Effectiveness of Message Frame-Tailoring in a Web-Based Smoking Cessation Program: Randomized Controlled Trial

Smoking cessation message testing to inform app-based interventions for young adults - an online experiment

BACKGROUND

To improve the efficacy of digital smoking cessation interventions for young adults, intervention messages need to be acceptable and appropriate for this population. The current study compared ratings of smoking cessation and urge reduction messages based on Cognitive Behavioral Therapy (distraction themed) and Acceptance and Commitment Therapy (acceptance themed) in young adults who smoke.

METHODS

A total of 124 intervention messages were rated by an online Qualtrics panel of N = 301 diverse young adults who currently smoked tobacco cigarettes (Age M = 26.6 years; 54.8% male; 51.5% racial/ethnic minority; 16.9% sexual or gender minority (SGM); 62.5% daily smoking). Each participant rated 10 randomly selected messages (3,010 total message ratings; 24.3 ratings per message) on 5-point scales (higher scores representing more favorable ratings) evaluating quality of content, quality of design, perceived support for coping with smoking urges, and perceived support for quitting smoking. Mixed models examined associations between message category (distraction vs. acceptance), participant level predictors (sociodemographic variables, readiness and motivation to quit, daily smoking, psychological flexibility), and message ratings.

RESULTS

Overall ratings ranged from M = 3.61 (SD = 1.25) on support for coping with urges to M = 3.90 (SD = 1.03) on content, with no differences between distraction and acceptance messages. Male participants gave more favorable ratings on the dimensions of support for coping (p < 0.01) and support for quitting (p < 0.01). Participants identifying as SGM gave lower ratings for message design (p < 0.05). Participants with a graduate degree gave higher ratings on support for coping with urges and support for quitting (both p < 0.05). Higher motivation to quit was associated with more favorable scores across all dimensions (all p < 0.01). Those smoking daily rated messages as less helpful for coping with urges (p < 0.01) and quitting smoking (p < 0.05) compared to those smoking non-daily. Few interactions were found between message category distraction vs. acceptance and participant characteristics.

CONCLUSIONS

Distraction and acceptance messages received similar ratings among young adults who smoke cigarettes. Message revisions may be needed to increase appeal to women, SGM, those with lower education, and those less motivated to quit. Messages will be refined and used in an ongoing micro-randomized trial to investigate their real-time impact on smoking urges and behaviors.

Smoking cessation message testing to inform app-based interventions - an online experiment

Background: To improve the efficacy of digital smoking cessation interventions for young adults, intervention messages need to be acceptable and appropriate for this population. The current study compared ratings of smoking cessation and urge reduction messages based on Cognitive Behavioral Therapy (distraction themed) and Acceptance and Commitment Therapy (acceptance themed) in young adults who smoke. Methods: A total of 124 intervention messages were rated by an online Qualtrics panel of N=301 diverse young adults who currently smoked tobacco cigarettes (Age M=26.6 years; 54.8% male; 51.5% racial/ethnic minority; 16.9% sexual or gender minority (SGM); 62.5% daily smoking). Each participant rated 10 randomly selected messages (3,010 total message ratings; 24.3 ratings per message) on 5-point scales (higher scores representing more favorable ratings) evaluating quality of content, quality of design, perceived support for coping with smoking urges, and perceived support for quitting smoking. Mixed models examined associations between message category (distraction vs. acceptance), participant level predictors (sociodemographic variables, readiness and motivation to quit, daily smoking, psychological flexibility), and message ratings. Results: Overall ratings ranged from M=3.61 (SD=1.25) on support for coping with urges to M=3.90 (SD=1.03) on content, with no differences between distraction and acceptance messages. Male participants gave more favorable ratings on the dimensions of support for coping (p<0.01) and support for quitting (p<0.01). Participants identifying as SGM gave lower ratings for message design (p<0.05). Participants with a graduate degree gave higher ratings on support for coping with urges and support for quitting (both p<0.05). Higher motivation to quit was associated with more favorable scores across all dimensions (all p<0.01). Those smoking daily rated messages as less helpful for coping with urges (p<0.01) and quitting smoking (p<0.05) compared to those smoking non-daily. Few interactions were found between message category distraction vs. acceptance and participant characteristics. Conclusions: Distraction and acceptance messages received similar ratings among young adults who smoke cigarettes. Message revisions may be needed to increase appeal to women, SGM, those with lower education, and those less motivated to quit. Messages will be refined and used in an ongoing micro-randomized trial to investigate their real-time impact on smoking urges and behaviors.

Autonomy support in telehealth: an evolutionary concept analysis

Aims

Autonomy support plays a critical role in safeguarding patients' fundamental rights and promoting health behaviors. The context of autonomy support is transitioning from traditional face-to-face healthcare settings to telehealth, leading to an evolution in the connotation of autonomy support. This study aimed to clarify the connotation of autonomy support in telehealth and to develop a conceptual framework to guide innovations in clinical practice and the advancement of related theories.

Methods

Rodgers' evolutionary method was used to clarified attributes, antecedents, and consequences of autonomy support in telehealth. The integrative review strategy of Whittemore and Knafl was used as the methodology for searching relevant literature.

Results

Twenty-five articles were included. The attributes were identified as: (i) technical feedback; (ii) virtual agent; (iii) choice; (iv) rationale; (v) empathy; (vi) collaboration; and (vii) strengths. The antecedents were: (i) telehealth service system; (ii) change in awareness toward autonomy support; and (iii) patient preference of needs for autonomy. The consequences were: (i) multidimensional perception; (ii) emotional experience; (iii) health behavior; (iv) social relation; and (v) technological dependence.

Conclusion

This study clarified the attributes, antecedents, and consequences of autonomy support in telehealth, developing and improving a conceptual framework for autonomy support. These findings will provide a theoretical foundation for developing technology-enabled autonomy support strategies in telehealth practice, better adapting to the emerging needs of patients in the context of the digital age.

Injunctive social norms and perceived message tailoring are associated with health information seeking

Social norms messages may promote information seeking, especially when the norms refer to a group with which a person identifies. We hypothesized that tailored social norms messages would increase COVID-19 testing willingness and intentions. College students (n = 203, 75% female, 87% White) were randomly assigned to one of four conditions in a 2 (Descriptive norms: Relevant vs. Irrelevant to COVID-19 testing) x 2 (Tailoring: Specific vs. General group information) experimental design. Participants reported COVID-19 testing willingness and intentions, perceived injunctive norms, and identification and connectedness with the group in the message. Although neither the norm nor tailoring manipulation worked as intended, participants who perceived greater message tailoring and injunctive norms reported greater willingness and intentions, with no effect of perceived descriptive norms on either outcome. Tailored messages as well as messages promoting injunctive norms may promote information seeking across health contexts, thereby enabling more informed decisions.

Effects of an Explicit Value Clarification Method With Computer-Tailored Advice on the Effectiveness of a Web-Based Smoking Cessation Decision Aid: Findings From a Randomized Controlled Trial

BACKGROUND

Smoking continues to be a driver of mortality. Various forms of evidence-based cessation assistance exist; however, their use is limited. The choice between them may also induce decisional conflict. Offering decision aids (DAs) may be beneficial; however, insights into their effective elements are lacking.

OBJECTIVE

This study tested the added value of an effective element (ie, an "explicit value clarification method" paired with computer-tailored advice indicating the most fitting cessation assistance) of a web-based smoking cessation DA.

METHODS

A web-based randomized controlled trial was conducted among smokers motivated to stop smoking within 6 months. The intervention group received a DA with the aforementioned elements, and the control group received the same DA without these elements. The primary outcome measure was 7-day point prevalence abstinence 6 months after baseline (time point 3 [t=3]). Secondary outcome measures were 7-day point prevalence of abstinence 1 month after baseline (time point 2 [t=2]), evidence-based cessation assistance use (t=2 and t=3), and decisional conflict (immediately after DA; time point 1). Logistic and linear regression analyses were performed to assess the outcomes. Analyses were conducted following 2 (decisional conflict) and 3 (smoking cessation) outcome scenarios: complete cases, worst-case scenario (assuming that dropouts still smoked), and multiple imputations. A priori sample size calculation indicated that 796 participants were needed. The participants were mainly recruited on the web (eg, social media). All the data were self-reported.

RESULTS

Overall, 2375 participants were randomized (intervention n=1164, 49.01%), of whom 599 (25.22%; intervention n=275, 45.91%) completed the DAs, and 276 (11.62%; intervention n=143, 51.81%), 97 (4.08%; intervention n=54, 55.67%), and 103 (4.34%; intervention n=56, 54.37%) completed time point 1, t=2, and t=3, respectively. More participants stopped smoking in the intervention group (23/63, 37%) than in the control group (14/52, 27%) after 6 months; however, this was only statistically significant in the worst-case scenario (crude P=.02; adjusted P=.04). Effects on the secondary outcomes were only observed for smoking abstinence after 1 month (15/55, 27%, compared with 7/46, 15%, in the crude and adjusted models, respectively; P=.02) and for cessation assistance uptake after 1 month (26/56, 46% compared with 18/47, 38% only in the crude model; P=.04) and 6 months (38/61, 62% compared with 26/50, 52%; crude P=.01; adjusted P=.02) but only in the worst-case scenario. Nonuse attrition was 34.19% higher in the intervention group than in the control group (P<.001).

CONCLUSIONS

Currently, we cannot confidently recommend the inclusion of explicit value clarification methods and computer-tailored advice. However, they might result in higher nonuse attrition rates, thereby limiting their potential. As a lack of statistical power may have influenced the outcomes, we recommend replicating this study with some adaptations based on the lessons learned.

TRIAL REGISTRATION

Netherlands Trial Register NL8270; https://www.trialregister.nl/trial/8270.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/21772.

Communicating risk to promote colorectal cancer screening: a multi-method study to test tailored versus targeted message strategies

Colorectal cancer (CRC) screening rates are suboptimal, partly due to poor communication about CRC risk. More effective methods are needed to educate patients, but little research has examined best practices for communicating CRC risk. This multi-method study tests whether tailoring CRC risk information increases screening intentions. Participants (N = 738) were randomized with a 2:2:1 allocation to tailored, targeted, and control message conditions. The primary outcome was intention to screen for CRC (yes/no). Additional variables include perceived message relevance, perceived susceptibility to CRC, and free-text comments evaluating the intervention. A chi-square test determined differences in the proportion of participants who intended to complete CRC screening by condition. A logistic-based path analysis explored mediation. Free-text comments were analyzed using advanced topic modeling analysis. CRC screening intentions were highest in the tailored intervention and significantly greater than control (P = 0.006). The tailored message condition significantly increased message relevance compared with control (P = 0.027) and targeted conditions (P = 0.002). The tailored condition also increased susceptibility (P < 0.001) compared with control, which mediated the relationship between the tailored condition and intention to screen (b = 0.04, SE = 0.02, 95% confidence interval = 0.02, 0.09). The qualitative data reflect similar trends. The theoretical mechanisms and practical implications of tailoring health education materials about CRC risk are discussed.

The Usability of an Online Tool to Promote the Use of Evidence-Based Smoking Cessation Interventions

To increase usage of evidence-based smoking cessation interventions (EBSCIs) among smokers, an online decision aid (DA) was developed. The aims of this study were (1) to conduct a usability evaluation; (2) to conduct a program evaluation and evaluate decisional conflict after using the DA and (3) to determine the possible change in the intention to use EBSCIs before and directly after reviewing the DA. A cross-sectional study was carried out in September 2020 by recruiting smokers via the Internet (n = 497). Chi-squared tests and t-tests were conducted to test the differences between smokers who differed in the perceived usability of the DA on the program evaluation and in decisional conflict. The possible changes in intention to use EBSCIs during a cessation attempt before and after reviewing the DA were tested using t-tests, McNemar's test and χ2 analysis. The participants evaluated the usability of the DA as moderate (MU; n = 393, 79.1%) or good (GU; n = 104, 20.9%). GU smokers rated higher on all the elements of the program evaluation and experienced less decisional conflict, but also displayed a higher intention to quit. After reviewing the DA, the participants on average had a significantly higher intention to use more EBSCIs, in particular in the form of eHealth. Recommendations to make the DA more usable could include tailoring, using video-based information and including value clarification methods. Furthermore, a hybrid variant in which smokers can use the DA independently and with the guidance of a primary care professional could aid both groups in choosing a fitting EBSCI option.

Message Frame-Tailoring in Digital Health Communication: Intervention Redesign and Usability Testing (Preprint)

Background

Message frame–tailoring based on the need for autonomy is a promising strategy to improve the effectiveness of digital health communication interventions. An example of a digital health communication intervention is Personal Advice in Stopping smoking (PAS), a web-based content-tailored smoking cessation program. PAS was effective in improving cessation success rates, but its effect sizes were small and disappeared after 6 months. Therefore, investigating whether message frame–tailoring based on the individual’s need for autonomy might improve effect rates is worthwhile. However, to our knowledge, this has not been studied previously.

Objective

To investigate whether adding message frame–tailoring based on the need for autonomy increases the effectiveness of content-tailored interventions, the PAS program was redesigned to incorporate message frame–tailoring also. This paper described the process of redesigning the PAS program to include message frame–tailoring, providing smokers with autonomy-supportive or controlling message frames—depending on their individual need for autonomy. Therefore, we aimed to extend framing theory, tailoring theory, and self-determination theory.

Methods

Extension of the framing theory, tailoring theory, and self-determination theory by redesigning the PAS program to include message frame–tailoring was conducted in close collaboration with scientific and nonscientific smoking cessation experts (n=10), smokers (n=816), and communication science students (n=19). Various methods were used to redesign the PAS program to include message frame–tailoring with optimal usability: usability testing, think-aloud methodology, heuristic evaluations, and a web-based experiment.

Results

The most autonomy-supportive and controlling message frames were identified, the cutoff point for the need for autonomy to distinguish between people with high and those with low need for autonomy was determined, and the usability was optimized.

Conclusions

This resulted in a redesigned digital health communication intervention that included message frame–tailoring and had optimal usability. A detailed description of the redesigning process of the PAS program is provided.

Trial Registration

Netherlands Trial Register NL6512 (NRT6700); https://www.trialregister.nl/trial/6512

A Web-Based Intervention to Increase Smokers' Intentions to Participate in a Cessation Study Offered at the Point of Lung Screening: Factorial Randomized Trial

BACKGROUND

Screen ASSIST is a cessation trial offered to current smokers at the point of lung cancer screening. Because of the unique position of promoting a prevention behavior (smoking cessation) within the context of a detection behavior (lung cancer screening), this study employed prospect theory to design and formatively evaluate a targeted recruitment video prior to trial launch.

OBJECTIVE

The aim of this study was to identify which message frames were most effective at promoting intent to participate in a smoking cessation study.

METHODS

Participants were recruited from a proprietary opt-in online panel company and randomized to a 2 (benefits of quitting vs risks of continuing to smoke at the time of lung screening; BvR) × 2 (gains of participating vs losses of not participating in a cessation study; GvL) message design experiment (N=314). The primary outcome was self-assessed intent to participate in a smoking cessation study. Message effectiveness and lung cancer risk perception measures were also collected. Analysis of variance examined the main effect of the 2 message factors and a least absolute shrinkage and selection operator (LASSO) approach identified predictors of intent to participate in a multivariable model. A mediation analysis was conducted to determine the direct and indirect effects of message factors on intent to participate in a cessation study.

RESULTS

A total of 296 participants completed the intervention. There were no significant differences in intent to participate in a smoking cessation study between message frames (P=.12 and P=.61). In the multivariable model, quit importance (P<.001), perceived message relevance (P<.001), and affective risk response (ie, worry about developing lung cancer; P<.001) were significant predictors of intent to participate. The benefits of quitting frame significantly increased affective risk response (Meanbenefits 2.60 vs Meanrisk 2.40; P=.03), which mediated the relationship between message frame and intent to participate (b=0.24; 95% CI 0.01-0.47; P=.03).

CONCLUSIONS

This study provides theoretical and practical guidance on how to design and evaluate proactive recruitment messages for a cessation trial. Based on our findings, we conclude that heavy smokers are more responsive to recruitment messages that frame the benefits of quitting as it increased affective risk response, which predicted greater intention to participate in a smoking cessation study.

Tailored Web-Based Smoking Interventions and Reduced Attrition: Systematic Review and Meta-Analysis

Background

The increasing number of internet users presents an opportunity to deliver health interventions to large populations. Despite their potential, many web-based interventions, including those for smoking cessation, face high rates of attrition. Further consideration of how intervention features impact attrition is needed.

Objective

The aim of this systematic review is to investigate whether tailored web-based smoking cessation interventions for smokers are associated with reduced rates of attrition compared with active or passive untailored web-based interventions. The outcomes of interest were dropout attrition at 1-, 3-, 6-, and 12-month follow-ups.

Methods

Literature searches were conducted in May 2018 and updated in May 2020 on MEDLINE (Medical Literature Analysis and Retrieval System Online), PsycINFO (Psychological Information), EMBASE (Excerpta Medica dataBASE), CINAHL (Cumulated Index to Nursing and Allied Health Literature), Scopus, and the Cochrane Tobacco Addiction Group Specialized Register with the following search terms: smoking cessation, tailored, or web- or internet-based. Included studies were published in English before or in May 2020 using a randomized controlled trial design. Studies were restricted to those with web-based delivery, a tailored intervention group, an untailored control group, and a reported outcome of smoking cessation. Studies were assessed for methodological quality using the Cochrane Risk of Bias tool. Two reviewers independently extracted the study characteristics and the number of participants lost to follow-up for each treatment group.

Results

A total of 13 studies were included in the systematic review, of which 11 (85%) were included in the meta-analysis. Tailoring had no statistically significant effect on dropout attrition at 1-month (risk ratio [RR]=1.02, 95% CI 0.95-1.09; P=.58; I²=78%), 3-month (RR=0.99, 95% CI 0.95-1.04; P=.80; I²=73%), 6-month (RR=1.00, 95% CI 0.95-1.05; P=.90; I²=43%), or 12-month (RR=0.97, 95% CI 0.92-1.02; P=.26; I²=28%) follow-ups. Subgroup analyses suggested that there was a statistically significant effect of tailoring between the active and passive subgroups at 1-month (P=.03), 3-month (P<.001), and 6-month (P=.02) follow-ups but not at 12-month follow-up (P=.25).

Conclusions

The results suggest that tailoring of web-based smoking cessation interventions may not be associated with reduced rates of dropout attrition at 1-, 3-, 6-, or 12-month follow-ups. Significant differences between studies that include untailored active and passive control groups suggest that the role of tailoring may be more prominent when studies include a passive control group. These findings may be because of variability in the presence of additional features, the definition of smokers used, and the duration of smoking abstinence measured. Future studies should incorporate active web-based controls, compare the impact of different tailoring strategies, and include populations outside of the Western countries.