Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Computer-based counselling programme for stopping smoking
- Jean-Francois Etter (8 October 1999)
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Teenage smoking, eating disorders and weight control.
- John F Morgan (10 October 1999)
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Re: Computer-based counselling programme for stopping smoking
- Paul Aveyard (12 October 1999)
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Re: Teenage smoking, eating disorders and weight control.
- Paul Aveyard (12 October 1999)
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Adult Doses Applied to Adolescents
- James O Prochaska (13 October 1999)
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Re: Adult Doses Applied to Adolescents
- Paul Aveyard, K K Cheng, Terry Lawrence (14 October 1999)
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Public health warning - always read ''eLetter'' responses for full peer review of published papers
- Christopher Loughlan (16 November 1999)
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Jean-Francois Etter, phD University of Geneva
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Editor, Aveyard and colleagues publish in BMJ a study showing that a computer- based counselling program for smoking prevention was ineffective in 13-14 years old children (1). This program was based on Prochaska's Transtheoretical model of change. This model explains how adult smokers progress towards smoking cessation. It was a wrong idea to use Prochaska’s model to prevent smoking initiation in children, since this model does not address the determinants of smoking initiation (peer-pressure, low self- esteem, etc.). Thus it is not very astonishing that the program was ineffective. Prochaska and his team conducted 4 different randomized trials that all showed that a similar computer-based « expert-system » was effective in adult smokers (differences in quit rates between intervention and control groups ranged from 6 to 14%) (2). We made available on the Internet a computer-tailored smoking cessation counselling program based on Prochaska's model. After answering a questionnaire on the screen, smokers can obtain a personal evaluation report in 10 seconds, at www.stop-tabac.ch. From February to October 1999, over 9000 persons obtained a personal counselling report on this site, in English and in French. Thus contrary to the conclusion of the BMJ study, we believe that computer- tailored interventions ("expert systems") are effective. Since large number of smokers can be recruited in these interventions, expert-systems can have a large impact on public health. Sincerely, Jean-François Etter, PhD (1) Aveyard RP, Cheng KK Almond J, et al. Cluster randomised controlled trial of expert system based on the transtheoretical ("stages of change") model for smoking prevention and cessation in schools. BMJ 1999;319:948-953. (2) Velicer WF, et al. An expert system intervention for smoking cessation. Patient Education and Counseling 1999;36:119-129. |
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John F Morgan, Senior Registrar Department of General Psychiatry, St. George’s Hospital Medical School, London.
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Sir, Aveyard et al (1) report the failure of a smoking prevention and cessation programme based on the transtheoretical model of behavioural change. A number of putative reasons for this failure were outlined in the same edition (2), but no mention was made of the association between smoking and pursuit of thinness among schoolgirls (3), nor the association between smoking and eating disorders (4). These associations are likely to influence the ‘decision balance’ element of the transtheoretical model in schoolgirls, with nicotine misuse seen as an effective means of achieving weight control and cessation as resulting in weight gain. It seems unlikely that class and computer interventions would truly address subjective distortions in perception of weight and shape, which are so common in this group. The limited existing literature suggests that smoking intervention programmes for teenage girls must consider specifically the motive of weight control in order to be effective. Smoking is associated with pursuit of thinness and eating disorders, and preventative measures must address both behaviours in synchrony. John F. Morgan Department of General Psychiatry St. George’s Hospital Medical School London SW17 0RE, UK SW17 0RE, UK 1. Aveyard P, Cheng K K, Almond J, Sherratt E, Lancashire R, Lawrence T, Griffin C, Evans O. Cluster randomised controlled trial of expert system based on the transtheoretical ("stages of change") model for smoking prevention and cessation in schools. BMJ 1999; 319: 948-953. 2. Reid D. Failure of an intervention to stop teenagers smoking. BMJ 1999; 319: 934-935. 3. Crisp AH, Stavrakaki C, Halek C, Williams E, Sedgwick P, Kiossis I. Smoking and pursuit of thinness in schoolgirls in London and Ottawa. Postgrad Med J 1998; 74: 473-479. 4. Morgan JF, Lacey JH. Smoking, eating disorders and weight control. Postgrad Med J 1999; 75(880): pp.127. |
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Paul Aveyard, Lecturer in public health medicine Department of Public Health and Epidemiology, University of Birmingham B15 2TT
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Etter states that the transtheoretical model should not be used to explain why children take up smoking. He may be right, but the originators of the model have applied the model to this problem[1]. Prochaska and colleagues developed an expert system based on this research to prevent smoking uptake[2] amongst those who have not yet become regular smokers and to help regular or ex-smokers stop smoking. We tested this expert system and even the cessation module, based on the research Etter quotes in adults, was ineffective in young people. We did not conclude that expert systems in general do not work, only that this one does not do so. 1. Pallonen UE, Prochaska JO, Velicer WF, Prokhoro AV, Smith NF. Stages of acquisition and cessation for adolescent smoking: An empirical integration. Addictive Behaviors 1998;23:303-324. 2. Redding CA, Prochaska JO, Pallonen UE, et al. Transtheoretical individualized multimedia expert systems targeting adolescents' health behaviors. Cognitive and Behavioral Practices 1998;In press. |
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Paul Aveyard, Lecturer in public health medicine Department of Public Health and Epidemiology, University of Birmingham Birmingham B15 2TT
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The expert system we tested includes questions about weight control and those for whom this was a salient issue would receive advice directed to that area. Morgan is right to believe however, that the expert system does not deal with subjective distortions of weight and shape. Is this an important reason for the failure of the intervention? If so, and Morgan is right that this is predominantly a female issue, then we might expect the intervention to be effective in males but not females. We reanalysed our data splitting by sex and initial smoking status using those individuals for whom we had smoking status at the beginning and the end of the study. The unadjusted odds ratios (95% confidence intervals) for smoking in the intervention group relative to the control group were: female baseline smokers 1.01 (0.65 - 1.57), male baseline smokers 0.87 (0.55 - 1.36), female baseline non-smokers 1.10 (0.77 - 1.56), male baseline non-smokers 1.42 (1.06 - 1.89). These results give mixed support to Morgan's hypothesis, but as unintended sub-group analysis, a reasonable interpretation would be that there is no effect of sex on the intervention. We believe therefore that the reason the intervention failed is more likely to be common to both sexes and is unlikely to be due to inattention to weight concerns. |
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James O Prochaska, Director, Cancer Prevention Research Center University of Rhode Island, Kingston, RI, USA
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My colleagues and I have read the article by Paul Aveyard et al. on Smoking Prevention and Cessation in Schools, which examines the use of computer delivered expert system interventions that we have developed. For unreported reasons, Aveyard et al. applied our adult dose for smoking to an adolescent population. In our standard adult protocol we provide three expert system interventions over 6 to 12 months. With adolescents Aveyard et al. provided three expert system interventions over a comparable period of time. Our behavior change protocol for adolescent populations calls for 6 to 8 expert system interventions over two academic years. One of the reasons our treatment with adolescents is at least twice the duration with more expert system interventions is that smoking increases over a two year duration with adolescents while it decreases with adults. Why would Aveyard et al. expect an adult dose for smoking to be effective with adolescents? I know of no evidence and Aveyard et al. provide no evidence nor rationale for applying our adult dose of expert systems to adolescents. We will be reporting shortly the important pattern of results that were produced when our two year adolescent protocol was applied to an adolescent population. Competing Interests I am one of the developers of the expert system under discussion. The expert systems for smoking are owned by the University of Rhode Island and are licensed to Johnson and Johnson Health Services, Inc. A sublicense has been developed with Nelson Communications in the United States and Public Management Associates for commercial in the United Kingdom. Pro- Change Behavior Systems, L.L.C., of which I am a principal, provides R & D services to these two companies. |
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Paul Aveyard, Lecturer of Public Health Medicine, Professor of Epidemiology, Senior Health Advisor Department of Public Health & Epidemiology, University of Birmingham, Birmingham B15 2TT, K K Cheng, Terry Lawrence
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Prochaska implies that there is a well known adult dose and an adolescent dose of the expert system . The only evidence on how many doses of the expert system should be used is from a trial in adults and that evidence suggests that one not three is enough[1]. Prochaska and colleagues' only other published study on transtheoretical model expert system in adolescents used 3 sessions[2]. There is no evidence on which to base a decision about how many sessions adolescents might need. Prochaska advances the argument that because the prevalence of smoking in the group of adolescents is changing rapidly, individuals within that group are less susceptible to change by the intervention and need more sessions to achieve the same effect that adults would achieve with fewer sessions. This is a non sequitur. Our data show that 37% of regular adolescent smokers were preparing to stop smoking, compared to about 20% that is typical in adult populations[3]. Individuals in preparation are more likely to have quit at one year than individuals in earlier stages of change[4]. This reflects itself in the high quit rates achieved by both intervention and control groups (over 25% at one year). On such basis, it seems more likely that the adolescent cessation expert system, the only one that can be compared to the adult expert system, should be more successful and require fewer sessions, yet we found no effect. A better explanation for the failure of the intervention is one advanced by Reid[5]. Teenage smokers have very variable smoking histories and do not construe their behaviour in the same way that questionnaires do. Perhaps the concept of being a regular smoker is foreign to most young teenage smokers as is the idea of needing to go through a process to stop smoking, so the expert system's messages were lost on them. 1. Velicer WF, Prochaska JO, Fava JL, Laforge RG, Rossi. Interactive versus noninteractive interventions and dose-response relationships for stage-matched smoking cessation programs in a managed care setting. Health Psychology 1999;18:21-28. 2. Pallonen UE, Velicer WF, Prochaska JO, et al. Computer-based smoking cessation interventions in adolescents: description, feasibility, and six- month follow-up findings. Substance Use & Misuse 1998;33:935-965. 3. Velicer WF, Fava JL, Prochaska JO, Abrams DB, Emmons KM, Pierce JP. Distribution of smokers by stage in three representative samples. Preventive Medicine 1995;24:401-411. 4. Diclemente CC, Prochaska JO, Fairhurst SK, Velicer WF, Velasquez MM, Rossi JS. The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting & Clinical Psychology 1991;59:295-304. 5. Reid D. Failure of an intervention to stop teenagers smoking. British Medical Journal 1999;319:934-935. |
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Christopher Loughlan
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I write to you regarding the downstream consequences of incomplete peer review. The eLetter facility of your journal now provides an excellent forum for rapid and more extensive critical appraisal of published papers. I cite two recently published papers in the public health domain1; 2. Within a short period of time these articles had generated critical re-appraisals (post-publication peer review) using the journal's email 'eletter' response facility. The article on health related physical activity2 generated the following comments: 'a surprising perpetuation of a common misconception', 'question the validity of their conclusion',' asked the wrong questions and therefore have drawn the wrong conclusions', ' is totally unjustified and seriously misleading'. Your journal has given fair and comprehensive coverage to research on and discussion of peer review. One article concluded peer review 'is expensive, slow, prone to bias, open to abuse, possibly anti-innovatory, and unable to detect fraud …(and) that the published papers are often grossly deficient'3. One particular weakness occurs when ensuing editorials then make generalised comments on the basis of published 'evidence'? Such editorial of course are written at the time of going to print and therefor are unable to benefit from the process of rapid critical appraisal through the eLetter facility. Notwithstanding professional individual responsibility of all clinicians to carefully consider research publications, they would confront bold proclamations in editorial comments in your journal: exercise on prescription in primary care is a 'scarce waste of resources', and smoking prevention programmes in adolescents 'do not work'. Any damage done by theses editorials or comments are hard if not impossible to undue- published papers become 'frozen' and editorials are based at the time of going to print. Moreover through publication in the journal they have been given a 'stamp of approval' - a form of scientific legitimacy. Clinicians, who already find it extremely difficult to keep up to date with research evidence, are more likely to skim through summaries for updating knowledge on effectiveness. Clearly if we are to support the drive towards evidence-based health care, the NHS needs a more robust system of peer review from which we can have evidence-based editorials. When Gray wrote on the quality of knowledge management4, he likened information as a valuable resource on a par with money, people, buildings and energy. When things go wrong in these comparable sectors we can't simply leave them there 'frozen'. The resource will lose its value and in patient terms, both reduce the quality of care and increase risk of harm. Research governance in the NHS is concerned with putting in place management processes that can monitor and demonstrate that NHS research monies are supporting high quality research in national priority topics5. If so much effort and resources are being placed to ensure the UK is served by high quality research, then the whole effort has to be underpinned by a system which can demonstrate published papers of the highest quality. Implementation of research findings is hard enough - difficulties here should not be compounded by public health research of questionable quality finding its way to being published in high quality journals. The BMJ email response facility to articles is a great leap forward in this context but should be integrated with a wider, more encompassing, strategic framework for research and critical debate publication. There is now even greater responsibility on journals to minimise uncertainty when writing editorials at the time of 'going to print'. Dr C Loughlan
Reference List 1. Aveyard P. Cluster randomised controlled trial of expert system based on the transtheoretical ("stages of change") model for smoking prevention and cessation in schools. British Medical Journal 1999;319:948 -953. 2. Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The Newcastle Exercise Project: a randomised controlled trial of methods to promote physical activity in primary care. British Medical Journal 1999;319:828-832. 3. Smith R. Peer review: reform or revolution. British Medical Journal 1997;315:759-760. 4. Gray MJA. Evidence-based health care How to make health policy and management decisions. London: Churchill Livingstone, 1998; 5. Loughlan, C. Research governance - a framework for developing and maintaining bes practice in research and development in the NHS. 1999. London, Insitute of Child Health, Gt Ormond St. NHS R&D Directors' Forum. Aynsley- Green , M. Conference Proceedings |
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