Jamie Brown, University College London

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1 Jamie Brown, University College London The prevalence and characteristics of smokers interested in internet-based smoking cessation interventions: cross-sectional findings from a national household survey A8

2 Prevalence and characteristics of smokers interested in internet-based smoking cessation interventions Cross-sectional findings from a national household survey Dr Jamie Brown, Prof Susan Michie, Dr Tobias Raupach & Prof Robert West CRUK Health Behaviour Research Centre University College London UKCTCS, York 2012

survey Dr Jamie Brown, Prof Susan Michie, Dr Tobias Raupach & Prof Robert West

3 Internet-based cessation interventions Face-to-face behavioural support combined with medication is most effective (Brose et al., 2011; Fiore et al., 2008) However, vast majority do not use face-to-face support and almost half attempt to stop unaided (Raupach, Brown, & West, 2012) The internet could be ideal medium for helping those who do not wish, or are unable, to engage in face-to-face behavioural support (Graham et al., 2007; Saul et al., 2007)

, 2008) However, vast majority do not use face-to-face support and almost half attempt to stop unaided (Raupach,

4 Advantages of internet support Extremely cost-effective Increased convenience and confidentiality, and reduced stigma (Marks et al., 2007; Murray, 2008) Overcomes physical or geographical barriers to accessing support Potential for interactivity and tailoring Allows dissemination of evidence-based support faithfully and flexibly update content (Andersson, 2010)

, 2007; Murray, 2008) Overcomes physical or geographical barriers to accessing support

5 Does it work? Internet can be effective delivery mode for the behavioural support of a variety of health issues (Andrews et al., 2010; Marks, et al., 2007) Internet-based smoking cessation interventions (ISCIs) can help smokers to quit compared with brief written materials or no intervention (Civljak et al., 2010; Myung et al., 2009; Shahab & McEwen, 2009)

6 Interest in ISCIs Accurate estimate of reach of ISCIs is necessary for calculations of impact (Glasgow et al., 1999) Previous estimates often based on national figures for access or reported interest among non-representative samples (Swartz et al., 2006; Westmaas et al., 2011) Understanding characteristics of interested smokers may help: i. Development including tailoring dimensions, choice of content and features, navigational architecture, language style & complexity ii. Dissemination especially online advertising can be targeted to certain groups

, 2006; Westmaas et al., 2011) Understanding characteristics of interested smokers may help: i.

7 Research questions How many smokers in a nationally representative sample are interested in using ISCIs? What smoking, internet use and socio-demographic characteristics are associated with interest in the use of these interventions?

What smoking, internet use and socio-demographic

Study design and sampling Cross-sectional household surveys of representative samples of adults in England, as part of the Smoking Toolkit Study (www.smokinginengland.

8 Study design and sampling Cross-sectional household surveys of representative samples of adults in England, as part of the Smoking Toolkit Study ( Each month new sample of ~ 1800 adults aged 16 and over completes a face to face computerassisted survey (~ 500 will be smokers) Methods available in more detail elsewhere and have been shown to result in a sample that is nationally representative (Fidler et al., 2011)

info) Each month new sample of ~ 1800 adults aged 16 and over completes a face to face computerassisted survey

9 Participants Respondents eligible for inclusion if reported smoking cigarettes daily or occasionally at the time of the survey Between Feb-Apr 2012 the survey included questions about interest in ISCIs and internet use, in addition to regular smoking and sociodemographic 5,405 surveyed 1,190 current smokers 1,128 complete data

included questions about interest in ISCIs and internet use, in addition to

10 Participants Total sample (n=1128) Mean (SD) age 41.7 (16.7) % (N) Women 47.6 (537) % (N) Routine & Manual 72.4 (817) Mean (SD) Heaviness of Smoking Index 2.0 (1.5) Mean (SD) Strength of Urges score 2.1 (1.0) % Motivated to quit within 3 mnths 20.3 (229) % Quit attempt in past year 30.9 (348) % Face-to-face support in most recent attempt 1.3 (15) % Access internet at least weekly 70.1 (791) % Handheld computer access 41.6 (469) % Online cessation searching in past 3 mnths 3.0 (34) % Online health searching in past 3 mnths 9.5 (107) % Online other info searching in past 3 mnths 63.5 (716)

3 (229) % Quit attempt in past year 30.9 (348) % Face-to-face support in most recent attempt 1.3 (15) % Access internet at least weekly 70.

11 % Interested current smokers Prevalence % 46.6% % 0 Internet Apps ISCIs (either)

12 Interested (n=488) Not interested (n=640) Adj. OR (95% CI) Mean (SD) age 36.6 (13.5) 45.6 (17.9) 0.98 ( )* % (N) Women 47.3 (231) 47.8(306) 1.06 ( ) % (N) Routine & Manual 69.5 (339) 74.7 (478) 0.98 ( ) Mean (SD) Heaviness of Smoking Index 2.1 (1.5) 1.9 (1.5) 1.10 ( ) Mean (SD) Strength of Urges score 2.3 (1.0) 2.0 (1.0) 1.29 ( )* % Motivated to quit within 3 mnths 29.3 (143) 13.4 (86) 2.16 ( )* % Quit attempt in past year 41.0 (200) 23.1 (148) 1.76 ( )* % Face-to-face support in most recent attempt 1.8 (9) 0.9 (6) 0.96 ( ) % Access internet at least weekly 85.9 (419) 58.1 (372) 2.17 ( )* % Handheld computer access 56.4 (275) 30.3 (194) 1.65 ( )* % Online cessation searching in past 3 mnths 5.3 (26) 1.2 (8) 2.82 ( )* % Online health searching in past 3 mnths 11.3 (55) 8.1 (52) 0.82 ( ) % Online other info searching in past 3 mnths 77.7 (379) 52.7 (337) 1.43 ( )

51)* % Motivated to quit within 3 mnths 29.3 (143) 13.4 (86) 2.16 (1.54-3.02)* % Quit attempt in past year 41.0 (200) 23.1 (148) 1.76 (1.30-2.37)* % Face-to-face support in most recent attempt 1.

13 Discussion ISCIs represent excellent opportunity to deliver low-cost behavioural support to a large number of smokers which is currently not being realised Interest is expressed regardless of social grade internet may offer means of delivering support equitably The pattern of associations provided in the current study presents a comprehensive characterisation of smokers interested in using ISCIs useful for development and dissemination of future interventions

means of delivering support equitably The pattern of associations provided in the current study presents a

14 Conclusion Almost half of all smokers in England are interested in using online smoking cessation interventions yet fewer than 1% have used them to support a quit attempt in the past year Interest is not associated with social grade but is associated with being younger, more highly motivated, more cigarette dependent, having attempted to quit recently, having regular internet and handheld computer access and having recently searched for online smoking cessation information and support

associated with being younger, more highly motivated, more cigarette dependent, having attempted to quit recently, having

15 Acknowledgments We are grateful to Cancer Research UK and the Department of Health for funding this study The research team is part of the UK Centre for Tobacco Control Studies

16 Disclosure Funding Sources for Presented Work Cancer Research UK and the Department of Health At outset data collection for the wider Smoking Toolkit Study was supported by Pfizer, GlaxoSmithKline and Johnson and Johnson Industry Funding to the Investigator TR has received honoraria from Pfizer, Novartis, GlaxoSmithKline, AstraZeneca and Roche as a speaker in activities related to continuing medical education. RW undertakes research and consultancy and receives fees for speaking from companies that develop and manufacture smoking cessation medications (Pfizer, J&J, McNeil, GSK, Nabi, Novartis, and Sanofi-Aventis). He also has a share of a patent for a novel nicotine delivery device. JB has received research funding from Pfizer. SM has no conflicts. Off-label medication uses discussed None

17 Additional slides

18 Interested (n=488) Not interested (n=640) OR (95% CI) Mean (SD) age 36.6 (13.5) 45.6 (17.9) 0.97 ( ) a % (N) Women 47.3 (231) 47.8(306) 0.98 ( ) % (N) Routine & Manual 69.5 (339) 74.7 (478) 0.77 ( ) Mean (SD) Heaviness of Smoking Index 2.1 (1.5) 1.9 (1.5) 1.10 ( ) a Mean (SD) Strength of Urges score 2.3 (1.0) 2.0 (1.0) 1.33 ( ) a % Motivated to quit within 3 mnths 29.3 (143) 13.4 (86) 2.67 ( ) a % Quit attempt in past year 41.0 (200) 23.1 (148) 2.31 ( ) a % Face-to-face support in most recent attempt 1.8 (9) 0.9 (6) 1.99 ( ) % Access internet at least weekly 85.9 (419) 58.1 (372) 4.37 ( ) a % Handheld computer access 56.4 (275) 30.3 (194) 2.97 ( ) a % Online cessation searching in past 3 mnths 5.3 (26) 1.2 (8) 4.45 ( ) a % Online health searching in past 3 mnths 11.3 (55) 8.1 (52) 1.44 ( ) % Online other info searching in past 3 mnths 77.7 (379) 52.7 (337) 3.13 ( ) a

50) a % Motivated to quit within 3 mnths 29.3 (143) 13.4 (86) 2.67 (1.98-3.60) a % Quit attempt in past year 41.0 (200) 23.1 (148) 2.31 (1.78 2.99) a % Face-to-face support in most recent attempt 1.

19 Limitations Questions used to derive interest in ISCIs were framed positively (e.g., If there were an internet site or app that was proven to help with stopping smoking, how likely is it that you would try it? ). Similarly, expressing an interest in a survey is clearly quite different from actually accessing a programme to support a quit attempt Nevertheless, there is a large literature that shows interest is at least associated with usage (Webb & Sheeran, 2006). Future research may be able to derive the specific relationship between this expression of interest and future uptake of ISCIs by investigating interest and uptake in other types of cessation support which are already widely available. However, even if interest is over-estimated, it is improbable it would account for the extent of the discrepancy between interest in and use of ISCIs, which is highlighted by the current study. Another potential limitation may have been to operationalise interest in ISCIs as an expression of interest in either an internet site or an app. While both require the internet and a computer for delivery, there are also clear differences including that only sites require regular internet access and only apps require ongoing access to a handheld computer. Indeed, fewer smokers were interested in apps as compared to internet sites; however, similar proportions of smokers who had regular internet access and those with ongoing access to handheld computers were interested in sites and apps respectively. More importantly, in sensitivity analyses in which smokers were characterised separately according to interest in either sites or apps the pattern of results was unchanged. Together these results suggest that the current operationalisation of ISCIs for the purposes of estimating and characterising interest is suitable; however experimental research is needed to establish whether there are important differences in efficacy according to delivery mode of either internet site or app. A final limitation is potential error or bias in the measurement of certain smoking characteristics. For example, smokers often forget failed quit attempts, particularly if they only lasted a short time or occurred long ago (Berg et al., 2010). However, it is unlikely that forgetting would differ as a function of interest in ISCIs, and quit attempts as with all other variables of interest in the present study were assessed with a validated measure (Kotz, et al., in press).

Similarly, expressing an interest in a survey is clearly quite different from actually accessing a programme to support a quit attempt Nevertheless, there is a large literature that shows interest is

Translating evidence-based guidelines into practice: a survey of practices of commissioners and managers of the English stop smoking services

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