Project 1 is a web-based program to help individuals who are in the "Preparation Stage" (ready to quit smoking within 30 days) to quit smoking. The overall goal of the study is to identify optimal population-based health communications strategies tailored to specific characteristics of the individual. This project will focus on identifying and specifying active psychosocial and communication components or "factors" of smoking cessation interventions.

cancer prevention, tobacco, smoking cessation, depth of tailoring, fractional factorial design, Internet, web, email

Phase I:

1. Using a fractional factorial design, screen for the effects of six potentially active psychosocial and communication components of web-based smoking cessation interventions: message content, message framing, exposure schedule, use of testimonials, and message source.
2. Investigate how psychosocial and communication component effects are moderated by relevant characteristics of the individual (e.g., stage of change; baseline level of motivation and self-efficacy; barriers, need for cognition; health locus of control; and socio-demographics and health status).
   

Phase II:

1. In follow-up experiments with a new sample, refine our understanding of how the active psychosocial and communication components identified in Phase I influence the primary outcome variables by manipulating factor levels and factors related to the screened component.
2. Refine and further explore root causes for promising interactions between psychosocial and communication components, and specific individual characteristics.

4,000 smokers in 3 Cancer Research Network HMOs

Phase I:
Phase I of Project Quit uses a fractional factorial design to identify the active psychosocial and communication components of web-based smoking cessation interventions: message content, message depth, message framing, exposure schedule, use of testimonials, and message source. It also investigates how psychosocial and communication component effects are moderated by relevant characteristics of the individual (e.g., baseline level of motivation and self-efficacy; barriers, need for cognition; health locus of control; and socio-demographics and health status).

Participants are recruited from three Health Maintenance Organizations participating in the National Cancer Institute's (NCI) Cancer Research Network (CRN): Group Health (GH) of Seattle, Washington, HealthPartners (HP) of Minneapolis, Minnesota, and the Henry Ford Health System's Health Alliance Plan (HFHS) of Detroit, Michigan. All three are not-for-profit health care delivery systems.

After the baseline survey, participants are randomized into one of 16 study arms. All participants receive a web-based guide to help them quit smoking, along with a free 10-week supply of nicotine replacement therapy patches. Email messages are sent to participants about various aspects of the program, including patch use and step down process, and the availability of new web guide materials.

The 6 components for each web guide include:

• Source Letter: available immediately after baseline survey
• Action Plan: available immediately OR 7 days before Quit date
• Efficacy x 2: available immediately OR 1 day before and 7 days after Quit date
• Outcomes: available immediately OR 14 days after Quit date
• Testimonial: available immediately OR 21 days after Quit date

Additional factors:

• High vs. Low Depth: All components are tailored, using a high or low degree of depth.
• Single vs. Multiple Exposure: Participants receive web guide components either all at once (immediately after baseline survey), OR as listed above, over time.
• Gain vs. Loss Framed Messages: Outcomes messages are written either in terms of the benefits users stand to gain by quitting or the risks they stand to face by continuing to smoke.

Based on Phase I findings, 7-day abstinence (measured at 6 months) was most influenced by high-tailored success stories (testimonials) and high-personalized message source (source letter). Cumulative assignment of the three tailoring depth factors (message source, testimonial, and efficacy) also resulted in increasing rates of six-month cessation, demonstrating an effect of tailoring depth.

Phase II:
In follow-up experiments with a new sample from the same HMOs, Phase II refines our understanding of the active psychosocial and communication components identified in Phase I.

Phase II explores Message Source and the use of Testimonials. Whereas message source and testimonials were only a small part of Phase I, each of the six web components in Phase II contains a testimonial and a manipulated message source. Phase II also varies the characters portrayed in the testimonials. Participants receive testimonials from one of three character types (Caregiver, Rebel, Self-made). Analysis will explore relationships between character types, participant characteristics, program satisfaction, and cessation rates.

Participants are randomized into one of 25 study arms. Control subjects receive the best of Phase 1's program (all 6 components highly tailored, Outcomes gain-framed, highly personalized source Welcome Letter).

Intervention subjects will receive highly tailored messages in all web guide components, and are randomly assigned to receive one of each of the following:

• Story first vs. Advice first (ordering effect)
• Source tailoring text (HMO Project Quit team friendly vs. HMO Project Quit program institution neutral)

Program components are delivered over time, similar to Phase I multiple exposure. Email messages are sent to participants about various aspects of the program, including patch use, the step down process and the availability of new web materials.

Phase I Findings

• Abstinence was most influenced by high-tailored success stories (testimonials) and high-personalized message source (source letter).
• Cumulative assignment of the three tailoring depth factors (message source, testimonial, and efficacy) also resulted in increasing rates of six-month cessation, demonstrating an effect of tailoring depth.
• Greater engagement with a web-based smoking cessation program results in greater subsequent cessation.
• The depth of tailoring in smoking cessation messages results in greater perceptions of message relevance, which, in turn, results in greater engagement with a web-based smoking cessation program.
• A significant number of smokers can be recruited through Health Maintenance Organizations (HMOs) for web-based smoking cessation interventions.
• African Americans with a large number of people supporting their quit efforts were more than two times more likely to quit than those with few or no supporters, regardless of tailoring intensity.
  

Phase II Findings
Study in progress.

<i>Phase I Conclusion</i><br>
The study identified relevant components of smoking cessation interventions that should be generalizable to other cessation interventions. The study also demonstrates the importance of higher-depth tailoring in smoking cessation programs. Finally, the fractional factorial design allowed efficient examination of the study aims. The rapidly changing interfaces, software, and capabilities of eHealth are likely to require such dynamic experimental approaches to intervention discovery.<br><br>

<i>Phase II Conclusion</i><br>
Study in progress.

<i>Phase I Publications</i><br>
Strecher, VJ. McClure, J., Alexander, G., Nair, V., Konkel., Greene, S., Collins, L., Carlier, C., Wiese, C., Chakroborty, B., Little, R., Pomerleau, C., Pomerleau, O. Web-based Smoking Cessation Components and Tailoring Depth: Results of A Randomized Trial. American Journal of Preventive Medicine. May 2008, Vol 34(5):373-381.<br><br>

McClure, J.B., Greene, S.M., Wiese, C., Johnson, K.E., Alexander, G., & Strecher, V. Interest in an online smoking cessation program and effective recruitment strategies: Results from Project Quit. Journal of Medical Internet Research (Aug 22, 2007); 8(3):e14 <br><br>

Collins LM, Murphy SA, Strecher V. The multiphase optimization strategy (MOST) and the sequential multiple assignment randomized trial (SMART): new methods for more potent eHealth interventions. Am J Prev Med. 2007 May;32(5 Suppl):S112-8.<br><br>

Collins, L.M., Murphy, S.A., Nair, V. and Strecher, V. (2005) A Strategy for Optimizing and Evaluating Behavioral Interventions. The Annals of Behavioral Medicine, 30:65-73.<br><br>

<i>Phase II Publications</i><br>
Study in progress.