Following this trend, Web-assisted tobacco interventions (WATI) are proving to be efficacious [20-22]. A popular component of WATI is a social network, comprising online communities of people with a common interest who use a website to communicate with each other, also commonly known as support groups, user forums, or discussion boards. Although there is some evidence that social networks can potentially enhance effectiveness and adherence to eHealth interventions [23,24], very little research has been conducted on how social networks function or who accesses them. There are no best practices for their implementation or maintenance.

In a 2010 study, Cobb et al [25] identified the consistent contributions of specific members over time in QuitNet, a large online community for smoking cessation. In 2010, Selby et al [24] found that 25% of first posts made within StopSmokingCenter.net (SSC) were from recent quitters who were struggling with their quit attempts. Their study also found that 35.0% of first replies were from members who had quit within the past month, 49.0% were from members who had quit for more than 1 month but less than 1 year, and 6.6% of first responses to new messages were from experienced members who had quit for more than a year [24]. In a 2007 analysis of AlcoholHelpCenter.net, an online social network for problem drinkers, Cunningham et al [26] found that discussions clustered around nodes of one or more active users. Most recently in 2011, Jones et al [27] identified members in a self-harm discussion forum (SharpTalk) who logged on for much greater times than others and mainly posted in response to other participants.

Social network members who assume leadership roles by providing direct support, advice, and direction are defined by Cobb et al as key players, by Selby et al as posters, by Cunningham et al as active users, and by Jones et al as caretakers. For consistency in this study we collectively define key players, posters, active users, or caretakers as superusers. The purpose of this observational study was to analyze data from two large but distinct WATI to help gain insight into superuser demographic characteristics and how they use social networks.

While the potential to help individuals through legitimate and validated eHealth interventions is exciting, the explosive growth of Internet access parallels the ever-increasing number of websites and Internet protocols (or IPs or URLs, commonly referred to as domain names or IP addresses). The overwhelming number of websites available can be especially confusing for general Internet users when distinguishing between legitimate and nonlegitimate eHealth resources [28]. Because the vast majority of search engines and directories generate revenue by promoting website URLs during general searches, and advertisers can maximize their budgets by using algorithms that deliver appealing campaigns to specific demographics and psychographics, it may become increasingly difficult and expensive for legitimate eHealth resources to attract new users.

One method for legitimate eHealth interventions to attract users is through directories such as Beacon [29], an Australia-based organization that publicizes only eHealth IPs that have undergone randomized controlled trials and pass an independent review from a panel of experts. The challenge for important resources such as Beacon is that they require consistent international funding, promotion, and cross-collaborative support to remain effective. Users may also seek new, innovative technologies that may be missed by such directories, since publishing outcome data from randomized controlled trials lags behind adoption of emerging tools.

An alternative grassroots method that can attract general users is through social networking and the retention of superusers. As they expand the size of a network and facilitate discussion, superusers are valuable assets for eHealth social networks to recruit and retain.

For organizations implementing and managing online social networks, identifying and retaining superusers could contribute to the natural development and growth of website traffic and promote adherence. The challenge is determining how to identify superusers, how to attract them, and how to promote their retention. The first step in this process is to begin to understand who superusers are.

As an initial step designed to investigate superuser characteristics, this observational study analyzed data from two large social networks for smoking cessation: the Canadian Cancer Society’s Smokers’ Helpline Online (SHO) (http://smokershelpline.ca; Figure 1, Figure 2) [30], and the SSC (http://www.stopsmokingcenter.net; Figure 3, Figure 4) [31]. Both programs are available free of charge and are anonymous. We chose the SHO and the SSC social networks due to their large size, active participation, and considerable operational differences.

As a publicly funded program with an internationally recognized and respected brand, SHO undertakes substantial promotional campaigns extending to Internet, television, radio, and print advertising, attracting many smokers. The SHO social network is also used to promote offline activities, such as The Ontario Driven to Quit Challenge. Also, SHO program health educators are required to rigorously monitor content posted by members. An unlimited number of individuals may register for the SHO program. The SHO is a licensed version of the SSC that is modified and updated by the Canadian Cancer Society.

Contrarily, the SSC is not a recognized brand, has never been advertised or promoted, and is maintained as a social enterprise. The organization that operates the SSC (Evolution Health System Inc, San Francisco, CA, USA) does not actively promote the program, nor does it optimize search engine rankings or actively seek links from other websites. Therefore, members using the SSC are a self-seeking, naturalistic Internet population. Although users must endorse a user agreement to participate in the SSC social network, unlike in the SHO, health educators control very little content posted by members.

To actively participate in each social network, registration is required. However, actively participating in the social networks is voluntary; in the study period only 7.90% (n = 1670) of SHO registrants and 14.25% (n = 1627) of SSC registrants made at least one post in the social network (see Table 1). Program registrants and lurkers do not have to register to browse member conversations within each social network.

Every post made in each support group is published immediately. However, to ensure compliance with program rules and regulations, trained health educators review and approve each post through WebTriage (Evolution Health System Inc, San Francisco, CA, USA), a software application designed to facilitate the rapid approval, editing, or deletion of each post.

SHO health educators are paid employees who also manage the Canadian Cancer Society’s telephone quitline. SSC health educators are paid employees of Evolution Health Systems Inc. In addition to training in the use of WebTriage, all health educators receive training in cognitive behavioral therapy, stages of change, motivational interviewing, life coaching, data protection, and user privacy. During high-volume seasons, SSC health educators assist SHO health educators with moderating the SHO social network (WebTriage).

For over 5 years, SHO and SSC social network managers have met together on a bimonthly basis to discuss social network management policies, specific incidences within each support group, moderating strategies designed to increase social network traffic, and the management of superuser populations.

On a quarterly basis, SHO and SSC social network managers meet to review cumulative statistical reports, which include the number of program registrants, number of social network posts, traffic statistics (page views, visits, and unique visitors), and basic demographic data collected at registration.

At the onset of this study, we conducted informal qualitative, in-person interviews with health educators and their management teams. In these interviews, we asked interviewees to reflect on bimonthly and quarterly meetings, each program’s promotional and operational differences, and each network’s tone and social environment. In these interviews all health educators felt that each program attracted superusers with heterogeneous characteristics, and that in each social network posting behavior and demographics would be correlated.

However, health educator and social network managers indicated that, based on their years of experience, they could not generalize superusers into a single category, and that three distinct types of superusers existed: (1) superusers who cumulatively authored the greatest number of posts (posters), (2) superusers who mainly initiated threads (thread starters), and (3) superusers who only communicated with certain members (clique members), and that management styles differed for each of these superuser subgroups.

All study participants consented to the use of their anonymous data for research purposes. Data collection procedures adhered to international privacy guidelines [32-34] and were in accordance with the Helsinki Declaration of 1975, as revised in 2008 [35]. As the study was based on unidentifiable archival data, the study was deemed to be exempt from further review.

Registration to both SHO and SSC is anonymous and free of any commitment or fees. From June 26, 2008 to October 12, 2010 (839 calendar days), 1670 members posted at least once in the SHO social network, and there were 84,599 posts made in 7916 threads. From May 17, 2007 to October 12, 2010 (1245 calendar days), 1627 members posted at least once in the SSC social network, and there were 133,753 posts made in 10,967 threads (see Table 2). During the study periods both programs used identical question formats and response options in the analysis of demographic characteristics.

Users completed a baseline questionnaire upon program registration. Questions were based on the North American Quitline Consortium Minimal Data Set [36]. All data were self-reported. On registration, each user is assigned an anonymous user identification, which becomes his or her primary key. We extracted cross-sectional data sets containing posting behaviors and demographic characteristics from each program’s customized Structured Query Language database. Health educators’ posts were excluded from analysis. Users’ primary keys linked their posting behavior with their demographic data.

In accordance with observations by Cobb et al [25], Selby et al [24], Cunningham et al [26], and Jones et al [27], analysis of posting behavior in both social networks revealed right-skewed distributions, meaning that, cumulatively, most users posted infrequently, and that superusers were responsible for the majority of posts (see Figure 5 and Figure 6).

In each social network, we combined the top 100 posters (ranked according to their total number of posts), thread starters (ranked according to the total number of threads they started), and clique members (ranked according to the number of threads they participated in) in a single database (n = 300). Duplicate entries were removed, leaving a sample of 219 unique superusers. We conducted a power analysis [37] and estimated a total sample size of 95 SHO and 124 SSC superusers to have a power >80% to test the hypothesis at the P < .05 level of significance.

At registration, SHO and SSC used identical formats and response options for the following demographic variables: gender, age, cigarettes per day, past quit attempts, cohabitant smokers, years smoked, and past nicotine replacement therapy usage. Both programs collected other demographic data, but question formats or response options differed significantly, and thus we excluded those data from analysis.

Descriptive statistics pertaining to general posting behavior and demographic characteristics of both superuser groups are presented first. Next, we conducted sets of univariate logistic regressions to detect differences in demographic characteristics between SHO and SSC superusers. Finally, Pearson correlations were computed to detect relationships between behavior and demographic characteristics in each superuser subgroup. All analyses were performed using SPSS for Windows version 18.0 (IBM Corporation, Somers, NY, USA). The significance level was set at P < .05.

The 95 SHO and 124 SSC superusers accounted for 0.4% and 1.1% of total program registrants and 5.7% and 7.6% of all active social network members. They were responsible for 34.78% (n = 29,422) and 46.22% (n = 62,820) of all social network posts (see Table 3).

Analysis of demographic characteristics collected at registration (means) and their standard deviations revealed, from the perspective of marketing and moderating techniques, slightly distinct populations (see Table 4).

A multivariate logistic regression revealed no statistically significant differences in demographic characteristics between the two populations. Gender, age, cigarettes per day, past quit attempts, cohabitant smokers, years smoked, and past or current use of nicotine replacement therapy were all nonsignificant.

To gain further understanding of superuser and superuser-subset characteristics, we determined Pearson correlations to investigate associations between posting behavior and five key demographic characteristics (age, cigarettes smoked per day, quit attempts, cohabitant smokers, and years smoked).

To our knowledge, this is the first study that compared demographic characteristics and posting behavior of the most active participants (superusers) from two moderated social networks designed to assist with smoking cessation. A particular strength is that both programs have relatively few barriers to enrollment in comparison with entry barriers that are typical of Internet-based clinical trials [39], as we collected data from WATI operating in their naturalistic Internet environments.

Another strength is the applicability of findings. Results from this study will influence SHO promotional efforts and operations. Web promotion is generally directed at specific and targeted demographics, such as those reported in the Health Canada general population survey. However, to attract superusers, who are not easily defined, promotional efforts should be broadened. Second, as a results of this study management will modify the training programs of SHO and SSC health educators. Health educators will be introduced to strategies that encourage the participation of superusers once identified within the network, and work is underway to develop computer algorithms that will assist health educators with the early identification of superusers and superuser subtypes.

It is important to note that we have used the term superuser and the three superuser subgroups (posters, thread starters, and clique members) only for the purpose of clarifying observations within this specific investigation. These participatory patterns have not been validated, and further research is required to determine whether they are observable across other types of WATI or health care-based social networks.

To more thoroughly understand superuser characteristics, future studies should compare superuser populations versus nonsuperuser populations (or social network members who create limited posts) and those who register with WATI but do not actively participate in the social network (lurkers). Future research studies should also incorporate the analysis of additional demographic and psychographic characteristics such as occupation, level of education, Goldberg Depression Scale score, Fagerström Test for Nicotine Dependence score, or frequency of Internet usage. These data may be collected at registration; however, in our experience, questions presented to users at registration are most often regarded as intrusive. To maximize use of Web-based programs in a naturalistic setting, registration questions should be kept to an absolute minimum, and other creative means of data collection should be used within interactive program content.

It is also important to note that this study focused only on smokers, and future studies should examine social network behavior and demographic characteristics from superusers, superuser subsets, moderate posters, and lurkers from other condition areas such as depression, panic disorder, problem drinking, self-harm, or healthy weight. This type of research may offer insight into general user characteristics for those who are attracted to Internet programs, and may be used in the development of predictive algorithms.

The results of this study indicate that superusers play powerful roles within social network traffic. While SHO and SSC superusers accounted for only 0.4% and 1.1% of total program registrants, they were responsible for 34.78% and 46.22% of social network content. The results of this study support the previous research of Cobb et al, Selby et al, Cunningham et al, and Jones et al, indicating that different types of superusers (and superuser subgroups) frequently exist.

Significant and well-recognized barriers to treatment include social stigmas that prevent treatment seeking [40] and inconveniences involved with physically attending treatment or in-person group therapy [41]. Whether individuals act as superusers or passively read the posts from others, the Internet’s ability to anonymously and conveniently reach large numbers of individuals can significantly affect health on a population level.

The results of this study suggest that further research in this fast-growing field is required, and that there is potential to maximize the impact of social networks that promote wellness. However, to fully understand the unique mechanisms of Internet-based behavior change, collaboration and knowledge transfer between researchers, nonprofit organizations, and private organizations is recommended.