web-accessible tobacco interventions. We report on our feasibility evaluation of using theory-driven implementation science techniques to translate an e-referral system (ReferASmoker.org) into the workflow of 137 community-based medical and dental practices, including system use, patient registration, implementation costs, and lessons learned. After 6 months, 2,376 smokers were e-referred (medical, 1,625; dental, 751). Eighty-six percent of the medical practices [75/87, mean referral = 18.7 (SD = 17.9), range 0-105] and dental practices [43/50, mean referral = 15.0 (SD = 10.5), range 0-38] had e-referred. Of those smokers e-referred, 25.3 registered [mean smoker registration rate-medical 4.9 (SD = 7.6, range 0-59), dental 3.6 (SD = 3.0, range 0-10)]. Estimated mean implementation costs are medical practices, US$429.00 (SD = 85.3); and dental practices, US$238.75 (SD = 13.6). High performing practices reported specific strategies to integrate ReferASmoker.org; low performers reported lack of smokers and patient disinterest in the study. Thus, a majority of practices e-referred and 25.3 % of referred smokers registered demonstrating e-referral feasibility. However, further examination of the identified implementation barriers is important as of the estimated 90,000 to 140,000 smokers seen in the 87 medical practices in 6 months, only 1,625 were e-referred.

Variations in tobacco control in National Dental PBRN practices: the role of patient and practice factors.

We engaged dental practices enrolled in The National Dental Practice-Based Research Network to quantify tobacco screening (ASK) and advising (ADVISE); and to identify patient and practice -characteristics associated with tobacco control. Dental practices (N = 190) distributed patient surveys that measured ASK and ADVISE. Twenty-nine percent of patients were ASKED about tobacco use during visit, 20% were identified as tobacco users, and 41% reported being ADVISED. Accounting for clustering of patients within practices, younger age and male gender were positively associated with ASK and ADVISE. Adjusting for patient age and gender, a higher proportion of non-whites in the practice, preventive services and proportion on public assistance were positively associated with ASK. Proportion of tobacco users in the practice and offering other preventive services were more strongly associated with ASK and ADVISE than other practice characteristics. Understanding variations in performance is an important step toward designing strategies for improving tobacco control in dentistry.

Crowdsourced peer- versus expert-written smoking-cessation messages.

BACKGROUND: Tailored, web-assisted interventions can reach many smokers. Content from other smokers (peers) through crowdsourcing could enhance relevance. PURPOSE: To evaluate whether peers can generate tailored messages encouraging other smokers to use a web-assisted tobacco intervention (Decide2Quit.org). METHODS: Phase 1: In 2009, smokers wrote messages in response to scenarios for peer advice. These smoker-to-smoker (S2S) messages were coded to identify themes. Phase 2: resulting S2S messages, and comparison expert messages, were then e-mailed to newly registered smokers. In 2012, subsequent Decide2Quit.org visits following S2S or expert-written e-mails were compared. RESULTS: Phase 1: a total of 39 smokers produced 2886 messages (message themes: attitudes and expectations, improvements in quality of life, seeking help, and behavioral strategies). For not-ready-to-quit scenarios, S2S messages focused more on expectations around a quit attempt and how quitting would change an individual's quality of life. In contrast, for ready-to-quit scenarios, S2S messages focused on behavioral strategies for quitting. Phase 2: In multivariable analysis, S2S messages were more likely to generate a return visit (OR=2.03, 95% CI=1.74, 2.35), compared to expert messages. A significant effect modification of this association was found, by time-from-registration and message codes (both interaction terms p<0.01). In stratified analyses, S2S codes that were related more to "social" and "real-life" aspects of smoking were driving the main association of S2S and increased return visits. CONCLUSIONS: S2S peer messages that increased longitudinal engagement in a web-assisted tobacco intervention were successfully collected and delivered. S2S messages expanded beyond the biomedical model to enhance relevance of messages. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT00797628 (web-delivered provider intervention for tobacco control [QUIT-PRIMO]) and NCT01108432 (DPBRN Hygienists Internet Quality Improvement in Tobacco Cessation [HiQuit]).

Development of an interactive, Web-delivered system to increase provider-patient engagement in smoking cessation.

BACKGROUND: Patient self-management interventions for smoking cessation are effective but underused. Health care providers do not routinely refer smokers to these interventions. OBJECTIVE: The objective of our study was to uncover barriers and facilitators to the use of an e-referral system that will be evaluated in a community-based randomized trial. The e-referral system will allow providers to refer smokers to an online smoking intervention during routine clinical care. METHODS: We devised a four-step development and pilot testing process: (1) system conceptualization using Delphi to identify key functionalities that would overcome barriers in provider referrals for smoking cessation, (2) Web system programming using agile software development and best programming practices with usability refinement using think-aloud testing, (3) implementation planning using the nominal group technique for the effective integration of the system into the workflow of practices, and (4) pilot testing to identify practice recruitment and system-use barriers in real-world settings. RESULTS: Our Delphi process (step 1) conceptualized three key e-referral functions: (1) Refer Your Smokers, allowing providers to e-refer patients at the point of care by entering their emails directly into the system, (2) practice reports, providing feedback regarding referrals and impact of smoking-cessation counseling, and (3) secure messaging, facilitating provider-patient communication. Usability testing (step 2) suggested the system was easy to use, but implementation planning (step 3) suggested several important approaches to encourage use (eg, proactive email cues to encourage practices to participate). Pilot testing (step 4) in 5 practices had limited success, with only 2 patients referred; we uncovered important recruitment and system-use barriers (eg, lack of study champion, training, and motivation, registration difficulties, and forgetting to refer). CONCLUSIONS: Implementing a system to be used in a clinical setting is complex, as several issues can affect system use. In our ongoing large randomized trial, preliminary analysis with the first 50 practices using the system for 3 months demonstrated that our rigorous preimplementation evaluation helped us successfully identify and overcome these barriers before the main trial. TRIAL: Clinicaltrials.gov NCT00797628; http://clinicaltrials.gov/ct2/show/NCT00797628 (Archived by WebCite at http://www.webcitation.org/61feCfjCy).

The art and science of patient storytelling-harnessing narrative communication for behavioral interventions: the ACCE project.

Narrative communication is an emerging form of persuasive communication used in health education to solicit actual patient stories. Eliciting a narrative is an open-ended process and may or may not map to desired intervention objectives or underlying behavioral constructs. In addition, incorporating actual, unscripted narratives into multimedia interventions is challenging. The authors evaluated a protocol of editing narratives for a multimedia intervention to promote smoking cessation in the African American community that maintains fidelity to the original message and was related to behavioral constructs from social cognitive theory. The authors used four steps: (a) narrative collection (videotaping), (b) narrative review (rating of content), (c) narrative editing (documentary style), and (d) pilot testing (usability and assessment of transportation). The authors videotaped 50 personal smoking cessation narratives. After coding for presence of theoretical constructs, perceived risks of smoking (present in 53% of narratives) was the most common related behavioral construct. Four narratives were chosen for inclusion in the DVD. Pilot testing showed viewers reported high level of transportation into the narrative. The authors found that some behavioral constructs were rare and difficult to solicit in this population but that the final product was engaging to the viewers. Lessons learned may be useful for other video-based behavioral interventions that incorporate personal narratives.

Cognitive mapping tobacco control advice for dentistry: a dental PBRN study.

OBJECTIVE: To identify facilitative strategies that could be used in developing a tobacco cessation program for community dental practices. METHODS: Nominal group technique (NGT) meetings and a card-sort task were used to obtain formative data. A cognitive mapping approach involving multidimensional scaling and hierarchical cluster analysis was used for data analysis. RESULTS: Three NGT meetings conducted with 23 dental professionals yielded 27 nonredundant facilitative strategies. A 2-dimensional 4-cluster cognitive map provided an organizational framework for understanding these strategies. CONCLUSION: Views of the target population solicited in a structured format provided clear direction for designing a tobacco cessation intervention.

Impact of content-specific email reminders on provider participation in an online intervention: a dental PBRN study.

Engaging busy healthcare providers in online continuing education interventions is challenging. In an Internet-delivered intervention for dental providers, we tested a series of email-delivered reminders - cues to action. The intervention included case-based education and downloadable practice tools designed to encourage providers to increase delivery of smoking cessation advice to patients. We compared the impact of email reminders focused on 1) general project announcements, 2) intervention related content (smoking cessation), and 3) unrelated content (oral cancer prevention focused content). We found that email reminders dramatically increased participation. The content of the message had little impact on the participation, but day of the week was important - messages sent at the end of the week had less impact, likely due to absence from clinic on the weekend. Email contact, such as day of week an email is sent and notice of new content post-ing, is critical to longitudinal engagement. Further research is needed to understand which messages and how frequently, will maximize participation.