Original Paper

Interest in an Online Smoking Cessation Program and Effective Recruitment Strategies: Results From Project Quit

Jennifer B McClure¹, PhD; Sarah M Greene¹, MPH; Cheryl Wiese¹, MA; Karin E Johnson¹, PhD; Gwen Alexander², PhD; Victor Strecher¹, PhD

¹Group Health Cooperative Center for Health Studies, Seatle, WA, USA
²Henry Ford Health System, Detroit, MI, USA
³University of Michigan, Ann Arbor, MI, USA

ABSTRACT

(J Med Internet Res 2006;8(3):e14)
doi:10.2196/jmir.8.3.e14

KEYWORDS

Internet; tobacco dependence; nicotine dependence; smoking cessation; recruitment activities

In recent years there has been an explosive growth of Internet users around the world and a corresponding upsurge in interest in using the Internet to deliver online public health interventions such as smoking cessation treatment. The potential advantages of Internet-based treatment are clear. From the users' perspective, online treatment programs are convenient; content can be accessed 24 hours a day, 7 days a week, 365 days a year. They also offer a greater level of anonymity than in-person or phone-based counseling, which users may find appealing. From a delivery perspective, Internet programs allow rapid, broad, and economical treatment dissemination. Programs can be highly tailored to mimic the individualization of one-to-one counseling, and the Internet has the potential to reach audiences who might not seek services otherwise due to issues of cost, accessibility, or stigma.

Whether Internet-based smoking cessation programs will be as effective as person-to-person counseling remains to be proven. To date, very few randomized efficacy trials have been conducted [1], but some promising preliminary data [2-4] suggest that well-designed online cessation programs could be effective public health interventions, particularly when combined with pharmacotherapy [5].

The ultimate impact of any public health intervention, however, is dependent on its reach, as well as its efficacy [6]. Internet-based programs have the potential to reach millions of people, but potential reach is not actual reach. Actual reach requires access, acceptability, and utilization. While ongoing research seeks to establish the efficacy of online treatment, it is equally important to evaluate the acceptability and utilization of these programs in their target audiences. This assessment is hard to do because it requires a defined recruitment population and control over individuals' exposure to program advertisements, which is not possible in most research settings. No published studies to date, that we are aware of, have recruited smokers for Internet-based cessation treatment using a well-defined population that would allow accurate estimates of treatment uptake among smokers. Our best estimates come from surveys of Internet users. According to a recent Pew survey, 7% of adult US Internet users, approximately 8 million people, reported that they have searched online for information on how to quit smoking [7], but searching for information online is not the same as enrolling in an online cessation program. Joining a program requires a higher level of commitment and effort. This could partly explain why only 5-14% of smokers follow through with treatment referrals after being advised to quit [8-10] and less than 7% of smokers in the United States enroll in clinic-based cessation programs [11]. Research is needed that will allow us to better understand the acceptability and reach of Internet-based smoking cessation treatment. Moreover, it is important to understand how best to advertise these programs to smokers to maximize treatment uptake.

In this paper we report on smokers' interest in Project Quit, an online, individually tailored, cognitive-behavioral support program with adjunctive nicotine replacement therapy (NRT) patches. Participants were recruited from two large health care organizations in the United States using a combination of individual-level and population-level recruitment strategies. Working within the health care organizations provided a defined patient population, making it possible to estimate interest in this program among likely smokers who were invited to participate and to evaluate the effectiveness of our recruitment strategies.

Setting

Project Quit is a collaborative study between the University of Michigan (UM), Group Health Cooperative (GHC), and the Henry Ford Health System (HFHS). The primary purpose of Project Quit is to evaluate the "active ingredients" of an individually tailored, online smoking cessation program. A secondary aim is to evaluate smokers' interest in Web-based cessation treatment and evaluate optimal strategies for promoting this service among smokers. Project Quit is being conducted in two independent phases, each testing slightly different treatment content. This paper reports the recruitment outcomes for the first phase.

The Project Quit Internet program was primarily designed and maintained by the Center for Health Communications Research at UM. Study participants were recruited from the memberships of GHC and the Health Alliance Plan (HAP) of HFHS. Both GHC and HFHS are not-for-profit integrated health care delivery systems. At the time of this study, GHC served more than 540000 enrollees (adults and children) in Washington State and Idaho. An estimated 200000 adults and children in the greater Detroit, Michigan area were insured through HAP and received services through HFHS. Both GHC and HFHS/HAP provide behavioral counseling and pharmacotherapy for smoking cessation as covered insurance benefits, but at the time of this study neither offered an online cessation program.

All participants in this study received access to a tailored, cognitive-behavioral treatment program for smoking cessation that was delivered via the Internet. Treatment varied by the type and intensity of tailoring, but all participants received a personally tailored program and a 10-week supply of NRT patches. All treatment was provided free of charge. The study protocol was reviewed and approved by the Institutional Review Board (IRB) of each collaborating institution.

Recruitment

Participants were recruited through a combination of individual-level and population-level strategies. Each of the two health care organizations identified likely current smokers via either automated smoking status data collected during recent medical appointments (Organization 1) or documentation of smoking in electronic medical charts, use of an internal list of smokers collected during prior research, or lists of patients with smoking-related conditions who had previously been prescribed cessation medications (Organization 2). Thus, all invitees were known to have been recent smokers with a high probability of current smoking. Likely smokers were prescreened for minimal inclusion criteria (eg, age) and were mailed a study invitation letter. The letter content was comparable across both health care organizations, but not identical due to different IRB requirements. Both letters briefly described the Project Quit program and study eligibility criteria and invited smokers to visit the Project Quit website to learn more about the study and be screened for eligibility. Individuals could also inform study staff if they did not want to be contacted further about this research. Finally, each site allowed people to refer friends and family members to the program, as long as referred smokers were members of one of the health care organizations. Information on how to refer a friend or family member was included in the invitation letter.

After approximately three months, we determined that we needed to boost our monthly enrollment rate to reach our recruitment goal during the study time frame. In an effort to expedite progress toward our overall recruitment goal, we amended the protocol to include a reminder mailing to likely smokers. Reminders were sent to all individuals who, at that point, had not yet visited the website or opted out of further contact regarding the study. From that point forward, reminder letters were sent to all persons who, four weeks after they received the initial invitation letter, had not visited the website or opted out of contact.

We also utilized several population-level enrollment strategies. The study was advertised in each health care organization's quarterly membership newsletter and was the focus of a feature article in one newsletter issue at Organization 2. Ads appeared in three to four issues total, depending on the site. Each site also advertised through a variety of supplemental strategies. Organization 1 highlighted the program in one issue of its staff newsletter and on the "Join a Study" page of the institution's website. Organization 2 advertised the study during a local promotion of the 2004 Great American Smokeout and allowed physician and nurse referrals, though the latter was not widely promoted among staff. Participants were actively recruited from September 2004 to July 2005.

Letters were proactively mailed to 34533 likely smokers at Organization 1 (n = 18668) and Organization 2 (n = 15865). Quarterly newsletters were mailed to the entire membership of each health care organization, including approximately 563200 adults with GHC or HAP insurance coverage. Based on smoking prevalence data from automated medical records at Organization 1 and regional smoking prevalence estimates for Organization 2 [12], approximately 63180 adults at Organization 1 and 34506 adults at Organization 2 were smokers. At Organization 1, the staff newsletter ad was distributed to approximately 10000 employees, of whom 1000 were estimated to have been smokers based on internal smoking prevalence data among staff. It is not possible to estimate how many smokers were exposed to the other referral sources (eg, friend and family referrals, website posting).

Each recruitment strategy was associated with a unique referral code. Potential participants used these codes to log in to the Project Quit website. It is possible that some participants were exposed to more than one recruitment strategy (eg, invitation letter and newsletter ad); however, by using the referral codes we were able to track which promotional strategy they were responding to when they enrolled and to which health care organization they belonged. After logging into the site, individuals were able to read an overview of the study, be screened for eligibility, and provide informed consent.

Participants

Individuals were eligible to participate if (1) they had smoked at least 100 cigarettes in their lifetime, currently smoked at least 10 cigarettes per day, and had smoked in the past 7 days; (2) were seriously considering quitting in the next 30 days; (3) were 21 to 70 years old; (4) were a member of GHC or HFHS/HAP; (5) had home or work access to the Internet and an email account that they used at least twice weekly; (6) were not currently enrolled in another formal smoking cessation program or currently using pharmacotherapy for smoking cessation; and (7) had no medical contraindications for NRT.

Project Quit Recruitment Response

During the 11-month recruitment period for phase one of Project Quit, 3256 people from both health care organizations visited the website; 2651 were screened for eligibility (81% of website visitors); 2011 were eligible (62% of website visitors); and 1866 enrolled (57% of website visitors).

We examined the response to each recruitment strategy by evaluating the number of people who responded to each and either visited the website to learn about Project Quit or consented and enrolled in the study (Table 1). Because the total response rate to each of the supplemental strategies (eg, friend and family referrals, website posting, staff newsletter, physician referral) was low, these strategies are combined into a single category in Table 1. Nearly 9% of study participants (n = 159) were referred by friends or family, but response to each of the other supplemental referral sources ranged from 2 to 18 enrollees.