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Computer-Facilitated 5A's for Smoking Cessation: A Randomized Trial of Technology to Promote Provider Adherence.

ABSTRACT: INTRODUCTION:Although evidence-based, the 5A's (Ask, Advise, Assess, Assist, and Arrange) for smoking cessation are often incompletely delivered by primary care providers. This study examines whether a computer tablet 5A's intervention improves primary care provider adherence to the 5A's. STUDY DESIGN:Cluster RCT. SETTING/PARTICIPANTS:All primary care providers in three urban, adult primary care clinics were randomized for participation. Any English- or Spanish-speaking patient with a primary care appointment who had smoked >100 lifetime cigarettes and at least one cigarette in the past week was eligible. INTERVENTION:A cluster RCT comparing computer-facilitated 5A's with usual care assessed effects on provider adherence to each of the 5A's as determined by patient report. Intervention subjects used a computer tablet to complete the 5A's immediately before a primary care appointment. A tailored, patient handout and a structured, clinician guide were generated. Data were collected in 2014-2015 and analyzed in 2016-2017. MAIN OUTCOME MEASURES:Provider adherence to the 5A's. RESULTS:Providers (N=221) saw 961 patients (n=412 intervention, n=549 control) for a total of n=1,340 encounters with n=1,011 completed post-visit interviews (75.4% completion). Intervention providers had significantly higher odds of completing Assess (AOR=1.32, 95% CI=1.02, 1.73) and Assist (AOR=1.45, 95% CI=1.08, 1.94). When looking at first study visits only, intervention providers had higher odds for Arrange (AOR=1.72, 95% CI=1.23, 2.40) and all 5A's (AOR=2.04, 95% CI=1.35, 3.07) but study visit did not influence receipt of the other 5A's. CONCLUSIONS:A computer-facilitated 5A's delivery model was effective in improving the fidelity of provider-delivered 5A's to diverse primary care patients. This relatively low-cost, time-saving intervention has great potential for smoking cessation and other health behaviors. Future studies should identify ways to promote and sustain technology implementation. TRIAL REGISTRATION:This study is registered at www.clinicaltrials.gov NCT02046408.

SUBMITTER: Satterfield JM

PROVIDER: S-EPMC6020838 | biostudies-literature | 2018 Jul

REPOSITORIES: biostudies-literature

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Computer-Facilitated 5A's for Smoking Cessation: A Randomized Trial of Technology to Promote Provider Adherence.

Satterfield Jason M JM Gregorich Steven E SE Kalkhoran Sara S Lum Paula J PJ Bloome Jessica J Alvarado Nicholas N Muñoz Ricardo F RF Vijayaraghavan Maya M

American journal of preventive medicine 20180618 1

<h4>Introduction</h4>Although evidence-based, the 5A's (Ask, Advise, Assess, Assist, and Arrange) for smoking cessation are often incompletely delivered by primary care providers. This study examines whether a computer tablet 5A's intervention improves primary care provider adherence to the 5A's.<h4>Study design</h4>Cluster RCT.<h4>Setting/participants</h4>All primary care providers in three urban, adult primary care clinics were randomized for participation. Any English- or Spanish-speaking pat ...[more]

PMID: 29929682

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Project description:BackgroundThe 5As for smoking cessation is an evidence-based intervention to aid providers in counseling patients to quit smoking. While most providers "ask" patients about their tobacco use patterns and "advise" them to quit, fewer patients report being "assessed" for their interest in quitting, and even fewer report subsequent "assistance" in a quit attempt and having follow-up "arranged".PurposeThis article describes the design of an implementation study testing a computer tablet intervention to improve provider adherence to the 5As for smoking cessation. Findings will contribute to the existing literature on technology acceptance for addressing addictive behaviors, and how digital tools may facilitate the broader implementation of evidence-based behavioral counseling practices without adversely affecting clinical flow or patient care.MethodsThis project develops and tests a computer-facilitated 5As (CF-5As) model that administers the 5As intervention to patients with a computer tablet, then prompts providers to reinforce next steps. During the development phase, 5As' content will be programmed onto computer tablets, alpha and beta-testing of the service delivery model will be done, and pre-intervention interview and questionnaire data will be collected from patients, providers, and clinic staff about 5As fidelity and technology adoption. During the program evaluation phase, a randomized controlled trial comparing a group who receives the CF-5As intervention to one that does not will be conducted to assess 5As fidelity. Using the technology acceptance model, a mixed methods study of contextual and human factors influencing both 5As and technology adoption will also be conducted.ConclusionsTechnology is increasingly being used in clinical settings. A technological tool that connects patients, providers, and clinic staff to facilitate the promotion of behavioral interventions such as smoking cessation may provide an innovative platform through which to efficiently and effectively implement evidence-based practices.

Project description:BackgroundComputer-tailored health communication (CTHC), a widely used strategy to increase the effectiveness of smoking cessation interventions, is focused on selecting the best messages for an individual. More recently, CTHC interventions have been tested using contextual information such as participants' current stress or location to adapt message selection. However, mood has not yet been used in CTCH interventions and may increase their effectiveness.ObjectiveThis study aims to examine the association of mood and smoking cessation message effectiveness among adults who currently smoke cigarettes.MethodsIn January 2022, we recruited a web-based convenience sample of adults who smoke cigarettes (N=615; mean age 41.13 y). Participants were randomized to 1 of 3 mood conditions (positive, negative, or neutral) and viewed pictures selected from the International Affective Picture System to induce an emotional state within the assigned condition. Participants then viewed smoking cessation messages with topics covering five themes: (1) financial costs or rewards, (2) health, (3) quality of life, (4) challenges of quitting, and (5) motivation or reasons to quit. Following each message, participants completed questions on 3 constructs: message receptivity, perceived relevance, and their motivation to quit. The process was repeated 30 times. We used 1-way ANOVA to estimate the association of the mood condition on these constructs, controlling for demographics, cigarettes per day, and motivation to quit measured during the pretest. We also estimated the association between mood and outcomes for each of the 5 smoking message theme categories.ResultsThere was an overall statistically significant effect of the mood condition on the motivation to quit outcome (P=.02) but not on the message receptivity (P=.16) and perceived relevance (P=.86) outcomes. Participants in the positive mood condition reported significantly greater motivation to quit compared with those in the negative mood condition (P=.005). Participants in the positive mood condition reported higher motivation to quit after viewing smoking cessation messages in the financial (P=.03), health (P=.01), quality of life (P=.04), and challenges of quitting (P=.03) theme categories. We also compared each mood condition and found that participants in the positive mood condition reported significantly greater motivation to quit after seeing messages in the financial (P=.01), health (P=.003), quality of life (P=.01), and challenges of quitting (P=.01) theme categories than those in the negative mood condition.ConclusionsOur findings suggest that considering mood may be important for future CTHC interventions. Because those in the positive mood state at the time of message exposure were more likely to have greater quitting motivations, smoking cessation CTHC interventions may consider strategies to help improve participants' mood when delivering these messages. For those in neutral and negative mood states, focusing on certain message themes (health and motivation to quit) may be more effective than other message themes.

Project description:BackgroundBlended face-to-face and web-based treatment is a promising way to deliver smoking cessation treatment. Since adherence has been shown to be an indicator of treatment acceptability and a determinant for effectiveness, we explored and compared adherence and predictors of adherence to blended and face-to-face alone smoking cessation treatments with similar content and intensity.ObjectiveThe objectives of this study were (1) to compare adherence to a blended smoking cessation treatment with adherence to a face-to-face treatment; (2) to compare adherence within the blended treatment to its face-to-face mode and web mode; and (3) to determine baseline predictors of adherence to both treatments as well as (4) the predictors to both modes of the blended treatment.MethodsWe calculated the total duration of treatment exposure for patients (N=292) of a Dutch outpatient smoking cessation clinic who were randomly assigned either to the blended smoking cessation treatment (n=130) or to a face-to-face treatment with identical components (n=162). For both treatments (blended and face-to-face) and for the two modes of delivery within the blended treatment (face-to-face vs web mode), adherence levels (ie, treatment time) were compared and the predictors of adherence were identified within 33 demographic, smoking-related, and health-related patient characteristics.ResultsWe found no significant difference in adherence between the blended and the face-to-face treatments. Participants in the blended treatment group spent an average of 246 minutes in treatment (median 106.7% of intended treatment time, IQR 150%-355%) and participants in the face-to-face group spent 238 minutes (median 103.3% of intended treatment time, IQR 150%-330%). Within the blended group, adherence to the face-to-face mode was twice as high as that to the web mode. Participants in the blended group spent an average of 198 minutes (SD 120) in face-to-face mode (152% of the intended treatment time) and 75 minutes (SD 53) in web mode (75% of the intended treatment time). Higher age was the only characteristic consistently found to uniquely predict higher adherence in both the blended and face-to-face groups. For the face-to-face group, more social support for smoking cessation was also predictive of higher adherence. The variability in adherence explained by these predictors was rather low (blended R2=0.049; face-to-face R2=0.076). Within the blended group, living without children predicted higher adherence to the face-to-face mode (R2=0.034), independent of age. Higher adherence to the web mode of the blended treatment was predicted by a combination of an extrinsic motivation to quit, a less negative attitude toward quitting, and less health complaints (R2=0.164).ConclusionsThis study represents one of the first attempts to thoroughly compare adherence and predictors of adherence of a blended smoking cessation treatment to an equivalent face-to-face treatment. Interestingly, although the overall adherence to both treatments appeared to be high, adherence within the blended treatment was much higher for the face-to-face mode than for the web mode. This supports the idea that in blended treatment, one mode of delivery can compensate for the weaknesses of the other. Higher age was found to be a common predictor of adherence to the treatments. The low variance in adherence predicted by the characteristics examined in this study suggests that other variables such as provider-related health system factors and time-varying patient characteristics should be explored in future research.Trial registrationNetherlands Trial Register NTR5113; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5113.

Project description:Web-based smoking cessation interventions can deliver evidence-based treatments to a wide swath of the population, but effectiveness is often limited by insufficient adherence to proven treatment components. This study evaluated the impact of a social network (SN) intervention and free nicotine replacement therapy (NRT) on adherence to evidence-based components of smoking cessation treatment in the context of a Web-based intervention.A sample of adult U.S. smokers (N = 5290) was recruited via BecomeAnEX.org, a free smoking cessation Web site. Smokers were randomized to one of four arms: (1) an interactive, evidence-based smoking cessation Web site (WEB) alone; (2) WEB in conjunction with an SN intervention designed to integrate participants into the online community (WEB+SN); (3) WEB plus free NRT (WEB+NRT); and (4) the combination of all treatments (WEB+SN+NRT). Adherence outcomes assessed at 3-month follow-up were as follows: Web site utilization metrics, use of skills training components, intratreatment social support, and pharmacotherapy use.WEB+SN+NRT outperformed all others on Web site utilization metrics, use of practical counseling tools, intratreatment social support, and NRT use. It was the only intervention to promote the sending of private messages and the viewing of community pages over WEB alone. Both social network arms outperformed WEB on most metrics of online community engagement. Both NRT arms showed higher medication use compared to WEB alone.This study demonstrated the effectiveness of two approaches for improving adherence to evidence-based components of smoking cessation treatment. Integrated approaches to medication provision and social network engagement can enhance adherence to components known to improve cessation.This study demonstrated that an integrated approach to medication provision and social network integration, when delivered through an online program, can enhance adherence across all three recommended components of an evidence-based smoking cessation program (skills training, social support, and pharmacotherapy use). Nicotine replacement therapy-when provided as part of an integrated program-increases adherence to other program elements, which in turn augment its own therapeutic effects. An explicit focus on approaches to improve treatment adherence is an important first step to identifying leverage points for optimizing intervention effectiveness.

Project description:BackgroundMindfulness training shows promise for improving smoking cessation and lapse recovery, and between-session mobile health messages could enhance treatment engagement and effectiveness. Personalized, in-the-moment text messaging support could be particularly useful for low-income smokers with fewer smoking cessation resources.ObjectiveThis pilot study examined the feasibility of a text messaging program (iQuit Mindfully) as an adjunct to in-person Mindfulness-Based Addiction Treatment (MBAT) for smoking cessation.MethodsA total of 71 participants were randomly assigned to MBAT (n=33) or iQuit Mindfully (n=38; MBAT + between-session text messages); of these, 70% (50/71) were African American, and 61% (43/71) had an annual household income of US $30,000 or less. All participants received 8 weekly therapist-led group counseling sessions, nicotine patches, and self-help materials. Outcomes were feasibility (attrition, engagement, and participants' ratings), participants' feedback regarding the text messaging intervention, and smoking cessation (assessed in person).ResultsStrong retention was achieved (76% [54/71] at the end of treatment, and 89% [63/71] at 1-month follow-up). In the iQuit Mindfully group, engagement was high (88% [29/33] indicated reading all or most texts, and 89% [34/38] engaged in interactive texting), and participants provided positive ratings (on a 1-10 scale, average rating for recommending the program to others was 8.4 [SD 2.5]). Participants indicated benefiting from the texts (eg, appreciating encouraging reminders, coping strategies, and social support) and suggested improvements (eg, more personalization). Overall, biochemically confirmed smoking cessation rates were 22% (12/55) at the end of treatment and 19% (12/62) at 1-month follow-up, with no differences between conditions. Living below the poverty level predicted worse cessation outcomes at 1-month follow-up among participants receiving in-person only treatment (P=.03) but not among those receiving iQuit Mindfully.ConclusionsText messaging appears to be a feasible and acceptable modality for supporting mindfulness-based smoking cessation treatment. The availability of 24/7 text messaging might be particularly helpful for low-income smokers who have access to fewer cessation resources and experience significant day-to-day barriers to quitting.Trial registrationClinicalTrials.gov NCT03029819; https://clinicaltrials.gov/ct2/show/NCT03029819.

Project description:ImportanceThe National Lung Screening Trial (NLST) found a reduction in lung cancer mortality among participants screened with low-dose computed tomography vs chest radiography. In February 2015, Medicare announced its decision to cover annual lung screening for patients with a significant smoking history. These guidelines promote smoking cessation treatment as an adjunct to screening, but the frequency and effectiveness of clinician-delivered smoking cessation interventions delivered after lung screening are unknown.ObjectiveTo determine the association between the reported clinician-delivered 5As (ask, advise, assess, assist [talk about quitting or recommend stop-smoking medications or recommend counseling], and arrange follow-up) after lung screening and smoking behavior changes.Design, setting, and participantsA matched case-control study (cases were quitters and controls were continued smokers) of 3336 NLST participants who were smokers at enrollment examined participants' rates and patterns of 5A delivery after a lung screen and reported smoking cessation behaviors.Main outcomes and measuresPrevalence of the clinician-delivered 5As and associated smoking cessation after lung screening.ResultsDelivery of the 5As 1 year after screening were as follows: ask, 77.2%; advise, 75.6%; assess, 63.4%; assist, 56.4%; and arrange follow-up, 10.4%. Receipt of ask, advise, and assess was not significantly associated with quitting in multivariate models that adjusted for sociodemographic characteristics, medical history, screening results, nicotine dependence, and motivation to quit. Assist was associated with a 40% increase in the odds of quitting (odds ratio, 1.40; 95% CI, 1.21-1.63), and arrange was associated with a 46% increase in the odds of quitting (odds ratio, 1.46; 95% CI, 1.19-1.79).Conclusions and relevanceAssist and arrange follow-up delivered by primary care providers to smokers who were participating in the NLST were associated with increased quitting; less intensive interventions (ask, advise, and assess) were not. However, rates of assist and arrange follow-up were relatively low. Our findings confirm the need for and benefit of clinicians taking more active intervention steps in helping patients who undergo screening to quit smoking.

Project description:BACKGROUND:Improving practice nurses' (PN) adherence to smoking cessation counseling guidelines will benefit the quality of smoking cessation care and will potentially lead to higher smoking abstinence rates. However, support programs to aid PNs in improving their guideline uptake and adherence do not exist yet. OBJECTIVE:The aim of this study was to assess the effects of a novel computer-tailored electronic learning (e-learning) program on PNs' smoking cessation guideline adherence. METHODS:A Web-based randomized controlled trial (RCT) was conducted in which an intervention group (N=147) with full access to the e-learning program for 6 months was compared with a control group (N=122) without access. Data collection was fully automated at baseline and 6-month follow-up via online questionnaires, assessing PNs' demographics, work-related factors, potential behavioral predictors based on the I-Change model, and guideline adherence. PNs also completed counseling checklists to retrieve self-reported counseling activities for each consultation with a smoker (N=1175). To assess the program's effectiveness in improving PNs' guideline adherence (ie, overall adherence and adherence to individual counseling guideline steps), mixed linear and logistic regression analyses were conducted, thus accommodating for the smokers being nested within PNs. Potential effect moderation by work-related factors and behavioral predictors was also examined. RESULTS:After 6 months, 121 PNs in the intervention group (82.3%, 121/147) and 103 in the control group (84.4%, 103/122) completed the follow-up questionnaire. Mixed linear regression analysis revealed that counseling experience moderated the program's effect on PNs' overall guideline adherence (beta=.589; 95% CI 0.111-1.068; PHolm-Bonferroni =.048), indicating a positive program effect on adherence for PNs with a more than average level of counseling experience. Mixed logistic regression analyses regarding adherence to individual guideline steps revealed a trend toward moderating effects of baseline levels of behavioral predictors and counseling experience. More specifically, for PNs with less favorable scores on behavioral predictors (eg, low baseline self-efficacy) and high levels of counseling experience, the program significantly increased adherence. CONCLUSIONS:Results from our RCT showed that among PNs with more than average counseling experience, the e-learning program resulted in significantly better smoking cessation guideline adherence. Experienced PNs might have been better able to translate the content of our e-learning program into practically applicable counseling strategies compared with less experienced colleagues. Less favorable baseline levels of behavioral predictors among PNs possibly contributed to this effect, as there was more room for improvement by consulting the tailored content of the e-learning program. To further substantiate the effectiveness of e-learning programs on guideline adherence by health care professionals (HCPs), it is important to assess how to support a wider range of HCPs. TRIAL REGISTRATION:Netherlands Trial Register NTR4436; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4436 (Archived by WebCite at http://www.webcitation.org/6zJQuSRq0).

Dataset Information

Computer-Facilitated 5A's for Smoking Cessation: A Randomized Trial of Technology to Promote Provider Adherence.

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Computer-Facilitated 5A's for Smoking Cessation: A Randomized Trial of Technology to Promote Provider Adherence.

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