Web Based Programs for
Smokeless Tobacco Cessation
Herb Severson, Ph.D.
Oregon Research Institute
Eugene, Oregon
16000
14000
12000
10000
8000
6000
4000
2000
0
1960 1965 1970 1975 1980 1985 1990 1995 2000 2003
National Agriculture Statistics Services: National Department of Agriculture
 70% of Americans use Internet – 48% are active
users
 Broadband in home – 103 million
 Access is 52% of rural areas
 Positive outcome for managing
 Depression
 Diabetes
 Weight loss & physical activity
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Most ST users are in rural areas
Few seek cessation services
Web-based can reach users 24/7
Highest ST use in 18 – 24 age group
Previous studies show self-help quitting works
for ST
 Smoking Cessation
 QuitNet
 Free & Clear
 American Cancer Society
 Other smoking cessation efficacy studies
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Feil et al., 2003
McKay et al., 2008
Stoddard, 2005
Etter, 2005
Lenert et al., 2004
Brendryen et al 2008
Swartz et al., 2006
Strecher et al., 2005 & 2008
Munoz et al., 2006 & 2009
 Many studies had brief follow-up (1 – 2 months)
 Most all had positive results
 Some were supplemented by counseling calls
and nicotine replacement
 Most participants spend little time on the site –
However, positive relations between exposure
and outcome
 Tailored presentation of intervention to match
user interests
 Tracking and displaying users progress over
time
 Users set there own pace and access all parts of
program
 Enable access to virtual community of users and
support from others and experts
 Randomized Clinical trial for ST Cessation with
Adults
 Participants enroll and are randomized to tailored &
non-tailored condition
 Tailored has a Personal Quit Assistant (PQA) and
person develops a Plan for quitting and uses the
program to stay quit (relapse prevention)
 All participants get help in quitting
 Follow-up at 6-weeks, 6-months, and one year
Feature
SLT Cessation Behavior Change
Content
SLT Health Information
Links to outside Websites
Video Testimonials
Guided Path for Accessing
Content †
Web Forums for Support
Tailored E-mail Reminders
†
Enhanced
Condition
x
Basic
Condition
x
x
x
x
x
x
x
x
x
The Enhanced condition used a hybrid approach that combined a guided path (tunnel design) with unrestricted
access to website content (matrix design) while the Basic Condition used primarily a matrix design.
Total hits at Chewfree.com
login page:
59,545
Total hits from unique IP
addresses:
21,945
Total number starting screening
process:
5,756
Total number randomized:
2,423
Randomized to
Experimental:
Randomized to
Control:
1,260
1,263
Email Prompts
Percentage of participants sent treatmentrelated email prompts
Participant visits
Number of visits
Aggregate duration of visits
Number of daily visits post-enrollment
Number of days of program access postenrollment
Web page views
Overall number of Web page views
Specific Web page views (selected
smokeless tobacco cessation content)
Web forum postings
Visits by Participant*
Condition
N
Enhanced
1,200
2.00
Basic
1,175
1.00
*P<.001
Median Interquartile
Range
Overall Visits Duration by
Participant*(min)
Median
Interquartile
Range
3 (1-4)
28.99
37.75
(13.60-51.35)
1 (1-2)
12.50
15.83
(6.60-22.43)
3 Month
No. (%)
6 Month
No. (%)
3 & 6 Month
No. (%)
Enhanced Condition
30.7†
28.5†
21.8†
Basic Condition
19.5
20.3
12.6
Enhanced Condition
19.0†
16.0 ‡
11.8†
Basic Condition
13.4
11.7
7.5
Responders
Intent-to-Treat
Enhanced and Basic conditions significantly different:
† p < .001; ‡ p = .001, * p < .01
N
Outside
Links (%)
Print
Content (%)
ST Quitting
Guide (%)
Enhanced
1,200
18.2
78.3
12.2
Basic
1,175
32.1
96.3
87.5
Condition
Video
Testimonial
(%)
List of
Support
People (%)
Set Quit
Date (%)
Staying Quit
Content After
Quitting (%)
Enhanced
68.2
24.7
63.3
32.8
Condition
Users
Forum Type
Posting by User
N
%
Median
Interquartile
Range
Peer
481
38.2
2
481
Expert
65
5.2
1
65
 Very cost effective (after development)
 Minimizes need for professional -demonstrates comparable results to
other self-help cessation programs for ST
users
 Assistance is available 24 hours per day
 Can reach remote subjects
 Could supplement other interventions
 Eakin et al, 1989
 3 sessions group treatment
 36% abstinence at end of treatment
 16% quit at 3 month
 Walsh et al, 2000
 Group treatment of baseball players in high school, self-quit guide,
dental exam, brief counseling
 27% cessation for treatment
 14% for control
 Chakravorty – n=83; age 14 – 18
 Nicotine gum vs mint snuff vs lecture only
 Two treatment groups = 37% abstinence
 Stotts et al, 2003
 Nicotine patch plus counseling = 32% abstinence but no difference
in active and placebo patches
 Targets ST users aged 14 – 25
 Compares two web sites
 Interactive, targeted and tailored with social support
via blogs
 Generic, static, information only site
 Evaluate the efficacy of the web-based cesstion
program with 1500 ST users randomized to two
web sites- Tailored vs Text based sites at 6
months post enrollment.
Recruit 1,500 ST
Users
Age 15 - 25
Screen
Consent
Baseline
Randomize
Interactive
Web Site
Static Information
Web Site
6 week Follow Up
6 week Follow Up
6 Month Follow Up
6 Month Follow Up
 Current use of snuff or chewing tobacco
 Provide consent
 U.S. or Canadian resident between 15 – 25
years old
 Have used ST products for a year
 Use at least one tin or pouch per week
 Interested in quitting
 Able to read English
 Use email at least once per week
 Willing to provide phone, email, & address
Getting
Ready
Quitting
• Intro
• Method
• Quit Date
•Set Stage
•Personal Contract
•Do It!
My Plan
• Intro
• Remember Reasons
• Get Support
• Manage Mood
• Avoid Traps
• Use Substitutes
• Reward Progress
Retooling
Staying
Quit
Blogs
• Peer-to-Peer
• Ask the Expert
Resources
• What is Smokeless Tobacco?
• What is nicotine?
• History of Smokeless Tobacco?
• Who uses Smokeless Tobacco?
•Health Effects of Smokeless Tobacco?
•Nicotine replacement products
•Prescription meds for quitting smoking
•Fake chew or herbal snuff
•Links to other websites
•Relaxation skills
Getting
Ready
Quitting
• Intro
• Method
• Quit Date
•Set Stage
•Personal Contract
•Do It!
• Intro
• Remember Reasons
• Get Support
• Manage Mood
• Avoid Traps
• Use Substitutes
• Reward Progress
Staying
Quit
Blogs
• Peer-to-Peer
• Ask the Expert
Resources
Retooling
My Plan
• What is Smokeless Tobacco?
• What is nicotine?
• History of Smokeless Tobacco?
• Who uses Smokeless Tobacco?
•Health Effects of Smokeless Tobacco?
•Nicotine replacement products
•Prescription meds for quitting smoking
•Fake chew or herbal snuff
•Links to other websites
•Relaxation skills
28
Count of Users
24
20
16
12
8
4
0
Average recruits per week = 12
Table 1. Participant Characteristics
Age
Caucasian
Gender
M =20.85
92.38%
97% male
Days a tin lasts
2.12
Years as a regular chewers
4.66
Use chew < 30 minutes after waking
33%
Ready to quit (11 pt scale: 0 = not ready; 10=
ready)
2.88
Current smoker
12%
 How can you help?
 Recruiting young patients who use ST to use the web
site for assisting them to quit.
 Distribute flyers about the MLD program to patients
 Tell young adult patients between the ages of 14 and
25 about the MLD site as a resource for quitting.
 Web based cessation programs for ST are
efficacious
 Cessation rates for self help programs are
similar to clinical interventions
 We need to provide ST users with a variety of
options fo supporting their quitting on their own