1. Web Based Programs for Smokeless Tobacco Cessation Herb Severson, Ph.D. Oregon Research Institute Eugene, Oregon

3. National Agriculture Statistics Services: National Department of Agriculture

4.  70% of Americans use Internet – 48% are active users  Broadband in home – 103 million  Access is 52% of rural areas

5.  Positive outcome for managing  Depression  Diabetes  Weight loss & physical activity

6.  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

7.  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

8.  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

9.  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

11.  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

14. Feature Enhanced Condition Basic Condition SLT Cessation Behavior Change Content  SLT Health Information  Links to outside Websites  Video Testimonials  Guided Path for Accessing Content †  Web Forums for Support  Tailored E-mail Reminders  † 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.

15. 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

16. 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

17. Visits by Participant* Overall Visits Duration by Participant*(min) ConditionNMedian Interquartile Range Median Enhanced1,2002.00 3 (1-4) 28.9937.75(13.60-51.35) Basic1,1751.00 1 (1-2) 12.5015.83(6.60-22.43) *P<.001

20. 3 Month No. (%) 6 Month No. (%) 3 & 6 Month No. (%) Responders Enhanced Condition 30.7 † 28.5 † 21.8 † Basic Condition 19.520.312.6 Intent-to-Treat Enhanced Condition 19.0 † 16.0 ‡ 11.8 † Basic Condition 13.411.77.5 Enhanced and Basic conditions significantly different: † p <.001; ‡ p =.001, * p <.01

21. ConditionN Outside Links (%) Print Content (%) ST Quitting Guide (%) Enhanced1,20018.278.312.2 Basic1,17532.196.387.5 Condition Video Testimonial (%) List of Support People (%) Set Quit Date (%) Staying Quit Content After Quitting (%) Enhanced68.224.763.332.8

22. Users Posting by User Forum Type N%Median Interquartile Range Peer48138.22481 Expert655.2165

23.  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

24.  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

26.  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.

27. Recruit 1,500 ST Users Age 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

28.  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

29. My Plan Quitting Getting Ready Intro Method Quit Date Set Stage Personal Contract Do It!

31. Intro Remember Reasons Get Support Manage Mood Avoid Traps Use Substitutes Reward Progress Peer-to-Peer Ask the Expert Staying Quit Retooling Blogs

33. 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

35. Getting Ready 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!

36. November 2008 January 2009 April 2009 June 2009 August 2009 Average recruits per week = 12 28 24 20 16 12 8 4 0 Count of Users

39.  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.

40.  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