The Internet is a viable channel to deliver evidence-based smoking cessation treatment that has the potential to make a large population impact on reducing smoking prevalence. There is high demand for smoking cessation information and support on the Internet. Approximately 7% (10.2 million) of adult American Internet users have searched for information on quitting smoking. Little is known about these individuals, their smoking status, what type of cessation services they are seeking on the Internet, or how frequently these searches for cessation information are conducted.
The primary goal of this study was to characterize individuals who search for smoking cessation information on the Internet to determine appropriate triage and treatment strategies. The secondary goal was to estimate the incidence of searches for cessation information using publicly available search engine data.
We recruited individuals who clicked on a link to a leading smoking cessation website (QuitNet) from within the results of a search engine query. Individuals were “intercepted” before seeing the QuitNet home page and were invited to participate in the study. Those accepting the invitation were routed to an online survey about demographics, smoking characteristics, preferences for specific cessation services, and Internet search patterns. To determine the generalizability of our sample, national datasets on search engine usage patterns, market share, and keyword rankings were examined. These datasets were then used to estimate the number of queries for smoking cessation information each year.
During the 10-day study period, 2265 individuals were recruited and 29% (N = 655) responded. Of these, 59% were female and overall tended to be younger than the previously characterized general Internet population. Most (76%) respondents were current smokers; 17% had quit within the last 7 days, and 7% had quit more than 7 days ago. Slightly more than half of active smokers (53%) indicated that they were planning to quit in the next 30 days. Smokers were more likely to seek information on how to quit and on medications; former smokers were more interested in how to cope with withdrawal. All participants rated withdrawal information and individually tailored information as being more useful, while displaying little interest in telephone counseling, expert support, or peer support. Publicly available data from large search engines suggest that 4 million Americans search for resources on smoking cessation each year.
This study adds to the limited data available on individuals who search for smoking cessation information on the Internet, supports the prior estimates of the size of the population, and indicates that these individuals are in appropriate stages for both active cessation interventions and aggressive relapse prevention efforts. Continued development and evaluation of online interventions is warranted, and organizations seeking to promote cessation should carefully evaluate the Internet as a possible modality for treatment and as a gateway to other traditional programs.
The Internet has become the first source of health information for many people, primarily due to the ease of finding information [
The Internet is a powerful delivery channel that has the potential to deliver behavior change interventions on a population-wide basis to help people modify risk factors such as smoking [
The incidence of cessation-related Internet searches may provide an effective proxy for consumer demand for cessation services. To date, there is little information about the rate at which searches for smoking cessation information occur. Several different techniques have been used to estimate the frequency of general health-related Internet searches [
The primary purpose of this study was to characterize individuals who search for smoking cessation information. Specifically, we sought to gather information about sociodemographic and smoking history variables, search patterns (eg, time of day, search terms used), and perceptions about specific types of cessation services. Additionally, we used publicly available data to estimate the incidence of these searches. This information will be critical to develop appropriate and effective online cessation treatment programs, to triage patients as part of a stepped-care treatment model, or to successfully recruit smokers into treatment via the Internet.
Our recruitment strategy leveraged the prominent position of QuitNet (
We recruited individuals based on four inclusion criteria: (1) use of the terms “quit smoking,” “quitting smoking,” “stop smoking,” or “stopping smoking” in a search engine query; (2) use of one of three major search engines (Google, Yahoo!, or MSN) to conduct these queries; (3) no prior visit to the QuitNet website (defined as www.quitnet.com or www.quitnet.org) as determined by the absence of a persistent (long-term) tracking cookie; and (4) location within the United States as determined by reverse lookup of IP (Internet protocol) addresses. When eligible Internet users clicked on the QuitNet link in the results of a search engine query, they were “intercepted” and recruited to participate in the study. The recruitment screen contained links to the survey and to the QuitNet website (
Generalizabilty was established from the complete panel of respondents, while we restricted further analysis to the respondents that reported any history of smoking and were seeking assistance for themselves.
The survey consisted of 10 questions that included basic demographic information (age, gender), reasons for searching for cessation information, current smoking status, readiness to quit, quitting history (number of past quit attempts, length of quit, quit methods used), information desired, and ratings of perceived helpfulness of various online cessation features (eg, bulletin board, assistance in setting a quit date). The survey questions were administered on three separate screens, with no more than three questions per screen. Date and time of survey completion were automatically logged to the database.
Data on utilization of QuitNet after survey administration were extracted, including registration and total time online. Time online was defined as the time between the first page view after completion of the survey through the time of the last page view.
To determine the generalizability of our final sample, we compared survey respondents to nonrespondents who went on to register and use the QuitNet website on the demographic, website utilization, and search pattern variables obtained from the QuitNet database. In addition, we sought to determine the generalizability of our sample to the broader population of individuals who search for online smoking cessation information throughout the year. To do this, we examined the percentage of participants referred from each search engine as well as the total volume of cessation search terms used in Internet search engine queries, using publicly available data from Nielsen/NetRatings [
For the 10-item survey, frequency tables were used to summarize the categorical data, and nonparametric tests were used to determine the statistical significance level. We used
Finally, to estimate the incidence of cessation-related Internet searches each year, we replicated the technique used by Eysenbach and Kohler [
During the 10-day study period, 2265 eligible US residents were intercepted. Of those, 35.8% (N = 811) clicked on the “survey” link, 48% (N = 1088) clicked on the link to take them directly to the site (“declined”), and 16.2% (N = 366) did neither (“abandoned”). Of the 811 individuals who clicked through to the survey, 87.2% (N = 655) completed the full survey, yielding an overall response rate of 29% (
Eligibility and Recruitment Results
To assess generalizability, we compared all survey participants (N = 655) with nonrespondents who proceeded to register with QuitNet (N = 243). Overall, nonrespondents (N = 1454, abandoned and declined) were significantly less likely than survey respondents to register on QuitNet (16.7 vs 51.4%, Χ2
2 = 303.7,
As shown in
Comparison of search engine usage to Nielsen/NetRatings statistics
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57 | 60 | |
Yahoo! | 29 | 23 |
MSN | 14 | 17 |
Total | 100 | 100 |
The use of key search terms (“quit smoking,” “quitting smoking,” “stop smoking,” or “stopping smoking”) by survey respondents was also consistent with search patterns captured by Overture and Wordtracker. As shown in
Frequency of smoking-related search terms in search engine queries
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quit smoking | 52.9 | 55.4 | 59.1 | 47.8 |
stop smoking | 24.9 | 23.9 | 31.1 | 36.5 |
quitting smoking | 21.9 | 20.4 | 9.0 | 13.4 |
stopping smoking | 0.3 | 0.4 | 0.6 | 1.8 |
giving up smoking | 0.00 | 0.00 | 0.2 | 0.6 |
As shown in
Participants were asked the reason they were searching for smoking cessation information. The majority of survey respondents (90.1%, n = 590) indicated that they were looking for help or support for themselves; 5.6% (n = 37) were looking for general information; 3.4% (n = 22) were looking for help for someone else; and 1% (n = 6) were health professionals or researchers looking for information. Further analyses were limited to individuals looking for cessation help or support for themselves or for general cessation information (N = 626). Among these individuals, 75.4% (n = 472) were current smokers, 17.4% (n = 109) had quit within 7 days (“recent quitters”), and 7.2% (n = 45) had quit more than 7 days ago (“longer-term quitters”).
Demographic and smoking characteristics of study participants (N = 626)
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< 18 | 5 (0.8) |
18-25 | 117 (18.7) |
26-34 | 232 (37.0) |
35-44 | 161 (25.7) |
45-54 | 87 (13.9) |
55-64 | 20 (3.2) |
65 or older | 4 (0.6) |
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Male | 243 (38.8) |
Female | 383 (61.2) |
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Current smoker | 472 (75.4) |
Not thinking of quitting | 1 (0.2) |
Thinking of quitting in 6 months | 222 (35.5) |
Thinking of quitting in 30 days | 249 (39.8) |
Quit ≤ 1 week | 109 (17.4) |
Quit > 1 week, ≤ 1 month | 43 (6.9) |
Quit > 1 month | 2 (0.3) |
The majority of current smokers (52.8%, n = 249) planned to quit in the next 30 days, 47.0% (n = 222) planned to quit in the next 6 months, and one person (0.2%) was not thinking about quitting. Smokers had made an average of 5.1 quit attempts (SD = 14.7; median = 1) during the past year.
As shown in
Information sought by smoking status (N = 626)
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How to quit | 88.1 | 54.1 | 40.0 | 104.7 | < .001 |
Medications | 30.7 | 5.5 | 4.4 | 41.0 | < .001 |
Alternative methods | 57.6 | 16.5 | 17.8 | 77.3 | < .001 |
Withdrawal | 59.7 | 77.1 | 66.7 | 11.7 | .003 |
*Current smokers are the reference group.
Note: Multiple responses were allowed, so total percentages within smoking category exceed 100%.
Participants were also asked to rate the perceived helpfulness of various smoking cessation treatment interventions on a scale from 1 to 5, with 1 representing “very helpful” and 5 representing “not helpful at all.” As shown in
Perceived helpfulness of Internet features by smoking status
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Information on withdrawal | 1.84 (1.15) | 1.90 (1.17) | 1.67 (1.08) | .06 | 1.51 (0.75) | .04 |
Individually tailored information | 1.90 (1.18) | 1.88 (1.18) | 2.00 (1.25) | .36 | 1.79 (0.95) | .62 |
A meter that keeps track of personal data | 2.14 (1.37) | 2.14 (1.37) | 2.14 (1.42) | 1.0 | 2.15 (1.31) | .97 |
Information on medication side effects | 2.59 (1.38) | 2.55 (1.38) | 2.79 (1.34) | .11 | 2.54 (1.43) | .97 |
Assistance in choosing a medication product | 2.72 (1.37) | 2.61 (1.36) | 2.97 (1.38) | .02 | 3.24 (1.24) | .007 |
Information on medications | 2.72 (1.36) | 2.62 (1.36) | 2.97 (1.37) | .02 | 3.23 (1.23) | .007 |
Online, personal help from a professional | 2.81 (1.38) | 2.79 (1.40) | 2.86 (1.29) | .67 | 2.88 (1.39) | .70 |
Ability to find buddies | 2.82 (1.37) | 2.87 (1.39) | 2.74 (1.29) | .40 | 2.59 (1.34) | .22 |
Assistance in setting a quit date | 2.83 (1.39) | 2.69 (1.37) | 3.25 (1.32) | < .001 | 3.39 (1.37) | .003 |
Support via chat, forums, or email | 2.90 (1.38) | 2.98 (1.39) | 2.67 (1.35) | .04 | 2.57 (1.30) | .07 |
Additional information that arrives by email | 2.95 (1.40) | 2.91 (1.43) | 3.06 (1.30) | .34 | 3.08 (1.26) | .49 |
Talking by phone with a professional counselor | 3.21 (1.35) | 3.17 (1.39) | 3.32 (1.22) | .32 | 3.46 (1.29) | .20 |
*
Note: 1 = very helpful; 2 = helpful; 3 = somewhat helpful; 4 = not very helpful; 5 = not helpful at all
Proportion of participants (N = 626) rating Internet cessation services as helpful or very helpful
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Information on withdrawal | 460 | 73.5 |
Individually tailored information | 450 | 71.9 |
A meter that keeps track of personal data | 405 | 64.7 |
Information on medication side effects | 303 | 48.4 |
Information on medications | 275 | 43.9 |
Assistance in choosing a medication product | 273 | 43.6 |
Online, personal help from a professional | 265 | 42.3 |
Ability to find buddies | 250 | 39.9 |
Assistance in setting a quit date | 248 | 39.6 |
Support from others, via chat, forums, or email | 233 | 37.2 |
Additional information that arrives by email | 223 | 35.6 |
Talking by phone with a professional counselor | 184 | 29.4 |
Over the course of 9 months, 541685 searches were extracted from MetaSpy, of which a total of 38 were smoking cessation related. Assuming a total search engine volume of 52 billion searches per year [
The Internet holds great potential to impact population smoking prevalence by delivering evidence-based treatments to greater numbers of smokers who may never receive treatment through other modalities. This is the first study to characterize the population of individuals looking for cessation information online. Results suggest that the Internet may be an effective way to reach smokers who are younger, who search for cessation services during work hours, and who have recently quit on their own.
The relatively large proportion (17.4%) of recent quitters (within 7 days) in this study who are actively seeking assistance is of particular importance. The majority of self-quitters relapse within 8 days [
New population-based strategies to identify and reach smokers with evidence-based cessation treatment are needed [
Several limitations should be considered when interpreting results of this study. The relatively low response rate (29%) raises concern about the generalizability of findings. Survey respondents were more likely to go on to register with the site; this likely indicates that they were in a more advanced stage of change than nonrespondents. It may, however, also indicate that the survey itself acted as an incentive to proceed to registration. Furthermore, we worked from the assumption that individuals who clicked on the link to QuitNet in search engine results were representative of the entire population of searchers. Although consistent with utilization patterns of search engines, this assumption has never been tested for searches on smoking cessation, or the QuitNet site in particular. It is possible that less motivated searchers may find the query results unappealing and not click on any link at all, thus biasing our results toward individuals closer to quitting.
A second potential limitation is the method we used to estimate the total number of people seeking smoking cessation information each year. This method does not take into account searches using other keywords or individuals using resources other than search engines to find information (eg, health Web portals, referrals from health professionals, direct-to-consumer advertising, or quit lines). In addition, individuals may search for information multiple times, making it difficult to estimate the actual number of unique individuals as opposed to the total number of searches. Finally, the dataset used to derive these estimates is of commercial nature and published online in a promotional context. It has not been peer-reviewed or made available in its raw form. The data for this study were collected from 2003-2004; it is possible that in the intervening time the demographics or search behavior of smokers has changed. However, given the limited changes in both search engine technology as well as the demographics of smokers in the United States, this seems unlikely. Despite these limitations, this study provides valuable information about people who search for smoking cessation information online, and it demonstrates a new methodology for validating this kind of survey data.
This study suggests that the potential public health impact that can be achieved through Internet-based smoking cessation programs is significant given the reach of the Internet—should these interventions be proven effective. Given that individuals may conduct multiple searches, our estimate of 3.6 million active searches per year for smoking cessation information is consistent with the 2004 data that showed 7% (about 10 million) of Internet users in the United States had searched for information on quitting smoking [
The public health community has invested heavily over the past 15 years in successfully de-normalizing smoking and encouraging cessation. However, low uptake rates seen in clinical programs and telephone quit lines call for new population-based approaches. Even if Internet-assisted tobacco interventions prove to have limited efficacy, the Web may still serve as a point of entry to multi-modality treatment programs. These programs may serve to simply link online searchers to more traditional treatment programs (such as telephone counseling or local group sessions), provide pharmaceutical products, or, in more sophisticated settings, use the Web as a platform to integrate voice counseling, local groups, mailed pharmaceutical products, and other proven modalities. We anticipate that the consumer demand demonstrated in this report will ultimately drive increasing services that will reflect a mixture of these different evidence-based treatments.
Survey deployment and data collection were performed at QuitNet Inc. by Dr. Cobb with support by the company. Drs. Graham and Cobb had complete access to all raw data, and performed all analysis and writing of the manuscript.
At the time of the survey design and data collection Dr. Cobb served as an executive of QuitNet Inc. as well as holding a financial interest in the company. Dr. Graham has served as a consultant to the company in the past. At the time of submission of the manuscript, neither author had an affiliation or financial involvement with QuitNet Inc.
Sample search engine screenshot
Survey invitation interception page