1. Internet and Telephone Treatment for
Smoking Cessation
Amanda L. Graham, PhD
Director, Research Development
The Steven A. Schroeder Institute for Tobacco Research & Policy Studies
Associate Professor (Adjunct)
Georgetown University / Lombardi Comprehensive Cancer Center
PRESENTED AT:
NORTH AMERICAN QUITLINE CONSORTIUM 2011 WEBINAR SERIES
“ARE INNOVATIONS IN WEB AND PHONE TECHNOLOGY INCREASING OUR EFFECTIVENESS WITH TOBACCO USERS?”
FEBRUARY 9 & 11, 2011

2. National Cancer Institute
R01 CA104836

3. Overview
 Background & rationale for trial
 Research design and methods
 Major outcomes
 Secondary analyses currently underway
 Future research

4. Study Team
David Abrams, PhD Brown
Beth Bock, PhD Brown
Charles Neighbors, PhD, MBA Brown
George Papandonatos, PhD Brown
Raymond Niaura, PhD Brown
Nathan Cobb, MD QuitNet
David Rosenbloom, PhD QuitNet
David Tinkelman, MD National Jewish Health

5. Content & Quality of
Internet Cessation
1. To examine the quality of smoking cessation
treatment on the Internet
2. To identify high-quality websites
that warrant effectiveness
evaluation
3. To adapt PHS Clinical Practice
Guideline to create an
evaluation tool
Bock B, Graham A, et al. Smoking cessation treatment on the Internet: content, quality,
and usability. Nic Tob Research, 6: 207-219, 2004. PMID: 15203794.

6. Content & Quality of
Internet Cessation

7. Why QuitNet?
PARTNERS:
7 US states
2 CA provinces
13 Counties
17 employers
4 HMOs

8. Initial Evaluation of
QuitNet
• Observational study in December 2002
• Total # surveyed = 1,501
– Bounced email: 12.3%
• Incentives
– 2 days after initial email: $20
– 6 days after initial email: $40
• Responders: 25.6% (N=385)
Cobb NK, Graham AL, et al. Initial evaluation of a real-world Internet smoking cessation
system. Nic Tob Research, et al. (2005). NicotinePMID: 16036277.
Source: Cobb, Graham 7: 207-216, 2005. and Tobacco Research.

9. Smoking Outcomes
Least conservative
ADHERENCE SAMPLE (N=223): 30.0%
– Respondents only
INTENTION TO TREAT (N=1,024): 7.0%
– Counts all non-responders as smokers
Most conservative

10. Smoking Outcomes:
Secondary Analyses
Least conservative
ADHERENCE SAMPLE (N=223): 30.0%
– Respondents only
• Used site ≥ 2x (N=336): 13.1%
• Used site >1x (N=488): 9.8%
• Excluding bounced (N=892): 8.0%
INTENTION TO TREAT (N=1,024): 7.0%
– Counts all non-responders as smokers
Most conservative

11. Utilization &
Smoking Outcomes
Quitters Smokers
P value
(N=67) (N=156)
9 2
# logins, median (IQR) <.001
(1-42) (1-5)
103 33
# minutes online, median (IQR) <.001
(33-339) (17-83)
% posting in forums 19.4% 4.5% <.001
% with buddy 19.4% 9.6% <.05
% sent Qmail 25.4% 9.0% <.01
% received Qmail 41.8% 20.5% <.001

12. Utilization &
Smoking Outcomes
• Community participation & smoking outcomes:
 7-day pp. abstinence: OR=3.24 ***
 2-month continuous abstinence: OR=4.03 ***
• Intensity of website use & smoking outcomes:
 7-day pp. abstinence: OR=2.34 ***
 2-month continuous abstinence: OR=6.07 ***

13. Study Design

14. Interventions:
Control Condition
 Static site designed
by research team
 “look and feel” of
QuitNet
 Extracted content
from QuitNet
 No interactive
features
 No online
community

15. Interventions:
Enhanced Internet
 Premium service
 Membership fee
paid for by grant
 6 month access

16. Interventions:
Internet + Phone
• Strong evidence base for telephone
counseling
– 2003 Cochrane review included 27 trials
• Broad reach of telephone counseling
– 38 states had quitlines
– Feb 3, 2004: 1-800-QUITNOW
• Web + phone offering on the horizon

17. Interventions:
Internet + Phone
 Non-profit, non-sectarian
 World-recognized
academic medical and
research center for over
110 Years
 #1 Respiratory hospital
since 1998
 Call center operations for
more than 35 years
 Quit Line
 Weight Management
 Disease Management
 Lung Line and Physician Line

18. Interventions:
Internet + Phone
 Intake call
 Entry call
 Preparation call
 2 support calls after quit date
 Additional support calls as
needed
 Motivational interviewing
approach (e.g., roll with
resistance, support self
efficacy, listen reflectively,
clarify and summarize)
 Use of QuitNet encouraged &
reinforced

19. Recruitment
Approach
“Active User
Interception
Sampling”
Google, AOL, MSN,
Yahoo!
 Quit smoking
 Stop smoking
 Quitting smoking
 Stopping smoking
Graham AL et al. Characteristics of smokers reached and recruited to an internet
smoking cessation trial: a case of denominators. Nic Tob Research, 8: S43-48, 2006.
PMID: 17491170.

21. Eligibility Screening
 Smoking rate (5+ cpd)
• Time to first cig.
• Quits past year
• Age 1st puff
 Current age (18+ years)
• Gender
• Race
• Education
• Zip code
 Prior use QuitNet (none)

22. Informed Consent
3 explicit steps:
Do you give informed
consent?
Contact information
“Digital signature”

23. Baseline Telephone
Assessment
Graham AL et al. Internet- vs. telephone-administered questionnaires in a randomized trial of smoking
cessation. Nic Tob Research, 8 Suppl 1: S49-57, 2006. PMID: 17491171.
Graham AL & Papandonatos GD. Reliability of internet- versus telephone-administered questionnaires
in a diverse sample of smokers. J Med Int Res, 10: e8, 2008. PMID: 18364345.

24. Recruitment
Results

25. Participants

26. Follow-Up Results
3mo 6mo 12mo 18mo $25 / phone survey
Basic Internet 79.1 77.3 72.5 68.6
$15 / web survey
Enhanced Internet 76.7 74.0 72.2 69.0
(for telephone non-
Enhanced Internet
73.5 72.6 69.9 67.1 responders)
+ Phone
Total 76.4 74.7 71.5 68.2 $20 bonus at end of
P‐value 0.05 0.12 0.53 0.74 study for completing
all 4 surveys

27. 25
20 Basic Internet
30 day abstinence
15 Enhanced
Internet
10
Enhanced
Internet + Phone
5
0
3 mo 6 mo 12 mo 18 mo

28. 20
18
prevalence abstinence
30 day multiple point
16 Basic Internet
14
12 Enhanced
10 Internet
8 Enhanced
6 Internet + Phone
4
2
0
3 mo 6 mo 12 mo 18 mo

29. Secondary Analyses
1. Early advantage for Enhanced Internet +
Telephone counseling
2. Improvement in both Internet conditions over
time
3. Overall performance of the comparison condition
(Why did the control group do so well?)

30. Secondary Analyses:
Utilization Data
Telephone Counseling Utilization Website Utilization
Data (0-3 months) Data (0-3 months)
N=675 N=675
# calls completed, M (SD) 3.6 (3.3) # logins, median (IQR) 3.0 (9.0)
0 calls 26.7% 0 logins 24.1%
1 call 2.5% 1 login 15.9%
2 calls 14.5% 2 login 11.4%
3 calls 11.1% 3 login 7.3%
4 calls 8.3% 4 login 4.4%
5+ calls 36.9% 5+ logins 36.9%

31. Secondary Analyses:
Utilization Data
Responder only full sample (ITT): 25.9%
Compared to no treatment:
0 1‐4 5+
Logins logins logins  5+ logins were 2.3x more
likely to quit (95% CI
0 calls 13.8% 12.5% 21.1% 1.31 – 4.13, p<.01)
 5+ calls were 3.4x more
1‐4 calls 17.6% 8.7% 25.8%
likely to quit (1.82 – 6.44,
p<.001)
5+ calls 31.6% 26.2% 44.5%
 Additive effect, not
multiplicative

32. Population Impact
EFFICACY x REACH = IMPACT
(# using method
(% abstinent) (total # quitters)
annually)
None (unaided) 3% 16,000,000 480,000
Rx NRT (1995) 14% 2,500,000 350,000
OTC NRT (1996) 14% 6,300,000 882,000
Internet + Phone (3mo ITT) 19.0% 320,000** 60,800
Internet + Phone (3mo hi adh) 45.5% 320,000** 145,600
Behavioral counseling 24% 395,000 94,800
Inpatient treatment 32% 500 160
** US quitlines receive calls from 320,000 smokers annually (Source: NAQC, 2008)
Adapted from Shiffman et al. (1998), Annual Review of Public Health .

33. Utilization &
18 Month Outcomes
0
min
< 90
min

34. Social Networks &
Cessation
Table 1. Website utilization patterns among
BecomeAnEX.org members by community
involvement
No
Community
Community
3+ logins 8% 28%
# days
5.0 ± 29.0 22.1 ± 59.1
website use
# interactive
1.9 ± 1.6 3.4 ± 2.0
tools used

35. “Integrator” Pilot
Study
• N=244 randomized to EX vs. EX + SN
• Intervention feasible & well received
– High ratings on positive adjectives (encouraging,
welcoming, supportive)
– Low ratings on negative adjectives (annoying, intrusive,
irrelevant)
– More satisfied with website
– Greater perceived helpfulness of website
• 1.7x more likely to return to the website 3+ times
• 2.3x more likely to be abstinent at 30 days

36. Summary &
Implications
1. Make sure Internet cessation program is
evidence based and leverages the full
functionality of the Internet
2. Seamless integration of treatments each with
unique advantages rather than parallel offerings
3. Adherence is critical

37. Amanda L. Graham, PhD
Phone: 202.454.5938
Email: agraham@legacyforhealth.org