BMJ  2003;327:E57-E58 (4 October), doi:10.1136/bmjusa.01090002 (published 5 September 2002)

BMJ USA: Editorial

Tailoring smoking cessation programs to the specific needs and interests of the patient

What's the next generation of research?

This article originally appeared in BMJ USA

Ideally, smoking cessation programs should be able to reach a large number of smokers, be effective in achieving long-term abstinence, and achieve these goals at a reasonable cost. Current anti-smoking efforts, unfortunately, have not been able to offer all of these characteristics. Community- and media-based cessation programs (eg, quit contests) have been able to reach a large number of smokers but lack effectiveness.¹ On the other hand, intensive, multi-session clinical interventions can achieve relatively high long-term abstinence rates,² but their reach is limited. Smoking cessation clinics have a limited impact on population cessation rates, and some have even advocated abandoning the clinic approach to cessation.³

Computer-based smoking cessation interventions hold the promise of combining the benefits of high-reach media-based interventions, individually-oriented clinics, and popular self-help programs.^{4 5} With the rapid development of computer technology, tailoring a cessation program to the specific needs and interests of the smoker has become increasingly more sophisticated and less expensive.⁵ Tailored interventions generally require: (a) collection of information, at an individual level, relevant to the targeted behavior, (b) decision rules that use this information to generate messages tailored to the specific needs of the user, and (c) a feedback protocol that combines these messages in a clear, vivid manner, into a feedback report for the user. Embodiments of tailored interventions can now be readily disseminated through print materials, telephone messages, Internet web sites, personal digital assistant (PDA) messages, and other new media channels. If found to be effective, tailored interventions could become powerful tools for the clinician.

The study by Lennox et al,⁶ published in this issue of BMJ USA (BMJ USA p 461), tests the effectiveness of one embodiment of a tailored intervention: tailored printed smoking cessation letters. The study failed to demonstrate an advantage for the tailored letter condition. This is one of a number of studies testing the effectiveness of tailored smoking cessation materials that have failed to reject the null hypothesis. In fact, there are both positive and negative results for tailored interventions in every health-related behavior for which these interventions have been tested. However, a large number of studies examining the impact of tailored print materials have now been published, with a majority demonstrating positive results.^{4 5 7-10} In a recent meta-analysis of tailored and untailored self-help smoking cessation materials, Lancaster et al⁷ found an odds ratio of 1.41 (95% confidence interval (CI) 1.14-1.75) for computer-tailored materials compared with untailored or stage-matched materials (eight studies), and a non-significant odds ratio of 1.08 (95% CI 0.97-1.21) for untailored materials compared with brief personal advice (28 studies). (Stage-matched materials are materials matched to the patient's stage of readiness to change the targeted behavior.)

The study by Lennox et al does not provide a basis for rejecting tailored communications. The study has important strengths, including randomized treatment allocation and a relatively large sample size, but there are also significant problems, including an inadequate analysis of outcome data, undue and problematic reliance on partially-collected biochemical samples for self-reported cessation validation, an outdated approach to tailoring, an incomplete review of the literature, and inaccurate descriptions of other research. These problems require more detailed attention than the space for this editorial allows, and are therefore addressed in a "rapid response" to the paper on the BMJ 's web site.¹¹

There are also a number of studies supporting the efficacy of tailored interventions in areas other than smoking cessation. The large majority of tailoring studies have demonstrated positive results. These include the areas of dietary fat reduction,¹² breast cancer screening,¹³ and physical activity. ¹⁴ In each of these areas, there are also negative results. An important goal for future research is to determine the reasons for these mixed results.

Simply asking whether tailoring works is like asking whether movies entertain. Clearly some entertain and others do not. Different movies also entertain different audiences. A recent request for applications from the National Cancer Institute states that "The NCI now funds many studies that compare tailored print interventions to usual care interventions. . . . However, when these studies have not been successful in achieving significant impact, it usually has not been possible to identify the reasons." We believe that the study by Lennox et al falls into this category. Accordingly, the next generation of tailoring research should begin to examine the "active ingredients" of tailoring: which variables should we tailor on, for whom do these active ingredients work, and why do they work.^{4 15}

University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan, USA (strecher{at}umich.edu)

Cancer Prevention Research Center, University of Rhode Island, Kingston, Rhode Island, USA (velicer{at}uri.edu)

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  Competing interests: Dr Strecher is chairman of the board and a consultant to HealthMedia, Inc, 130 S. First Street, Ann Arbor, Michigan 48104 (www.healthmedia.com). Dr Velicer is a principal in Pro-Change Behavior Systems, Inc, P.O. Box 755, West Kingston, Rhode Island 02892 (www. prochange.com/home2.htm).

References

1. Lichtenstein E, Glasgow RE. Smoking cessation: What have we learned over the past decade? J Consult Clin Psychol 1992;60:518-527 [CrossRef][Web of Science][Medline]
2. Fiore MC. US public health service clinical practice guideline: treating tobacco use and dependence. Respir Care 2000;45:1200-1262 [Medline]
3. Chapman S. Stop Smoking Clinics: A case for their abandonment. Lancet 1985;1:918-920 [CrossRef][Web of Science][Medline]
4. Strecher VJ. Computer-tailored smoking cessation materials: A review and discussion. Pat Educ and Counseling 1999;36:107-117
5. Velicer WF, Prochaska J O. An expert system intervention for smoking cessation. Pat Educ and Counseling 1999;36:119-129
6. Lennox AS, Osman LM, Reiter E, Robertson R, Friend J, McCann I, Skatun D, Donnan PT. Cost effectiveness of computer tailored and non-tailored smoking cessation letters in general practice: randomised controlled trial. BMJ 2001;322:1396 [Abstract/Free Full Text]
7. Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ 2000;321:355-358 [Free Full Text]
8. Velicer WF, Prochaska JO, Fava JL, Laforge RG, Rossi JS. Interactive versus non-interactive interventions and dose-response relationships for stage matched smoking cessation programs in a managed care setting. Health Psychol 1999;18:21-28 [CrossRef][Web of Science][Medline]
9. Prochaska J O, Velicer WF, Fava JL., Rossi JS, Tsoh JY. Evaluating a population-based recruitment approach and a stage-based expert system intervention for smoking cessation. Addict Beh 2001;26:583-602 [CrossRef][Web of Science][Medline]
10. Prochaska JO, Velicer WF, Fava JL, Ruggiero L, Laforge RG, Rossi JS, Johnson SS, Lee PA. Counselor and stimulus control enhancements of a stage-matched expert system intervention for smokers in a managed care setting. Prev Med 2001;32:23-32 [CrossRef][Web of Science][Medline]
11. Strecher VJ, Velicer WF, Little R. Rapid response: comments on Lennox et al. http://bmj.com/cgi/eletters/322/7299/ 1396 (accessed August 12, 2001).
12. Brug J, Campbell M, van Assema P. The application and impact of computer-generated personalized nutrition education: a review of the literature. Patient Educ Couns 1999;36:145-156 [CrossRef][Web of Science][Medline]
13. Skinner CS, Strecher VJ, Hospers H. Physicians' recommendations for mammography: do tailored messages make a difference? Am J Public Health 1994;84:43-49 [Abstract/Free Full Text]
14. Bock BC, Marcus BH, Pinto BM, Forsyth LH. Maintenance of physical activity following an individualized motivationally tailored intervention. Ann Behav Med 2001 Spring;2323 (2):79-87 [CrossRef][Web of Science][Medline]
15. Abrams D, Mills S, Bulger D. Related Articles. Challenges and future directions for tailored communication research. Ann Behav Med 1999;21:299-306 [Web of Science][Medline]

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Rapid Responses:

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Reply to Strecher et al

Ehud B Reiter, et al.
bmj.com, 11 Sep 2002 [Full text]

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