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1.  Explaining socio-economic differences in intention to smoke among primary school children 
BMC Public Health  2014;14:191.
Background
Smoking prevalence is higher among low socio-economic status (LSES) groups, and this difference may originate from a higher intention to smoke in childhood. This study aims to identify factors that explain differences in intention to smoke between children living in high socio-economic status (HSES) and LSES neighbourhoods.
Methods
Cross-sectional data were derived from the baseline assessment of a smoking prevention intervention study. Dutch primary school children, aged 10 – 11 years (N = 2,612), completed a web-based questionnaire about their attitude, subjective norm, self-efficacy expectations, modelling and intention to smoke. Linear and logistic regression analyses were performed to assess potential individual cognitive (attitude, subjective norm and self-efficacy) and social environmental (modelling) mediators between SES and intention to smoke.
Results
Multiple mediation models indicated that modelling mediated the association between SES (B = -0.09 (p < 0.01)) and intention to smoke (B = 1.06 (p < 0.01)). Mainly the father, mother and other family members mediated this association. Gender did not moderate the association between SES and intention to smoke and the potential mediators indicating that there are no differences in mediating factors between boys and girls.
Conclusions
This study indicates that future smoking prevention studies may focus on the social environment to prevent smoking onset. However, replication of this study is warranted.
Trial registration
This study was approved by the Medical Ethics Committee of the Atrium-Orbis-Zuyd Hospital (NL32093.096.11 / MEC 11-T-25) and registered in the Dutch Trial Register (NTR3116).
doi:10.1186/1471-2458-14-191
PMCID: PMC3938073  PMID: 24555819
Socio-economic status; Intention to smoke; Primary school; Mediation analyses
2.  Correlates of the Intention to Implement a Tailored Physical Activity Intervention: Perceptions of Intermediaries 
The public health impact of health behaviour interventions is highly dependent on large-scale implementation. Intermediaries—intervention providers—determine to a large extent whether an intervention reaches the target population, and hence its impact on public health. A cross-sectional study was performed to identify the correlates of intermediaries’ intention to implement a computer-tailored physical activity intervention. According to theory, potential correlates are intervention characteristics, organisational characteristics, socio-political characteristics and intermediary characteristics. This study investigated whether intermediary characteristics mediated the association between the intervention, organisational and socio-political characteristics and intention to implement the intervention. Results showed that intervention characteristics (i.e., observability (B = 0.53; p = 0.006); relative advantage (B = 0.79; p = 0.020); complexity (B = 0.80; p < 0.001); compatibility (B = 0.70; p < 0.001)), organisational characteristics (i.e., type of organization (B = 0.38; p = 0.002); perceived task responsibility (B = 0.66; p ≤ 0.001); capacity (B = 0.83; p < 0.001)), and the social support received by intermediary organisations (B = 0.81; p < 0.001) were associated with intention to implement the intervention. These factors should thus be targeted by an implementation strategy. Since self-efficacy and social norms perceived by the intermediary organisations partially mediated the effects of other variables on intention to implement the intervention (varying between 29% and 84%), these factors should be targeted to optimise the effectiveness of the implementation strategy.
doi:10.3390/ijerph110201885
PMCID: PMC3945575  PMID: 24518647
intervention implementation; hypothesized determinants of implementation intention; tailored intervention; intervention characteristics; organisational characteristics; socio-political characteristics; intermediary characteristics
3.  Integrating a tailored e-health self-management application for chronic obstructive pulmonary disease patients into primary care: a pilot study 
BMC Family Practice  2014;15:4.
Background
Changes in reimbursement have been compelling for Dutch primary care practices to apply a disease management approach for patients with chronic obstructive pulmonary disease (COPD). This approach includes individual patient consultations with a practice nurse, who coaches patients in COPD management. The aim of this study was to gauge the feasibility of adding a web-based patient self-management support application, by assessing patients’ self-management, patients’ health status, the impact on the organization of care, and the level of application use and appreciation.
Methods
The study employed a mixed methods design. Six practice nurses recruited COPD patients during a consultation. The e-Health application included a questionnaire that captured information on demographics, self-management related behaviors (smoking cessation, physical activity and medication adherence) and their determinants, and nurse recommendations. The application provided tailored feedback messages to patients and provided the nurse with reports. Data were collected through questionnaires and medical record abstractions at baseline and one year later. Semi-structured interviews with patients and nurses were conducted. Descriptive statistics were calculated for quantitative data and content analysis was used to analyze the qualitative data.
Results
Eleven patients, recruited by three nurses, used the application 1 to 7 times (median 4). Most patients thought that the application supported self-management, but their interest diminished after multiple uses. Impact on patients’ health could not be determined due to the small sample size. Nurses reported benefits for the organization of care and made suggestions to optimize the use of the reports.
Conclusion
Results suggest that it is possible to integrate a web-based COPD self-management application into the current primary care disease management process. The pilot study also revealed opportunities to improve the application and reports, in order to increase technology use and appreciation.
doi:10.1186/1471-2296-15-4
PMCID: PMC3907149  PMID: 24400676
Chronic obstructive pulmonary disease; e-Health intervention; Tailoring; Self-management; Smoking cessation; Physical activity; Medication adherence; Primary care
4.  Pathways of Change Explaining the Effect of Smoke-Free Legislation on Smoking Cessation in the Netherlands. An Application of the International Tobacco Control Conceptual Model 
Nicotine & Tobacco Research  2012;14(12):1474-1482.
Introduction:
This study aims to test the pathways of change from individual exposure to smoke-free legislation on smoking cessation, as hypothesized in the International Tobacco Control (ITC) Conceptual Model.
Methods:
A nationally representative sample of Dutch smokers aged 15 years and older was surveyed during 4 consecutive annual surveys. Of the 1,820 baseline smokers, 1,012 participated in the fourth survey. Structural Equation Modeling was employed to test a model of the effects of individual exposure to smoke-free legislation through policy-specific variables (support for smoke-free legislation and awareness of the harm of [secondhand] smoking) and psychosocial mediators (attitudes, subjective norm, self-efficacy, and intention to quit) on quit attempts and quit success.
Results:
The effect of individual exposure to smoke-free legislation on smoking cessation was mediated by 1 pathway via support for smoke-free legislation, attitudes about quitting, and intention to quit smoking. Exposure to smoke-free legislation also influenced awareness of the harm of (secondhand) smoking, which in turn influenced the subjective norm about quitting. However, only attitudes about quitting were significantly associated with intention to quit smoking, whereas subjective norm and self-efficacy for quitting were not. Intention to quit predicted quit attempts and quit success, and self-efficacy for quitting predicted quit success.
Conclusions:
Our findings support the ITC Conceptual Model, which hypothesized that policies influence smoking cessation through policy-specific variables and psychosocial mediators. Smoke-free legislation may increase smoking cessation, provided that it succeeds in influencing support for the legislation.
doi:10.1093/ntr/nts081
PMCID: PMC3509014  PMID: 22491892
5.  Designing a theory- and evidence-based tailored eHealth rehabilitation aftercare program in Germany and the Netherlands: study protocol 
BMC Public Health  2013;13:1081.
Background
Cardiac rehabilitation programs aim to improve health status and to decrease the risk of further cardiac events. Persons undergoing rehabilitation often have difficulties transferring the learned health behaviors into their daily routine after returning home and maybe to work. This includes physical activity as well as fruit and vegetable consumption. Computer-based tailored interventions have been shown to be effective in increasing physical activity as well as fruit and vegetable consumption. The aim of this study is, to support people in transferring these two learned behavior changes and their antecedents into their daily life after cardiac rehabilitation.
Methods
The study will have a randomized controlled design and will be conducted among German and Dutch people who participated in cardiac rehabilitation. The study will consist of one intervention group which will be compared to a waiting list control group. During the eight week duration of the intervention, participants will be invited to participate in the online after-care program once per week. The intervention encourages participants to define individual health behavior goals as well as action, and coping plans to reach these self-determined goals. The effectiveness of the program will be compared between the intervention condition and the control group in terms of behavior change, antecedents of behavior change (e.g., self-efficacy), ability to return to work and increased well-being. Further, subgroup-differences will be assessed including differences between the two countries, socioeconomic inequalities and across age groups.
Discussion
The present study will make a contribution to understanding how such an online-based tailored interventions enables study participants to adopt and maintain a healthy lifestyle. Implications can include how such an online program could enrich cardiac rehabilitation aftercare further.
Trial registration
NTR 3706, NCT01909349
doi:10.1186/1471-2458-13-1081
PMCID: PMC3840618  PMID: 24245493
Cardiac rehabilitation aftercare; Physical exercise; Fruit and vegetable consumption; Multiple behavior changes; Internet based intervention; Tailored feedback; Cardiovascular diseases
6.  Determinants of binge drinking in a permissive environment: focus group interviews with Dutch adolescents and parents 
BMC Public Health  2013;13:882.
Background
Compared to other European countries, the Netherlands score among the highest of binge drinking rates of 16 to 18 year old adolescents. Dutch adolescents aged 16 are legally allowed to buy and consume low strength alcoholic beverages. This study focused on determinants of binge drinking in such a permissive environment from the perspectives of adolescents and parents.
Methods
Focus group interviews were conducted with adolescents aged 16 to 18 (N = 83), and parents of adolescents from this age group (N = 24). Data was analysed using thematic analyses methods.
Results
Most reasons adolescents mentioned for drinking were to relax, increase a good mood and to be social. Also peers around them influenced and increased adolescents’ drinking. Comparing adolescents and parental statements about their perspectives how alcohol use is handled and accepted by the parents we found that generally, those perspectives match. Parents as well as adolescents stated that alcohol use is accepted by parents. However, when looking at essential details, like the acceptable amounts that children may consume, the perspectives differ enormously. Adolescents think their parents accept any amount of drinking as long as they do not get drunk, whereas parents reported acceptable limits of 1 or 2 glasses every two weeks. Parents further indicated that they felt unsupported by the Dutch policies and regulations of alcohol use. Most of them were in favour of an increase of the legal purchasing age to 18 years.
Conclusions
Parents and adolescents should both be targeted in interventions to reduce alcohol use among adolescents. In particular, communication between parents and children should be improved, in order to avoid misconceptions about acceptable alcohol use. Further, adolescents should be supported to handle difficult social situations with peers where they feel obliged to drink. Additionally, revisions of policies towards a less permissive standpoint are advised to support parents and to impede availability of alcoholic beverages for adolescents/children younger than 18 years.
doi:10.1186/1471-2458-13-882
PMCID: PMC3852358  PMID: 24063544
Alcohol; Adolescents; Binge drinking; Focus group interviews; Parents
7.  Long-term efficacy of a printed or a Web-based tailored physical activity intervention among older adults 
Background
This study provides insight into the long-term efficacy (i.e. 12 month results) of the Web-based or print-delivered tailored Active Plus intervention (with and without environmental approach) to promote physical activity (PA) among the over-fifties. Differences in effect among subgroups are studied as well.
Methods
Intervention groups (i.e. print-delivered basic (PB; N = 439), print-delivered environmental (PE; N = 435), Web-based basic (WB; N = 423), Web-based environmental (WE; N = 432)) and a waiting list control group (N = 411) were studied in a clustered randomized controlled trial. Intervention participants received tailored advice three times within 4 months. Long-term effects (12 months after the intervention has started, i.e. 8 months after the intervention was completed) on PA (i.e. self-reported weekly minutes and days of sufficient PA) were tested using multilevel linear regression analyses. Participants’ age, gender, BMI, educational level, PA intention and the presence of a chronic physical limitation were considered to be potential moderators of the effect.
Results
Overall, the Active Plus intervention was effective in increasing weekly days of sufficient PA (B=0.49; p=.005), but ineffective in increasing weekly minutes of PA (B=84.59; p=.071). Per intervention condition analysis showed that the PB-intervention (Bdays=0.64; p=.002; Bmin=111.36; p=.017) and the PE-intervention (Bdays=0.70; p=.001; Bmin=157.41; p=.001) were effective in increasing days and minutes of PA. Neither Web-based conditions significantly increased PA, while the control group decreased their PA. In contrast to the intervention effect on minutes of PA, the effect on weekly days of PA was significantly moderated by the participants’ baseline intention to be sufficiently physically active.
Conclusions
In general, after 12 months the print-delivered interventions resulted in stronger effects than the Web-based interventions. The participants’ baseline intention was the only significant moderator of the intervention effect. All other assessed user characteristics did not significantly moderate the effect of the intervention, which might indicate that the intervention is sufficiently tailored to the different participant characteristics. Additional efforts should be taken to increase the sustainability of Web-based interventions.
Trial registration
Dutch Trial Register: NTR2297.
doi:10.1186/1479-5868-10-104
PMCID: PMC3766084  PMID: 24228862
Tailored intervention; Physical activity; Effect; Implementation costs; Older adults; Print-delivered; Web-based
8.  The use of a proactive dissemination strategy to optimize reach of an internet-delivered computer tailored lifestyle intervention 
BMC Public Health  2013;13:721.
Background
The use of reactive strategies to disseminate effective Internet-delivered lifestyle interventions restricts their level of reach within the target population. This stresses the need to invest in proactive strategies to offer these interventions to the target population. The present study used a proactive strategy to increase reach of an Internet-delivered multi component computer tailored intervention, by embedding the intervention in an existing online health monitoring system of the Regional Public Health Services in the Netherlands.
Methods
The research population consisted of Dutch adults who were invited to participate in the Adult Health Monitor (N = 96,388) offered by the Regional Public Health Services. This Monitor consisted of an online or a written questionnaire. A prospective design was used to determine levels of reach, by focusing on actual participation in the lifestyle intervention. Furthermore, adequacy of reach among the target group was assessed by composing detailed profiles of intervention users. Participants’ characteristics, like demographics, behavioral and mental health status and quality of life, were included in the model as predictors.
Results
A total of 41,155 (43%) people participated in the Adult Health Monitor, of which 41% (n = 16,940) filled out the online version. More than half of the online participants indicated their interest (n = 9169; 54%) in the computer tailored intervention and 5168 participants (31%) actually participated in the Internet-delivered computer tailored intervention. Males, older respondents and individuals with a higher educational degree were significantly more likely to participate in the intervention. Furthermore, results indicated that especially participants with a relatively healthier lifestyle and a healthy BMI were likely to participate.
Conclusions
With one out of three online Adult Health Monitor participants actually participating in the computer tailored lifestyle intervention, the employed proactive dissemination strategy succeeded in ensuring relatively high levels of reach. Reach among at-risk individuals (e.g. low socioeconomic status and unhealthy lifestyle) was modest. It is therefore essential to further optimize reach by putting additional effort into increasing interest in the lifestyle intervention among at-risk individuals and to encourage them to actually use the intervention.
Trial registration
Dutch Trial Register (NTR1786) and Medical Ethics Committee of Maastricht University and the University Hospital Maastricht (NL2723506809/MEC0903016).
doi:10.1186/1471-2458-13-721
PMCID: PMC3750934  PMID: 23914991
Internet-delivered interventions; Online interventions; Reach; Computer tailoring; Lifestyle; User characteristics; Proactive dissemination
9.  A randomised controlled trial testing a web-based, computer-tailored self-management intervention for people with or at risk for chronic obstructive pulmonary disease: a study protocol 
BMC Public Health  2013;13:557.
Background
Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality. Effective self-management support interventions are needed to improve the health and functional status of people with COPD or at risk for COPD. Computer-tailored technology could be an effective way to provide this support.
Methods/Design
This paper presents the protocol of a randomised controlled trial testing the effectiveness of a web-based, computer-tailored self-management intervention to change health behaviours of people with or at risk for COPD. An intervention group will be compared to a usual care control group, in which the intervention group will receive a web-based, computer-tailored self-management intervention. Participants will be recruited from an online panel and through general practices. Outcomes will be measured at baseline and at 6 months. The primary outcomes will be smoking behaviour, measuring the 7-day point prevalence abstinence and physical activity, measured in minutes. Secondary outcomes will include dyspnoea score, quality of life, stages of change, intention to change behaviour and alternative smoking behaviour measures, including current smoking behaviour, 24-hour point prevalence abstinence, prolonged abstinence, continued abstinence and number of quit attempts.
Discussion
To the best of our knowledge, this will be the first randomised controlled trial to test the effectiveness of a web-based, computer-tailored self-management intervention for people with or at risk for COPD. The results will be important to explore the possible benefits of computer-tailored interventions for the self-management of people with or at risk for COPD and potentially other chronic health conditions.
Dutch trial register
NTR3421
doi:10.1186/1471-2458-13-557
PMCID: PMC3691773  PMID: 23742208
Internet intervention; Tailoring; Randomised controlled trial; Chronic obstructive pulmonary disease; Self-management; Health behaviour; Chronic disease
10.  Predictors of car smoking rules among smokers in France, Germany and the Netherlands 
The European Journal of Public Health  2012;22(Suppl 1):17-22.
Background: As exposure to tobacco smoke pollution (TSP) has been identified as a cause of premature death and disease in non-smokers, and studies have demonstrated that smoking in cars produces high levels of TSP, this study will investigate smokers’ rules for smoking in their cars, and predictors of car smoking rules, including potentially modifiable correlates. Methods: Data were drawn from nationally representative samples of current smokers from the International Tobacco Control Policy Evaluation Project surveys in France (2007), Germany (2007), and the Netherlands (2008). Smokers in France and Germany were asked about smoking rules in their cars, and smokers in the Netherlands were asked about smoking rules in cars carrying children. Results: In France and Germany, 59% and 52% of smokers respectively, allowed smoking in their cars. In the Netherlands, 36% of smokers allowed smoking in cars carrying children. Predictors of allowing smoking in cars included: being a daily vs. non-daily smoker, being younger vs. older age, having no (young) children in the home, being a heavier smoker, and allowing smoking in the home. In the Netherlands, smokers who agreed that TSP is dangerous to non-smokers were less likely to allow smoking in cars carrying children. Conclusion: Overall, a sizeable proportion of smokers allowed smoking in their cars across the three countries. Media campaigns with information about the dangers of TSP may increase the adoption of smoke-free cars. These media campaigns could target smokers who are most likely to allow smoking in cars.
doi:10.1093/eurpub/ckr200
PMCID: PMC3269296  PMID: 22294780
11.  Comparative impact of smoke-free legislation on smoking cessation in three European countries 
Background: Little is known about the differential impact of comprehensive and partial smoke-free legislation on smoking cessation. This study aimed to examine the impact of comprehensive smoke-free workplace legislation in Ireland and England, and partial hospitality industry legislation in the Netherlands on quit attempts and quit success. Methods: Nationally representative samples of 2,219 adult smokers were interviewed in three countries as part of the International Tobacco Control (ITC) Europe Surveys. Quit attempts and quit success were compared between period 1 (in which smoke-free legislation was implemented in Ireland and the Netherlands) and period 2 (in which smoke-free legislation was implemented in England). Results: In Ireland, significantly more smokers attempted to quit smoking in period 1 (50.5%) than in period 2 (36.4%) (p < 0.001). Percentages of quit attempts and quit success did not change significantly between periods in the Netherlands. English smokers were significantly more often successful in their quit attempt in period 2 (47.3%) than in period 1 (26.4%) (p = 0.011). In the first period there were more quit attempts in Ireland than in England and fewer in the Netherlands than in Ireland. Fewer smokers quitted successfully in the second period in both Ireland and the Netherlands than in England. Conclusion: The comprehensive smoke-free legislation in Ireland and England may have had positive effects on quit attempts and quit success respectively. The partial smoke-free legislation in the Netherlands probably had no effect on quit attempts or quit success. Therefore, it is recommended that countries implement comprehensive smoke-free legislation.
doi:10.1093/eurpub/ckr203
PMCID: PMC3451298  PMID: 22294778
12.  A web-based computer-tailored smoking prevention programme for primary school children: intervention design and study protocol 
BMC Public Health  2012;12:277.
Background
Although the number of smokers has declined in the last decade, smoking is still a major health problem among youngsters and adolescents. For this reason, there is a need for effective smoking prevention programmes targeting primary school children. A web-based computer-tailored feedback programme may be an effective intervention to stimulate youngsters not to start smoking, and increase their knowledge about the adverse effects of smoking and their attitudes and self-efficacy regarding non-smoking.
Methods & design
This paper describes the development and evaluation protocol of a web-based out-of-school smoking prevention programme for primary school children (age 10-13 years) entitled ‘Fun without Smokes’. It is a transformation of a postal mailed intervention to a web-based intervention. Besides this transformation the effects of prompts will be examined. This web-based intervention will be evaluated in a 2-year cluster randomised controlled trial (c-RCT) with three study arms. An intervention and intervention + prompt condition will be evaluated for effects on smoking behaviour, compared with a no information control condition. Information about pupils’ smoking status and other factors related to smoking will be obtained using a web-based questionnaire. After completing the questionnaire pupils in both intervention conditions will receive three computer-tailored feedback letters in their personal e-mail box. Attitudes, social influences and self-efficacy expectations will be the content of these personalised feedback letters. Pupils in the intervention + prompt condition will - in addition to the personalised feedback letters - receive e-mail and SMS messages prompting them to revisit the ‘Fun without Smokes’ website. The main outcome measures will be ever smoking and the utilisation of the ‘Fun without Smokes’ website. Measurements will be carried out at baseline, 12 months and 24 months of follow-up.
Discussion
The present study protocol describes the purpose, intervention design and study protocol of ‘Fun without Smokes’. Expectations are that pupils receiving tailored advice will be less likely to smoke after 24 months in contrast to pupils in the control condition. Furthermore, tailored feedback letters and prompting is expected to be more effective than providing tailored feedback letters only.
Trial registration
Dutch Trial Register NTR3116
doi:10.1186/1471-2458-12-277
PMCID: PMC3372447  PMID: 22490110
13.  Effectiveness of a Web-Based Multiple Tailored Smoking Cessation Program: A Randomized Controlled Trial Among Dutch Adult Smokers 
Background
Distributing a multiple computer-tailored smoking cessation intervention through the Internet has several advantages for both provider and receiver. Most important, a large audience of smokers can be reached while a highly individualized and personal form of feedback can be maintained. However, such a smoking cessation program has yet to be developed and implemented in the Netherlands.
Objective
To investigate the effects of a Web-based multiple computer-tailored smoking cessation program on smoking cessation outcomes in a sample of Dutch adult smokers.
Methods
Smokers were recruited from December 2009 to June 2010 by advertising our study in the mass media and on the Internet. Those interested and motivated to quit smoking within 6 months (N = 1123) were randomly assigned to either the experimental (n = 552) or control group (n = 571). Respondents in the experimental group received the fully automated Web-based smoking cessation program, while respondents in the control group received no intervention. After 6 weeks and after 6 months, we assessed the effect of the intervention on self-reported 24-hour point prevalence abstinence, 7-day point prevalence abstinence, and prolonged abstinence using logistic regression analyses.
Results
Of the 1123 respondents, 449 (40.0%) completed the 6-week follow-up questionnaire and 291 (25.9%) completed the 6-month follow-up questionnaire. We used a negative scenario to replace missing values. That is, we considered respondents lost to follow-up to still be smoking. The computer-tailored program appeared to have significantly increased 24-hour point prevalence abstinence (odds ratio [OR] 1.85, 95% confidence interval [CI] 1.30–2.65), 7-day point prevalence abstinence (OR 2.17, 95% CI 1.44–3.27), and prolonged abstinence (OR 1.99, 95% CI 1.28–3.09) rates reported after 6 weeks. After 6 months, however, no intervention effects could be identified. Results from complete-case analyses were similar.
Conclusions
The results presented suggest that the Web-based computer-tailored smoking cessation program had a significant effect on abstinence reported after a 6-week period. At the 6-month follow-up, however, no intervention effects could be identified. This might be explained by the replacement of missing values on the primary outcome measures due to attrition using a negative scenario. While results were similar when using a less conservative scenario (ie, complete-case analyses), the results should still be interpreted with caution. Further research should aim at identifying strategies that will prevent high attrition in the first place and, subsequently, to identify the best strategies for dealing with missing data when studies have high attrition rates.
Trial Registration
Dutch Trial Register NTR1351; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1351 (Archived by WebCite at http://www.webcitation.org/67egSTWrz)
doi:10.2196/jmir.1812
PMCID: PMC3414857  PMID: 22687887
Smoking cessation; Web-based intervention; computer tailoring; iterative feedback; intervention; randomized controlled trial
14.  Trends in socioeconomic inequalities in smoking prevalence, consumption, initiation, and cessation between 2001 and 2008 in the Netherlands. Findings from a national population survey 
BMC Public Health  2012;12:303.
Background
Widening of socioeconomic status (SES) inequalities in smoking prevalence has occurred in several Western countries from the mid 1970’s onwards. However, little is known about a widening of SES inequalities in smoking consumption, initiation and cessation.
Methods
Repeated cross-sectional population surveys from 2001 to 2008 (n ≈ 18,000 per year) were used to examine changes in smoking prevalence, smoking consumption (number of cigarettes per day), initiation ratios (ratio of ever smokers to all respondents), and quit ratios (ratio of former smokers to ever smokers) in the Netherlands. Education level and income level were used as indicators of SES and results were reported separately for men and women.
Results
Lower educated respondents were significantly more likely to be smokers, smoked more cigarettes per day, had higher initiation ratios, and had lower quit ratios than higher educated respondents. Income inequalities were smaller than educational inequalities and were not all significant, but were in the same direction as educational inequalities. Among women, educational inequalities widened significantly between 2001 and 2008 for smoking prevalence, smoking initiation, and smoking cessation. Among low educated women, smoking prevalence remained stable between 2001 and 2008 because both the initiation and quit ratio increased significantly. Among moderate and high educated women, smoking prevalence decreased significantly because initiation ratios remained constant, while quit ratios increased significantly. Among men, educational inequalities widened significantly between 2001 and 2008 for smoking consumption only.
Conclusions
While inequalities in smoking prevalence were stable among Dutch men, they increased among women, due to widening inequalities in both smoking cessation and initiation. Both components should be addressed in equity-oriented tobacco control policies.
doi:10.1186/1471-2458-12-303
PMCID: PMC3356226  PMID: 22537139
Netherlands; Smoking; Social class; Trends
15.  Are the stages of change relevant for the development and implementation of a web-based tailored alcohol intervention? A cross-sectional study 
BMC Public Health  2012;12:360.
Background
Computer-tailored programs are a promising tool to stimulate health behavior change, such as reducing alcohol intake. Yet more research is needed to assess whether groups differing in their motivational level to change may need different types of feedback. Furthermore, it is unknown whether motivational level may also determine reactions to computer-tailored interventions. Our aim is to identify the potential relevance of the application of the stages of change concept in the development and implementation of alcohol interventions.
Methods
A web-based instrument was used to disseminate a questionnaire and to provide tailored feedback messages among adults in the Netherlands (N = 170; 96 females). Motivational level was assessed by the stage of change construct. The survey furthermore assessed alcohol consumption, attitude, social influence, self-efficacy, and program evaluation (i.e., survey items, tailored advice, layout and functionality of the program). The Least Significant Difference method was used to compare people in different stages of change with regard to psychosocial determinants of drinking behavior and program evaluation.
Results
Of the respondents, 34.1% (n = 58) reported no intention to change to healthier drinking habits in the foreseeable future (precontemplation), 22.9% (n = 39) intended to improve their drinking behavior in the near future (contemplation/preparation) and 42.9% (n = 73) reported to currently adhere to the Dutch alcohol consumption guidelines (action/maintenance). When comparing the three groups, people in the action or maintenance stage reported the lowest number of pros of drinking alcohol, having most healthy drinking role models and the highest levels of self-efficacy regarding healthy drinking in difficult situations, whereas precontemplators reported to receive the least social support regarding healthy drinking. In general, the intervention was positively evaluated, but it seemed to be most appreciated by contemplators and preparers.
Conclusions
Stage-matched interventions may be useful to encourage people to reduce their alcohol intake. Different factors seem to be important for people in different motivational stages. Longitudinal studies are needed to determine whether these factors also predict stage transition. The intervention could be optimized by tailoring the feedback messages more precisely to the needs of people in different motivational stages, for example by applying the different processes of change.
doi:10.1186/1471-2458-12-360
PMCID: PMC3487757  PMID: 22594949
16.  Effectiveness of two intensive treatment methods for smoking cessation and relapse prevention in patients with coronary heart disease: study protocol and baseline description 
Background
There is no more effective intervention for secondary prevention of coronary heart disease than smoking cessation. Yet, evidence about the (cost-)effectiveness of smoking cessation treatment methods for cardiac inpatients that also suit nursing practice is scarce. This protocol describes the design of a study on the (cost-)effectiveness of two intensive smoking cessation interventions for hospitalised cardiac patients as well as first results on the inclusion rates and the characteristics of the study population.
Methods/design
An experimental study design is used in eight cardiac wards of hospitals throughout the Netherlands to assess the (cost-)effectiveness of two intensive smoking cessation counselling methods both combined with nicotine replacement therapy. Randomization is conducted at the ward level (cross-over). Baseline and follow-up measurements after six and 12 months are obtained. Upon admission to the cardiac ward, nurses assess patients’ smoking behaviour, ensure a quit advice and subsequently refer patients for either telephone counselling or face-to-face counselling. The counselling interventions have a comparable structure and content but differ in provider and delivery method, and in duration. Both counselling interventions are compared with a control group receiving no additional treatment beyond the usual care. Between December 2009 and June 2011, 245 cardiac patients who smoked prior to hospitalisation were included in the usual care group, 223 in the telephone counselling group and 157 in the face-to-face counselling group. Patients are predominantly male and have a mean age of 57 years. Acute coronary syndrome is the most frequently reported admission diagnosis. The ultimate goal of the study is to assess the effects of the interventions on smoking abstinence and their cost-effectiveness. Telephone counselling is expected to be more (cost-)effective in highly motivated patients and patients with high SES, whereas face-to-face counselling is expected to be more (cost-)effective in less motivated patients and patients with low SES.
Discussion
This study examines two intensive smoking cessation interventions for cardiac patients using a multi-centre trial with eight cardiac wards. Although not all eligible patients could be included and the distribution of patients is skewed in the different groups, the results will be able to provide valuable insight into effects and costs of counselling interventions varying in delivery mode and intensity, also concerning subgroups.
Trial registration
Dutch Trial Register NTR2144
doi:10.1186/1471-2261-12-33
PMCID: PMC3459718  PMID: 22587684
Coronary heart disease; Smoking cessation; Face-to-face counselling; Telephone counselling; Nicotine replacement therapy; Cost-effectiveness study
17.  Internet-Based Computer Tailored Feedback on Sunscreen Use 
Background
Skin cancer incidence rates signify the need for effective programs for the prevention of skin cancer and for helping skin cancer patients. Internet and computer tailored (CT) technology fosters the development of highly individualized health communication messages. Yet, reactions to Internet CT programs may differ per level of involvement and education level and remain understudied.
Objective
First, we identified perceptions concerning sunscreen use in Dutch adults and assessed differences in differences between the general public and skin cancer patients, and between low and high educated respondents. Second, we assessed program evaluations of these groups about a new Dutch CT Internet-based program promoting sunscreen use, and potential differences between groups
Methods
A cross-sectional research design was used. In total, 387 respondents participated and filled out an online questionnaire based on the I-Change Model assessing socio-demographics, history of skin cancer, sunscreen use, and beliefs about sunscreen use. The responses were fed into a computer program that generated personal tailored feedback on screen; next we assessed their program evaluations
Results
Of the 132 patients, 92 were female (69.7%) and 40 were male (30.3%). In the general population (N = 225), 139 (54.5%) respondents were female and 116 (45.5%) were male. Men (50.9 years) were 8 years older than women (43.1 years). Most patients were diagnosed with basal cell carcinoma (N = 65; 49.2%), followed by melanoma (N = 28; 21.2%) and squamous cell carcinoma (N = 10; 7.6%); 22% (N = 29) did not remember their skin cancer type. Patients had higher knowledge levels, felt significantly more at risk, were more convinced of the pros of sunscreen, experienced more social support to use sunscreen, had higher self-efficacy, and made more plans to use sunscreen than respondents without skin cancer (N=255; all P’s< .01). Low (N=196) educated respondents scored lower on knowledge (P<.003) but made more action plans (P<.03) than higher educated respondents (N=191). The CT feedback was evaluated positively by all respondents, and scored a 7.8 on a 10 point scale. Yet, patients evaluated the CT program slightly more (P<.05) positive (8.1) than non-patients. (7.6). Lower educated respondents were significantly (P<.05) more positive about the advantages of the program.
Conclusions
First, involvement with skin cancer was reflected in more positive beliefs toward sunscreen use in patients in comparison with non-patients. Second, the CT Internet program was well accepted by both patients and non-patients, and low and high educated respondents, perhaps because higher educated respondents were more knowledgeable about sunscreen use and skin cancer. Third, a pro-active approach as conducted in our study is very well suited to reach various groups of people and is more likely to be successful than a reactive approach
doi:10.2196/jmir.1902
PMCID: PMC3376524  PMID: 22547528
Health communication, Computer tailoring; Web-based interventions, Internet
18.  Identifying Factors for Optimal Development of Health-Related Websites: A Delphi Study Among Experts and Potential Future Users 
Background
The Internet has become a popular medium for offering tailored and targeted health promotion programs to the general public. However, suboptimal levels of program use in the target population limit the public health impact of these programs. Optimizing program development is considered as one of the main processes to increase usage rates.
Objective
To distinguish factors potentially related to optimal development of health-related websites by involving both experts and potential users. By considering and incorporating the opinions of experts and potential users in the development process, involvement in the program is expected to increase, consequently resulting in increased appreciation, lower levels of attrition, and higher levels of sustained use.
Methods
We conducted a systematic three-round Delphi study through the Internet. Both national and international experts (from the fields of health promotion, health psychology, e-communication, and technical Web design) and potential users were invited via email to participate. During this study an extensive list of factors potentially related to optimal development of health-related websites was identified, by focusing on factors related to layout, general and risk information provision, questionnaire use, additional services, and ease of use. Furthermore, we assessed the extent to which experts and potential users agreed on the importance of these factors. Differences as well as similarities among experts and potentials users were deduced.
Results
In total, 20 of 62 contacted experts participated in the first round (32% response rate); 60 of 200 contacted experts (30% response rate) and 210 potential users (95% response rate) completed the second-round questionnaire, and 32 of 60 contacted experts completed the third round (53% response rate). Results revealed important factors consented upon by experts and potential users (eg, ease of use, clear structure, and detailed health information provision), as well as differences regarding important factors consented upon by experts (eg, visual aids, self-monitoring tool, and iterative health feedback) or by potential users only (eg, bread crumb navigation and prevention of receiving spam).
Conclusions
This study is an important first step in determining the agreed-upon factors that should be taken into account when developing online health promotion programs. The public health impact of these programs will be improved by optimizing the development process in line with these factors.
doi:10.2196/jmir.1863
PMCID: PMC3374541  PMID: 22357411
Health promotion; Internet interventions; health behavior change; optimal development; Delphi study; experts; users
19.  Knowledge, attitudes and preferences regarding genetic testing for smoking cessation. A cross-sectional survey among Dutch smokers 
BMJ Open  2012;2(1):e000321.
Objectives
Recent research strongly suggests that genetic variation influences smokers' ability to stop. Therefore, the use of (pharmaco) genetic testing may increase cessation rates. This study aims to assess the intention of smokers concerning undergoing genetic testing for smoking cessation and their knowledge, attitudes and preferences about this subject.
Design
Online cross-sectional survey.
Setting
Database internet research company of which every inhabitant of the Netherlands of ≥12 years with an email address and capable of understanding Dutch can become a member.
Participants
587 of 711 Dutch smokers aged ≥18 years, daily smokers for ≥5 years and smoke on average ≥10 cigarettes/day (response rate=83%).
Primary and secondary outcome measures
Smokers' knowledge, attitudes and preferences and their intention to undergo genetic testing for smoking cessation.
Results
Knowledge on the influence of genetic factors in smoking addiction and cessation was found to be low. Smokers underestimated their chances of having a genetic predisposition and the influence of this on smoking cessation. Participants perceived few disadvantages, some advantages and showed moderate self-efficacy towards undergoing a genetic test and dealing with the results. Smokers were mildly interested in receiving information and participating in genetic testing, especially when offered by their general practitioner (GP).
Conclusions
For successful implementation of genetic testing for smoking in general practice, several issues should be addressed, such as the knowledge on smoking cessation, genetics and genetic testing (including advantages and disadvantages) and the influence of genetics on smoking addiction and cessation. Furthermore, smokers allocate their GPs a crucial role in the provision of information and the delivery of a genetic test for smoking; however, it is unclear whether GPs will be able and willing to take on this role.
Article summary
Article focus
Intention of smokers to undergo genetic testing for smoking cessation.
Smokers' knowledge, attitudes and preferences regarding genetic testing for smoking.
To aid decisions on the most appropriate strategies for counselling patients and communicating their test results with regard to a genetic test for smoking.
Key messages
Smokers are mildly interested in receiving more information and participating in genetic testing for smoking cessation, especially when offered by their general practitioner.
Knowledge on smoking cessation, genetics and genetic testing (including advantages and disadvantages) and the influence of genetics on smoking cessation is low.
Strengths and limitations of this study
This study provides valuable information on the needs and attitudes of smokers regarding genetic testing for smoking cessation, which can aid decisions for future implementation.
Under-representation smokers intending to stop smoking might have led to an underestimation of smokers interested in genetic testing.
Low knowledge level on genetic testing for smoking cessation and genetics in general might have influenced participants' ability to answer the questions.
Interest in undergoing genetic testing may reflect a generally positive attitude towards genetic testing rather than actual uptake.
Selection bias might have occurred due to the non-representative nature of the internet population and the self-selection of participants (volunteer effect); however, unlikely due to high response rate (83%).
doi:10.1136/bmjopen-2011-000321
PMCID: PMC3253420  PMID: 22223839
Nicotine dependence; smoking cessation; (pharmaco) genetic testing; knowledge; attitudes; preferences; pharmacogenetics; smoking
20.  Study protocol of a Dutch smoking cessation e-health program 
BMC Public Health  2011;11:847.
Background
The study aims to test the differential effects of a web-based text and a web-based video-driven computer-tailored approach for lower socio-economic status (LSES) and higher socio-economic status (HSES) smokers which incorporate multiple computer-tailored feedback moments. The two programs differ only in the mode of delivery (video- versus text-based messages). The paper aims to describe the development and design of the two computer-tailored programs.
Methods/design
Respondents who smoked at the time of the study inclusion, who were motivated to quit within the following six months and who were aged 18 or older were included in the program. The study is a randomized control trial with a 2 (video/text) * 2(LSES/HSES) design. Respondents were assigned either to one of the intervention groups (text versus video tailored feedback) or to the control group (non-tailored generic advice). In all three conditions participants were asked to fill in the baseline questionnaire based on the I-Change model. The questionnaire assessed socio-demographics, attitude towards smoking, knowledge, self-efficacy, social influence, depression, level of addiction, action planning, goal actions, intention to quit smoking, seven-day point prevalence and continued abstinence. Follow-up measurements were conducted at six and twelve months after baseline.
Discussion
The present paper describes the development of the two computer-tailored smoking cessation programs, their components and the design of the study. The study results reveal different working mechanisms of multiple tailored smoking cessation interventions and will help us to gain more insight into effective strategies to target different subgroups, especially smokers with a lower socio-economic status.
Trial registration
Dutch Trial Register NTR3102
doi:10.1186/1471-2458-11-847
PMCID: PMC3220643  PMID: 22059446
21.  Optimizing diffusion of an online computer tailored lifestyle program: a study protocol 
BMC Public Health  2011;11:480.
Background
Although the Internet is a promising medium to offer lifestyle interventions to large amounts of people at relatively low costs and effort, actual exposure rates of these interventions fail to meet the high expectations. Since public health impact of interventions is determined by intervention efficacy and level of exposure to the intervention, it is imperative to put effort in optimal dissemination. The present project attempts to optimize the dissemination process of a new online computer tailored generic lifestyle program by carefully studying the adoption process and developing a strategy to achieve sustained use of the program.
Methods/Design
A prospective study will be conducted to yield relevant information concerning the adoption process by studying the level of adoption of the program, determinants involved in adoption and characteristics of adopters and non-adopters as well as satisfied and unsatisfied users. Furthermore, a randomized control trial will be conducted to the test the effectiveness of a proactive strategy using periodic e-mail prompts in optimizing sustained use of the new program.
Discussion
Closely mapping the adoption process will gain insight in characteristics of adopters and non-adopters and satisfied and unsatisfied users. This insight can be used to further optimize the program by making it more suitable for a wider range of users, or to develop adjusted interventions to attract subgroups of users that are not reached or satisfied with the initial intervention. Furthermore, by studying the effect of a proactive strategy using period prompts compared to a reactive strategy to stimulate sustained use of the intervention and, possibly, behaviour change, specific recommendations on the use and the application of prompts in online lifestyle interventions can be developed.
Trial registration
Dutch Trial Register NTR1786 and Medical Ethics Committee of Maastricht University and the University Hospital Maastricht (NL2723506809/MEC0903016).
doi:10.1186/1471-2458-11-480
PMCID: PMC3130675  PMID: 21689412
22.  Testing a Dutch web-based tailored lifestyle programme among adults: a study protocol 
BMC Public Health  2011;11:108.
Background
Smoking, high alcohol consumption, unhealthy eating habits and physical inactivity often lead to (chronic) diseases, such as cardiovascular diseases and cancer. Tailored online interventions have been proven to be effective in changing health behaviours. The aim of this study is to test and compare the effectiveness of two different tailoring strategies for changing lifestyle compared to a control group using a multiple health behaviour web-based approach.
Methods
In our Internet-based tailored programme, the five lifestyle behaviours of smoking, alcohol intake, fruit consumption, vegetable consumption, and physical activity are addressed. This randomized controlled trial, conducted among Dutch adults, includes two experimental groups (i.e., a sequential behaviour tailoring condition and a simultaneous behaviour tailoring condition) and a control group. People in the sequential behaviour tailoring condition obtain feedback on whether their lifestyle behaviours meet the Dutch recommendations. Using a step-by-step approach, they are stimulated to continue with a computer tailored module to change only one unhealthy behaviour first. In the course of the study, they can proceed to change a second behaviour. People in the simultaneous behaviour tailoring condition receive computer tailored feedback about all their unhealthy behaviours during their first visit as a stimulation to change all unhealthy behaviours. The experimental groups can re-visit the website and can then receive ipsative feedback (i.e., current scores are compared to previous scores in order to give feedback about potential changes). The (difference in) effectiveness of the different versions of the programme will be tested and compared to a control group, in which respondents only receive a short health risk appraisal. Programme evaluations will assess satisfaction with and appreciation and personal relevance of the intervention among the respondents. Finally, potential subgroup differences pertaining to gender, age and socioeconomic status regarding the behaviour effects and programme evaluation will be assessed.
Discussion
Research regarding multiple behaviour change is in its infancy. We study how to offer multiple behaviour change interventions optimally. Using these results could strengthen the effectiveness of web-based computer-tailoring lifestyle programmes. This study will yield new results about the need for differential lifestyle approaches using Internet-based expert systems and potential differences in subgroups concerning the effectiveness and appreciation.
Trial registration
Dutch Trial Register NTR2168.
doi:10.1186/1471-2458-11-108
PMCID: PMC3050747  PMID: 21324181
24.  Validation of smoking cessation self-reported by patients with chronic obstructive pulmonary disease 
Purpose
The present study reports on the biochemical validation of the self-reported smoking status of patients with chronic obstructive pulmonary disease (COPD). The objective is to establish the proportion of overestimation of self-reported success rates.
Methods
A cross-sectional smoking-status validation study including 60 patients with COPD who reported that they had stopped smoking. In the analysis of urine samples, a cut-off point of 50 ng/mL of cotinine was used.
Results
At the time of biochemical validation, 55 patients reported that they had quit smoking while five patients resumed smoking. Smoking status was biochemically confirmed for 43 patients (78%) and 12 patients (22%) were classified as smokers. The sensitivity of the self- report of smoking was 29% and the specificity was 100%.
Conclusion
Many primary care patients with COPD do not provide valid information on their smoking status, which hamper adequate therapeutic interventions. Integration of biochemical validation in daily care could overcome this problem, but may harm the doctor–patient relationship.
doi:10.2147/IJGM.S15231
PMCID: PMC3048344  PMID: 21403797
chronic obstructive pulmonary disease; smoking cessation; biochemical validation; general practice; outcome measurement
25.  Tailored Print Communication and Telephone Motivational Interviewing Are Equally Successful in Improving Multiple Lifestyle Behaviors in a Randomized Controlled Trial 
Annals of Behavioral Medicine  2010;41(1):104-118.
Background
Computer tailoring and motivational interviewing show promise in promoting lifestyle change, despite few head-to-head comparative studies.
Purpose
Vitalum is a randomized controlled trial in which the efficacy of these methods was compared in changing physical activity and fruit and vegetable consumption in middle-aged Dutch adults.
Methods
Participants (n = 1,629) were recruited via 23 general practices and randomly received either four tailored print letters, four motivational telephone calls, two of each type of intervention, or no information. The primary outcomes were absolute change in self-reported physical activity and fruit and vegetable consumption.
Results
All three intervention groups (i.e., the tailored letters, the motivational calls, and the combined version) were equally and significantly more effective than the control group in increasing physical activity (hours/day), intake of fruit (servings/day), and consumption of vegetables (grams/day) from baseline to the intermediate measurement (week 25), follow-up 1 (week 47) and 2 (week 73). Effect sizes (Cohen’s d) ranged from 0.15 to 0.18. Participants rated the interventions positively; interviews were more positively evaluated than letters.
Conclusions
Tailored print communication and telephone motivational interviewing or their combination are equally successful in changing multiple behaviors.
Electronic supplementary material
The online version of this article (doi:10.1007/s12160-010-9231-3) contains supplementary material, which is available to authorized users.
doi:10.1007/s12160-010-9231-3
PMCID: PMC3030742  PMID: 20878293
Fruit and vegetable consumption; Physical activity; Motivational interviewing; Computer tailoring; Pedometer

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