Web Based Programs for Smokeless Tobacco Cessation

Herb Severson, Ph.D.Oregon Research InstituteEugene, Oregon

Growing Tobacco in Wisconsin

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

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

Basic Condition

Enhanced Condition

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 visitsAggregate duration of visitsNumber of daily visits post-enrollmentNumber of days of program access post-enrollment

Web page views Overall number of Web page viewsSpecific 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 12.6Intent-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: Get ReadyRemember Reasons - Health

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: QuittingMy Quit Date: September 17, 2009

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

MyLastDip.com: Blogs

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 MonthNo

vem

ber

2008

Janu

ary

20

09

April

2009

June

20

09

Augu

st

2

009

Average recruits per week = 12

28

24

20

16

12

8

4

0

Cou

nt o

f Use

rs

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.

Summary 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