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Smoking among cancer survivors increases the risk of late effects and second cancers. This article reports on Partnership for Health-2 (PFH-2)—an effort to develop an effective and scalable version of Partnership for Health (PFH), which was a previously tested peer-delivered telephone counseling program that doubled smoking cessation rates among childhood cancer survivors who smoke.
This paper presents results from a randomized controlled trial evaluating the effectiveness of PFH-2 in targeted and tailored Web-based versus print formats. The overall goal was to determine whether the intervention outcomes in these self-guided scalable formats approximate what was found in a more intensive telephone counseling program.
This study was a randomized controlled trial with a 15-month follow-up that included 374 smokers who were survivors of childhood or young adult cancers, recruited from five survivorship clinics. Participants were randomly assigned to a Web-based or print format of the PFH intervention; all had access to free pharmacotherapy. The website was designed to provide new content at each log-on, and a peer counselor moderated a forum/chat feature. The primary outcome was smoking status at 15 months post randomization.
In total, 58.3% (77/132) of Web participants logged on at least once (mean visits 3.25). Using multiple imputation methods for missing data, there were similar rates of cessation in the two arms (print: 20/128, 15.6%; Web: 33/201, 6.4%), and no differences in quit attempts or readiness to quit. The quit rates were equivalent to those found in our previous telephone counseling intervention. There were high rates of satisfaction with both of the PFH-2 interventions.
The print and Web formats yielded equivalent levels of success to those found with our telephone-delivered intervention and are comparable to other Internet treatment studies. This study provides important options for survivorship programs that may not have resources for interpersonal forms of cessation counseling. Efforts to increase patient use of the interventions may result in higher cessation rates.
Clinicaltrials.gov NCT00588107; http://clinicaltrials.gov/ct2/show/NCT00588107 (Archived by WebCite at http://www.webcitation.org/6K1gJtFEC).
Remarkable improvements in the treatment and long-term survival of childhood and young adult cancer survivors have resulted in prevention of adverse late effects and second primary cancers being a key part of survivorship care [
This team’s previous work has demonstrated the efficacy of Partnership for Health (PFH)
A recent evaluation of existing infrastructure for delivering smoking cessation services in the context of survivorship programs revealed relatively few resources; only 3% of programs assessed smoking status at every visit, as recommended by Public Health Service (PHS) guidelines, and only 25% offered cessation services [
This paper presents results from a randomized control trial evaluating the effectiveness of Partnership for Health-2 (PFH-2) in targeted and tailored Web-based versus print formats. The overall goal was to determine the outcomes for these self-guided scalable formats and whether they approximate what was found in a more intensive telephone counseling program. Our hypothesis was that the Web format would yield higher quit rates than print and would be similar in effectiveness to that found in the original PFH counseling intervention.
PFH-2 was conducted in collaboration with five cancer centers in the United States and Canada, with Institutional Review Board (IRB) approval at all sites. The study was also advertised on childhood and young adult survivorship websites. Eligibility included: diagnosed with cancer before age 35, currently between ages 18-55, completed cancer treatment for ≥2 years, mentally able to provide informed consent, reachable by telephone, able to speak English, and a current smoker (defined as smoking within the previous 30 days). Participants were informed that the study was examining different ways to deliver health information, including information about tobacco use, to survivors. They were not required to be interested in smoking cessation in order to participate. Baseline data collection began on December 2005 and follow-up data collection ended in October 2009.
A preliminary screen for eligiblity was performed at each site via medical record review or brief telephone screening. After consent for sharing contact information was obtained, contact information was forwarded to the survey team to verify eligibility, obtain informed consent for study participation, and administer the baseline telephone survey.
PFH-2 was a stratified randomized controlled trial with cancer center as strata. The goal was to test two scalable intervention formats for smoking cessation among childhood and young adult survivors, developed from an evidence-based intervention, and to determine whether the Web intervention, with the advantages that an interactive website has to offer, would outperform tailored and targeted print materials. Participants were randomized to one of two intervention conditions within strata, in a 5:3 randomization scheme: (1) PFH-2 Print Materials Intervention, or (2) PFH-2 Web Intervention. The random allocation sequence was generated by the study biostatistician. Randomization was done by the survey team and supervised by the biostatistician, following completion of the baseline survey. Study design is provided in detail elsewhere [
The Print Materials arm received tailored and targeted self-help materials that were developed for the peer counselor condition in PFH-1. The materials were organized into a series of manuals, based on readiness to change [
A baseline feedback report (BFR) was generated for each individual and sent between 5 and 10 business days following completion of the baseline survey. The BFR reflected information that patients gave on the baseline survey about their readiness to quit, perceived risk, nicotine dependence, and, based on these factors, which intervention manual to start with, drawing on approaches we have used previously [
Illustration of the interaction of smoking and cancer treatment/late effects.
Within 5-10 business days following completion of the baseline survey, those assigned to the Web intervention were sent log-on information. The Web intervention consisted of seven discrete tailored sessions designed to parallel the counseling sessions of the original PFH study and mirror the basic content of the PFH-2 print materials. The content was dynamically tailored, matching the participants’ stage of readiness. Upon first log-on, participants saw their BFR, described above, on their home page. The home page also highlighted active components of the intervention that participants had not yet navigated. Patients saw refreshed content on the home page as they progressed from session to session. A peer counselor moderated the website’s discussion forum and served as a resource for questions.
Participants who never logged in or stopped using the site received additional email prompts that highlighted content that survivors might find particularly important or engaging, along with biweekly emailed newsletters. Those who had not accessed the website within 11 weeks were sent a final letter along with the print materials to increase the likelihood of some exposure to the intervention content and to approximate likely approaches in a clinic setting. Participants had access to the website for 6 months regardless of their log-in status. For quality assurance purposes, several “test participants” were created and followed throughout the implementation period to identify glitches or issues with the Web system. These “participants” were not included in the tracking data and did not impact on intervention delivery in any way.
Age, gender, race, ethnicity, marital status, education, height, weight, employment status, type of cancer, and cancer treatment were assessed.
Internet access and utilization were measured with questions about whether participants owned a computer, whether they had access to the Internet at home and/or work, and how frequently they used a computer, email, and the Internet [
“Smoking status” was assessed by self-reported assessment of smoking, even a puff, in the past 30 days. The bogus pipeline procedure was used to increase the accuracy of self-report, following standard implementation methods [
“The Stages of Change Scale” assessed motivation to quit smoking [
Participants were asked about rules regarding smoking at home and work (smoking unrestricted inside the building/house, limited to certain rooms, or forbidden inside the building/house).
“Cancer-related distress” was assessed with the Intrusive Thoughts subscale of the Impact of Events Scale (IES), which measures frequency with which thoughts regarding cancer recurrence intrude into consciousness [
Participants were asked if they had a regular health care provider and if they had been seen by their primary care physician or their oncologist in the past year.
Use of the Web-based intervention was assessed using Web analytics. Use of the print intervention was assessed on the follow-up survey, with questions about the percentage of materials read and frequency of use.
Original sample size calculations were adjusted due to the discovery during implementation that the participating survivorship programs’ estimates of smokers were an over-estimate. Thus, we used a 5:3 allocation scheme to ensure an adequate sample size to evaluate the use of the Web-based intervention. With this approach, we had 71% power to detect a difference of 9% in quit rate between the Web and print groups. Baseline comparisons of patient characteristics between intervention arms were assessed. Depression level was the only variable of significance in this comparison and was, in addition to site, controlled for in all future analyses. All outcome analyses were conducted using multiple imputation methods based on the assumption of arbitrary missing patterns and thus used Markov chain Monte Carlo methods. This assumes multivariate normality to impute missing values (11.7%, 27/230 of the Web group and 12.5%, 18/144 of the print group were missing at follow-up). All analyses followed procedures described in the SAS OnlineDoc Version 8 for multiple imputation [
We assessed eligibility among 4399 survivors; 4025 people were excluded (35.88%, 1444/4025 were not reached; the majority of the remainder were ineligible due to smoking status); 46.7% (374/801) of eligible survivors were enrolled in the study. In total, 88.0% (329/374) of enrollees completed the 15-month follow-up (see
Mean age at enrollment was 32 years (SD 7.94) and at cancer diagnosis was 12 years (SD 8.06). The sample was evenly split by gender (51.3%, 192/374 male) and was predominantly white (86.4%, 323/374). In total, 36.1% (135/374) had a high school education or less and 29.7% (111/374) had at least a college degree. About half (176/374) were married or living with a partner and the majority (79.4%, 297/374) were employed in the last year. There were no differences between the two arms at baseline on any demographic or cancer-related variables (see
A total of 59.9% (224/374) of the sample smoked less than one pack of cigarettes per day (range <1 to 60; mean 10/day). About half of the sample was nicotine dependent. The majority (63.1%, 236/374) were in preparation to quit smoking and 55.9% (209/374) screened positive for possible depression.
There were no differences in any baseline demographic variables among completers and drop-outs except employment status; drop-outs were more likely to be employed.
There were no significant differences between the two interventions arms in terms of smoking status at follow-up. At the final assessment, 16.5% of Web participants (22/132) and 15.5% of print participants (20/127) reported being abstinent for the previous 30 days (see
Several factors were associated with smoking abstinence in multivariate analyses, including gender (
An exploratory comparison of quit rates in the original PFH peer-delivered telephone intervention with the current Web and print condition suggests that the PFH-2 interventions attained equivalent levels of cessation. The original telephone-delivered intervention resulted in quit rates of 15% at 12-month follow-up. Although this was not a randomized comparison, these results do suggest that both Web- and print-based intervention methods developed specifically for cancer survivors do have a similar level of intervention impact to that found with a more intensive peer-counseling telephone intervention.
There were no significant differences between the two arms in terms of quit attempts (see
Demographic factors associated with quit attempts in multivariable analyses included male gender (
There were also no significant differences between the two arms in terms of impact on readiness to quit smoking. Only two variables, using pharmacotherapy and nicotine dependence, were associated with readiness to quit in multivariable analyses: using pharmacotherapy was associated with being in the action (OR 5.33, 95% CI 1.20-23.64) (
Baseline variables by treatment condition (n=329).
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Treatment condition |
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Print |
Web |
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n | % | n | % |
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Gender (Female) | 70 | 55.6 | 93 | 45.8 | .19 | |
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.85 | |||||
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≤ high school or GED | 43 | 34.1 | 75 | 36.9 |
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Some college or training after college | 50 | 39.7 | 63 | 31.0 |
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College graduation | 35 | 27.8 | 63 | 31.0 |
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Age (LS means) | 33.59 | 32.50 | .23 | |||
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Employed, past year |
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97 | 77.0 | 159 | 78.3 | .46 |
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.47 | |||||
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White | 111 | 88.1 | 173 | 85.2 |
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Non-white | 17 | 13.5 | 28 | 13.8 |
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.71 | |||||
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Married/living with partner | 61 | 48.4 | 100 | 49.3 |
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Never married and not living with partner | 55 | 43.7 | 83 | 40.9 |
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Divorced/no longer living with partner | 12 | 9.5 | 18 | 8.9 |
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.79 | |||||
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Leukemia | 34 | 27.0 | 45 | 22.2 |
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Hodgkins disease | 21 | 16.7 | 40 | 19.7 |
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CNS malignancy | 15 | 11.9 | 17 | 8.4 |
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Non-Hodgkins Lymphoma | 6 | 4.8 | 14 | 6.9 |
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Bone cancer | 10 | 7.9 | 15 | 7.4 |
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Other | 42 | 33.3 | 70 | 34.5 |
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Received radiation | 81 | 64.3 | 122 | 60.1 | .71 |
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Received chemotherapy | 96 | 76.2 | 153 | 75.4 | .91 |
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Received surgery | 93 | 73.8 | 141 | 69.5 | .53 |
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.13 | |||||
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Yes | 22 | 17.5 | 24 | 11.8 |
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.22 | |||||
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None | 47 | 37.3 | 78 | 38.4 |
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Little | 22 | 17.5 | 47 | 23.2 |
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Some | 29 | 23.0 | 35 | 17.2 |
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More | 30 | 23.8 | 41 | 20.2 |
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Screened positive for possible depression | 85 | 67.5 | 100 | 49.3 | .003 | |
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Perceived personal control (LS means) | 10.88 | 11.76 | .07 | |||
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.61 | |||||
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No chance/very unlikely/unlikely | 29 | 23.0 | 41 | 20.2 |
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Moderate chance | 37 | 29.4 | 60 | 29.6 |
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Likely | 36 | 28.6 | 53 | 26.1 |
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Very likely/certain to happen | 25 | 19.8 | 44 | 21.7 |
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.67 |
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Excellent/very good | 43 | 34.1 | 66 | 32.5 |
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Good | 53 | 42.1 | 77 | 37.9 |
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Fair/poor | 32 | 25.4 | 58 | 28.6 |
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.86 |
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Precontemplation | 15 | 11.9 | 33 | 16.3 |
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Contemplation | 34 | 27.0 | 39 | 19.2 |
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Preparation | 77 | 61.1 | 127 | 62.6 |
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.79 | |||||
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Daily | 81 | 64.3 | 124 | 61.1 |
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Less than daily, but monthly or more | 20 | 15.9 | 43 | 21.2 |
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Less than monthly or never | 27 | 21.4 | 34 | 16.7 |
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aControlling for site.
Recruitment and retention rates (Consolidated Standard of Reporting Trials Statement - CONSORT).
Multivariable models predicting smoking at 15-month follow-up (n=374).
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Abstainer vs smoker at follow-up |
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Adjusted OR (95% CI) |
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REFa | 1.00 | |
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Web | .87 | 1.07 (0.50-2.26) |
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Male | .04 | 0.49 (0.25-0.97) |
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Female | REF | 1.00 |
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White | .57 | 1.37 (0.46-4.06) |
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Non-white | REF | 1.00 |
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Yes | .22 | 0.62 (0.29-1.34) |
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No | REF | 1.00 |
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Leukemia | .03 | 2.64 (1.07-6.52) |
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Hodgkins Disease | 1.00 | 1.00 (0.31-3.20) |
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CNS malignancy | .63 | 0.65 (0.12-3.68) |
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Non-Hodgkins Lymphoma | .01 | 6.35 (1.48-27.17) |
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Bone cancer | .86 | 1.13 (0.27-4.68) |
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Other | REF | 1.00 |
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Yes | .01 | 0.39 (0.19-0.81) |
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No | REF | 1.00 |
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Yes | .01 | 3.39 (1.29-8.88) |
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No | REF | 1.00 |
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No chance/very unlikely/unlikely | REF | 1.00 |
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Moderate chance | .77 | 0.88 (0.37-2.11) |
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Likely | .08 | 0.40 (0.14-1.12) |
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Very likely/certain to happen | .12 | 0.45 (0.16-1.23) |
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There are no rules | .05 | 0.38 (0.14-0.98) |
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People can only smoke in certain rooms | .16 | 0.35 (0.08-1.53) |
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People cannot smoke inside | REF | 1.00 |
aREF: reference point.
Multivariable models predicting quit attempts among smokers at 15-month follow-up (n=374).
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4 or more times vs none |
1-3 times vs none |
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Adjusted OR (95% CI) |
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Adjusted OR (95% CI) | |||||
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Web | .90 | 1.05 (0.51-2.18) | .96 | 1.02 (0.54-1.90) | |||||
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REFa | 1.00 | REF | 1.00 | ||||||
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Male | .06 | 2.06 (0.98-4.33) | .01 | 2.27 (1.18-4.40) | |||||
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Female | REF | 1.00 | REF | 1.00 | |||||
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White | .09 | 0.38 (0.12-1.18) | .01 | 0.28 (0.10-0.74) | |||||
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Non-white | REF | 1.00 | REF | 1.00 | |||||
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Yes | .30 | 0.67 (0.32-1.43) | .60 | 0.83 (0.43-1.63) | |||||
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No | REF | 1.00 | REF | 1.00 | |||||
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Did not complete HS / GED | .78 | 1.34 (0.16-11.36) | .01 | 5.24 (1.50-18.33) | |||||
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Completed HS / GGED | .23 | 0.53 (0.19-1.49) | .58 | 0.77 (0.31-1.93) | |||||
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Some college or training after HS | .79 | 1.13 (0.45-2.85) | .64 | 1.23 (0.51-2.97) | |||||
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College graduate | REF | 1.00 | REF | 1.00 | |||||
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Yes | <.001 | 9.45 (2.90-30.74) | <.001 | 9.27 (3.04-28.28) | |||||
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No | REF | 1.00 | REF | 1.00 | |||||
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Daily | .03 | 3.33 (1.12-9.90) | .06 | 2.20 (0.97-4.96) | |||||
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< than daily, but monthly or more | .03 | 4.01 (1.12-14.40) | .04 | 2.89 (1.05-7.95) | |||||
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< than monthly/never | REF | 1.00 | REF | 1.00 | |||||
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No chance/very unlikely/unlikely | REF | 1.00 | REF | 1.00 | |||||
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Moderate chance | .24 | 1.93 (0.64-5.80) | .03 | 3.33 (1.16-9.56) | |||||
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Likely | .36 | 1.67 (0.55-5.10) | .07 | 2.52 (0.91-6.97) | |||||
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Very likely/certain to happen | .52 | 0.69 (0.22-2.17) | .55 | 1.39 (0.47-4.09) | |||||
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Yes | REF | 1.00 | REF | 1.00 | |||||
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No | .002 | 3.70 (1.66-8.25) | .15 | 1.65 (0.83-3.26) |
aREF: reference point.
Of the Web participants, 58.3% (77/132) logged on at least once (mean visits 3.25). Among visitors to the site, 13% (10/77) logged on once, 20% (15/77) twice, 13% (10/77) three times, and 54% (42/77) logged on four or more times (range 6-98 times). Those who reported using the website more frequently (3+ times) had higher quit attempts and lower smoking rates at follow-up, compared with less frequent users (see
Among the print condition participants, 58.3% (74/127) reported reading most or all of the print materials. About half reported using the materials on multiple occasions. Those who used more of the print materials (most/all) had higher quit attempts and lower smoking rates at follow-up, compared with those who used the materials less.
In total, 13.9% (36/259) of participants requested pharmacotherapy, with no differences between arms. Among those who requested this assistance, it was provided in 87% (31/36) of the cases; the primary reason for not providing it was that the participant did not have a regular physician who could confirm that there were no contraindications.
Of the Web participants who logged in, 87.9% (116/132) reported being satisfied or very satisfied with the site. Further, 75.8% (100/132) reported that the site provided new information about smoking, 83.3% (110/132) felt it provided new information about survivorship, and the majority felt that it was updated often enough; 81.1% (107/132) would recommend the site to other survivors.
In the print condition, 92.1% (117/127) reported being satisfied or very satisfied with the materials. Further, 93.7% (119/127) reported that the materials provided new information about smoking and 89.0% (113/127) felt they provided new information about survivorship; 88.2% (112/127) would recommend the materials to other survivors.
In total, 79.9% (299/374) of the sample owned a computer and had access to the Internet at home and/or work; the majority (77.0%, 288/374) used the Internet at least once per week. Those who did not have regular Internet access had less education (
Quit attempts and smoking rate at follow-up among high/low intervention users.
Quit Attempts | Smoking Rate (cigs/day) | |||
Web | Web | |||
Low Use | 2.0 | 3.42 | 13.7 | 9.8 |
High Use | 4.45 | 6.47 | 9.84 | 3.42 |
This paper assesses the efficacy of a print versus Web version of the Partnership for Health intervention. Both interventions were developed to address scalability of smoking cessation interventions among childhood and young adult cancer survivors. PFH-2 was designed to translate core components of PFH [
A Web-based approach was selected because of the presumed computer affinity of this younger population, as well as the potential for dissemination. We did offer access to the Internet via MSN TV to the 20% that did not have Internet access. Surprisingly, the majority of these participants declined the offer. This may reflect an active choice among these individuals not to engage with this technology and suggests that, at least in the population of childhood and young adult cancer survivors, efforts to increase access may not be helpful. Among those who received the print materials, engagement was good, which may be preferable in some settings and to some participants.
A key issue facing any disseminated, patient-guided intervention is level of patient engagement. Low levels of intervention use is a common problem in both Web and print interventions [
Use of pharmacotherapy was quite low, particularly given the high level of readiness to quit and the fact that it was available at no cost. This is somewhat puzzling, but may be a function of survivors’ heavy use of medications as part of cancer treatment and possibly survivorship, which may make them more reticent to use pharmacologic treatments for non-cancer-related issues. In 2014, CMS (Center for Medicare and Medicaid Services) programs will cover all FDA-approved medications and cessation counseling [
This study highlights the need to develop an effective infrastructure for delivery of smoking cessation services to childhood and young adult cancer survivors. The infrastructure for identifying smokers within long-term survivorship care programs is largely missing [
Cancer survivors are a unique population that should be uniquely aware of risks for cancer. However, not all childhood and young adult survivors are well informed about their cancer, its treatment, and the associated late effects, in large part because of the young age at diagnosis, disease, and treatment complexity, and the fact the knowledge about late effects has been emerging over time [
The lack of an effective implementation infrastructure posed a challenge in the design of PFH-2, as it does in many implementation research studies. We considered comparing the PFH-1 peer counseling condition with the website. However, if we had concluded that the peer counseling was superior, we would not have moved the field forward in terms of having an evidence-based intervention that could be sustained and scaled in real-world conditions. Given that we did not have a mechanism to deploy peer counselors that would be sustainable following completion of the study, we felt it was best to learn from the peer counselor model and adapt to a sustainable format. Thus, PFH-2 was designed with the real-world constraints of survivorship care in mind and compared best survivorship-focused print materials with the website, which provided some interactivity but was more sustainable and scalable than peer counseling. This approach is consistent with several of the broad principles outlined by Kottke et al [
Study limitations should be noted. The response rate was impacted by stringent IRB requirements regarding patient contact and release of contact information to the coordinating center, which may impact on generalizability of findings. Cessation outcomes were self-reported, which is typical in population-level and Web-based studies such as this, but still a limitation [
There are several important strengths to note. A population-based approach was used in conducting this study, identifying all potential smokers within several different survivorship programs in the United States and Canada, which contributes to the external validity of the findings. Data were conservatively analyzed using multiple imputation methods for missing data. This study builds on the previous effective PFH intervention and was designed to determine how best to deliver that intervention in a more scalable format. The study design emphasized external validity and maximizing generalizability of study findings.
Smoking cessation among childhood and young adult cancer survivors is critical. Effective evidence-based programs should be integrated into primary and survivorship care delivery on an on-going and routine basis. This study demonstrated that it was possible to achieve equivalent cessation rates with tailored and targeted Web- and print-based materials designed specifically for survivors and that these cessation rates were equivalent to those found with a more labor-intensive telephone-based intervention. These findings suggest that survivorship programs have flexibility in the format in which cessation services are delivered without sacrificing effectiveness. Patients who reported more frequent use of the materials had better cessation rates, suggesting that developing methods for increasing patient engagement in print and Web-based interventions might optimize outcomes. Future research should examine such approaches to increase engagement and should also evaluate whether survivorship-focused interventions are critical or if survivors experience equal benefits from robust Web-based interventions available to the general public.
CONSORT-EHEALTH checklist V1.6.2 [
baseline feedback report
Impact of Events Scale
Institutional Review Board
Partnership for Health
Partnership for Health-2
Public Health Service
This study was supported by grants from the National Cancer Institute, (5R01CA106914-5 and 1K05 CA124415). The authors would like to acknowledge Martha Zorn for her work on the data management and Nancy Klockson for participation in the manuscript preparation.
All authors made substantial contributions to the development of this manuscript and have given final approval of the version to be published. KE was the study PI and oversaw all aspects of the study conceptualization, design, implementation, analysis, and reporting. EP was the study biostatistician and provided input to the study design, data collection procedures, and completed all analyses. KSH provided critical input into and oversaw study implementation procedures and drafted the Methods section of this paper. JF, JO, DH, MG, LD, VT, and JdM all contributed to the study design and implementation, participated in data analysis, and contributed to the Introduction, Results, and Discussion sections of this manuscript.
None declared.