Tobacco control is at a crossroads. On the positive side, tobacco-related diseases are being prevented and treated better than ever. For example, in the United States, the overall cancer death rate decreased by 12% between 1991 and 2003. A significant proportion of this decline (40%) is not due to breakthroughs in molecular medicine, gene therapy, or other highly technical treatments, but to a behavioral intervention: smoking cessation [1]. This effect is evident in all cancers put together, not just lung cancer.

While positive, the gains shown in countries where tobacco use was first widespread (and where tobacco control efforts first took hold) are made less visible by the threat that tobacco continues to pose globally. Tobacco was responsible for more than 100 million deaths worldwide in the 20^th century and is forecast to kill at least one billion more in the century to come. More troubling perhaps is that 80% of such deaths are projected to occur in the developing world [2], where tobacco companies have focused their marketing efforts [3]. Half of the current smokers today (about 650 million people) will die as a result of tobacco use, with tobacco use accounting for the premature death of 4.9 million people worldwide [4].

To profile the state of tobacco and its current threat and impact on population health, the World Health Organization identified six strategies that are essential to reducing the burden of tobacco worldwide: 1) Monitor tobacco use and prevention policies, 2) Protect people from tobacco smoke, 3) Offer help to quit tobacco use, 4) Warn about the dangers of tobacco, 5) Enforce bans on tobacco advertising, promotion and sponsorship, and 6) Raise taxes on tobacco (MPOWER). Combined, these MPOWER strategies comprise the comprehensive tobacco control strategy that is reflected in the Framework Convention on Tobacco Control [5], the world’s first global public health treaty. What the report does not articulate – indeed what tobacco control struggles with as a whole – is how strategies like these can be carried out in practice and identifying the methods that are effective, transnational in scope, efficient in their use of scarce resources, and accessible to those that need them.

It is here that technology-enabled information tools hold promise. Web-assisted tobacco interventions (WATI) represent the vanguard of a new method of engaging the public, health professionals, and researchers alike in tobacco control as part of a greater public eHealth strategy. Technologies such as interactive websites, wireless phones, and handheld computers have shown promise as tools to support smoking prevention and cessation [6-13], health policy development [14] and knowledge translation for health promotion [15]. To support establishment of this nascent transdisciplinary field of research and practice, the WATI Initiative was developed in 2004 to support the development, study, and implementation of technology-delivered interventions to support tobacco control [16]. The Web part of WATI refers not only to interventions that are accessible from a desktop and the World Wide Web, but also to other networked technologies such as wireless phones or hybrid mobile devices such as the iPhone, Blackberry or other ‘smart phone’ handsets. As information becomes more tightly integrated across technologies this will remain an important distinction, particularly given the blurring of technologies that allow tools to be accessed across platforms and devices.

WATI resources have focused on four key areas: 1) cessation, 2) prevention, 3) social support, and 4) professional development and training. They can be used as a stand-alone intervention, a complement to other (mostly non-Internet) resources, or as an integrated component within a larger intervention [17]. WATI-focused research has received considerable attention within the eHealth field, including many publications in this journal over the past 10 years [8, 18-26]. WATI resources are becoming popular in part because the high proximal (and rising) levels of Internet access in many countries [27] and the prospect that, with wide reaching accessibility, a small shift in behavior attributed to a Web intervention can readily translate into a large population health effect.

Never before has this been more important considering the prognosis outlined by the WHO. Yet in spite of such promise, eHealth’s principal challenge is ensuring the distribution of benefits are equitable and do not simply confer advantages to those who already have resources [28]. It also means considering how eHealth tools used in a developed nation may not be the same ones we employ in the developing world to address tobacco control. For example, as anyone who has travelled widely can see, wireless phones are used for much more than talking (such as banking or ecommerce) in Africa, Asia and Europe, but much less so in North America. Likewise, penetration of smart phone technology through tools such as the Blackberry and others remain largely confined to the US, Canada and Western Europe. But in both cases, the use of technology is rapidly transforming the way people interact locally and globally.

However, these changes are providing avenues for tobacco promotion as well as control. Advertisements, such as the one depicted in Figure 1 from one of the author’s recent visits to Tanzania, illustrate ways in which technology is being blended into promotions for tobacco products. Here, a phone camera is used as a technology-friendly way to accent cigarette promotions. In other areas, the Internet has provided a transnational avenue towards the establishment of ‘dark markets’ where the tobacco industry has sought to exploit, reaching populations that are illegal to sell to, such as youth, in places where they are otherwise legally forbidden to advertise [29-31] and where the regulations governing Internet communications are often unclear.

Figure 1

Cigarette billboard advertisement, Arusha, Tanzania, January 2007