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Web Based Programs for Smokeless Tobacco Cessation
Herb Severson, Ph.D.Oregon Research InstituteEugene, Oregon
Tobacco Production in Wisconsin in Acres
1960 1965 1970 1975 1980 1985 1990 1995 2000 20030
2000
4000
6000
8000
10000
12000
14000
16000
National Agriculture Statistics Services: National Department of Agriculture
Use of Internet
70% of Americans use Internet – 48% are active users
Broadband in home – 103 million Access is 52% of rural areas
Web-based Health Behavior Change
Positive outcome for managing Depression Diabetes Weight loss & physical activity
Why Web-based Cessation for ST Users?
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
Web-based Tobacco Cessation
Smoking Cessation QuitNet Free & Clear American Cancer Society
Other smoking cessation efficacy studies 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
What Did We Learn About Web-based Cessation?
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
Key Features in Successful Web-based Health Behavior Programs
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
CHEWFREE.COM
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
FeatureEnhanced Condition
Basic Condition
SLT Cessation Behavior Change Content
x x
SLT Health Information x xLinks to outside Websites x xVideo Testimonials xGuided Path for Accessing Content †
x
Web Forums for Support xTailored E-mail Reminders 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.
Comparison of Enhanced & Basic Conditions forChewFree.com
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:
1,260
Randomized to Control:
1,263
Participant Enrollment
Measures of Program Exposure
Email Prompts Percentage of participants sent treatment-related email prompts
Participant visits Number of visits
Aggregate duration of visits
Number of daily visits post-enrollment
Number of days of program access post-enrollment
Web page views Overall number of Web page views
Specific Web page views (selected smokeless tobacco cessation content)
Web forum postings
Visit Details by Participant
Visits by Participant*Overall Visits Duration by Participant*(min)
Condition N Median Interquartile Range
Median Interquartile Range
Enhanced 1,200 2.00 3 (1-4) 28.99 37.75(13.60-51.35)
Basic 1,175 1.00 1 (1-2) 12.50 15.83(6.60-22.43)
*P<.001
3 MonthNo. (%)
6 MonthNo. (%)
3 & 6 MonthNo. (%)
Responders
Enhanced Condition
30.7† 28.5† 21.8†
Basic Condition 19.5 20.3 12.6
Intent-to-Treat
Enhanced Condition 19.0† 16.0 ‡ 11.8†
Basic Condition 13.4 11.7 7.5Enhanced and Basic conditions significantly different:† p < .001; ‡ p = .001, * p < .01
Tobacco Abstinence at Follow-up Assessments for ChewFree.com
Web Page Viewing by Participants Who Accessed at Least One Web Page Containing Smokeless Tobacco Cessation Content
Condition 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
ConditionVideo
Testimonial (%)
List of Support
People (%)
Set Quit Date (%)
Staying Quit Content After Quitting (%)
Enhanced 68.2 24.7 63.3 32.8
Web Forum Activity in the Enhanced Condition (N=1,260 users)
Users Posting by User
Forum Type N % Median Interquartile Range
Peer 481 38.2 2 481
Expert 65 5.2 1 65
Summary - CHEWFREE.COM
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
Teen ST Cessation Research 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
MyLastDip.com Project
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.
Design for MyLastDip.com ProjectRecruit 1,500 ST
UsersAge 15 - 25
Screen
Consent
Baseline
Randomize
Interactive Web Site
6 week Follow Up
6 Month Follow Up
Static Information Web Site
6 week Follow Up
6 Month Follow Up
Inclusion Criteria – MyLastDip.com
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
My Plan
QuittingGetting Ready
MyLastDip.com: Program Content
• Intro• Method• Quit Date•Set Stage•Personal Contract•Do It!
MyLastDip.com: Program Content
• Intro• Remember Reasons• Get Support• Manage Mood• Avoid Traps• Use Substitutes• Reward Progress • Peer-to-Peer
• Ask the Expert
Staying Quit
Retooling
Blogs
MyLastDip.com: Program Content
• 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
Resources
Getting Ready
MyLastDip.com: Program Content
• 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
Resources
• Intro• Remember Reasons• Get Support• Manage Mood• Avoid Traps• Use Substitutes• Reward Progress
• Peer-to-Peer• Ask the Expert
Staying Quit
Retooling
Blogs
My Plan
Quitting
• Intro• Method• Quit Date•Set Stage•Personal Contract•Do It!
MyLastDip Enrollment by MonthN
ovem
ber
2008
Janu
ary
20
09
Apr
il
2009
June
2009
Aug
ust
2
009
Average recruits per week = 12
28
24
20
16
12
8
4
0
Co
un
t o
f U
sers
Table 1. Participant Characteristics
Age M =20.85
Caucasian 92.38%
Gender 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%
MyLast Dip
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.