Development and acceptability of an educational video about a smoking cessation quitline for use in adult outpatient mental healthcare

Abstract

Tobacco use is a leading preventable cause of early mortality and is prevalent among adults with mental health diagnoses, especially in the southern USA. Increasing cessation resources in outpatient mental health care and targeting individuals most receptive to changing their behavior may improve cessation. Drawing on the transtheoretical model, our goals were to develop an educational video about the Louisiana Tobacco Quitline and evaluate its acceptability. We designed the video with knowledge derived from Louisiana-specific data (2016 Louisiana Adult Tobacco Survey, N = 6,469) and stakeholder feedback. Bivariate associations between demographic/tobacco-use characteristics and participants’ stage of quitting (preparation phase vs. nonpreparation phase) were conducted, which informed design elements of the video. Four stakeholder advisory board meetings involving current smokers, mental health clinicians, and public health advocates convened to provide iterative feedback on the intervention. Our stakeholder advisory board (n = 10) and external stakeholders (n = 20) evaluated intervention acceptability. We found that 17.9% of Louisiana adults were current smokers, with 46.9% of them in the preparation phase of quitting. Using insights from data and stakeholders, we succeeded in producing a 2-min video about the Louisiana Tobacco Quitline which incorporated three themes identified as important by stakeholders: positivity, relatability, and approachability. Supporting acceptability, 96.7% of stakeholders rated the video as helpful and engaging. This study demonstrates the acceptability of combining theory, existing data, and iterative stakeholder feedback to develop a quitline educational video. Future research should examine whether the video can be used to reduce tobacco use.

We analyzed national data and partnered with community members who smoke to create a positive, relatable, and approachable video about a smoking cessation helpline.

Implications.

Practice: This study demonstrates the use of theory and an iterative stakeholder engagement process to develop a brief video intervention about smoking cessation for use in outpatient mental healthcare.

Policy: Video-based interventions that link the target population to a statewide tobacco cessation quitline may increase its utilization.

Research: Future research is needed to assess the effectiveness of this video-based intervention in improving the utilization of the telehealth Quitline and its effects on tobacco cessation in the Deep South.

Tobacco use is the largest risk factor of preventable morbidity and mortality in the USA [1] and is especially prevalent among people with mental health diagnoses living in Deep South states such as Louisiana. In 2017, 14% of adults smoked cigarettes nationally, whereas 23% of adults in Louisiana smoked cigarettes [2]. Although smoking rates have decreased nationally, there remains little change in the smoking rates among those with mental health conditions [3]. In 2016, an estimated 41% of adults with self-reported mental health diagnoses used tobacco in the last year [4]. Tobacco use among those with mental health diagnoses contributes to poorer health outcomes seen in this population, including an average lifespan decrease of 25 years [5]. Given that the national burden of tobacco use disproportionately affects those with mental health diagnoses, there is a need for tobacco cessation interventions in outpatient mental healthcare.

Telehealth services, including quitlines, can provide accessible counseling and resources to smokers interested in cessation. Their efficacy has been established in community samples [6–8], but less than 5% of current smokers utilize quitline services annually [9, 10]. Accordingly, national guidelines emphasize increasing their promotion in diverse populations [11] including those with mental health diagnoses, given high relapse rates in these populations [12] and the accessibility, anonymity, and low cost of quitlines [5].

The present investigation describes the development of a video-based intervention for use in outpatient mental healthcare aimed at encouraging the use of the Louisiana Tobacco Quitline, and was guided by theory, statewide data, and stakeholder engagement. First, to characterize an appropriate target population, we used the stages of change framework of the transtheoretical model [13, 14], which suggests that interventions should be “stage matched” to the target population’s specific change-related cognitions and behavior. Quitlines are well suited for individuals in the third phase of this model, called “preparation.” This phase applies to tobacco users actively preparing to quit who may be receptive to guidance on planning and initiating concrete steps toward that goal. To inform our video design, we analyzed statewide data on Louisiana tobacco users and sought iterative stakeholder feedback. Collaborating with stakeholders produces more meaningful and culturally applicable content that increases engagement and uptake of information [15]. Combining these techniques may help to develop a video that in future studies could increase quitline utilization and tobacco cessation in the Deep South.

METHODS

An iterative six-step process was used to integrate theory, data, and stakeholder feedback to develop a video-based intervention about the Louisiana Tobacco Quitline (Fig. 1). The video was designed to be informative, understandable (e.g., Flesch-Kincaid level ≤6), and compelling. Steps included conducting secondary analyses of statewide data to gain background information about the demographics and tobacco use behaviors of current smokers in Louisiana, holding four stakeholder meetings to learn more about the specific needs of current smokers with mental health diagnoses, and conducting a summative evaluation of the video. Our approach is supported by past research focused on the development and implementation of patient education interventions [16], and was approved by the Institutional Review Board (FWA00002055-1701).

Fig 1.

Overview of the six-step process used to create the video-based intervention about the Louisiana Tobacco Quitline.

Tobacco-use data

As a part of the Center for Disease Control and Prevention’s National Adult Tobacco Survey, the Louisiana Public Health Institute administered the 2016 Adult Tobacco Survey statewide to assess the tobacco use habits of adults (N = 6,469) in Louisiana. The survey was conducted from February 2016 to November 2016, used complex sampling with random-digit dials and telephone numbers stratified by geographic location, and had a response rate of 19.8% [17]. Participants were defined as current smokers if responding “yes” to the question “Have you smoked at least 100 cigarettes in your entire life?” and responding “every day” or “some days” to the question “Do you now smoke cigarettes every day, some days, or not at all?” We used SPSS 22.0 to perform secondary analyses on specific questions to determine the prevalence of current smokers in the preparation phase of quitting and to summarize demographic and tobacco-use characteristics. Current smokers were operationalized as in the preparation phase of quitting if they responded “yes” to the question “Do you want to quit smoking cigarettes for good?” and had responded 1 or more to the question “During the past 12 months, how many times have you stopped smoking for one day or longer because you were trying to quit smoking cigarettes for good?” Chi-square tests of independence and t-tests assessed whether smokers in the preparation stage of quitting versus other smokers differed on key participant characteristics, which were selected based on data availability.

Stakeholder advisory board meetings

The stakeholder advisory board consisted of current smokers, mental health clinicians, and public health advocates in New Orleans. Current smokers were recruited through ads posted on Craigslist and were screened by phone. Inclusion criteria for current smokers were current daily use of cigarettes, having an interest in quitting, and participation in outpatient mental healthcare in the past year; exclusion criteria were lack of availability or severe, unmanaged mental health diagnoses. Clinicians and public health advocates were recruited by email from known colleagues and their network of collaborators; to be eligible, they had to presently devote professional time to research or care related to mental health, tobacco use, or both. Stakeholders (n = 16) attended up to four advisory meetings (attendance from 10 to 16/meeting), including 11 current smokers with mental health diagnoses and 5 health professionals. They were diverse with respect to race (50% White, 50% African American) and gender (62.5% female, 37.5% male).

Based on our prior experience developing and evaluating health education interventions [18–20], we developed the video using professional animation software from Vyond.com. We received iterative feedback from stakeholders on the content, format, and appropriateness of the script and eventual video. Across four meetings, we sought extensive feedback on the proposed video-based delivery platform (meeting 1), the intervention’s script and content (meeting 2), an intervention prototype, especially attending to the visual aspects of the video (meeting 3), and the near-final version of the intervention (meeting 4).

Summative evaluation

Most of our stakeholder advisory board (n = 10) and an external panel of stakeholders uninvolved in designing the video (n = 20, using same eligibility criteria) evaluated the final video using a 6-item de novo measure. They rated from 1 (Strongly disagree) to 5 (Strongly agree) the extent to which the video was engaging (item 1) and helpful (item 2), whether it would encourage people to use the Quitline (item 3), whether they would recommend the video (item 4), whether they felt their ideas were heard (item 5), and whether they enjoyed participating (item 6). The external panel solely rated items 1–4. We evaluated acceptability by examining item and total means and standard deviations, with a mean ≥4 (Agree) indicating acceptability.

RESULTS

Tobacco use survey data

Using the Louisiana tobacco-use dataset, we gained key insights into smokers in the preparation stage of quitting in our state. Among respondents, 17.9% (1,159/6,469) identified as current smokers, with 46.9% (544/1,159) in the preparation phase. Smokers in the preparation phase of quitting (Table 1) ranged from ages 18 to 87, with a mean age of 47 (Gender: 52.3% female; Race: 60.2% White, 35.6% African American; Relationship Status: 40.4% Married or living with a partner; Education level: 13.3% Bachelor’s degree or higher). In addition to traditional cigarettes, smokers in the preparation stage of quitting reported using menthol cigarettes (48.3%) and vaping devices (14.2%). Smokers in the preparation stage of quitting were more likely than nonpreparation phase smokers to be African American (p < .001), use menthol cigarettes (p = .001), and vape (p = .03). Accordingly, in the video, we portrayed individuals as diverse with respect to age, gender, and race, and mentioned menthols and vaping devices.

Table 1.

Demographics and Smoking Habits of Current Smokers in the 2016 Louisiana Adult Tobacco Survey

	Nonpreparation phase Smokers		Smokers in the preparation stage of quitting
Variable	n = 615	%	n = 544	%	p
Age					.147a
<30	99	16.4	86	16.0
30–39	96	15.9	102	19.0
40–49	101	16.8	92	17.1
50–59	139	23.1	138	25.7
60–69	111	18.4	88	16.4
70+	56	9.3	32	5.9
Gender, female	293	47.6	284	52.3	.985
Race/ethnicity
White	461	75.5	325	60.2	<.001
African American	134	22.0	192	35.6	<.001
American Indian or Alaska Native	74	12.2	59	10.9	.518
Asian	9	1.5	9	1.7	.794
Native Hawaiian or Other Pacific Islander	6	1.0	7	1.3	.616
Hispanic/Latina/o	19	3.1	26	4.9	.137
Relationship Status, Married/living with partner	293	47.6	220	40.4	.014
Education Level, Bachelor’s degree or higher	80	13.1	72	13.3	.942
Health Insurance present	446	73.4	398	73.8	.852
Employment Status, not currently working	302	49.4	270	49.7	.920
Tobacco-use habits in the past 30 days…
Cigarettes smoked were primarily menthol	235	38.4	262	48.3	.001
Use of any flavored cigarettes	25	4.1	25	4.6	.648
Use of discounts to purchase cigarettes	86	14.1	85	15.7	.458
Use of e-cigarettes/vaping devices	59	9.6	77	14.2	.030
Use of chewing tobacco, snuff, or dip	40	6.5	37	6.8	.844
Use of snus	6	1.0	5	0.9	.919
Use of cigars or cigarillos	78	12.7	76	14.0	.508
Purchased cigarettes for oneself	570	92.7	502	92.4	.880

Note: With the exception of age, all variables were dichotomous and their relationship with preparation phase status was assessed with chi-square tests of independence. The dichotomous variables were dummy-coded, with a value of 1 indicating the characteristic was present and a value of 0 indicating the characteristic was absent.

^aThis was obtained from a t-test with age as a continuous variable. We present the age categories in the table to give a more specific overview of the age distribution of the sample.

Stakeholder advisory board meetings

Figure 1 provides a detailed description of the video development process, including the focus of each stakeholder meeting. After the final video was developed, stakeholders (n = 30)—including those involved with the development process (n = 10) and external stakeholders (n = 20)—rated the video as highly acceptable, as 96.7% felt the video was both helpful (M = 4.50, SD = 0.57) and engaging (M = 4.53, SD = 0.57). They felt that the video would encourage people to use the Quitline (M = 4.17, SD = 0.91), and they would recommend the video (M = 4.27, SD = 0.87). The internal stakeholders who were on the advisory board (n = 10) felt that their ideas were heard (M = 4.80, SD = 0.42) and enjoyed participating (M = 5.00, SD = 0.00). The stakeholders also emphasized three themes across the meetings, which we incorporated into the video (see Fig. 2): positivity, relatability, and approachability. The video had a Flesch-Kincaid grade level of 5.6 and was brief (325 words, 132 seconds). Stakeholders appreciated the motivational and optimistic tone and were inspired by the idea of a preselected “quit day” to begin smoking cessation. They also expressed gratitude for the resources in the video, including a list of coping mechanisms, mental health counseling, and a Quit Coach to help plan and maintain cessation.

Fig 2.

Stakeholders desired three themes (positivity, relatability, and approachability) to be evident throughout the video. They made specific suggestions on how to incorporate the themes into different scenes.

Discussion

Given the need to increase utilization of tobacco cessation interventions in the Deep South [21, 22], especially in outpatient mental health populations [23, 24], the present investigation documented the development and acceptability of a theory-based video suitable for linking the target population with a telehealth tobacco quitline. The study provides an illustrative example of how investigators can use theory, public health data, and an iterative stakeholder engagement process to design interventions. This formative research sets the stage for follow-up studies examining the effectiveness of the intervention in improving utilization of the telehealth Quitline and tobacco cessation by southern U.S. tobacco users in outpatient mental healthcare.

To the best of our knowledge, this was the first study integrating theory and stakeholder engagement to develop a video-based intervention designed to increase utilization of a tobacco quitline in the Deep South. The research was grounded in the stages of change of the transtheoretical model [14, 23] with the premise that by developing an intervention targeting tobacco users in the “preparation” phase of quitting, we could increase utilization of a tobacco quitline in a future study. These tobacco users intend to take action toward quitting in the near future and may be responsive toward small steps in that direction. Although the transtheoretical model has been criticized at times [25], we found it valuable in explaining the rationale for the research to local funders and stakeholders given that behavioral health research is less familiar in this region. The stakeholder engagement process was vital for incorporating into the video the perspectives of current smokers in Louisiana with mental health diagnoses, and past research suggests it could increase the success of our intervention [15]. The four stakeholder meetings ensured that the information was portrayed in a relatable and approachable manner (Fig. 2), with a resulting video that is brief, suitable for low-literacy populations, and rated as highly acceptable.

The central limitations of this formative research should be noted. Foremost, the process of developing an iterative, stakeholder-informed intervention is time-consuming relative to traditional research. These substantive efforts could be a barrier for early career researchers, and the eventual payoff is often contingent upon receiving continued funding for follow-up investigations. Nonetheless, formative research with stakeholders can accelerate knowledge translation by increasing the likelihood that interventions will be acceptable to the target population, effective, scalable, and disseminable. Additionally, the development of the intervention could have been influenced by the idiosyncratic characteristics of stakeholders. We minimized this limitation by recruiting stakeholders through the community rather than a specific clinic, ensuring the stakeholders were representative of the target, and including supplemental feedback from external stakeholders who were less vested in the particular video. Finally, the Louisiana Adult Tobacco Survey did not include any data on mental health symptoms or mental health diagnoses. We overcame the limitations of those data by conducting stakeholder meetings which focused on understanding the needs of current smokers with mental health diagnoses. As these limitations are reasonable given the methodology, the study met its objective of developing an appropriate intervention for the target population. Given the flexibility of the animation software used, it can be easily modified as information about the Quitline evolves or if other teams would like to tailor our video to meet the needs of their own population.

In summary, we used theory, public health data, and an iterative stakeholder engagement process to develop an intervention that may have the potential to increase utilization of a tobacco quitline among smokers in outpatient mental healthcare. The next phase of this research is to examine the effectiveness of the video intervention in improving the utilization of the Louisiana Tobacco Quitline and tobacco cessation in outpatient mental health clinics in the Deep South.

Funding This study was funded by the Louisiana Cancer Research Center and the National Institutes of Health (U54MD007595).

Compliance with Ethical Standards

Conflicts of Interest: The authors declare that they have no conflicts of interest.

Authors’ Contributions:

M.H. designed the study and gained funding for the research. A.S.K., L.M.P., W.F.A., and S.K. designed and edited the video. A.S.K., L.M.P., W.F.A., and M.H. collected the data. L.M.P. and M.H. analyzed the data. All authors contributed to interpreting the findings, writing the manuscript, and providing critical feedback on the final draft of the manuscript.

Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent: Informed consent was obtained from all individual participants included in the study. This article does not contain any studies with animals performed by any of the authors.