Using Information Technology to SupportSmoking-related Behaviour Change:Web-Assisted Tobacco InterventionsBY CAMERON NORMAN, PH.D.

Probably, like the majority of Canadians over the age of 12, you regularly use theinternet – email, the World Wide Web, interactive chatlines, and other features – and youhave also sought out health information online for yourself or family members that extendsbeyond your clinical practice. Sixty-five percent of Canadian households1 and 64% ofAmericans2 report recent use of the Internet for health information. The use of informationtechnology for health is on the rise and continues to be one of the most sought-after topicson the internet.2 Consumer use of information technology for health (or eHealth3) hasgrown in popularity, with eHealth journals now ranking among the top academic publica-tions. Although popular with consumers and professionals alike, the healthcare sector isstill unclear on how to adequately and effectively use technology as an intervention mediumand unsure about what evidence exists to guide program delivery. This issue of SmokingCessation Rounds highlights how information technology can assist Canadian smokers toquit. It also describes how healthcare practitioners can effectively extend the clinicalencounter beyond the consultation room.

Web-assisted tobacco interventions: An overview

Web-assisted tobacco interventions (WATI) are a class of technology-enabled behav-ioural change interventions that are in use throughout the world. WATI is a promisingmedium for delivering smoking cessation programming and supporting health professionaltraining in tobacco control. The acronym, WATI, was first proposed by Peter Selby, MD,and Scott McIntosh, PhD. Since 2004, it has been used to frame a growing community ofpractice around the development, study, and implementation of technology-based interven-tions that support tobacco control. The Web part of WATI refers not only to World WideWeb information accessible from a desktop, but also to other networked technologies (eg,cell phones and personal digital assistants [PDAs]). As information becomes more tightlyintegrated across technologies, this will remain an important distinction, particularly sincemuch of the developing world (where the burden of smoking-related disease is most likelyto be felt in the coming decades) does not have sufficient access to the internet through con-ventional means,4 and relies on cell phones and other tools or media for health information.

WATI resources have been developed to focus on 4 key areas: cessation, prevention,social support, and professional development/training. They can be used as a stand-aloneintervention, a complement to other (mostly non-internet) resources, or as an integratedcomponent within a larger intervention. Research on WATI has quickly become a leadingarea within eHealth in general, as evidenced by the large number of tobacco-related manu-scripts published in the Journal of Medical Internet Research,5-11 the leading eHealth peer-reviewed publication in the world. WATI has greatly influenced tobacco control as evi-denced by a special issue of the journal, Nicotine and Tobacco Research, that was devotedto WATI.Why WATI? Tobacco use is a global phenomenon that requires control strategies that areequal in reach and appeal. The World Health Organization estimates that half of the current

The Minto Preventionand Rehabilitation CentreUniversity of OttawaHeart Institute

ANDREW PIPE, CM, MD,MEDICAL DIRECTOR

CO-EDITOR,SMOKING CESSATION ROUNDS

DAVID DAVIDSON, MD, CCFP

MICHÉLE DE MARGERIE, MD, CCFP

ROBERT SWENSON, MD, FRCPC

GEORGE FODOR, MD, PHD, FRCPC

ROBERT REID, MBA, PHD

DOUG WILKINS, MD, FRCPC

Centre for Addiction andMental HealthUniversity of TorontoAddictions Program,Nicotine Dependence Clinic

PETER SELBY, MBBS, CCFPCLINICAL DIRECTOR AND HEAD

CO-EDITOR, SMOKING

CESSATION ROUNDS

TONY GEORGE, MD, FRCPC

BERNARD LE FOLL, MD, PHD

CURTIS HANDFORD, MD, CCFP

The editorial content of SmokingCessation Rounds is determined solely bythe Minto Prevention and RehabilitationCentre, University of Ottawa Heart Instituteand the Addiction Medicine Service,Centre for Addiction and Mental Health,University of Toronto.

DE L’UNIVERSITÉ D’OTTAWAINSTITUT DE CARDIOLOGIE

U N I V E R S I T Y O F O T TA W AH E A R T I N S T I T U T E

UNIVERSITYOF TORONTO

Available on the Internet at www.smokingcessationrounds.ca

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A PHYSICIAN LEARNING RESOURCE FROM THE MINTO PREVENTION AND REHABILITATION CENTRE, UNIVERSITY OF OTTAWA HEARTINSTITUTE AND THE ADDICTION MEDICINE SERVICE, CENTRE FOR ADDICTION AND MENTAL HEALTH, UNIVERSITY OF TORONTO

smokers today (about 650 million people) will die as aresult of tobacco use.12 Tobacco use accounts for 22% ofall disease-related deaths in Canada13 and the prematuredeath of 4.9 million people worldwide.12 Given the scopeof the problem, cessation support services must be avail-able in settings beyond the clinical encounter if substan-tive decreases in smoking-related morbidity and mortalityare to be achieved. In order to achieve such wide-scalereductions in smoking-attributable disease, interventionsmust be developed that are effective, plausible, afford-able, and available at the population level.14

Web-assisted tobacco interventions offer these bene-fits. In addition, they have the added benefits of beingrelatively low-cost per smoker served and accessible24-hours/day, every day of the year, for those with accessto an internet connection. Web-assisted behaviour-changetools have had small and medium-sized effects onchanging behaviour across a variety of health condi-tions,15-18 with tobacco control becoming one of theleaders in developing and evaluating interventions for theinternet.19-23 The evidence base, while small, is strong insuggesting that eHealth interventions are effective atchanging behaviour17,18,24 and, given the high proximallevels of internet access in many countries, a small shift inbehaviour attributed to an accessible Web interventioncan translate into a large population health effect.

Cessation information online

Quality and access are among the greatest concernsexpressed about using eHealth.25-28 Bock and col-leagues29 reviewed the findings from an online search ofcessation information resources using US Public HealthService (US PHS) and National Cancer Institute guide-lines to determine the relative quality of sites most likelyto be accessed by the public. The study examined sitesidentified through the first 10 pages retrieved by majorsearch engines (eg, Google) to reflect the sites a healthconsumer would likely find when searching for theseterms: smoking, quit smoking, stop smoking, andsmoking cessation. Of the 46 sites that met the searchcriteria, over 80% did not cover one or more of the keycomponents of tobacco treatment recommended in theUS PHS guidelines, suggesting that practitioners shouldbe cautious when relying on websites as a source ofinformation on smoking cessation. This review has sincebeen updated and, although the quality of some siteshas improved, the authors still recommend, “buyersbeware.”30

Interactive Web-assisted tobacco interventions

Following Bock’s review of health informationresources, in 2007, a review was conducted for HealthCanada to locate and catalogue those resources that wereinteractive and designed as stand-alone interventions, orWeb-assisted tobacco interventions.31 WATIs were identi-fied through three methods:• A review of the published literature, using the data-bases PubMed, PsycInfo, ERIC, Social Science Abstracts,and Web of Science for Web-assisted tobacco interven-tions and related technology and tobacco control articles.

• A survey of all attendees at the 3rd WATI workshop heldas a pre-conference event and part of the World Congresson Internet and Medicine (MEDNET) in October 2006,where participants were asked to list all of the WATIresources they were aware of in any language.• A comprehensive Web search using both Google.ca andthe metasearch engines Ixquick and Metacrawler, anddeep-Web search tools such as CompletePlanet. Thesearch yielded 35 unique, interactive tools worldwide;31

the majority of these sites were based in North America(N=25) and over 80% were in English. Two wirelessphone interventions were also identified, while 3 inter-ventions used variants of the same WATI platformcreated by V-CC Systems, a private, for-profit company,with support and guidance from the Centre for Addictionand Mental Health (CAMH) in Toronto, University ofToronto.

An examination of this catalogue of resources(http://www.wati.net) will reveal that the majority ofinteractive resources are devoted to smoking cessation,while those with a focus on prevention and training arethe next most popular. Social support is an aspect thatis embedded in all 3 types of interventions and alsooffered on its own through self-organized electronicforums on Yahoo! Groups, Facebook, MySpace, andsimilar platforms.

Using WATI to support smoking cessation:Three orders of intervention

Most examples of WATI and use of the internet forhealth issues, focus on some version of a stand-alonewebsite that features information, links, and perhaps atype of interactive component. The most common WATIresources are designed as self-contained resources;however, there are examples of technologies that comple-ment existing treatments or are integrated within a largerprogram. These different strategies reflect 3 orders ofbehavioural eHealth interventions:• First order: Stand-alone• Second order: Complementary• Third order: Integrated

The following sections explore each order of inter-vention, using examples drawn from the Canadian-based WATI resources focused on smoking cessationand prevention.

First-order WATI: Stand-alone resourcesThe website or tool designed to operate independ-

ently of any other resource is considered a first-ordereHealth intervention. It is the most common of the avail-able interactive technologies. Although such resourcesmay refer to others through links to other websites or ref-erences to other options (eg, books or telephone services),a first-order intervention is designed to be used independ-ently of any other source of support. Additional supportsmay include: pharmacotherapy, counseling, telephonequitlines, or various self-help approaches. Smokers maywish to (and may be encouraged to) use multiple methodsto quit but, from a design perspective, first-orderinterventions are created to provide a resource that could

because they are exclusively internet-driven and, thus,provide 24-hour/day support options. In websites wherelive support groups are present, there may be some limi-tations in the numbers and types of services availableduring certain hours, but basic functionality and scopeof resources are not significantly affected by time-of-dayrestrictions. The same is not always true for second- orthird-order WATIs.

Second-order WATI: Complementary resourcesA second-order WATI is designed to be used in con-

junction with another type of resource (eg, a telephonehelpline) or as an adjunct to clinical treatment. Unlikefirst-order interventions, however, these types of WATIare explicitly designed to complement other methods. Thesecond-order WATI may include areas where users inputinformation from other resources or they may providemore detailed levels of information than another medium.

One such example is the Canadian Cancer Society’s(CCS) Smokers’ Helpline website in Ontario (http://www.smokershelpline.ca). This resource was designed to com-plement the existing telephone quitline and serve as anadditional means of support, particularly during thehours when the phoneline is unavailable (Table 1). TheHelpline provides information, quitting tips, and links tosupport via the website in a manner that is self-driven.It complements the use of the telephone service, which iswidely promoted by the CCS. For the Helpline, telephonecounseling is the primary vehicle for intervention;however, by adding the website component, the CCS isable to provide a trustworthy option for callers to usewhen the phones are not in operation, as well as a sourceof additional information not considered practical forinclusion in a telephone call (eg, because it is too detailedor not critical). In this case, the website supplements andcomplements the phone-based intervention.

potentially serve as the sole source of support. The infor-mation, tools, and other features are not designed for usewith additional formalized supports such as quitlines orphysician assessments, although some encourage andadvise the user to seek out physician help. These toolstypically offer a wide range of options including assess-ments, information, social support methods (eg, discus-sion boards), access to online quit specialists and, in somecircumstances, opportunities to purchase cessation aidsdirectly through the website.

One example of this type of resource is the StopSmoking Centre developed by V-CC and the CAMH(http://www.stopsmokingcenter.net). This resource sup-ports quitters with a 24-hour accessible, personalized,and community-driven smoking cessation program. Itrequires users to register (for free) with the website tofacilitate tailoring and personalized support (althoughthis may be done using an anonymous email address toprotect privacy). The program is designed around anonline support group that enables users to provide peersupport and guidance to one another. Further, they aresupported by trained “Support Specialists” and a series oftools to develop quit plans and assess health risks. AnInstant Messenger feature enables users to immediatelycommunicate with “Quitting Buddies” for rapid cessa-tion-related peer support. A series of quit-plan exercisesbuilds specific, tailored action steps for users to followthat is supported by tools like the downloadable QuitMeter. The Quit Meter tracks the amount of money thatusers save (or have saved to date), along with estimateson the amount of health (years lived) that they havegained by stopping cigarette use.

For health practitioners, first-order interventionsare the easiest to recommend as options for patients toexplore on their own and, in many cases, they arefree-of-charge. First-order WATIs are the most flexible

Table 1. Smoking “Quitlines”

CCS Quitline Province Phone Hours of Operation WebsiteAlberta Quits Alberta 1-866-332-2322 not listed http://alberta.quitnet.com/QuitNow British Columbia 1-877-455-2233 not listed http://quitnow.caSmoker’s Helpline Manitoba 1-877-513-5333 M - Th 8a-8p; F 8a-4pSmoker’s Helpline New Brunswick 1-877-513-5333 M - Th 9a-9p; F 9a-5p http://www.smokershelpline.caSmoker’s Helpline Newfoundland/Labrador 1-800-363-5864 M - Th 9a-9p; F 9a-5p http://www.smokershelp.net/Smoker’s Helpline Nova Scotia 1-877-513-5333 M - Th 9a-9p; F 9a-5pSmoker’s Helpline Nunavut 1-866-877-3845 M - F 8:30a-5:00pSmoker’s Helpline Ontario 1-877-513-5333 M - Th 8a-9p; F 8-6;

Sat/Sun 9a-5p http://www.smokershelpline.caSmoker’s Helpline Prince Edward Island 1-888-818-6300 M - Th 9a-9p; F 9a-5pLigne J'arrête Québec 1-866-527-7383 M - F 8a-8pLigne poumons-9 Québec 1-888-768-6669 M - F 8:30a-4:30p http://pq.lung.ca/sections/

poste 232 poumon9/en/index.phpSmoker’s Helpline Saskatchewan 1-877-513-5333 M - Th 7a-7p; F 7a-4p

Organisation WebsiteThe Stop Smoking Center www.stopsmokingcenter.net Free to all smokers. Has self help and moderated mutual aid.

Evaluated and evidence based.Smoker's Helpline Online http://www.smokershelpline.ca For Ontario Residents onlyGo Smokefree www.gosmokefree.ca Auto-reroutes to: http://www.hc-sc.gc.ca/hl-vs/tobac-tabac/index_e.htmlSmokeFree http://www.smokefree.gov/ National Cancer Institute site for smokers in BCQuitNow http://quitnow.ca

With this CCS telephone-based service, callersspeak one-on-one with a trained “Quit Specialist”who works with the caller to:• develop a personalized quit plan• formulate strategies to cope with cravings• provide information on quitting methods• explore the potential for withdrawal symptoms

and plan for them• support stress management• inform callers of available services and resources

that go beyond the helpline (including the CCSSmokers’ Helpline website).To complement this resource, the helpline website

provides discussion forums for users to connect withother users (peer support). It also provides similarservices as the Stop Smoking Centre because theplatform is the same as the one provided by V-CC.The difference here is that the website is a secondaryresource to the telephone line but, otherwise, it func-tions in exactly the same manner as a stand-aloneWATI. The CCS Smokers’ Helpline illustrates howWATIs can be used differently depending on thecontext. It also indicates the flexibility of Webresources by demonstrating how a tool designed as astand-alone website can function as a supportiveadjunct to alternate treatment modalities and theresources scaled up to first- or second-order formats.The next example illustrates the further enhance-ment of such approaches into an integrated deliverymodel as part of a third-order intervention.

Third-order WATI: Integrated interventionsA WATI is considered a third-order intervention

when it is part of an integrated program of deliverywhere the information technology tool is but onecomponent. Unlike second-order interventions, athird-order WATI is embedded within a largerprogram structure and the resource is not viewed ascomplementary or stand-alone, but integral to thelarger initiative. These are the least-common formsof WATI, but also the most sophisticated and inten-sive programs of the group.

The Virtual Classroom on Tobacco Control,developed by Youth Voices Research at the Univer-sity of Toronto and TakingITGlobal, a youth-ori-ented nongovernmental organization (NGO), is oneexample of a third-order intervention. The VirtualClassroom is designed for both young smokers andnonsmokers (aged 12-24 years), and is intended fordelivery in educational settings (http://www.takingitglobal.org/tiged/projects/tobacco//). This compre-hensive classroom intervention is designed to facili-tate learning about tobacco in a global contextbeyond health and contains 4 interrelated units:• Facts & Figures – examines the health effects of

tobacco, from both a first-hand and second-handperspective

• The Smoking Zine – an interactive Web tool thatallows students to explore their smoking behav-

iours and intentions and is designed to supporthealthy decision-making about using cigarettes

• Denormalization – investigates the tobaccoindustry’s marketing campaigns that target youth,and highlights avenues for youth action

• Global and Social Justice – focuses on the tobaccoindustry’s exploitive practices in developing regionsof the world. It is also unique in that it providesoptions for smokers and nonsmokers alike.

The Virtual Classroom on Tobacco Control alsocontains interactive discussion boards and onlinestudent galleries and tools to support educators andhealth practitioners who use this resource withclasses or support groups. Professionals can posttheir own unique ideas in a special area andcomment on the areas that were the most well-received by learners and/or helpful to classroomneeds. The program is designed to facilitate net-worked knowledge between educators and studentsalike by offering ways to connect individuals orentire classrooms together and provide a sharedlearning experience. This enables the participants inthe intervention to actively learn from one anotherand supports one of the most powerful means oflearning new material.

A practitioner toolkit is designed to accompanythe electronic classroom environment and can beviewed online, downloaded and printed, or orderedfree-of-charge from Youth Voices. The guide allowsprofessionals to go through each section of theVirtual Classroom on Tobacco Control to decidewhich lessons and/or subjects would be most benefi-cial to their students. Each section includes a topic-overview, learning objectives, individual and groupactivities, as well as links to other evidence-informedonline resources.

Tools such as the Smoking Zine were originallydeveloped as first-order interventions and evolvedinto second-order interventions before becomingpart of the integrated Virtual Classroom. TheSmoking Zine has been evaluated in a longitudinalrandomized trial with >1400 young people. It wasfound to be an effective method of engaging high-risk smokers and preventing nonsmokers fromstarting to smoke,23 although no formal evaluationhas been conducted on the integrated Virtual Class-room format. The Smoking Zine is still available asa stand-alone first-order intervention: http://www.smokingzine.org.

Each of the 3 orders of intervention offersadvantages and disadvantages. First-order interven-tions are often simple and require relatively little userskill to access. Generally, they can be used with littleprofessional assistance, while second- and third-order interventions often necessitate some type ofnavigational support by the intervention provider.Although accessible, first-order interventions arelimited to the medium of the internet, whereassecond- and third-order interventions allow the

application of additional resources in a meaningful,coherent manner that facilitates interventions ofgreater intensity. All 3 orders offer advantages andit is important to understand the skill-set of thepatient before recommending one of these options.An assessment of eHealth-related skills, the eHealthLiteracy Scale, is publicly available.32 The needs,preferences, and skills of the patient, and theresources available to both the patient and theattending health practitioners should determinewhich model of WATI is best suited for supportingsmoking cessation.

The future for WATI

Information technologies are rapidly evolving,both in their functionality and in the manner inwhich they are used. The internet experience isbecoming more social in nature, with content, indi-viduals, and ideas being networked in ways thatsurpass the initial World Wide Web. Perhaps this iswhy these new methods of networking knowledgethrough information technology are called Web2.0.33 This consumer-centered approach to knowl-edge creation and transfer allows users to create,edit, and share information among themselves via awebsite that is provided without an intermediary.Most importantly, these tools are often free-of-charge and require little technical skill to operate,enabling any Web-user to operate them with ease.This new approach to internet use is led by “socialmedia” tools such as blogs (customizable webdiaries),34 wikis (easily editable web pages),35 pod-casting (audio or video broadcasts),36 and socialnetwork websites like MySpace.com37 that presentnew opportunities to engage smokers in cessationactivities. These tools enable users not only to createcontent, but also to network their collective knowl-edge in ways beyond a typical website and they arecurrently in use by millions of young adults in NorthAmerica.38-40 The social networking website, Face-book, alone, has more than 30 million users andis among the most widely visited websites on theinternet.41 Groups have already developed thatpromote and denounce smoking, creating a micro-cosm of society within its electronic boundaries.These tools provide new strategies to engage thepublic and deliver consumer-driven interventions.Just as WATI approaches have not replaced thephysician as an important contributor to cessationefforts, these new technologies and tools add to theavailable options rather than cast them aside.

In addition to the role played by these technolo-gies in aiding tobacco control, they also provideopportunities to engage hard-to-reach populationssuch as youth, pregnant smokers (www.pregnets.org), and young adults. They also forecast methodsto engage future generations. In terms of internetuse, young Canadians comprise one of the most con-nected populations in the world and they frequentlyuse it as a source of health information.42-44 Researchwith Youth Voices Research (formerly TeenNet)45-50

has explored strategies to engage young adults insmoking prevention and cessation efforts throughtechnology and found that they like the media-basedapproach, and also appreciate the convenience andaccessibility of a Web-based service. This is the pop-ulation that will become the patients of tomorrowand developing ways to engage them, as well asthose in other age groups, is an important step forproviding the most appropriate smoking cessationresources possible.

WATI can offer a strategy that is flexible enoughto stand on its own and support the more intensivework of clinic-based care and treatment. By consid-ering the options available and the level of treatmentdesired, health professionals can develop or use amyriad of Web tools to deliver first-, second-, orthird-order WATI options in supporting their cessa-tion efforts, combining high tech with high touch inhelping people quit smoking.

Cameron Norman, Ph.D., is an Assistant Professor in theDepartment of Public Health Sciences, Faculty of Medicine,University of Toronto.

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© 2007 The Minto Prevention and Rehabilitation Centre, University of Ottawa Heart Institute and the Addiction Medicine Service, Centre for Addiction and MentalHealth, University of Toronto, which is solely responsible for the contents. Publisher: SNELL Medical Communication Inc. in cooperation with the Minto Prevention andRehabilitation Centre, University of Ottawa Heart Institute and the Addiction Medicine Service, Centre for Addiction and Mental Health, University of Toronto. ®SmokingCessation Rounds is a registered trade mark of SNELL Medical Communication Inc. All rights reserved. The administration of any therapies discussed or referred to inSmoking Cessation Rounds should always be consistent with the approved prescribing information in Canada. SNELL Medical Communication Inc. is committed to thedevelopment of superior Continuing Medical Education.

This publication is made possible by an educational grant from

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S N E L L

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Upcoming Meeting27 February – 1 March 2008Society for Research on Nicotine and Tobacco (SRNT)14th Annual MeetingHilton Portland and Executive TowerPortland, Oregon USAContact: www.srnt.org

Disclosure Statement: Dr. Norman is the principal investiga-tor of Youth Voices Research; however, he does not obtainany financial benefit from the use and distribution of theresources promoted in this article. Dr. Norman is a new inves-tigator fellow with the Canadian Institutes of Health Research(CIHR) Transdisciplinary Training Program in Tobacco Usein Special Populations.