UvA-DARE (Digital Academic Repository) Results of the PAS study: A Randomized Controlled Trial evaluating the effectiveness of a web-based multiple tailored smoking cessation programme combined with tailored counselling by practice nurses

This study investigated the effects of Web-based multiple computer tailoring and counseling by a practice nurse (MTC) compared with computer tailoring without counseling (MT) and usual care (UC) on smoking cessation rates, via a randomized controlled trial with 414 Dutch adult smokers, recruited by 91 practice nurses from May 2009 to June 2010. Logistic multilevel regression analyses were conducted with 24-hour point prevalence, 7-day point prevalence, and prolonged abstinence after 6 and 12 months as dependent variables and experimental condition as the independent variable. After 6 and 12 months, 38% and 56% of respondents were followed up, respectively. At both follow-ups, no main effects of the interventions could be identified when comparing them with care as usual and with each other—neither in analyses using available data nor in analyses using a negative scenario in which respondents lost to follow-up were considered to still be smoking. A Web-based multiple computer-tailored smoking cessation program combined with a single face-to-face counseling session by a practice nurse may not be more effective than this computer-tailored program alone or than usual smoking cessation care in the general practice setting. Yet before concluding that the addition of counseling to Web-based computer tailoring cannot be successful, more research needs to be conducted to identify the optimal number of counseling sessions to be combined with the Web-based program and to how to best attune the two modalities. Tobacco smoking is the most preventable cause of illness and premature death worldwide (U.S. Department of Health and Human Services [USDHHS], 2004; World Health Organization [WHO], 2008), and it is important that smokers are supported in their attempts to quit. A health communication strategy that has been proven effective in increasing smoking cessation rates is computer tailoring (Lancaster & Stead, 2005; Noar, Benac, & Harris, 2007). Computer-tailored health communication interventions are characterized by providing feedback adapted to the individual users’ characteristics, using a computerized process (Dijkstra & de Vries, 1999; Velicer & Prochaska, 1999). Compared with nontailored interventions, interventions that are tailored to the respondent’s personal characteristics and situation are more successful in attracting and keeping smokers’ attention (de Vries & Brug, 1999; Strecher et al., 2008), resulting in more careful processing of information (Dijkstra, 2005). While a single computer-tailored feedback message is already successful in increasing smoking cessation rates (Te Poel, Bolman, Reubsaet, & de Vries, 2009), providing feedback on multiple occasions (multiple computer tailoring) further increases this effect (Borland, Balmford, & Hunt, 2004; Dijkstra, de Vries, Roijackers, & van Breukelen, 1998b). Computer-tailored interventions are increasingly delivered through the Internet (Lustria, Cortese, Noar, & Glueckauf, 2009; Shahab & McEwen, 2009). This medium is highly accessible (Centraal Bureau voor de Statistiek, 2011; Internet World Stats, 2010), can reach a large audience with low costs, and offers the opportunity to participate at convenient moments in time (Civljak, Sheikh, Stead, & Car, 2010). Yet the effect sizes of Web-based computer tailoring as a standalone health communication intervention remain only small to medium (Lustria et al., 2013). Combining Web-based multiple computer tailoring with a second effective intervention might increase its effectiveness— and may even result in effects that exceed the sum of the two interventions’ individual effects (Naik & Raman, 2003). This increased effectiveness has been suggested to be caused by a process called multiple source perception: the idea that messages delivered via different media are perceived as more convincing and credible than messages delivered via a single medium (Voorveld, Neijens, & Smit, 2011). Indeed, the combination of a single printed tailored intervention with CONTACT E. S. Smit [email protected] Department of Communication Science, Amsterdam School of Communication Research/ASCoR, University of Amsterdam, PO Box 15791, 1001 NG Amsterdam, The Netherlands. Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/hhth. Trial ID number: Dutch Trial Register NTR1351. HEALTH COMMUNICATION 2016, VOL. 31, NO. 9, 1165–1173 http://dx.doi.org/10.1080/10410236.2015.1049727 © 2016 The Author(s). Published by Taylor & Francis This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. telephone counseling has been found to have a small though significant additional effect on smoking cessation rates compared to the tailored intervention only (Curry, McBride, Grothaus, Louie, & Wagner, 1995; Sutton & Gilbert, 2007). Moreover, a study that combined multiple (i.e., three) printed tailored feedback letters with proactive telephone calls from a counselor revealed small but positive effects after a 12-month follow-up period when compared with tailored feedback only (Prochaska et al., 2001). While these results are promising, however, no earlier research has studied the effectiveness of a smoking cessation intervention that combines Web-based multiple computer tailoring with face-to-face counseling delivered by a practice nurse (PN). Nonetheless, smoking cessation advice provided face-to-face by a general practitioner (GP) has been found to be effective in increasing smoking cessation rates and to outperform telephone counseling (Lemmens, Oenema, Knut, & Brug, 2008; Stead, Bergson, & Lancaster, 2008). GPs, however, often experience a lack of time and skills to support smokers to quit (Hoving, Mudde, & de Vries, 2007; Yarnall, Pollak, Krause, & Michener, 2003). As nurse-delivered smoking cessation interventions can also be effective (Lemmens et al., 2008; Rice & Stead, 2008) and Dutch GPs often employ a PN (Hingstman & Kenens, 2007), involving PNs in smoking cessation counseling can be a viable alternative. Therefore, this study aimed to answer the following research question: What is the effectiveness of a Web-based multiple computer-tailored smoking cessation program combined with face-to-face counseling by a PN (MTC) in comparison with the computer-tailored program as a stand-alone intervention (MT) and usual care (UC)? The main hypothesis in this study was that a combination of two of the few effective methods for smoking cessation (i.e., Web-based multiple computer tailoring and counseling by a health professional; MTC) would yield more effects on smoking cessation rates than the Web-based program alone (MT) and that both MTC and MT would outperform UC. Theoretical framework The Web-based multiple computer-tailored program and the counseling protocol that was developed to guide the counseling sessions were grounded in the I-Change Model (ICM; de Vries et al., 2003). The ICM is a behavior change theory that includes theoretical concepts from several sociocognitive models, such as the Transtheoretical Model (Prochaska & DiClemente, 1983), the Theory of Planned Behavior (Ajzen, 1985), Social Cognitive Theory (Bandura, 1986), and the Health Belief Model (Janz, Champion, & Strecher, 2002). The ICM proposes that a person’s behavioral intention is the most direct predictor of behavior. Intention, in turn, is predicted by three motivational constructs: attitude, perceived social influence, and self-efficacy. According to the ICM, a person’s attitude entails both the perceived advantages and disadvantages of the behavior. Perceived social influence refers to three related, though different, constructs: perceived social norms, social modeling, and social pressure. Perceived social norms reflect the perceived opinions held by others in the social environment, whereas social modeling refers to the perceived behavior of these others, and social pressure represents their perceived pressure or support to perform the behavior. Self-efficacy refers to a person’s level of confidence that she or he is able to perform the behavior. In studies that also used the ICM as a theoretical framework, a positive attitude toward smoking cessation, a social environment that is perceived as positive concerning smoking cessation, and a high self-efficacy to quit have all been found to positively influence a person’s intention to quit smoking (Dijkstra & de Vries, 2000; Hoving, Mudde, & de Vries, 2006; Panday, Reddy, Ruiter, Bergstrom, & de Vries, 2007; Vitoria, Salgueiro, Silva, & de Vries, 2009; de Vries & Mudde, 1998). Next to these motivational factors, the ICM includes several premotivational factors, including predisposing, awareness, and information factors. In addition, the ICM recognizes that although intention is a necessary prerequisite for behavior change to occur, several postmotivational factors play a role in bridging the gap between intention and behavior (Armitage & Conner, 2001). Although perceived barriers to change are expected to increase this gap, ability factors such as an individual’s skills to refrain from smoking and the formation of action plans (i.e., preparatory and coping planning) are assumed to decrease this gap.