Recruiting young adults into smoking cessation interventions: Current research on recruitment strategies. Written by Laura McCammon-Tripp

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Backgrounder Recruiting young adults into smoking cessation interventions: Current research on recruitment strategies Issue and Context Written by Laura McCammon-Tripp April 2010 Young adults

Twenty-seven per cent of Canadian young adults aged 20 to 24 years smoke and 21% of young adults aged 25 to 34 years smoke (Health Canada, 2010).

, 2007). While young adults report higher numbers of quit attempts annually than older adults, they are less likely to be successful in their attempts (Barker et al., 2006; Solberg et al., 2007). This suggests there is a need to assist young adults in moving from quit attempts to cessation.

1 Backgrounder Recruiting young adults into smoking cessation interventions: Current research on recruitment strategies Issue and Context Written by Laura McCammon-Tripp April 2010 Young adults continue to have the highest smoking rates among all Canadians. Twenty-seven per cent of Canadian young adults aged 20 to 24 years smoke and 21% of young adults aged 25 to 34 years smoke (Health Canada, 2010). On average, young adult smokers smoke fewer cigarettes per day, and are significantly more likely to report a quit attempt in the past year than older adults (Curry et al., 2007; Solberg et al., 2007). While young adults report higher numbers of quit attempts annually than older adults, they are less likely to be successful in their attempts (Barker et al., 2006; Solberg et al., 2007). This suggests there is a need to assist young adults in moving from quit attempts to cessation. Young adults are less likely to use traditional cessation interventions than older adults (Bader et al., 2007; Curry et al., 2007). This however, may not be solely due to a lack of awareness of interventions. In a survey of smokers in Vermont, 80% of young adults who had recently quit smoking were aware of free cessation treatments available to them. Despite this, the young adult survey participants were half as likely to have used pharmacological or psychological treatments to aid with cessation as older adults (Hughes et al., 2009). This suggests current interventions may not appeal to individuals in this age group or current recruitment strategies might not be successful in promoting the interventions to them. This backgrounder explores the current research on strategies to recruit young adults into smoking cessation programming. Determining how to design smoking cessation interventions to make them more appealing to young adults is also an important consideration when attempting to increase participation, but this is beyond the scope of this backgrounder. This document was produced by: Program Training and Consultation Centre (PTCC) c/o Cancer Care Ontario 505 University Avenue, 18th Floor Toronto, Ontario M5G 1X3

2 Possible Recruitment Methods Incentives Incentives can be used to recruit individuals into programming, and to reward individuals for quitting and remaining smoke-free (Cahill & Perera, 2008). Incentives can take a variety of forms including monetary incentives, promotional items, free nicotine replacement therapy (NRT) and refunding of program fees (Black et al., 1993; Cahill & Perera, 2008; Maher et al., 2007). In a review of the use of incentives in the adult population, Cahill and Perera (2008) suggest that while incentives do not appear to increase the long term quit rate of an intervention, they can increase enrolment leading to a larger total number of quits. Further, research suggests that incentives may be useful recruitment tools for young adults. Research by Maher and colleagues (2007) found, for example, that providing free NRT is a potentially useful tool. In a study conducted in Washington State the authors offered free NRT to young adults aged 18 to 29 years if they called the quitline and set a quit date. This incentive was advertized through community promotions, press releases, targeted materials and radio advertisements (Maher et al., 2007). The number of calls from young adults increased dramatically while the free NRT incentive was provided. Prior to the incentive the quitline received approximately 200 calls from young adults each month. While the free NRT was offered the number of calls per month from young adults ranged between 200 and The authors of this study conclude that offering free NRT to young adults could be an effective way to increase participation (Maher et al., 2007). Davidson and colleagues (in press) studied a smoking cessation intervention targeted at college fraternity and sorority members. As part of their recruitment strategy they offered a variety of incentives including raffles, food and monetary incentives. Incentives were offered at various periods during the intervention including during recruitment and for completing screening and follow-up assessments. Screening surveys were completed by 76% (3,276) of the group members. Twenty-three per cent (745) of those who completed the screening survey were eligible for the intervention, and 79% (592) of those who were eligible agreed to participate (Davidson et al., in press). While a variety of recruitment tools were used in addition to the incentives, researchers suggest the incentives likely played a role in the high recruitment rates. Researchers worked with members of the fraternities and sororities to determine what kinds of incentives would be most rewarding and valuable to participants. This, the authors suggest, was important to the success of the incentives and is a strategy that may be useful when selecting incentives for other interventions (Davidson et al., in press). Quit and Win Contests Quit and Win contests are incentive based interventions where smokers have the chance to win a prize if they quit smoking (Bains et al., 2000). There is some research to suggest Quit and Win programs may attract 2 Page

3 younger participants. In a study of a Quit and Win contest in Eastern Ontario, Bains and colleagues (2000) found that individuals who enrolled in the Quit and Win contest were younger than members of the randomly selected comparison group. Within the Quit and Win group, 61.9% of the participants were between 18 and 39 years of age (Bains et al., 2000). Research by Rooney and colleagues (2005) examined the effectiveness of a Quit and Win contest specifically targeted at young adults on three college campuses. The authors estimated that 2% of the smokers on campus participated in the intervention. Ninety-four per cent of the students who participated in the Quit and Win thought it would be a good way to encourage college smokers to quit (Rooney et al., 2005). While Quit and Win contests are programs rather than recruitment strategies, this research does suggest some programs may appeal to young adults specifically. In addition, this research suggests the potential to win an incentive may be a useful recruitment tool. Media Campaigns The evidence available to date suggests advertising cessation interventions in the media may be another useful technique for recruiting young adults. Online Advertising. The internet poses new opportunities for recruiting young adults into cessation interventions. For example, Graham and colleagues (2008) studied the utility of online advertising campaigns for recruiting adult smokers into an online cessation program. They tested four categories of ads with three online advertising partners (national websites, local websites and search engines). These campaigns were compared to traditional media campaigns which were run to promote the same program. Traditional media included outdoor advertising, direct mail, television and radio ads and billboards. The online ads and the traditional ads included the same content in most cases, and used the same logo and colour scheme (Graham et al., 2008). Comparisons were made between the number of individuals who were recruited by the online advertisements and the number of individuals who were recruited by traditional media. Overall, 81.6% of individuals who registered for the program were recruited with online ads and 18.4% were recruited with traditional media. Compared with the traditional media, the online advertising efforts recruited significantly more young adults (18 24 years) into the cessation program. The authors suggest this research provides evidence that online advertising can reach subgroups of the population who have traditionally been difficult to reach with other marketing methods (Graham et al., 2008). Targeted marketing. There is a lack of evidence on the influence of targeted marketing on the recruitment of young adults. Young adult smokers and former smokers who participated in focus groups conducted by Staten and colleagues (2006) felt that it would be useful to target media campaigns towards young adults. They spoke of how prevention messages targeted younger individuals and cessation messages targeted older adults, but none of the messaging focused on their age group. A participant indicated if the message doesn t speak to me, 3 Page

4 I don t hear it (Staten et al., 2006). This research suggests that targeted media campaigns might be a good way to reach young adults. Alternatively, the California Smokers Helpline does not target their messaging specifically at young adults, however have found their general messaging still reaches this population. They have consistently found that young adult callers are significantly more likely than older adult callers to indicate they heard about the program through the media (Cummins et al., 2007). Further research is needed to determine if targeted messages would be useful ways to reach young adults. In work conducted by An and colleagues (2007) online health surveys were used to recruit students into a cessation program. University students were ed an invitation to complete an online health screening survey. The informed students that the purpose of the survey was to investigate college life and health and that current smokers would be invited to participate in a cessation intervention. Thirty-two per cent of the eligible smokers who responded to the survey entered the cessation program. The authors estimate this strategy led to 9% of all potential smokers from the population enrolling in the intervention (An et al., 2007). While and the internet may be potentially useful tools for recruiting young adults into cessation programming, additional research is needed to investigate this recruitment channel. When considering using the internet for cessation programming and recruitment, it is important to remember that not all young adults will have equal access to this technology. In a focus group of employed and unemployed young adults, many participants indicated they did not own a computer or they did not have access to the internet (Bader et al., 2007). This suggests that recruitment strategies must be matched to the population of interest. Health Professionals Health professionals, including physicians, nurses and dentists, may be useful partners for recruiting young adults into cessation interventions. Young adults may already reach out to health professionals when they are considering cessation. Barker and colleagues (2006) surveyed young adults to determine the cessation methods they were most likely to use. Individuals were eligible to participate in the survey if they were current smokers between the ages of 16 and 24 years living in the United States. Random digit dialing, a method of generating telephone numbers at random, was used to identify potential respondents. Respondents were asked about their use of various assisted and unassisted cessation methods. Twenty per cent of respondents indicated they had spoken with a doctor, nurse or dentist about cessation, making this the most commonly used assisted method of cessation (Barker et al., 2006). This research suggests that health professionals have a role to play in encouraging young adults to quit smoking, and in referring them to cessation programs. While young adults can approach health professionals about cessation, health professionals can also proactively ask their patients about their smoking behaviours and refer them to cessation programs. Not all health 4 Page

5 professionals however currently speak with their patients about smoking. Research by Curry and colleagues (2007) found young adults were both less likely to have been asked about their smoking behaviours and less likely to be advised to quit smoking by physicians and dentists than older adults were. Work by Lawrance and Lawler (2008) however, found that many physicians working in university health clinics were addressing smoking with their patients. The results of a survey of physicians working at 16 Ontario university health clinics indicated that 20% of physicians report speaking with all or almost all of their patients about their smoking behaviour. In addition, 23.5% reported speaking with most of their patients and 31.3% reported speaking with half of their patients about smoking. When physicians did identify a patient as a smoker, 96% told the patient to quit smoking and 72% offered assistance with cessation (Lawrance & Lawler, 2008). Although not all young adult smokers are proactively asking their health professionals for cessation advice and not all health professionals are speaking with their patients about smoking, health professionals can be useful partners for recruiting young adults into cessation programming. Additional research is needed to determine how health professionals can be encouraged to speak with their patients, and the impact health professionals could have on recruitment. Future Research and Implications Overall, there is little evidence available on effective strategies to recruit young adults into cessation programming. There is however, some evidence to suggest incentives, quit and win contests, media campaigns and may be effective ways to promote cessation programs and recruit young adults into cessation programming. Health professionals may also have a role to play in promoting cessation programming to this population. Program providers are also beginning to use mobile phones, text messaging and social networking websites such as Twitter and Facebook to deliver smoking cessation interventions to young adults. While these technologies could also be used as recruitment tools, research is needed to investigate the effectiveness of doing so. Future research should investigate these technologies to determine if they could also be used as recruitment tools. Effective recruitment strategies are critical as the literature suggests few young adults participate in cessation interventions and although young adults are motivated to quit, few are successful in their quit attempts. The evidence available to date identifies some potential recruitment strategies, however additional evidence is needed to determine the most effective ways to recruit young adults into smoking cessation programs. Suggested Citation: McCammon-Tripp, L. (2010). Recruiting young adults into smoking cessation interventions: Current research on recruitment strategies. Toronto, ON: Program Training and Consultation Centre, LEARN Project Comments and suggestions are welcome and can be sent to laura.mccammon-tripp@cancercare.on.ca 5 P age

6 References An, L. C., Hennrikus, D. J., Perry, C. L., Lein, E. B., Klatt, C., Farley, D. M., et al. (2007). Feasibility of internet health screening to recruit college students to an online smoking cessation intervention. Nicotine and Tobacco Research, 9(Suppl.1), S11-S18. Bader, P., Travis, H. E., & Skinner, H. A. (2007). Knowledge synthesis of smoking cessation among employed and unemployed young adults. American Journal of Public Health, 97(8), Bains, N., Pickett, Laundry, B., & Mecredy, D. (2000). Predictors of smoking cessation in an incentive-based community intervention. Chronic Diseases in Canada, 21(2). Retrieved March 18, 2010, from Barker, D. C., Giovino, G. A., Gable, J., Tworek, C., Orleans, C. T., & Malarcher, A. (2006). Use of cessation methods among smokers aged years United States, Morbidity and Mortality Weekly Report, 55(50), Black, D. R., Loftus, E. A., Chatterjee, R., Tiffany, S., & Babrow, A. S. (1993). Smoking cessation interventions for university students: Recruitment and program design considerations based on social marketing theory. Preventive Medicine, 22, Cahill, K., & Perera, R. (2008). Competitions and incentives for smoking cessation. Cochrane Database of Systematic Reviews. Retrieved March 9, 2010, from Cummins, S. E., Hebert, K. K., Anderson, C. M., Mills, J. A., & Zhu, S. (2007). Reaching young adult smokers through quitlines. American Journal of Public Health, 97(8), Curry, S. J., Sporer, A. K., Pugach, O., Campbell, R.T., & Emery, S. (2007). Use of tobacco cessation treatments among young adult smokers: 2005 national health interview survey. American Journal of Public Health, 97(8), Davidson, M. M., Cronk, N. J., Harris, K. J., Harrar, S., Catley, D., & Good, G. E. (in press). Strategies to recruit and retain college smokers in cessation trials. Research in Nursing & Health. Graham, A. L., Milner, P., Saul, J. E., & Pfaff, L. (2008). Online advertising as a public health and recruitment tool: Comparison of different media campaigns to increase demand for smoking cessation interventions. Journal of Medical Internet Research, 10(5), Article e50. Retrieved March 9, 2010, from Health Canada. (2010). Canadian tobacco use monitoring survey (CTUMS) 2008: Summary of annual results for Retrieved March 9, 2010, from Hughes, J. R., Cohen, B., & Callas, P. W. (2009). Treatment seeking for smoking cessation among young adults. Journal of Substance Abuse Treatment, 37, Page

7 Lawrance, K.G., & Lawler, S. A. (2008). Campus physicians tobacco interventions with university students: A descriptive study of 16 Ontario university clinics. Patient Education and Counselling, 70(2), Maher, J. E., Rohde, K., Pizacan, B., Dent, C., Stark, M. J., Dilley, J. A., et al. (2007). Does free nicotine replacement therapy for young adults prompt them to call a quitline? Tobacco Control, 16, Rooney, B.L., Silha, P., Gloyd, J., & Kreutz, R. (2005). Quit and win smoking cessation contest for Wisconsin college students. Wisconsin Medical Journal, 104(4), Solberg, L. I., Boyle, R. G., McCarty, M., Ashe, S. E., & Thoele, M. (2007). Young adult smokers: Are they different? American Journal of Managed Care, 13, Staten, R. R. & Ridner, S. L. (2006). College students perspective on smoking cessation: If the message doesn t speak to me, I don t hear it. Issues in Mental Health Nursing, 28, P age

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