David B. Abrams Ph.D.

DirectorOffice of Behavioral and Social Sciences Research

OBSSR

National Institutes of Health

AbramsD @ od.nih.gov

http://obssr.od.nih.gov

Transdisciplinary Tobacco Use Transdisciplinary Tobacco Use Research: Advancing the Science of Research: Advancing the Science of

Dissemination Dissemination

2

OBSSR at NIHOBSSR at NIH

OBSSR Other Scientificand Administrative

Units

ExtramuralPrograms

IntramuralPrograms

27 Institutes andCenters

Office of the Director

3

OBSSR: MissionOBSSR: Mission

Office of Behavioral and Social Sciences Research

Increase scope, support for BSSR Increase scope, support for BSSR Inform NIH and scientific communityInform NIH and scientific community Represent NIH BSSR and its valueRepresent NIH BSSR and its value Disseminate information to NIH and Disseminate information to NIH and

the publicthe public..

BSS Research by ICBSS Research by IC FY 2004FY 2004 (In Millions, (In Millions, BSS total= $2,991  ; ≈10% of NIH Total

NCINCINHLBINHLBINIDCRNIDCRNIDDKNIDDKNINDSNINDSNIAIDNIAIDNIGMSNIGMSNICHDNICHDNEINEINIEHSNIEHSNIANIANIAMSNIAMSNIDCDNIDCDNIMHNIMHNIDANIDANIAAANIAAANINRNINRNHGRINHGRINIBIBNIBIBNCRRNCRRNCCAMNCCAM

NCMHD NCMHD FICFIC

NLMNLMODOD

$ $ 312.0312.0 134.2134.2 23.523.5 107.8107.8 126.6126.6 33.033.0 14.914.9 400.7400.7 58.558.5

1 5.91 5.9 273.3 23.823.8 82.382.3 454.9454.9 472.2472.2 201.0201.0 110.6110.6 2.42.4 1.71.7 65.865.8 20.720.7 3.53.5 9.89.8 2.22.2 32.132.1

Where are we headed?Where are we headed?Transdisciplinary Research.Transdisciplinary Research.

Fundamental-BasicFundamental-Basic

TranslationalTranslational

DisseminationDissemination

Policy (science-Informed)Policy (science-Informed)

to improve individual, group and population to improve individual, group and population health, health care and well-beinghealth, health care and well-being

6

Transdisciplinary Transdisciplinary Science:

levels of influence

biobehavioral - genes, proteins, cells, memory, mood, cognition, behavior

intra-individual level variation

aggregate /systems, collective “Behavior”, sociocultural -economic-global interpersonal, nested contexts, social & physical environment

cluster, inter-individual variation

REFS, MONOGRAPHS - Abrams, Leslie, et al(2003,Dec); Abrams,1999a,b: IN: Nicotine & Tobacco Research.Clayton, Abrams, Merikangas, (2000); Mayhew, Flay, & Mott J (2000); Collins, Flaherty & Colby (2002); IN : Drug and Alcohol Dependence.

Transdisciplinary Science:

Lifespan Development sensitive periods and phases

individual - population - national - global

equi-finality and multi-finality - causal paths

time varying and time invariant events

evolutionary, revolutionary, turning points

More longitudinal research > 4 occasions

REFS, MONOGRAPHS - Clayton, Abrams, Merikangas, (2000); Mayhew, Flay, & Mott J (2000); Collins, Flaherty & Colby (2002); IN : Drug and Alcohol Dependence.Abrams, Leslie, et al(2003,Dec); Abrams,1999a,b: IN: Nicotine & Tobacco Research.

Transdisciplinary Integration:ACTION IN THE INTERACTION cells to society, over time - sensitive

developmental phases, generations

Source: Abrams (1999). Nicotine & Tobacco Research

in utero child adolesc. adult older

Individual

Variation

Bio-

Behavioral

Group

Variation

Nested- Contexts

cells

society

t1 t2 t3 t4

levels time

pathways, transitions, trajectories

Refining the phenotype for complex Refining the phenotype for complex disorders: the transdisciplinary promise ?disorders: the transdisciplinary promise ?

Individual susceptibility

+

En

viro

nm

enta

l exp

osu

re

+

Early Warning Sign (? Endophenotype- Biomarker of risk ? ppt -thanks to Dr. B. Lester)

& PersonalityBiology

BEHAVIOR

ValuesEvaluations

Bonding

Sense of Self

Environment

SocialSkills

SelfDetermin-

ation

SELFEFFICACY

SocialCompetence

Decisions/Intentions

ReligionCulture

PerceivedNorms

Motivationto Comply

Others'Beh&&Atts

SOCIALNORMATIVEBELIEFSContext

Social

DNA

ATTITUDES

InformationalEnvironment

CulturalKnowledgeExpectancies

EvaluationsValues

Environment

©2001 BrianFlay

14

Fundamental-BasicFundamental-Basic

*Translational *Translational

*Dissemination *Dissemination

Evidence-based guidelinesEvidence-based guidelines

Translational, Dissemination, Policy Research

translational Bench to Bedside - EFFICACYclinical intervention under ideal conditions. Internal validity

dissemination Bench, Bedside to Trench - REACHGroup, community, population - systems level implementation, in real world. External

validity / generalizability.

policy Research driven - EFFICIENT, SUSTAINEDlocal, state national, enforcement, economics, business models. Cost-

effectiveness and efficiency.

RE-AIM = Reach Efficacy Adoption

Implementation, MaintenanceGlasgow et al, 2004;2005

Put what is known into practice:

16

0

100

200

300

400

500

600

1950 2000 2025 2050

tob

ac

co

de

ath

s (

mil

lio

ns

)

Baseline: If current trends continue

if proportions of young adults taking upsmoking halves by 2020

if adult consumption halves by 2020

Source: Figure 7.1, Curbing the Epidemic: Governments and the Economics of Tobacco Control, World Bank, 1999.

Cessation to Reduce Death Cessation to Reduce Death and Diseaseand Disease

SocialPositions

Social & Cultural Processes

PsychologicalProcesses

Organization & Community Interventions

Primary and Secondary Prevention

Primary & Secondary Prevention & Treatment

Biological/ Genetic

EnvironmentalContext Healthy Public Policy

Levels of Causation for HealthInterventions

Primary & Secondary Prevention & Treatment

Levels

Adapted from McKinlay, J. B., & Marceau, L. D. (2000). Public health matters. Am J Pub Hlth, 90, 25-33, p. 29.

19

Chronic Care ModelChronic Care Model

Informed,Activated

Patient

ProductiveInteractions Prepared,

ProactivePractice Team

Functional and Clinical Outcomes

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Self-Management

Support

Health SystemResources and PoliciesCommunity

Health Care Organization

www.chroniccare.org

Biological

Psychological

Sociocultural

Tailored &Targeted

Interventions and policies

MolecularCellularIndividual

MolarSocietalGlobal

Abrams DB. (1999) Nicotine and Tobacco Research, s 1.

Ultimate Goal of Transdisciplinary Research

ScreeningInstruments

RiskProfiles

efficient, sustainable, policy

Eventually From Pharmaco-genetics Eventually From Pharmaco-genetics to...to...

Society, economicsCultureCommunityFamily, peersBehaviorCognitive Schema NeuroscienceGenetics

Tailoring: bio-genetic-pharmaco -behavioral - socio - cultural

Individual AND Cluster DIFFERENCES

x +

=

22

23

Purposes of RE-AIMPurposes of RE-AIM

To broaden criteria used to evaluate To broaden criteria used to evaluate programs to include external validityprograms to include external validity

To evaluate issues relevant to program To evaluate issues relevant to program adoption and implementationadoption and implementation

To help close the gap between research To help close the gap between research studies and practice by:studies and practice by: Informing design of interventionsInforming design of interventions Providing guides to adopteesProviding guides to adoptees

24

Proposed Translational Research Proposed Translational Research Measurement StandardsMeasurement Standards

Contextual factorsContextual factors Intervention fidelityIntervention fidelity Generalization (Reach, Adoption, Generalization (Reach, Adoption,

Maintenance)Maintenance)____________________________________________________________ Behavior Change (multiple levels?)Behavior Change (multiple levels?) Economic outcomesEconomic outcomes Quality of lifeQuality of life

25

Smoking Cessation and the InternetSmoking Cessation and the Internet

26

Study AimsStudy Aims

1. To examine the quality of smoking cessation

treatment on the Internet

To identify high-quality

websites that warrant

effectiveness evaluation

To adapt PHS Clinical

Practice Guideline to

create an evaluation tool

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Instrument Development ProcessInstrument Development Process

Smoking Treatment Content Scale

Are key components of the PHS Guideline

covered on website?

Smoking Treatment Rating Scale

What is the quality of coverage of PHS key

components?

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Search ResultsSearch Results

202 smoking-related websites found

Direct treatment only “…provision of organized, directive

information and support services related to

quitting smoking”

Excluded 156 websites

Final N = 46 treatment websites

Study period = spring/summer 2002

29

Results - AccuracyResults - Accuracy

No inaccurate information on 88.9% websites

Minor errors on 10% websites: Recommend pharmacotherapy Arrange follow-up contact

Significant / dangerous errors on 5% websites: Recommend pharmacotherapy Practical counseling Assist with quit plan

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ConclusionsConclusions

Few websites follow PHS Guideline

Few websites leverage interactive

capabilities

Quality of WATI falls short of ideal

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Conclusions -Transdisciplinary Integration and Dissemination

Challenge-

Mass-customization relies on

• knowledge of precise bio-psycho-social profiles of risks (who and what to target, when, where)

• knowledge of how to change behavior

• knowledge of how to deliver interventions proactively with sufficient impact to reduce population disease burden at societal level - translation of research evidence into practice

32

IMPACT = REACH x EFFICACYIMPACT = REACH x EFFICACY

Population Metrics for Population Metrics for Reducing Disease BurdenReducing Disease Burden

EFFICIENCY = IMPACT/COSTEFFICIENCY = IMPACT/COST

33

Centers for Behavioral and Preventive Medicine

Initial Evaluation of a “Real World” Internet Smoking Cessation System

Nathan Cobb, M.D., Amanda L. Graham, Ph.D.,

Beth C. Bock, Ph.D., George Papandonatos, Ph.D.,

David B. Abrams, Ph.D.

Nicotine and Tobacco Research, 2005

34

EXTERNAL VALIDITYEXTERNAL VALIDITY

Trochim, W.M. (2000). Research Methods Knowledge Base.

35

Consecutive registrants to Quitnet during a 14 day window (N=1,501).Consecutive registrants to Quitnet during a 14 day window (N=1,501).

Surveyed on the web at 3 months after registrationSurveyed on the web at 3 months after registration

7 day point prevalence, 24hr, longest duration - self report7 day point prevalence, 24hr, longest duration - self report

29 % response rate29 % response rate

Incentives for responding at 2 and 6 days ($20; $40) remindersIncentives for responding at 2 and 6 days ($20; $40) reminders

30% had quit prior to registration (relapse prevention)30% had quit prior to registration (relapse prevention)

As of may 2004 google alone refers over 650 “visitors”/day - over 237,000 per yearAs of may 2004 google alone refers over 650 “visitors”/day - over 237,000 per year

About 2400 unique anonymous users browse daily, 870,000/yrAbout 2400 unique anonymous users browse daily, 870,000/yr

Sample CharacteristicsSample Characteristics

36

Age: Age: 37.3 37.3 ±± 1.2 years 1.2 years

Gender: Gender: 71% female71% female

Race: Race: 91% Caucasian91% Caucasian

Education: Education: 85% some college or more85% some college or more

Smoking rate:Smoking rate: 21.24 21.24 ±± 9.6 cpd 9.6 cpd

From 20 countriesFrom 20 countries

Sample CharacteristicsSample Characteristics

37

Smoking Outcomes – AnalysesSmoking Outcomes – Analyses

Adherence sample (N=379)Adherence sample (N=379) 44.6%44.6% Omitting quittersOmitting quitters 30% 30% Used site >2x (N=565) Used site >2x (N=565) 20.4%20.4% Used site >1x (N=778) Used site >1x (N=778) 16.5%16.5% Excluding bounced (N=1,293) Excluding bounced (N=1,293) 13.1%13.1%

Intention to treat (N=1,474) Intention to treat (N=1,474) 11.5%11.5% Omitting quitters Omitting quitters 7% 7%

Least conservative

Most conservative

38

Opportunity: Program & Process Opportunity: Program & Process TrackingTracking

Mediators & moderators of efficient disseminationMediators & moderators of efficient disseminationto populations:to populations:

FrequencyFrequency

DurationDuration

ContentContent

Dose-intensityDose-intensity

Fidelity (as intended and as received)Fidelity (as intended and as received)

39

Examples from QuitNetExamples from QuitNet

Use of social supportUse of social support # Q-mail sent and received# Q-mail sent and received # bulletin board posts# bulletin board posts # buddies# buddies # exchanges with online counselors# exchanges with online counselors

Intensity of website useIntensity of website use # logins# logins Minutes per sessionMinutes per session Total time onlineTotal time online

Feature utilizationFeature utilization

Opportunity: Program & Process Opportunity: Program & Process TrackingTracking

40

Use of any social support & smoking outcomes:Use of any social support & smoking outcomes:

7-day pp. abstinence:7-day pp. abstinence: OR=3.23OR=3.23 2-month continuous abstinence:2-month continuous abstinence: OR=4.03OR=4.03

Intensity of website use & smoking outcomes:Intensity of website use & smoking outcomes:

7-day pp. abstinence:7-day pp. abstinence: OR=2.34OR=2.34 2-month continuous abstinence:2-month continuous abstinence: OR=6.07OR=6.07

Social support mediated intensity: OR declined Social support mediated intensity: OR declined from 2.34. to 1.52 from 2.34. to 1.52

(intensity attenuated after adjusting for social (intensity attenuated after adjusting for social support in bivariate logistic regression).support in bivariate logistic regression).

Process Tracking & Smoking Process Tracking & Smoking OutcomesOutcomes

41

Estimated Efficacy and Estimated Efficacy and Utilization of Approaches to Utilization of Approaches to Smoking CessationSmoking Cessation

EFFICACY REACH IMPACT (% quit at (# using method (total # 6 months) annually) quitters)

None (unaided) 3 22,800,000 684,000

Internet mass customize 12 7,000,000 840,000

Rx NRT (1995) 14 2,500,000 350,000

OTC NRT (1996) 14 6,300,000 882,000

Behavioral counseling 24 395,000 94,800

Inpatient treatment 32 500 160

Adapted from Shiffman et al. (1998). Annual Review of Public Health.

43

Causal Map of Factors in Causal Map of Factors in Tobacco Prevalence and Tobacco Prevalence and ConsumptionConsumption

Funding for tobaccocontrol programs

Gov. incomefrom tabacco

taxes

Tobacco controlprograms

Smokers

Perceived importance tofocus on other health

programs

Public awarenessof tobaccohealth risk

Pressure on tobaccocompanies to reducemarketing activities

Tobacco marketingactivities

Taxrevenues

fromsmokers

+

+

+

-

+

People quittingsmoking

-

Fraction of peoplesmoking

Smoking as asocial norm

People startingsmoking

Tobaccorevenues

+

+ +

+

++

+

Health care costs

+

Health insurerscoverage of tobacco

quitting costs

+

+

Researchersawarness of

tobacco healthrisk

Funding fortobacco health

research+

+

Govt awarenessof tobaccohealth risk

+

-

Pro-tobaccocontituencies

Anti-tobaccoconstituencies

++ +

+

Tobacco productsavailability

+

Tobaccogrowers

+

+

+

++

+

Govt willingness tolegislate tobacco

control

- + +

Tobaccotaxes

Govt funding oftobacco control

--

Trend in tobaccocompany revenues

+

-

Anti-smokinglegislation

-

44

““Shard” of Causal MapShard” of Causal MapSmokers

Tobacco marketingactivities

Fraction of peoplesmoking

Smoking as asocial norm

People startingsmoking

Tobaccorevenues

+

+ +

+

++

+

Tobacco productsavailability

+

Tobaccogrowers

+

+

45

Formal Systems Model: Public Formal Systems Model: Public OpinionOpinion

Public Supporters of

Tobacco ControlPublic Supporters

of Tobacco

Public support toUndecided

Undecided toDissenting

Dissenting toUndecided

Undecided toSupporting

Fraction of anti-tobaccobecoming undecided per year

Fraction of undecidedbecoming pro-tobacco per

year

Fraction of undecided becomingPro-control per year

Fraction of pro-tobaccobecoming undecided per year

Public Undecided

46

SummarySummary

Tobacco control has become a complex, adaptive Tobacco control has become a complex, adaptive environment.environment.

Systems approaches represent a major hope for Systems approaches represent a major hope for substantial future change in health outcomes.substantial future change in health outcomes.

This trend mirrors fundamental changes in how we This trend mirrors fundamental changes in how we solve problems within a society as a whole. solve problems within a society as a whole.

We seek integrated systems thinking within We seek integrated systems thinking within tobacco control, not just an implementation of tobacco control, not just an implementation of system techniques. system techniques.

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THE ENDTHE END