Index

Corresponding Author:
Judy Li, The Quit Group, PB Box 12605, Wellington 6144, New Zealand. Email: judi.li@quit.org.nz

Suggested citation: : Li J. Mobile Phones and the Internet as Quitting Smoking Aids. Cases in Public Health Communication & Marketing. 2009; 3:204-218. Available from: www.casesjournal.org/volume3.

Abstract

Due to the addictive nature of tobacco smoking, quitting is never easy. To provide support and advice for smokers wanting to quit smoking, New Zealand's Quit Group (Quit) has delivered a national toll-free Quitline service since 1999. This service is delivered with heavily government-subsidised nicotine replacement therapy (NRT, i.e. nicotine patches, gum and lozenges) as an adjunct, with the aim of increasing quitting smoking success. With the purpose of offering more choices to smokers with different needs, Quit re-designed their website in 2007 to provide an interactive web based service. The new website provides information on quitting, alongside a quit calculator, blogs and an online ordering service for subsidised NRT. The year after, Quit rolled out a cutting-edge mobile phone text messaging based service called Txt2Quit. This service provides automated text messages containing tips and support to those making a quit attempt. Both services are successful as measured by the number of new clients attracted to each (n=458 for the web community and n=317 for Txt2Quit on average per month), and their appeal to smokers who are demographically different from those using the traditional Quitline service.

Introduction

The Quit Group (Quit) is a charitable trust set up to run quit smoking programs and mass media quit campaigns in New Zealand. The programs are funded by New Zealand Ministry of Health. The New Zealand Quitline provides nation-wide toll-free quit smoking services. The service is unique, being the only nation-wide quitline that offers heavily government-subsidised nicotine replacement therapy (NRT) in addition to callback support. The Quitline is popular. In 2008 alone, 29,148 new clients joined its service. According to a nationally representative survey conducted in 2006, 46.7% of current smokers/recent quitters who had made a quit attempt in the previous twelve months had used the Quitline for support and advice in their most recent quit attempt (Ministry of Health, 2007). Quitlines in New Zealand and overseas appear to be more appealing to certain groups such as females ^1-3. In the last two years, the suite of quitting services offered, in addition to the Quitline, has been extended. The provision of alternative quit smoking support over the internet or mobile phone may enable Quit to support smokers who otherwise would not access the usual Quitline service.

In New Zealand, access to the internet and mobile phone ownership are relatively common. The latest Census data show that 60.5% of households have access to the internet and that 74.2% have access to a mobile phone ⁴. This supports the development of new quit smoking services utilizing these new technologies. In this article, I describe the features of Quit's web based service and mobile phone text messaging service (Ttx2Quit). I also measure their effectiveness in terms of 1) service usage volume and 2) their appeal to demographic groups that are different from the Quitline client profile.

Background

Quit Website
The Quit website (www.quit.org.nz) serves a number of purposes. Among others, it supports smokers who want to quit smoking, health professionals who provide subsidised NRT to their clients, and workplaces that provide quit smoking assistance to their staff. The 'Quitting Smoking' section of the website provides educational information on the harms of smoking and the benefits of quitting, as well as practical tips on ways to cope with cravings for smoking and how to develop and maintain a smoke free lifestyle. The written information was structured to provide customized information for smokers/quitters at different stages of their quit smoking journey, i.e. smokers who are considering quitting smoking, smokers who are ready to make a quit attempt, smokers who have successfully quit and wish to remain quit, and smokers who have not successfully quit but would like to make another quit attempt.

In addition to the written information, the website also contains some interactive features which were added during the website re-development undertaken in 2007. The first interactive feature is the 'Quit Calculator' (Figure 1). This enables current smokers/ex-smokers to work out how much money they will save/have saved from not smoking. The calculator requires users to enter the number of cigarettes they usually smoke per day, the number of cigarettes contained per packet and the cost per packet. The Quit Calculator then works out the amount saved for a week, a month and a whole year. Previous research studies showed that smokers are sensitive to tobacco price increases ⁵ and the cost of tobacco has been rated by many smokers/quitters as one of the main reasons for quitting smoking ⁶. The Quit Calculator aims to assist smokers/quitters to consciously think about the financial cost of their smoking, so that this becomes a motivator for quitting smoking or remaining smokefree.

Figure 1. Screenshots of the Quit Calculator.

The other new feature of the Quit website is a member-only section. Registered web community members received regular supportive 'QuitTips' emails that are automated. They also have access to quitting statistics in relation to their own quit date. As an example: "I have been quit for 5 Months, 3 Weeks, 2 Days, 23 hours, 19 minutes and 29 seconds (174 days). I have saved $1,298.27 by not smoking 2,449 cigarettes. I have saved 1 Week, 1 Day, 12 hours and 5 minutes of my life. My Quit Date: 13/10/2008 11:00 p.m.".

Web community members also have access to 'Quit Blogs', which provide an avenue for members to write about their quit journey, ask questions and gain support from or provide support to their peers (Figure 2). People do not have to be a member to view the public blogs, but they have to be a member to be able to post a blog. The rationale for having a blog feature is to build a virtual community for smokers or quitters to share their quit smoking experience, and to provide a way for smokers and quitters to track their own progress. Members have the option of making their blogs private (only viewable by themselves and online administrators) or public (viewable by all). All blogs are monitored by a team of online advisors (a trained group of Quitline Advisors) to ensure the content of the blogs are not offensive and they do not contain personal information or promotional materials, especially advertising for non evidence-based quit smoking services and products. Blog entries are moderated within the next business day.

Figure 1. Screenshots of the Quit Blog.

To encourage smokers to use NRT to help with their quitting, the Quit website has an easy-to-use online ordering system for smokers to obtain subsidised NRT. Smokers are only required to complete an online form which asks for their basic personal details and smoking information. The online advisors then use this information to work out the dosage which is appropriate to the client. To reduce barriers for accessing NRT, smokers do not need to be web community members to place an order; although the ordering process is even simpler for web community members as they are not required to re-enter their details.

Txt2Quit
Providing a quitting smoking intervention over mobile phones is innovative. As people tend to carry their mobile phones with them all the time, recipients of any texting service are able to receive immediate support with no time or place restrictions. Seeing this, Quit (supported by the New Zealand Ministry of Health) rolled out a world-leading mobile phone text messaging service called Txt2Quit in June 2008. This service is completely free to users. It is targeted towards younger smokers, i.e. aged between 16 and 24, but is available for anyone wishing to use it. People join the service either by phone through the national Quitline or on the internet via the Txt2Quit website (www.txt2quit.org.nz).

The service uses software developed for a randomized controlled trial called Stop Smoking with Mobile Phones (STOMP). Participants in the intervention group went through a 26-week mobile phone text messaging program. STOMP was found to be effective as participants in the intervention group were twice as likely to quit than those in the control group. The quit rate was measured using seven-day point prevalence (i.e. whether the person had smoked in the last seven days) at 6 weeks7. This finding was later replicated in a similar trial conducted in the UK8.

A standard Txt2Quit program lasts for 26 weeks. In cases where clients relapse and return to regular smoking but would like to give quitting another try, they are able to extend their program for up to another four weeks. Txt2Quit clients receive automated text messages on their mobile phone following a pre-determined schedule which refers to their nominated quit date as the starting point. Clients receive three text messages per week for up to two weeks prior to their quit day, three text messages a day for the first month following quit day, and three text messages a week after that for 20 weeks. The content and frequency of the text messages reflect the stage of the client's quitting. For example, messages received prior to the quit date focus on preparing to quit and messages received on and after the quit date are sent more frequently to start with and focus on strategies to cope with cravings and maintaining a smokefree lifestyle (See Table 1 for examples of the text messages used).

Table 1. Example of Txt2Quit mobile phone text messages

One novel feature of the service is the ability for the client to text 'crave' and 'slip up' to receive an immediate text message containing a tip for dealing with a craving or slip up. In terms of 'crave', clients can text 'crave alcohol', 'crave stress' and 'crave bored' to receive supportive messages that are specific to those three situations or just 'crave' for a generic response.

Between July and December 2008, among the different types of ad hoc text message request, "crave general" was used the most often (897 requests) followed by "slip-up" (628 requests). The average number of the three situation-specific crave requests during these months was 142.

The system can also recognize common spelling mistakes to reduce the chance of a no response from the automated system. In cases where the system can not recognize a message, it is assessed by a team of Txt2Quit coordinators (trained Quitline Advisors) who manually correct and re-send the text (if needed) on behalf of the client. The service also includes other features such as the ability for the client to specify a 'black out' period during which time no text messages will be sent by the automated system.

Txt2Quit clients are also eligible for subsidised NRT. In fact, NRT products are mentioned in some of the text messages, i.e. how to obtain them and the cost. Clients are encouraged to place an order via the web. Clients are re-directed from the Txt2Quit homepage to the online ordering form on the main Quit website, from a single click. Alternatively, they can also place an order by calling the Quitline.

Methods

Effectiveness of the Quit website and Txt2Quit are measured for the period of July to December 2008 using two outcome variables: 1) volume of service usage; and 2) their appeal to different smokers. The volume of service usage is measured by the number of clients registered to the Quit website and Txt2Quit, as well as the click site of certain pages on the Quit website. The appeal to different smokers is measured by the different demographic characteristics of clients who registered with the website and Txt2Quit, in comparison to the Quitline.

These data were extracted from the website management package and the client database used by Quit. The client database is a centralized system that stores clients' information and case files. Every time when a client uses the Quit services (include talking to a Quitline Advisor, logging onto the Quit website and sending/receiving a text message on the Txt2Quit program), a case note is created and stored in the client database. While Quitline case notes are entered manually by Quitline Advisors, case notes on website and Txt2Quit usage are generated automatically.

Some clients may have used more than one of these services within the study period (either concurrently or consecutively). In which case, they are counted once in each service they have used. Clients are not expected to use the Quitline and Txt2Quit concurrently. However, Quitline and Txt2Quit clients may use the web service at the same time. A statistics software package R 2.8.1 was used to compare the demographic characteristics of the Quitline, web service and Txt2Quit client populations, using the chi-square test, at the 95% level of confidence.

Evaluation

During the 6-month period between July and December 2008, a total of 2,745 and 1,901 smokers registered with the web based service and Txt2Quit, respectively. This averaged to 457.5 and 316.8 new clients joining each service each month. This compares to an average of 1,856 people joining the Quitline each month. Among the clients who registered with Txt2Quit, about 30% withdrew at some point during the program, while 15% extended their program after having a relapse.

The number of blogs posted and the click rate provides another indicator of website usage. During the same 6-month period, a total of 2,575 blogs were posted, averaging out to 429.2 blogs per month. Among them, 89.3% were public blogs and the remaining 10.7% were private. There was also a high usage of the Quit Calculator. The Calculator received 29,482 page views and 21,845 unique views (unique view counts repeat page views by the same IP address once only), averaging out to 4,913.7 page views and 3,640.8 unique views per month.

Tables 2 - 4 show the ethnicity, gender and age distribution of Quitline, web service and Txt2Quit clients. Due to the amount of missing ethnicity (n=613 out of 2,745) and gender (n=390 out of 2,745) data for web clients, these variables were excluded from the statistical testing. Txt2Quit attracted proportionately more Mãori (the indigenous people on New Zealand) and Pacific people to join this service compared with the Quitline, but this difference does not reach statistical significance. Female clients are over-represented in all services, and this gender split was even more evidenced in clients joining Txt2Quit. In terms of age, a large majority of Txt2Quit clients were under 25 years old. This is not surprising as the Txt2Quit service was advertised in a youth-targeted television campaign and was actively promoted by Quitline Advisors to under-25 clients calling the Quitline. The latter resulted in some clients joining Txt2Quit rather than using the Quitline. Comparing the age composition of Quitline and web service clients, the web service attracted significantly more younger clients (i.e. under 25) than the Quitline.

Table 2. Ethnicity of clients (multiple ethnicities allowed) joining each service between July and December 2008.

Quitline vs Web p-value < 0.01
Quitline vs Txt2Quit p-value < 0.01
Web vs Txt2Quit p-value < 0.01

Table 3. Gender of clients joining each service between July and December 2008.

Quitline vs Txt2Quit p-value < 0.01

Table 4. Age of clients joining each service between July and December 2008.

Quitline vs Web p-value < 0.01
Quitline vs Txt2Quit p-value < 0.01
Web vs Txt2Quit p-value < 0.01

It is of interest to determine if the availability of these new services has broadened Quit's client base to a new population of clients, or if it has diverted clients who would otherwise have used the Quitline to the new services. Comparing the number of Quitline registrations with the two preceding 6-month periods before Txt2Quit was introduced, the number of Quitline registrations decreased from 14,175 and 15,925 to 11,136 - a drop of approximately 4,000 registrations for a 6-month period. As noted previously, it is a planned strategy for Quitline Advisors to actively promote Txt2Quit services to clients under the age of 25. Therefore, a drop in Quitline registration is not unexpected. In addition, the volume of Quitline registrations is sensitive to many other factors such as television advertising9,10. Therefore, the relationship between the offering of Txt2Quit and the drop in Quitline registration should only be seen as correlational instead of causal. On the other hand, the web service serves dual purposes: 1) as an additional channel for Quitline or Txt2Quit clients to gain information and support, or 2) as the only source of support for those who prefer less intensive support. Therefore, for some clients, the offering of the new web service would be seen as an expansion of an existing service instead of an introduction of a new separate service. Unfortunately, the above assumption can be not tested as the current Quit database does not count clients who are using multiple services concurrently as a unique individual.

Some limitations in this evaluation are acknowledged. The web and mobile phone based services were only evaluated on the basis of service usage, not quitting outcome. Txt2Quit clients did receive a mobile phone text message at regular intervals to ask for their smoking status. This information, however, will be studied in a separate analysis on program effectiveness on completion of the first year of that service operating.

Lessons Learned

Introducing new programs is always challenging. Here, I outline some of the strategies to streamline the process. The development and testing phase of new services can be long and costly. For Txt2Quit, the development and testing phase was over 18 months long. To reduce the cost for testing, Quit recruited volunteers from its employees and friends/family to pre-test the program. The pre-testing focused on text message scheduling and functionality (i.e. immediate response to "crave" texts), not the actual content of the messages. Therefore, it is appropriate to involve Quit staff who are not current smokers. They also benefited by gaining a good understanding of how the program works.

As mentioned earlier, the web service and Txt2Quit are supported by a team of online advisors and Txt2Quit coordinators. Although they do not provide the same level of personalized support to clients as Quitline Advisors, it is still vital for them to possess adequate cessation knowledge and personal skills. For these reasons, they are seconded from the Quitline Advisors team and they work part time for both services. By having a centralized workforce, this allows a greater flexibility to schedule advisors to meet unexpected demand for any particular service.

The work responsibility of online advisors is diverse (i.e. moderate online blogs, process online NRT orders etc). To help them to prioritize their various tasks, a computer system was set up to record tasks as a queue. For example, online advisors would be alerted via their task list when a new blog is posted on the web and awaiting moderation. This system ensures all tasks are attended to in a timely fashion.

Future Developments and Conclusions

At the time of writing this article, some plans for further development were underway. Clients joining the Quitline are sent a hard copy of a Quit Book containing useful information on quitting smoking and encouraging smokers to develop their own quit plan. Quit is partway through developing an online version of the Quit Book so that it is available for online members to access via the Quit website. This will contain interactive features for users to record, edit and view their quit plan. Secondly, Quit has undertaken a Txt2Quit client survey to determine client's experience and satisfaction with the service. The results will be available at the end of the first year of the service and will provide important indicators for future development.

Overall, Quit has demonstrated the feasibility of providing health services to a wide variety of clients using new technologies in a 'real world setting', namely the internet and mobile phone. The findings suggest there is a demand for these new services from smokers wanting to quit, and that they attract a group of smokers who may otherwise be hesitant in using the traditional Quitline service.

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Author Information

Judy Li, a researcher at The Quit Group since 2005, conducts a variety of research such as media campaign analysis and smoking cessation programs monitoring and evaluation.