Evaluation of an Adolescent Smoking-Cessation Media Campaign: GottaQuit.com
http://www.100md.com
《小儿科》
Division of Adolescent Medicine, Strong Children's Research Center, University of Rochester, Rochester, New York
ABSTRACT
Objective.To evaluate the impact of a smoking-cessation media campaign for teens on utilization of a cessation Web site, GottaQuit.com.
Methods.Telephone surveys were conducted before and after the implementation of a countywide media campaign to promote the use of a smoking-cessation Web site for youths. The surveys were designed to assess teen awareness and utilization of the Web site, as well as tobacco use and cessation attempts. Supplemental 2003 Youth Risk Behavior Survey items also assessed use of the Web site.
Results.Most teen smokers reported that they wanted to quit smoking. Almost all teens reported exposure to GottaQuit.com ads and accurately identified GottaQuit.com as a Web site that offers cessation help for youths. Nearly 1 in 4 smokers who were trying to quit had visited GottaQuit.com or another Web site for cessation assistance.
Conclusions.The GottaQuit.com campaign effectively reached almost all teens, regardless of smoking status. Smokers were more likely than nonsmokers to have visited the Web site for help with quitting. Web adjuncts are likely to be used by adolescents who seek assistance in quitting.
Key Words: adolescent smoking smoking cessation media campaign cessation assistance tobacco use
Abbreviations: MSA, Master Settlement Agreement YRBS, Youth Risk Behavior Survey
Tobacco use is the single most preventable cause of death and disease in the United States, causing >440000 deaths each year.1 Nationally, health care expenditures to treat tobacco-related disease amount to more than $75 billion. Approximately 80% of adult smokers started smoking before the age of 18,1 and every day, nearly 2000 adolescents become established smokers.2 Although efforts have been made to reduce adult smoking rates, adolescent smoking remains a problem. Most teens have used tobacco before graduating from high school, and many began using in early adolescence. Even among youths who are not yet "regular" smokers, many report being addicted,3 and most adolescent smokers report that they would like to quit.4, 5 Youth smoking rates in Monroe County, New York, are comparable to rates for New York State and for much of the United States: from 1992 to 1999, smoking rates among public high school students ranged from 28% to 38%, and 66% of youths reported that they tried smoking during their high school years.6
A variety of strategies have been put into practice to prevent tobacco use and promote cessation for youths, including school-based interventions, increased tobacco excise taxes, and clinical smoking-cessation interventions.7, 8 Antismoking media campaigns have also been found to be effective in reducing adolescent cigarette consumption. The American Legacy Foundation's national tobacco countermarketing campaign, "truth," featured youths confronting tobacco industry practices in an attempt to positively change adolescent attitudes about tobacco use. Telephone surveys that were conducted before and after the "truth" campaign in Florida found that antitobacco attitudes and beliefs increased and that youths who were exposed to this campaign had high rates of message recall and reduced rates of smoking behavior.9, 10 Advertisements that are centered on the tobacco industry's manipulation of consumers, particularly youths, and on the negative effects of second-hand smoke have also been found to be effective deterrents to cigarette consumption.11
Adult smoking cessation is enhanced by inclusion of mailed and telephone adjuncts to public health or clinical cessation interventions.12–14 Telephone quitlines have become well established as effective in promoting cessation, reach many youths when specifically marketed to teens, and may help adolescents quit successfully.15 However, in focus groups, we and others have found that many adolescents who smoke and want to quit do not think of quitting with assistance of clinicians or other resources.16–18 In addition, although adolescents were interested in adjunct resources that may help them quit, they were hesitant to use telephone-based resources.16
The 1998 Master Settlement Agreement (MSA) between major tobacco manufacturers and the US State Attorneys General resolved outstanding state lawsuits and obligated tobacco companies to pay states an average of $10 billion per year.19 The Centers for Disease Control and Prevention published guidelines for the allocation of MSA funds,14 but there were no requirements that states allocate funds to tobacco-control programs. In New York State, counties also received a share of these funds, as they directly fund a portion of Medicaid expenditures. In Monroe County, New York, a portion of the MSA funds were used to implement a media campaign for a smoking-cessation Web site and quit helpline for teens, called GottaQuit.com.
GottaQuit.com was designed to promote adolescent smoking cessation and to complement adult cessation and youth tobacco prevention messages being sponsored by national and New York State advocacy groups. This media campaign, linked to an interactive youth cessation Web site, was introduced in January 2001 to help nicotine-addicted adolescents quit by providing adjuncts and supportive counseling. GottaQuit.com was publicized through paid media on television, radio, billboards, and city busses. The Web site features informational content, quit tips, and an e-mail "quit calendar," which provides tailored motivational encouragement for quitting. A section called "Talk To Us, Live" also allowed adolescents to connect with a trained quit coach and former smoker using instant message "chat" software. GottaQuit.com advertisement themes were developed on the basis of focus groups and expert opinion and focused on the fact that teen smokers want to quit but do not think of quitting with assistance.16 All advertisements emphasized the GottaQuit.com Web site as a place to get help quitting; most also featured a teenager explaining how smoking negatively interfered with their life. The 6 television ads used in the campaign are available for review at www.metrix-marketing.com/portfolio.htm.
This article reports on a pre/post cross-sectional evaluation of the GottaQuit.com smoking-cessation media campaign and Web site. We also examined adolescent and parent attitudes about tobacco, exposure to smoking-cessation and prevention media, adolescent tobacco use, and cessation attempts.
METHODS
We surveyed teens and their parents before implementation of GottaQuit.com in 2000 to determine demographic information including self-reported socioeconomic status20; media use; exposure to television, radio, billboard, or bus ads about adolescents and smoking; smoking prevalence and behavior; and cessation resources available to teen smokers. A random sample of 1000 households was selected from a school enrollment-based list of 18830 households in Monroe County, New York, with at least 1 child aged 14 to 19. Of these, we were able to identify working telephone numbers for 808 (81%) households. We successfully contacted 675 (84%) of these eligible households and obtained parent and adolescent consent and completed surveys with 418 (62%) of these adolescents. Of the 418 teens surveyed, 327 (78%) parents also completed a brief survey that assessed exposure to television, radio, or billboard messages about adolescents and smoking; content of the messages; whether they had talked to their child about tobacco; knowledge of cessation resources that are available to youths; knowledge of and attitude toward the tobacco settlement; personal smoking practices; and perceived smoking practices of their teen.
After GottaQuit.com had been in the field for 1 year, a follow-up adolescent survey assessed demographic information, media use, smoking prevalence and behavior, use and availability of cessation resources, and adolescent exposure and receptivity to GottaQuit.com and other teen smoking media campaigns. Media use was assessed by asking adolescents the amount of time that they spent listening to the radio during the week and on the weekend; adolescents in the postcampaign sample were also asked about television and Internet use. These measures were summed to estimate average weekly radio, television, and Internet use. For assessing receptivity to the campaign's messages, advertisement themes were described using cues identified as memorable in recall by teens during cognitive interview pilot testing. Receptivity to the ads then was determined by asking the adolescent how well the advertisement's theme and/or its character related to his or her own life or situation. For estimating the magnitude of false-positive exposure reports, youths were also asked about ads that did not exist. For the follow-up, we used a random sample of 606 households in Monroe County with at least 1 child aged 14 to 19. We were able to contact 333 (55%) households and completed surveys with 259 (78%) adolescents; 257 (99%) parents also completed a survey that was identical to the preintervention survey.
We also added supplemental items to the 2003 Monroe County Youth Risk Behavior Survey (YRBS). The YRBS was completed by 1688 adolescents sampled from 32 schools from all but 1 school district in Monroe County. The classroom participation rate was 87%. All adolescents were asked about current smoking status, whether they had ever visited GottaQuit.com or another Internet site to help them stop smoking, and how many times they visited GottaQuit.com in the past 12 months; smokers were asked whether they had tried to quit in the past year.
For both pre and post telephone surveys, parental consent and adolescent assent were obtained for adolescents who were younger than 18 years and informed consent was obtained for adolescents who were 18 and older. All study protocols were approved by the University of Rochester Research Subjects Review Board. The YRBS was administered by the county as part of their routine public health surveillance activities; these data were exempt from review.
RESULTS
Demographics and Media Use
The precampaign, postcampaign, and Monroe County YRBS samples had slightly different demographic profiles (Table 1). The samples were split nearly evenly between genders, with the postcampaign sample having a slightly higher percentage of female respondents than the other groups. The mean age of the precampaign and YRBS samples was younger than the age of the postcampaign sample. The majority of respondents were white, followed by black, and other, which included Hispanic, Asian, American Indian, Native Hawaiian or other Pacific Islander, and multiracial respondents. The YRBS sample had a higher percentage of black and other respondents.
Self-reported socioeconomic status and parents' education level were comparable between the postcampaign and postcampaign samples. The precampaign sample consisted of mostly high school students, whereas 42% of postcampaign respondents were college students. Both samples reported high levels of media use.
Parent Survey
The majority of parents reported that they felt comfortable talking to their adolescent about tobacco and smoking (93% postcampaign and 98% postcampaign; P = .004). A higher percentage of postcampaign parents were aware of teen cessation resources that are available in their community (43% vs 22% precampaign; P .0001). Two of 3 parents in each sample were aware of tobacco settlement monies (69% of postcampaign and 63% of postcampaign; not significant). The majority (81% and 85%; not significant) believed that it was a good or very good idea for Monroe County to use settlement monies for a media campaign directed at teen smokers. Smoking status was comparable between parents in the 2 samples.
Tobacco Use
Self-reported tobacco use was comparable between the precampaign and postcampaign samples (Table 2). On average, respondents were 14 years old when they first smoked, and comparable proportions reported having smoked daily during the 30 days preceding the survey ("current smokers"). Current smokers were significantly more likely to be older than nonsmokers in both samples. In the postcampaign sample, white teens were more likely than black teens or teens of other ethnic groups to be current smokers. No significant gender differences were found between smokers and nonsmokers in either sample.
Most current smokers considered themselves to be smokers and thought that they were addicted to nicotine. Teens in the postcampaign sample were less likely to report daily smoking but were more likely to classify themselves as regular smokers.
Cessation Help for Teen Smokers
The majority of smokers in both samples reported that they wanted to stop smoking completely (Table 2). Postcampaign smokers were more likely to report that they had seriously tried to quit smoking cigarettes and had tried to quit more times than precampaign smokers. No respondents in either sample reported having ever called a telephone hotline for help with quitting.
Impact of GottaQuit.com and Other Antitobacco Media
Most parents (82%) and adolescents (90%) in the precampaign sample reported that they had seen one or more television, radio, or billboard ads about adolescents and smoking. An even higher percentage in the postcampaign sample reported that they had seen 1 or more ads on this topic (91% and 98%, respectively). Television ads from the American Legacy Foundation's "truth" media campaign, which had run in the Rochester MSA media market, were recognized by 71% of adolescents in the precampaign sample and by 49% of adolescents in the postcampaign sample.
Most teens in the postcampaign sample had seen television ads (86%) or heard radio ads (82%) promoting Internet sites to help teens quit smoking. Thirty-seven percent of the precampaign sample also reported having seen television ads and 28% reported having heard radio ads for Internet or telephone services to help teens quit, although, to the best of our knowledge, no ads of this type were running before or during the time our survey was in the field. There were no differences by gender or smoking status as to whether teens recalled these ads.
Ninety-four percent of postcampaign respondents reported that they had seen an advertisement for GottaQuit.com, and most identified GottaQuit.com as a Web site that offers cessation help for youths (Table 3). There were no differences in gender, age, or smoking status in recall of specific GottaQuit.com ads. The majority of teens recognized the overall message of the campaign, "I've gotta quit, I just need a little help." Smokers were significantly more likely than nonsmokers to report that they believed that the ads related to their life (Table 3).
GottaQuit.com Utilization
One (25.7%) in 4 postcampaign telephone survey respondents who smoked reported that they had visited GottaQuit.com, compared with only 4% of nonsmokers (Table 3). Almost all Web-site users who smoked reported that they went to the Web site for help in quitting. Eleven percent of Monroe County YRBS respondents reported that they had visited GottaQuit.com or another Internet site for help in quitting (Table 4). Seventeen percent of smokers visited GottaQuit.com at least once during the 12 months preceding the survey, compared with 4% of nonsmokers (P .0001). In addition, 23% of teens who had tried to quit smoking in the past year had visited GottaQuit.com or another cessation Web site at least once. YRBS sample smokers were slightly less likely to report that they had visited GottaQuit.com (17.3%). This finding was not significantly different from the telephone survey estimate (P = .221).
DISCUSSION
The tobacco industry spends nearly $7 billion a year to advertise and promote cigarettes.1 Thus, successful counter-advertising and smoking-cessation strategies must be established. Evaluation of the GottaQuit.com adolescent smoking-cessation media campaign in Monroe County, NY, showed that almost all adolescents in the county had seen or heard 1 or more ads about the cessation Web site. This is the first report of a community-based cessation campaign that integrated Web adjuncts with mass media messages targeting youths. Most adolescents were aware that the Web site offered cessation help, the majority recognized the main theme of the campaign ("I've gotta quit, I just need a little help"), and most smokers reported that the advertisement themes related to their lives. Although GottaQuit.com campaign ads focused specifically on promoting cessation assistance, several also contained antitobacco messages, and the overall antitobacco theme was recalled by the majority of adolescents, regardless of smoking status.
Most adolescent smokers wanted to quit, and many had tried several times. This is consistent with other studies showing that many teen smokers are motivated to quit smoking.5, 21 Research suggests that youths may be especially in need of cessation interventions22; however, many do not think to get assistance with quitting.16 Most adolescents are not familiar with smoking-cessation programs, and some have concerns about confidentiality, parental involvement, and whether cessation counselors are able to relate to their experiences.18
The GottaQuit.com campaign and Web site generated a high rate of use. Even among telephone quitlines that are specifically promoted to adolescents, only a very small proportion of eligible youths call.15 Other state and community antitobacco media campaigns have been shown to be effective in increasing adolescents' antitobacco attitudes and beliefs,9, 10 reducing youth smoking rates and rates of progression to established smoking,10, 11, 23, 24 and reducing adult smoking rates when exposure to multimedia cessation ads was combined with cessation treatment.25 There were 12000 unique visitors and >27000 visitor sessions on GottaQuit.com during the first 6 months of the campaign. However, we were unable to track whether these hits were from users in Monroe County, and, because of cable television broadcast coverage patterns in advertising, the campaign media was also seen in the greater Rochester metropolitan area (a 6-county region) and in neighboring areas. Thus, we could not assess the number of hits in proportion to the number of teen smokers in the county. However, self-reported telephone survey data and county YRBS data showed that teen smokers were much more likely to visit the Web site. This is the first study that shows the potential of Web adjuncts for reaching a high proportion of adolescent smokers.
Our study showed that the GottaQuit.com campaign messages, which had been tailored to adolescents who smoked, were in fact highly salient to teen smokers. Youth smokers reported that they related to the characters, themes of addiction, and the desire to quit that were portrayed in the ads. Although some teens who were nonsmokers also visited the Web site as a result of the campaign's media messages, >1 in 4 smokers, compared with only 1 in 25 nonsmokers, visited the GottaQuit.com Web site at least once, primarily for help in quitting. These findings demonstrate that teen smokers are highly receptive to messages that promote Internet-based cessation resources for those who are motivated to quit.
Web-based health interventions have great potential for meeting adolescents' needs, as these media are nonjudgmental, are confidential, do not require interaction with others, and are not limited by time.17 The majority of teens also report being online on a frequent basis.26 A Web-based cessation program for college students found high levels of use, satisfaction, and comfort with using a Web site for cessation assistance.27 An online international smoking-cessation program for adults demonstrated the ability of the Internet to disseminate information and collect data on cessation.28 However, few Web-based studies have specifically targeted adolescents, and the usability and content of cessation Web sites are varied. The volume of health information that is available on the Internet may be difficult to manage for some adolescents, and limited access can have an impact on the quality of information obtained.29 Nonetheless, at least when combined with media to promote use, Web-based cessation is sought out by youths who smoke.
Descriptive literature on smoking-cessation Web sites has found that reading levels were high, that most sites did not address 1 or more key components of National Cancer Institute–recommended treatment or use the interactive capabilities of the Internet, and that sites are rarely easily found using commonly used search engines.30–33 Future study of Internet-based cessation adjuncts are needed to assess the relative effectiveness of these resources in helping teen smokers quit.
Parents who consistently communicate with their teens about smoking can have a significant impact on their smoking behaviors.34 Almost all parents in each phase of our study reported that they felt comfortable talking to their teen about tobacco, and most had talked with their teen about it at least once in the preceding 6 months. More postcampaign parents were aware of community resources, and many knew of a Web site that was available to assist teens with cessation. This increased awareness of available resources may be a result of the scope of the GottaQuit.com campaign, or more resources may have actually been available to teens in 2002 than in 2000. However, whether parents' communication about cessation opportunities helps decrease the chances that their adolescent will smoke over time is not known. Of policy interest, many parents were aware of tobacco settlement monies, and the majority thought that it was a good idea to use that money for teen smoking cessation. The high level of support from parents for this campaign may be useful for initiating or sustaining future antitobacco efforts.
Our study relied on self-reported behaviors and attitudes about tobacco use and cessation and the impact of GottaQuit.com campaign messages. As a result, respondents may have had a tendency to report socially desirable behaviors and attitudes or may not have recalled information accurately. Adolescents who participated in the study may have differed from those who declined, resulting in selection bias. In addition, the survey method may have had an effect on selection, as people in lower socioeconomic groups are less likely to have working telephones.35
The postcampaign sample was older than the precampaign sample, which was an unexpected sample bias. Although the age and ethnicity of our samples varied slightly, this is likely because the pre sample was drawn from a school-based list and the post sample from a random-digit dialed sample. The former is likely to underrepresent out-of-school youths, as evidenced by age being comparable to the school-based YRBS. Ethnicity distribution differences may reflect undercoverage and nonresponse biases among ethnic minority and/or poorer households, as poorer families move more frequently and have less reliable telephone service.35 Nearly half of the post sample attended college; thus, their attitudes and opinions about tobacco use and smoking cessation may differ from those of younger students. In addition, as the YRBS is administered only in school, data from this survey are also not representative of all adolescents in the county. Thus, findings may not be generalizable to other adolescents or to other geographic areas.
Another limitation of our study is that nearly all teens in each sample were classified as middle or high socioeconomic status. In 2001, the National Household Survey on Drug Abuse found cigarette use to be higher among youths from families with lower incomes than those with higher incomes.36 Additional research on Monroe County teens in lower socioeconomic groups would provide data on tobacco use and the impact of the campaign among this population.
CONCLUSIONS
The GottaQuit.com smoking-cessation media campaign effectively reached almost all teens in Monroe County, regardless of smoking status. Smokers were more likely than nonsmokers to have visited the GottaQuit.com Web site for help with smoking cessation. The majority of teen smokers in this study wanted to quit but had been unsuccessful in previous attempts. Exposure to this smoking-cessation media campaign effectively encouraged some adolescents to seek assistance in quitting from GottaQuit.com, and public support for this youth cessation media campaign was high. Additional studies are needed to evaluate the impact of cessation media and Web sites on youth quitting.
ACKNOWLEDGMENTS
This research was supported by the Monroe County Health Department.
We thank Tracy Crandall, Andrew Doniger, Deborah Ossip-Klein, Scott McIntosh, John Ricci, and John Riley for their role on Monroe County's project advisory committee and Cheryl Utter for assistance in developing and fielding the Monroe County Youth Risk Behavior Survey supplemental items.
FOOTNOTES
Accepted May 24, 2005.
No conflict of interest declared.
REFERENCES
Substance Abuse and Mental Health Services Administration. Results from the 2002 National Survey on Drug Use and Health: National Findings. Rockville, MD: Department of Health and Human Services, Office of Applied Studies; 2003. NHSDA Series H-22, DHHS Publication SMA 03–3836
DiFranza JR, Savageau JA, Fletcher K, et al. Measuring the loss of autonomy over nicotine use in adolescents: the DANDY (Development and Assessment of Nicotine Dependence in Youths) study. Arch Pediatr Adolesc Med. 2002;156 :397 –403
Balch GI, Tworek C, Barker DC, Sasso B, Mermelstein R, Giovino GA. Opportunities for youth smoking cessation: findings from a national focus group study. Nicotine Tob Res. 2004;6 :9 –17
Zhu SH, Sun J, Billings SC, Choi WS, Malarcher A. Predictors of smoking cessation in U.S. adolescents. Am J Prev Med. 1999;16 :202 –207
Monroe County Health Action. Adolescent Health Report Card Update, April 2001. Rochester, NY: Monroe County Health Department; 2001
Lantz PM, Jacobson PD, Warner KE, et al. Investing in youth tobacco control: a review of smoking prevention and control strategies. Tob Control. 2000;9 :47 –63
Liang L, Chaloupka F, Nichter M, Clayton R. Prices, policies and youth smoking, May 2001. Addiction. 2003;98 (suppl 1):105–122
Farrelly MC, Healton CG, Davis KC, Messeri P, Hersey JC, Haviland ML. Getting to the truth: evaluating national tobacco countermarketing campaigns. Am J Public Health. 2002;92 :901 –907
Sly DF, Heald GR, Ray S. The Florida "truth" anti-tobacco media evaluation: design, first year results, and implications for planning future state media evaluations. Tob Control. 2001;10 :9 –15
Goldman LK, Glantz SA. Evaluation of antismoking advertising campaigns. JAMA. 1998;279 :772 –777
Ossip-Klein DJ, Carosella AM, Krusch D. Self-help interventions for older smokers. Tob Control. 1997;6 :188 –193
Fiore MC, Bailey WC, Cohen SJ, et al. Smoking Cessation. Clinical Practice Guideline No. 18. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1996. AHCPR Publication 96-0692
Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—August 1999. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1999
Zhu SH, Anderson CM, Johnson CE, Tedeschi G, Roeseler A. A centralised telephone service for tobacco cessation: the California experience. Tob Control. 2000;9(suppl 2) :II48 –II55
Klein JD, Ossip-Klein DJ, McIntosh S, et al. Adolescent and physician preferences for smoking cessation: implications for clinical practice . Pediatr Res. 2000;47 :7A
Vuckovic N, Polen MR, Hollis JF. The problem is getting us to stop. What teens say about smoking cessation. Prev Med. 2003;37 :209 –218
Balch GI. Exploring perceptions of smoking cessation among high school smokers: input and feedback from focus groups. Prev Med. 1998;27 :A55 –A63
Daynard RA, Parmet W, Kelder G, Davidson P. Implications for tobacco control of the multistate tobacco settlement. Am J Public Health. 2001;91 :1967 –1971
Klein JD, Wilson KM, McNulty M, Kapphahn C, Collins KS. Access to medical care for adolescents: results from the 1997 Commonwealth fund survey of the health of adolescent girls. J Adolesc Health. 1999;25 :120 –130
Sussman S, Dent CW, Severson H, Burton D, Flay BR. Self-initiated quitting among adolescent smokers. Prev Med. 1998;27 :A19 –A28
Cromwell J, Bartosch WJ, Fiore MC, Hasselblad V, Baker T. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. Agency for Health Care Policy and Research. JAMA. 1997;278 :1759 –1766
Siegel M, Biener L. The impact of an antismoking media campaign on progression to established smoking: results of a longitudinal youth study. Am J Public Health. 2000;90 :380 –386
Bal DG, Lloyd JC, Roeseler A, Shimizu R. California as a model. J Clin Oncol. 2001;19(suppl) :69S –73S
McAlister A, Morrison TC, Hu S, et al. Media and community campaign effects on adult tobacco use in Texas. J Health Commun. 2004;9 :95 –109
Gray NJ, Klein JD, Noyce PR, Sesselberg TS, Cantrill JA. Health information-seeking in adolescence: the place of the internet. Soc Sci Med. 2005;60 :1467 –1478
Escoffery C, McCormick L, Bateman K. Development and process evaluation of a web-based smoking cessation program for college smokers: innovative tool for education. Patient Educ Couns. 2004;53 :217 –225
Wang J, Etter JF. Administering an effective health intervention for smoking cessation online: the international users of Stop-Tabac. Prev Med. 2004;39 :962 –968
Gray NJ, Klein JD, Cantrill JA, Noyce PR. Adolescent girls' use of the Internet for health information: issues beyond access. J Med Syst. 2002;26 :545 –553
Bock B, Graham A, Sciamanna C, et al. Smoking cessation treatment on the Internet: content, quality, and usability. Nicotine Tob Res. 2004;6 :207 –219
Edwards CC, Elliott SP, Conway TL, Woodruff SI. Teen smoking cessation help via the Internet: a survey of search engines. Health Promot Pract. 2003;4 :262 –265
Koo M, Skinner H. Improving web searches: case study of quit-smoking websites for teenagers. J Med Internet Res. 2003;5 :e28
Cheh JA, Ribisl KM, Wildemuth BM. An assessment of the quality and usability of smoking cessation information on the Internet. Health Promot Pract. 2003;4 :278 –287
Sargent JD, Dalton M. Does parental disapproval of smoking prevent adolescents from becoming established smokers Pediatrics. 2001;108 :1256 –1262
Thornberry OT, Massey JT. Trends in United States telephone coverage across time and subgroups. In: Groves RM, Biemer PP, Lyberg LE, Massey JT, Nichols WL, eds. Telephone Survey Methodology. New York, NY: Wiley; 2001:25 –49
Substance Abuse and Mental Health Services Administration. Summary of Findings From the 1999 National Household Survey on Drug Abuse. Rockville, MD: US Department of Health and Human Services, Office of Applied Studies; 2000. DHHS Publication SMA 00-3466(Jonathan D. Klein, MD, MP)
ABSTRACT
Objective.To evaluate the impact of a smoking-cessation media campaign for teens on utilization of a cessation Web site, GottaQuit.com.
Methods.Telephone surveys were conducted before and after the implementation of a countywide media campaign to promote the use of a smoking-cessation Web site for youths. The surveys were designed to assess teen awareness and utilization of the Web site, as well as tobacco use and cessation attempts. Supplemental 2003 Youth Risk Behavior Survey items also assessed use of the Web site.
Results.Most teen smokers reported that they wanted to quit smoking. Almost all teens reported exposure to GottaQuit.com ads and accurately identified GottaQuit.com as a Web site that offers cessation help for youths. Nearly 1 in 4 smokers who were trying to quit had visited GottaQuit.com or another Web site for cessation assistance.
Conclusions.The GottaQuit.com campaign effectively reached almost all teens, regardless of smoking status. Smokers were more likely than nonsmokers to have visited the Web site for help with quitting. Web adjuncts are likely to be used by adolescents who seek assistance in quitting.
Key Words: adolescent smoking smoking cessation media campaign cessation assistance tobacco use
Abbreviations: MSA, Master Settlement Agreement YRBS, Youth Risk Behavior Survey
Tobacco use is the single most preventable cause of death and disease in the United States, causing >440000 deaths each year.1 Nationally, health care expenditures to treat tobacco-related disease amount to more than $75 billion. Approximately 80% of adult smokers started smoking before the age of 18,1 and every day, nearly 2000 adolescents become established smokers.2 Although efforts have been made to reduce adult smoking rates, adolescent smoking remains a problem. Most teens have used tobacco before graduating from high school, and many began using in early adolescence. Even among youths who are not yet "regular" smokers, many report being addicted,3 and most adolescent smokers report that they would like to quit.4, 5 Youth smoking rates in Monroe County, New York, are comparable to rates for New York State and for much of the United States: from 1992 to 1999, smoking rates among public high school students ranged from 28% to 38%, and 66% of youths reported that they tried smoking during their high school years.6
A variety of strategies have been put into practice to prevent tobacco use and promote cessation for youths, including school-based interventions, increased tobacco excise taxes, and clinical smoking-cessation interventions.7, 8 Antismoking media campaigns have also been found to be effective in reducing adolescent cigarette consumption. The American Legacy Foundation's national tobacco countermarketing campaign, "truth," featured youths confronting tobacco industry practices in an attempt to positively change adolescent attitudes about tobacco use. Telephone surveys that were conducted before and after the "truth" campaign in Florida found that antitobacco attitudes and beliefs increased and that youths who were exposed to this campaign had high rates of message recall and reduced rates of smoking behavior.9, 10 Advertisements that are centered on the tobacco industry's manipulation of consumers, particularly youths, and on the negative effects of second-hand smoke have also been found to be effective deterrents to cigarette consumption.11
Adult smoking cessation is enhanced by inclusion of mailed and telephone adjuncts to public health or clinical cessation interventions.12–14 Telephone quitlines have become well established as effective in promoting cessation, reach many youths when specifically marketed to teens, and may help adolescents quit successfully.15 However, in focus groups, we and others have found that many adolescents who smoke and want to quit do not think of quitting with assistance of clinicians or other resources.16–18 In addition, although adolescents were interested in adjunct resources that may help them quit, they were hesitant to use telephone-based resources.16
The 1998 Master Settlement Agreement (MSA) between major tobacco manufacturers and the US State Attorneys General resolved outstanding state lawsuits and obligated tobacco companies to pay states an average of $10 billion per year.19 The Centers for Disease Control and Prevention published guidelines for the allocation of MSA funds,14 but there were no requirements that states allocate funds to tobacco-control programs. In New York State, counties also received a share of these funds, as they directly fund a portion of Medicaid expenditures. In Monroe County, New York, a portion of the MSA funds were used to implement a media campaign for a smoking-cessation Web site and quit helpline for teens, called GottaQuit.com.
GottaQuit.com was designed to promote adolescent smoking cessation and to complement adult cessation and youth tobacco prevention messages being sponsored by national and New York State advocacy groups. This media campaign, linked to an interactive youth cessation Web site, was introduced in January 2001 to help nicotine-addicted adolescents quit by providing adjuncts and supportive counseling. GottaQuit.com was publicized through paid media on television, radio, billboards, and city busses. The Web site features informational content, quit tips, and an e-mail "quit calendar," which provides tailored motivational encouragement for quitting. A section called "Talk To Us, Live" also allowed adolescents to connect with a trained quit coach and former smoker using instant message "chat" software. GottaQuit.com advertisement themes were developed on the basis of focus groups and expert opinion and focused on the fact that teen smokers want to quit but do not think of quitting with assistance.16 All advertisements emphasized the GottaQuit.com Web site as a place to get help quitting; most also featured a teenager explaining how smoking negatively interfered with their life. The 6 television ads used in the campaign are available for review at www.metrix-marketing.com/portfolio.htm.
This article reports on a pre/post cross-sectional evaluation of the GottaQuit.com smoking-cessation media campaign and Web site. We also examined adolescent and parent attitudes about tobacco, exposure to smoking-cessation and prevention media, adolescent tobacco use, and cessation attempts.
METHODS
We surveyed teens and their parents before implementation of GottaQuit.com in 2000 to determine demographic information including self-reported socioeconomic status20; media use; exposure to television, radio, billboard, or bus ads about adolescents and smoking; smoking prevalence and behavior; and cessation resources available to teen smokers. A random sample of 1000 households was selected from a school enrollment-based list of 18830 households in Monroe County, New York, with at least 1 child aged 14 to 19. Of these, we were able to identify working telephone numbers for 808 (81%) households. We successfully contacted 675 (84%) of these eligible households and obtained parent and adolescent consent and completed surveys with 418 (62%) of these adolescents. Of the 418 teens surveyed, 327 (78%) parents also completed a brief survey that assessed exposure to television, radio, or billboard messages about adolescents and smoking; content of the messages; whether they had talked to their child about tobacco; knowledge of cessation resources that are available to youths; knowledge of and attitude toward the tobacco settlement; personal smoking practices; and perceived smoking practices of their teen.
After GottaQuit.com had been in the field for 1 year, a follow-up adolescent survey assessed demographic information, media use, smoking prevalence and behavior, use and availability of cessation resources, and adolescent exposure and receptivity to GottaQuit.com and other teen smoking media campaigns. Media use was assessed by asking adolescents the amount of time that they spent listening to the radio during the week and on the weekend; adolescents in the postcampaign sample were also asked about television and Internet use. These measures were summed to estimate average weekly radio, television, and Internet use. For assessing receptivity to the campaign's messages, advertisement themes were described using cues identified as memorable in recall by teens during cognitive interview pilot testing. Receptivity to the ads then was determined by asking the adolescent how well the advertisement's theme and/or its character related to his or her own life or situation. For estimating the magnitude of false-positive exposure reports, youths were also asked about ads that did not exist. For the follow-up, we used a random sample of 606 households in Monroe County with at least 1 child aged 14 to 19. We were able to contact 333 (55%) households and completed surveys with 259 (78%) adolescents; 257 (99%) parents also completed a survey that was identical to the preintervention survey.
We also added supplemental items to the 2003 Monroe County Youth Risk Behavior Survey (YRBS). The YRBS was completed by 1688 adolescents sampled from 32 schools from all but 1 school district in Monroe County. The classroom participation rate was 87%. All adolescents were asked about current smoking status, whether they had ever visited GottaQuit.com or another Internet site to help them stop smoking, and how many times they visited GottaQuit.com in the past 12 months; smokers were asked whether they had tried to quit in the past year.
For both pre and post telephone surveys, parental consent and adolescent assent were obtained for adolescents who were younger than 18 years and informed consent was obtained for adolescents who were 18 and older. All study protocols were approved by the University of Rochester Research Subjects Review Board. The YRBS was administered by the county as part of their routine public health surveillance activities; these data were exempt from review.
RESULTS
Demographics and Media Use
The precampaign, postcampaign, and Monroe County YRBS samples had slightly different demographic profiles (Table 1). The samples were split nearly evenly between genders, with the postcampaign sample having a slightly higher percentage of female respondents than the other groups. The mean age of the precampaign and YRBS samples was younger than the age of the postcampaign sample. The majority of respondents were white, followed by black, and other, which included Hispanic, Asian, American Indian, Native Hawaiian or other Pacific Islander, and multiracial respondents. The YRBS sample had a higher percentage of black and other respondents.
Self-reported socioeconomic status and parents' education level were comparable between the postcampaign and postcampaign samples. The precampaign sample consisted of mostly high school students, whereas 42% of postcampaign respondents were college students. Both samples reported high levels of media use.
Parent Survey
The majority of parents reported that they felt comfortable talking to their adolescent about tobacco and smoking (93% postcampaign and 98% postcampaign; P = .004). A higher percentage of postcampaign parents were aware of teen cessation resources that are available in their community (43% vs 22% precampaign; P .0001). Two of 3 parents in each sample were aware of tobacco settlement monies (69% of postcampaign and 63% of postcampaign; not significant). The majority (81% and 85%; not significant) believed that it was a good or very good idea for Monroe County to use settlement monies for a media campaign directed at teen smokers. Smoking status was comparable between parents in the 2 samples.
Tobacco Use
Self-reported tobacco use was comparable between the precampaign and postcampaign samples (Table 2). On average, respondents were 14 years old when they first smoked, and comparable proportions reported having smoked daily during the 30 days preceding the survey ("current smokers"). Current smokers were significantly more likely to be older than nonsmokers in both samples. In the postcampaign sample, white teens were more likely than black teens or teens of other ethnic groups to be current smokers. No significant gender differences were found between smokers and nonsmokers in either sample.
Most current smokers considered themselves to be smokers and thought that they were addicted to nicotine. Teens in the postcampaign sample were less likely to report daily smoking but were more likely to classify themselves as regular smokers.
Cessation Help for Teen Smokers
The majority of smokers in both samples reported that they wanted to stop smoking completely (Table 2). Postcampaign smokers were more likely to report that they had seriously tried to quit smoking cigarettes and had tried to quit more times than precampaign smokers. No respondents in either sample reported having ever called a telephone hotline for help with quitting.
Impact of GottaQuit.com and Other Antitobacco Media
Most parents (82%) and adolescents (90%) in the precampaign sample reported that they had seen one or more television, radio, or billboard ads about adolescents and smoking. An even higher percentage in the postcampaign sample reported that they had seen 1 or more ads on this topic (91% and 98%, respectively). Television ads from the American Legacy Foundation's "truth" media campaign, which had run in the Rochester MSA media market, were recognized by 71% of adolescents in the precampaign sample and by 49% of adolescents in the postcampaign sample.
Most teens in the postcampaign sample had seen television ads (86%) or heard radio ads (82%) promoting Internet sites to help teens quit smoking. Thirty-seven percent of the precampaign sample also reported having seen television ads and 28% reported having heard radio ads for Internet or telephone services to help teens quit, although, to the best of our knowledge, no ads of this type were running before or during the time our survey was in the field. There were no differences by gender or smoking status as to whether teens recalled these ads.
Ninety-four percent of postcampaign respondents reported that they had seen an advertisement for GottaQuit.com, and most identified GottaQuit.com as a Web site that offers cessation help for youths (Table 3). There were no differences in gender, age, or smoking status in recall of specific GottaQuit.com ads. The majority of teens recognized the overall message of the campaign, "I've gotta quit, I just need a little help." Smokers were significantly more likely than nonsmokers to report that they believed that the ads related to their life (Table 3).
GottaQuit.com Utilization
One (25.7%) in 4 postcampaign telephone survey respondents who smoked reported that they had visited GottaQuit.com, compared with only 4% of nonsmokers (Table 3). Almost all Web-site users who smoked reported that they went to the Web site for help in quitting. Eleven percent of Monroe County YRBS respondents reported that they had visited GottaQuit.com or another Internet site for help in quitting (Table 4). Seventeen percent of smokers visited GottaQuit.com at least once during the 12 months preceding the survey, compared with 4% of nonsmokers (P .0001). In addition, 23% of teens who had tried to quit smoking in the past year had visited GottaQuit.com or another cessation Web site at least once. YRBS sample smokers were slightly less likely to report that they had visited GottaQuit.com (17.3%). This finding was not significantly different from the telephone survey estimate (P = .221).
DISCUSSION
The tobacco industry spends nearly $7 billion a year to advertise and promote cigarettes.1 Thus, successful counter-advertising and smoking-cessation strategies must be established. Evaluation of the GottaQuit.com adolescent smoking-cessation media campaign in Monroe County, NY, showed that almost all adolescents in the county had seen or heard 1 or more ads about the cessation Web site. This is the first report of a community-based cessation campaign that integrated Web adjuncts with mass media messages targeting youths. Most adolescents were aware that the Web site offered cessation help, the majority recognized the main theme of the campaign ("I've gotta quit, I just need a little help"), and most smokers reported that the advertisement themes related to their lives. Although GottaQuit.com campaign ads focused specifically on promoting cessation assistance, several also contained antitobacco messages, and the overall antitobacco theme was recalled by the majority of adolescents, regardless of smoking status.
Most adolescent smokers wanted to quit, and many had tried several times. This is consistent with other studies showing that many teen smokers are motivated to quit smoking.5, 21 Research suggests that youths may be especially in need of cessation interventions22; however, many do not think to get assistance with quitting.16 Most adolescents are not familiar with smoking-cessation programs, and some have concerns about confidentiality, parental involvement, and whether cessation counselors are able to relate to their experiences.18
The GottaQuit.com campaign and Web site generated a high rate of use. Even among telephone quitlines that are specifically promoted to adolescents, only a very small proportion of eligible youths call.15 Other state and community antitobacco media campaigns have been shown to be effective in increasing adolescents' antitobacco attitudes and beliefs,9, 10 reducing youth smoking rates and rates of progression to established smoking,10, 11, 23, 24 and reducing adult smoking rates when exposure to multimedia cessation ads was combined with cessation treatment.25 There were 12000 unique visitors and >27000 visitor sessions on GottaQuit.com during the first 6 months of the campaign. However, we were unable to track whether these hits were from users in Monroe County, and, because of cable television broadcast coverage patterns in advertising, the campaign media was also seen in the greater Rochester metropolitan area (a 6-county region) and in neighboring areas. Thus, we could not assess the number of hits in proportion to the number of teen smokers in the county. However, self-reported telephone survey data and county YRBS data showed that teen smokers were much more likely to visit the Web site. This is the first study that shows the potential of Web adjuncts for reaching a high proportion of adolescent smokers.
Our study showed that the GottaQuit.com campaign messages, which had been tailored to adolescents who smoked, were in fact highly salient to teen smokers. Youth smokers reported that they related to the characters, themes of addiction, and the desire to quit that were portrayed in the ads. Although some teens who were nonsmokers also visited the Web site as a result of the campaign's media messages, >1 in 4 smokers, compared with only 1 in 25 nonsmokers, visited the GottaQuit.com Web site at least once, primarily for help in quitting. These findings demonstrate that teen smokers are highly receptive to messages that promote Internet-based cessation resources for those who are motivated to quit.
Web-based health interventions have great potential for meeting adolescents' needs, as these media are nonjudgmental, are confidential, do not require interaction with others, and are not limited by time.17 The majority of teens also report being online on a frequent basis.26 A Web-based cessation program for college students found high levels of use, satisfaction, and comfort with using a Web site for cessation assistance.27 An online international smoking-cessation program for adults demonstrated the ability of the Internet to disseminate information and collect data on cessation.28 However, few Web-based studies have specifically targeted adolescents, and the usability and content of cessation Web sites are varied. The volume of health information that is available on the Internet may be difficult to manage for some adolescents, and limited access can have an impact on the quality of information obtained.29 Nonetheless, at least when combined with media to promote use, Web-based cessation is sought out by youths who smoke.
Descriptive literature on smoking-cessation Web sites has found that reading levels were high, that most sites did not address 1 or more key components of National Cancer Institute–recommended treatment or use the interactive capabilities of the Internet, and that sites are rarely easily found using commonly used search engines.30–33 Future study of Internet-based cessation adjuncts are needed to assess the relative effectiveness of these resources in helping teen smokers quit.
Parents who consistently communicate with their teens about smoking can have a significant impact on their smoking behaviors.34 Almost all parents in each phase of our study reported that they felt comfortable talking to their teen about tobacco, and most had talked with their teen about it at least once in the preceding 6 months. More postcampaign parents were aware of community resources, and many knew of a Web site that was available to assist teens with cessation. This increased awareness of available resources may be a result of the scope of the GottaQuit.com campaign, or more resources may have actually been available to teens in 2002 than in 2000. However, whether parents' communication about cessation opportunities helps decrease the chances that their adolescent will smoke over time is not known. Of policy interest, many parents were aware of tobacco settlement monies, and the majority thought that it was a good idea to use that money for teen smoking cessation. The high level of support from parents for this campaign may be useful for initiating or sustaining future antitobacco efforts.
Our study relied on self-reported behaviors and attitudes about tobacco use and cessation and the impact of GottaQuit.com campaign messages. As a result, respondents may have had a tendency to report socially desirable behaviors and attitudes or may not have recalled information accurately. Adolescents who participated in the study may have differed from those who declined, resulting in selection bias. In addition, the survey method may have had an effect on selection, as people in lower socioeconomic groups are less likely to have working telephones.35
The postcampaign sample was older than the precampaign sample, which was an unexpected sample bias. Although the age and ethnicity of our samples varied slightly, this is likely because the pre sample was drawn from a school-based list and the post sample from a random-digit dialed sample. The former is likely to underrepresent out-of-school youths, as evidenced by age being comparable to the school-based YRBS. Ethnicity distribution differences may reflect undercoverage and nonresponse biases among ethnic minority and/or poorer households, as poorer families move more frequently and have less reliable telephone service.35 Nearly half of the post sample attended college; thus, their attitudes and opinions about tobacco use and smoking cessation may differ from those of younger students. In addition, as the YRBS is administered only in school, data from this survey are also not representative of all adolescents in the county. Thus, findings may not be generalizable to other adolescents or to other geographic areas.
Another limitation of our study is that nearly all teens in each sample were classified as middle or high socioeconomic status. In 2001, the National Household Survey on Drug Abuse found cigarette use to be higher among youths from families with lower incomes than those with higher incomes.36 Additional research on Monroe County teens in lower socioeconomic groups would provide data on tobacco use and the impact of the campaign among this population.
CONCLUSIONS
The GottaQuit.com smoking-cessation media campaign effectively reached almost all teens in Monroe County, regardless of smoking status. Smokers were more likely than nonsmokers to have visited the GottaQuit.com Web site for help with smoking cessation. The majority of teen smokers in this study wanted to quit but had been unsuccessful in previous attempts. Exposure to this smoking-cessation media campaign effectively encouraged some adolescents to seek assistance in quitting from GottaQuit.com, and public support for this youth cessation media campaign was high. Additional studies are needed to evaluate the impact of cessation media and Web sites on youth quitting.
ACKNOWLEDGMENTS
This research was supported by the Monroe County Health Department.
We thank Tracy Crandall, Andrew Doniger, Deborah Ossip-Klein, Scott McIntosh, John Ricci, and John Riley for their role on Monroe County's project advisory committee and Cheryl Utter for assistance in developing and fielding the Monroe County Youth Risk Behavior Survey supplemental items.
FOOTNOTES
Accepted May 24, 2005.
No conflict of interest declared.
REFERENCES
Substance Abuse and Mental Health Services Administration. Results from the 2002 National Survey on Drug Use and Health: National Findings. Rockville, MD: Department of Health and Human Services, Office of Applied Studies; 2003. NHSDA Series H-22, DHHS Publication SMA 03–3836
DiFranza JR, Savageau JA, Fletcher K, et al. Measuring the loss of autonomy over nicotine use in adolescents: the DANDY (Development and Assessment of Nicotine Dependence in Youths) study. Arch Pediatr Adolesc Med. 2002;156 :397 –403
Balch GI, Tworek C, Barker DC, Sasso B, Mermelstein R, Giovino GA. Opportunities for youth smoking cessation: findings from a national focus group study. Nicotine Tob Res. 2004;6 :9 –17
Zhu SH, Sun J, Billings SC, Choi WS, Malarcher A. Predictors of smoking cessation in U.S. adolescents. Am J Prev Med. 1999;16 :202 –207
Monroe County Health Action. Adolescent Health Report Card Update, April 2001. Rochester, NY: Monroe County Health Department; 2001
Lantz PM, Jacobson PD, Warner KE, et al. Investing in youth tobacco control: a review of smoking prevention and control strategies. Tob Control. 2000;9 :47 –63
Liang L, Chaloupka F, Nichter M, Clayton R. Prices, policies and youth smoking, May 2001. Addiction. 2003;98 (suppl 1):105–122
Farrelly MC, Healton CG, Davis KC, Messeri P, Hersey JC, Haviland ML. Getting to the truth: evaluating national tobacco countermarketing campaigns. Am J Public Health. 2002;92 :901 –907
Sly DF, Heald GR, Ray S. The Florida "truth" anti-tobacco media evaluation: design, first year results, and implications for planning future state media evaluations. Tob Control. 2001;10 :9 –15
Goldman LK, Glantz SA. Evaluation of antismoking advertising campaigns. JAMA. 1998;279 :772 –777
Ossip-Klein DJ, Carosella AM, Krusch D. Self-help interventions for older smokers. Tob Control. 1997;6 :188 –193
Fiore MC, Bailey WC, Cohen SJ, et al. Smoking Cessation. Clinical Practice Guideline No. 18. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1996. AHCPR Publication 96-0692
Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—August 1999. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1999
Zhu SH, Anderson CM, Johnson CE, Tedeschi G, Roeseler A. A centralised telephone service for tobacco cessation: the California experience. Tob Control. 2000;9(suppl 2) :II48 –II55
Klein JD, Ossip-Klein DJ, McIntosh S, et al. Adolescent and physician preferences for smoking cessation: implications for clinical practice . Pediatr Res. 2000;47 :7A
Vuckovic N, Polen MR, Hollis JF. The problem is getting us to stop. What teens say about smoking cessation. Prev Med. 2003;37 :209 –218
Balch GI. Exploring perceptions of smoking cessation among high school smokers: input and feedback from focus groups. Prev Med. 1998;27 :A55 –A63
Daynard RA, Parmet W, Kelder G, Davidson P. Implications for tobacco control of the multistate tobacco settlement. Am J Public Health. 2001;91 :1967 –1971
Klein JD, Wilson KM, McNulty M, Kapphahn C, Collins KS. Access to medical care for adolescents: results from the 1997 Commonwealth fund survey of the health of adolescent girls. J Adolesc Health. 1999;25 :120 –130
Sussman S, Dent CW, Severson H, Burton D, Flay BR. Self-initiated quitting among adolescent smokers. Prev Med. 1998;27 :A19 –A28
Cromwell J, Bartosch WJ, Fiore MC, Hasselblad V, Baker T. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. Agency for Health Care Policy and Research. JAMA. 1997;278 :1759 –1766
Siegel M, Biener L. The impact of an antismoking media campaign on progression to established smoking: results of a longitudinal youth study. Am J Public Health. 2000;90 :380 –386
Bal DG, Lloyd JC, Roeseler A, Shimizu R. California as a model. J Clin Oncol. 2001;19(suppl) :69S –73S
McAlister A, Morrison TC, Hu S, et al. Media and community campaign effects on adult tobacco use in Texas. J Health Commun. 2004;9 :95 –109
Gray NJ, Klein JD, Noyce PR, Sesselberg TS, Cantrill JA. Health information-seeking in adolescence: the place of the internet. Soc Sci Med. 2005;60 :1467 –1478
Escoffery C, McCormick L, Bateman K. Development and process evaluation of a web-based smoking cessation program for college smokers: innovative tool for education. Patient Educ Couns. 2004;53 :217 –225
Wang J, Etter JF. Administering an effective health intervention for smoking cessation online: the international users of Stop-Tabac. Prev Med. 2004;39 :962 –968
Gray NJ, Klein JD, Cantrill JA, Noyce PR. Adolescent girls' use of the Internet for health information: issues beyond access. J Med Syst. 2002;26 :545 –553
Bock B, Graham A, Sciamanna C, et al. Smoking cessation treatment on the Internet: content, quality, and usability. Nicotine Tob Res. 2004;6 :207 –219
Edwards CC, Elliott SP, Conway TL, Woodruff SI. Teen smoking cessation help via the Internet: a survey of search engines. Health Promot Pract. 2003;4 :262 –265
Koo M, Skinner H. Improving web searches: case study of quit-smoking websites for teenagers. J Med Internet Res. 2003;5 :e28
Cheh JA, Ribisl KM, Wildemuth BM. An assessment of the quality and usability of smoking cessation information on the Internet. Health Promot Pract. 2003;4 :278 –287
Sargent JD, Dalton M. Does parental disapproval of smoking prevent adolescents from becoming established smokers Pediatrics. 2001;108 :1256 –1262
Thornberry OT, Massey JT. Trends in United States telephone coverage across time and subgroups. In: Groves RM, Biemer PP, Lyberg LE, Massey JT, Nichols WL, eds. Telephone Survey Methodology. New York, NY: Wiley; 2001:25 –49
Substance Abuse and Mental Health Services Administration. Summary of Findings From the 1999 National Household Survey on Drug Abuse. Rockville, MD: US Department of Health and Human Services, Office of Applied Studies; 2000. DHHS Publication SMA 00-3466(Jonathan D. Klein, MD, MP)