Computer-tailored smoking cessation materials: A review and discussion

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Abstract

Tailored smoking cessation materials combine many of the interactive, diagnostic elements of a clinical encounter with the dissemination potential of mass media. In this article, the differences between general, targeted and tailored smoking cessation materials are discussed, and the impact of tailored versus the general or targeted modalities is examined. A review of ten randomized trials of tailored materials found a significant impact of these materials in a majority of the studies. Very few patterns, in terms of the characteristics associated with the tailored materials, subject recruitment, subject characteristics, or follow-up procedures were found when comparing positive versus negative trials. The two trials that combined tailored materials with nicotine replacement therapy found a strong impact on smoking cessation; studies that examine the combined effects of tailored behavioral and pharmacological interventions are suggested. Another notable finding was the effect tailored materials had among precontemplators. Most studies that included precontemplators found a significant positive impact of materials tailored to this group. Taken together, these findings suggest important new avenues for reaching smokers.

Introduction

Smoking cessation researchers and practitioners have for years identified a conundrum in their work: cessation interventions that are intense, intimate and personal often result in high cessation rate; on the other hand, participation rates of these programs are usually low. These programs tend to base their success on a denominator that includes only those who entered the program or those who entered and remained in the program (e.g., “Of the six smokers who went through our group therapy program, three people quit – 50%”). When attention is focused on the denominator of all smokers in a catchment area, success rates plummet, indicating a relatively small contribution these programs have on the public's health 1, 2.

Minimal-contact cessation programs, such as self-help guides or physician-based counseling have the potential to reach far more smokers 1, 3. Instead of waiting for enrollees, these programs can proactively reach out to greater numbers. Unfortunately, the cessation rates of those receiving minimal-contact interventions are usually low. Many have exhorted over the years that even very low cessation rates from minimal-contact, high-reach programs would produce a greater public health impact than very high cessation rates from high-contact, low-reach programs (e.g., Ref. [2]). But extremely low success rates may, in the long run, reduce self-efficacy in both smokers and in the people trying to help them. A smoker who repeatedly tries to quit using relatively general, ineffective means could decide that quitting is too difficult. In a medical setting, a 5–10% success rate, while important from a public health perspective, is most likely invisible to a clinician; in the face of 90–95% failure rates, cessation counseling practices in this setting may rapidly extinguish.

To address this problem, authors of self-help materials for smoking cessation have infused their materials with more powerful strategies developed in clinical programs [3]. Moreover, regardless of the advances made in smoking cessation “bibliotherapies”, smokers do not appear to receive the impact of a clinical program through a booklet 2, 4. Such booklets can offer only “one-size-fits-all” generic support to the many combinations of motives and needs exhibited by smokers.

Using principles of market segmentation 5, 6, 7, researchers created smoking cessation guides better targeted to broad psychographic and sociodemographic groups. These guides appear to produce a higher cessation rate than more generic guides. For example, Rimer et al. [8]found that a self-help smoking cessation guide targeted to the needs of elderly smokers achieved higher abstinence rates than did a general self-help booklet. Cessation rates found for either group, however, were modest in relation to typical clinical cessation program effects. The authors correctly point out, however, that their reach to elderly smokers was extremely large, and that the targeted nature of the guide probably encouraged greater participation in the program.

Self-help programs targeted to Transtheoretical Model's stages of change have also demonstrated positive results [9]. A series of stage-matched guides mailed to smokers in all stages of change gradually resulted in a higher cessation rate (after 18 months, though not after six or 12 months) over general self-help manuals. The fact that the stage-matched manuals did not, for the first year, show an added benefit over the general self-help manuals could suggest that initial precontemplators receiving the stage-matched manuals were more effectively moved through stages than those receiving the general manuals. The data, however, do not support this explanation; a higher 18-month cessation rate was found among precontemplators receiving the general manuals than precontemplators receiving the stage-matched manuals. The greatest effect of the stage-matched manuals over the general manuals was actually found among initial preparers. A possible explanation for these results might be that preparers in the stage-matched group benefited from a guide that was more directed to quitting and contained less extraneous information more relevant to other stages.

In this article, a distinction is made between general, targeted and tailored materials. Note that the Rimer et al. [8]article refers to “tailored” materials in the way we are referring to “targeted” materials. General materials refer to the “one-size-fits-all” approach described previously. Targeted materials are defined as those intended to reach a specific sub-group of the general population. Based on the principles of market segmentation, targeted materials are attempting to meet the needs of a group similar in a priori specified characteristics as opposed to a specific individual.

To tailor materials, one must first collect information from an individual in order to create a program designed to meet his or her specific needs. Referred to in a variety of ways (e.g., “personalized materials”, “expert systems”, “mail-merge on steroids”), tailored materials require: (a) collection of characteristics, at an individual level, relevant to smoking cessation (or movement through stages of change), (b) an algorithm that uses these data to generate messages tailored to the specific needs of the user, and (c) a feedback protocol that combines these messages in a clear, vivid manner.

How many versions of self-help materials are actually needed? Could targeted materials suffice in addressing most smokers needs? Kreuter [10]studied the number of combinations of tailored smoking cessation materials required for subjects in a recent study. The materials tailored to stage of change, nicotine dependence, perceived barriers to and benefits of quitting, and previous quit attempts. Of 190 smokers, 186 (98%) required a different combination of the 1272 possible combinations of the smoking cessation messages. These results do not suggest that tailored materials are necessarily effective; they do, however, suggest that smokers are different from one another with respect to these factors and may require more than a one-size-fits-all treatment plan.

This review focuses on the first generation of tailored smoking cessation programs – those that use print media. Evaluation of this initial generation of tailored materials is critical as we develop broader, more interactive consumer health informatics programs. Advances in data collection modalities [e.g., the World Wide Web, interactive multimedia through CD-ROM or kiosk, interactive voice response (IVR), personal digital assistants (PDAs)] offer greater efficiencies in the processes required for tailoring. These same modalities should also produce important advances in tailored health feedback.

Even within the print medium, however, tailored materials can vary tremendously. Tailored print materials will vary by the theories and concepts used. They can vary by style (e.g., abstract versus contextualized) and tone (e.g., expert versus consumer-oriented). Tailored materials can look like computer printouts; but they can also look like newsletters, magazines, personal diaries, greeting cards, correspondence courses or any modality a strong imagination can create. Tailored messages can be very brief, essentially “cutting” out messages from a larger, general guide, and “pasting” them into a few pages. In contrast, a lengthy, tailored manual can be created. Tailored materials can be delivered at one point in time (“one-shot”) or can be delivered over time. Tailored materials delivered over time can use only the initial baseline data from which to tailor or can use information collected at multiple points in time. This method allows goal setting and feedback combinations unavailable in materials tailored only from baseline data. Tailored materials can be driven by a single theory or informed by a variety of concepts within multiple theories [11]. Tailored materials can also be combined with counseling protocols (e.g., telecounseling, provider counseling).

Over the past ten years, a variety of tailored print interventions for smoking cessation have been developed and evaluated in diverse settings. The studies of these interventions vary by methods of recruitment, methods of tailoring, setting, participants and length of contact. However, while there are significant differences between studies, each study compared a tailored feedback protocol to either a targeted material, a general material or a control condition.

Section snippets

Review

Table 1 presents an outline of smoking cessation interventions using tailored print materials. Each study was examined by their design, study groups, sample size, type of tailoring, theoretical concepts used in the tailoring process and relevant outcomes. All experimental group differences presented, unless otherwise stated, were statistically significant (p<0.05). Since each study used very different types of samples and therefore represent different, non-comparable denominators, specific

Discussion

Overall, the studies reviewed offer evidence supporting the effects of computer-based tailored materials. Six out of the nine smoking cessation studies found positive effects (at p<0.10). An additional study (15, second trial) found non-significant overall effects but significant effects for light-moderate smokers. The tenth study reviewed [24]focused only on initial precontemplators, primarily studying their movement through stages of change. Two studies that combined tailored materials with

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