Teen Smoking Cessation Websites

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Teen Smoking Cessation Websites
Scott McIntosh, Molly McNulty, Sheri Kardooni,
Leslie Hazel-Fernandez University of Rochester
Presented at the Web Assisted Tobacco
Intervention workshop, Toronto, Ontario January
18, 2004.
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• Content of Teen Smoking Sites
• There is very little literature on efficacy of
  any methods to help teens quit smoking from any
  particular medium. Therein lies the challenge of
  finding the content for web-based
  interventions.
• A Better Practices approach is to start with
  the evidence-base from other target populations.
• Smoking cessation in adults
• Web assisted interventions Available as evidence
  develops
• Manuals ? translated to Webpages (static or
  interactive)
• Telephone Quitlines ? methods translated
  (chatting / voice)
• Other risk-behavior change in teens
• (e.g., some evidence-base with websites for high
  risk sex behavior)
• Computer program in physician offices (Hollis, et
  al.)
• Peer Counseling in physician offices (Pbert, et
  al.)

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• Usability Issues
• Like content there is very little evidence in
  the literature for usability factors with
  teens. Must start with other sources of
  information on what impacts teens 1) market
  research, and 2) techniques targeted
  (developmentally) to adolescent preferences (ala
  successful tobacco company strategies).
• Teens are one of the biggest markets in the U.S.
• There is much literature on what attracts teens,
  and keeps their attention so they can be SOLD
  something.
• Websites designed by MARKETERS are relying on
  this evidence base but smoking teens are a
  sub-group, so different engagement via web-design
  issues may need consideration.
• DISCUSSION Smoking Teens will be actively
  seeking health related information when surfing
  for (or referred to) cessation sites. This type
  of surfing is motivationally different than
  surfing for entertainment, or surfing in
  reaction to marketing tactics. Nevertheless,
  those tactics can teach us a lot as we develop
  web-based interventions

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Workshop Topic for Discussion 9 Tips for
Web-Marketing to Teens 1) TEENS CHANGE AND
DEVELOP QUICKLY SO SEGMENT APPROPRIATELY
This is a basic marketing don't segment based
on simple demographics - segment based on
benefits that customers care about. In this case,
the customer cares about quitting smoking, not
about being entertained or sold something. 2)
GIVE THEM A PLACE TO BE HEARD Consider a
"comment board" to let them provide feedback to
the site and to each other, or an on-line poll
'Jam it or Can it?' Don't try to force products
or ideas down their throats as being the next big
thing just be cool and then let them
decide. 3) KEEP YOUR BRAND STRONG In this
case, the specific cessation program name, or
memorable cessation strategies.
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4) BE RELEVANT Be sure that your content is
relevant to teens' lives. - Use a Teen Focus
Group prior to development - Create a Teen
Advisory Board for ongoing reference 5) GET THE
LANGUAGE RIGHT Watch "MTV" or use data from
recent focus groups to use current terms. Teens
pick up on outdated language, and will be turned
off. 6) UPDATE, UPDATE, UPDATE! Especially
when catering to repeat visits. Teens get bored
quickly. 7) TAP INTO CELEBRITIES Name
recognition attracts teens. Famous ex-smokers
have appeal. 8) BE HONEST Teens recognize
dishonesty, and if any dishonesty is discovered
they will terminate the online relationship. 9)
HAVE INTEGRITY Teens respond to what is "real"
and "authentic". If treated with respect, they
will respond better.
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• Workshop Topic for Discussion
• Do what the tobacco companies have done
• Get them hooked early, and hooked for a lifetime
  (teen cessation intervention, not just
  prevention. Cessation intervention should treat
  nicotine addiction as a chronic disease)
• Try the product for free (Provide free web
  access, nicotine gum, barrier-free interactive
  features on the web)
• Celebrity spokesperson
• Focus on rebelliousness (Those companies are
  manipulating you! Like American Legacys The
  Truth Campaign)
• Want to be like an adult (It takes maturity and
  dedication to quit smoking)

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Need for Evidence Base Content Until we know
what works with adolescents in general,
applications to the web will be exploratory. This
exploration will occur on at least two fronts 1)
Content (use methods with evidence base) 2) The
Medium, or environment, of the Internet with
teens in general, with smokers in general, and
with the sub-population of SMOKING teens.
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• Need for Evidence Base
• Usability
• Usability (as linked to effectiveness for
  smoking cessation websites) will also be
  gathering evidence on two fronts
• 1) Efficacy/Effectiveness with smoking
  cessation in general
• interventions translated from other mediums
  (manual/phone)
• new web based interventions, evolving parallel
  to technology
• 2) Effectiveness with Special Populations,
  who use the internet differently.
• New teen smokers in 2004 are the first
  generation of smokers to grow up with the
  internet in their homes and schools most of their
  lives.

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Comparison of 3 Teen Sites Gottaquit.com,
Qweb.org, Nobutts.ucsd.edu 1) Structural
analysis 3) Content and Usability Analysis 2)
Teen Self-Survey
Three Teen Cessation Websites were selected from
listserve inquiries, search engines, and Medline.
They were non-randomly selected by committee for
1) variety in features, 2) funding source, 3)
convenience, and 4) having a Cessation focus.
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Websites GottaQuit.com - A Health Department
initiative (Monroe County, NY). It features
graphics, live chats with ex-smokers, pop-up
quizzes, and give-away prizes. Qweb.org -
Intervention component of Randomized Clinical
Trial at the U of R. It features live chats with
ex- smokers, real images of damaged lungs,
quizzes, and interventions with evidence base in
adult cessation literature (e.g. PHS Guidelines)
and focus groups. NoButts.ucsd.edu California
State Helplines website. It features cartoon
animations, games, quizzes, and fun random facts.
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Sample pages viewed by subjects
www.nobutts.ucsd.edu
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Structural Analysis Breadth versus Depth.
This menu is deep, but not broad.
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Structural Analysis This menu is broad, but
shallow.
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Structural Analysis Menu Mapping
Menu structures should be neither too broad nor
too deep, and should be adjusted to maximize the
flow of traffic to promote a pattern of use
that maximizes the treatment effect (based
initially on theory, and then on process and
outcome evaluations and evidence elsewhere in the
literature) (Dillman, 2000). Utilization patterns
and outcomes can be assessed by feedback from
your target population (focus groups, follow-up
evaluations), utilization software (for number of
hits per page), and by treatment efficacy
(outcome variables like cessation attempts and
success). See the handout for the structural
mapping of these three websites, and note the
differences in breadth and depth.
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Usability Analysis Content and usability was
analyzed by rating these 3 sites using the PHS
guidelines, the Usability methods described for
content analysis at usability.gov, and by Bock
and her colleagues (Bock et al., 2003). Refer to
the handout for a table of the ratings for these
three websites.
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Adolescent Survey A convenience sample of
adolescents from three Western New York High
Schools was identified. Schools independently
selected students to take the survey on school
computers on the same day they viewed the 3
websites. The anonymous surveys were collected by
study personnel, coded, and analyzed with SAS.
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Demographics (N203) GENDER Males 96
(47.29) Females 107 (52.71) GRADE 8th 9th
10 (5.02) 10th 81 (39.90) 11th 53
(26.11) 12th 59 (29.06) SMOKING STATUS
Smokers 22 (10.84) Non-smokers 124 (61.08)
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Results Sites Ranked as Favoritecompared to
other 2 sites NNoButts GGottaQuit
QQweb All Teens N (n90, 43.27 ) G (n60,
28.85) Q (n58, 27.88) ------------------------
-------------------------------------------- Non-S
mokers (n184, 88.46) N (n85, 46.20 ) G
(n52, 28.26) Q (n47, 25.54) Smokers (n24,
11.54) Q (n11, 45.83 ) G (n8, 33.33) N
(n5, 20.83) Differences in Ranking were
observed between Non-Smokers and Smokers
Non-smokers most often chose NoButts, and smokers
most often chose Qweb Chi-Square 6.48, plt.04
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Results (cont.) When asked to explain why they
selected their first ranked choice (open-ended),
these features were collapsed into categories 1
Information (n79, 26.87) educational,
realistic, can learn a lot, useful 2 Features
(n39, 13.27) sound, graphics, music,
animation, colors 3 Fun (n38, 12.93) games 4
Layout/ Navigation (n35, 11.9) loading time,
organization, best-looking, easy to use, fast,
easy to understand 5 Appeals to teens/ grabbed
attention (n33, 11.22) I liked it, most
interesting, memorable 6 Interactivity (n17,
5.78) liked answering questions, involved 7
Best/ best quality (n17, 5.78) updated often,
good site, coolest, nicest 8 Scare tactics (n13,
4.42) scary facts, gross pictures, lungs 9
Would help quit smoking (n11, 3.74)
persuasive, would work best, helpful, quitting
info, most effective 10 No Specific Reason (n6,
2.04) 11 Other (n5, 1.7) 12 Like Pop-ups (n1,
0.34)
Multiple responses allowed. Total responses
294
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Results (cont.) When asked to explain
why they selected their last ranked choice

1 Layout/ navigation
(n49, 24.26) not as appealing, too plain,
didnt like flash feature, hard to use, no
attention to detail, slow, too long to load, not
enough content, display was terrible 2
Information (n38, 18.81) not enough info,
facts, not good information 3 Doesnt appeal to
teens/ grab attention (n32, 15.84) not
interesting, dont like it, couldnt get into it,
doesnt keep attention, too serious, too
childish 4 Boring (n26, 12.87) not fun, dull 5
No reason (n19, 9.41) 6 Features(n10, 4.95)
sound, music, color, animation, graphics 7 Bad
(n10, 4.95) dumb, not good, stupid 8
Interactivity (n7, 3.47) not interactive
enough 9 Scare tactics (n2, 0.99) didnt like,
not enough 10 Other (n5, 2.48) 11 Wouldnt help
quit smoking (n4, 1.98) not effective, not
helpful to smoker, not enough on how to quit, no
referrals or help
Multiple responses allowed. Total responses
202
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Differences were found in rankings of the
Presentation of Health Benefits (of quitting)
between smokers and non-smokers.
Presentation of the Health Benefits of
Quitting NONSMOKERS were more likely to rank the
site containing high quality health benefit
information as their FAVORITE. 79 vs
55 p lt.03 SMOKERS were more likely to rank the
site containing high quality health benefit
information as their LEAST FAVORITE. 45
vs 21 p lt.03
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Discussion RANKINGS In this sample, Nonsmoking
Teens may prefer websites and features developed
from marketing principals and which have
interesting games, graphics and content designed
to keep their attention. Smoking Teens, however,
may prefer an evidence-based website designed to
use cessation strategies (i.e., evidence from
adult studies and literature). IMPLICATIONS
Research is needed to explore whether Smoking
Teens prefer sites which feature smoking
cessation content over style of presentation.
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Discussion (Cont.) Many factors influence the
inclusion of specific website features (e.g.,
graphics, chats, navigation), including the
funding agencys mission, the scope of the sites
goals, and the available technology webmaster
skills. Web-Intervention decisions about features
interactivity are often made on assumptions of
what the target population (Smoking Teens) will
favorably respond to. Results from this
exploratory pilot survey study indicate website
and website feature preferences for Nonsmoking
Teens and Smoking Teens may be different, and
research is needed to clarify these differences
to better inform Web Assisted Tobacco
Intervention with teens.
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THANK YOU! Scott McIntosh, PhD University of
Rochester 585.273.3876 scott_mcintosh_at_urmc.rochest
er.edu References Bock BC, Graham AL, Sciamanna
CN, et al. (In Press). Smoking Cessation
Treatmetn on the Internet Content, Quality, and
Usability. Nicotine Tobacco Research. Comeau W
(2001). Nine tips for e-marketing to teens.
marketingprofs.com accessed 12/28/03 at
http//www.marketingprofs.com/2/kewl.asp Dillman
DA (2000) Mail and Internet Surveys, The Tailored
Design Method, Second Edition, John Wiley Sons.