Introduction 1 2 3 4 6 7 8 10 10 8 2 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. Methods Recruitment and Eligibility www.quitnet.com 7 Appendix 1 11 12 11 13 Appendix 2 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. Measures 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. Statistical Analyses 14 t 8 Results Recruitment Outcomes Figure 1 Figure 1 Eligibility and Recruitment Results  Generalizability 2 2 P t P t P 2 2 P Table 1 2 2 P 14 Table 1 Comparison of search engine usage to Nielsen/NetRatings statistics     Relative Reach of Search Engines Search Engine Survey Recruitment (%) National Usage (%) Google 57 60 Yahoo! 29 23 MSN 14 17 Total 100 100 Table 2 Table 2 Frequency of smoking-related search terms in search engine queries      Search Term Searches (%) Survey Participants (%)  ( 2 4 P Overture (%)  ( 2 4 P Wordtracker (%)  ( 2 4 P 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 Participant Characteristics Table 3 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”). Table 3 Demographic and smoking characteristics of study participants (N = 626)   Characteristic Number of Participants (%) Age < 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) Gender Male 243 (38.8) Female 383 (61.2) Smoking Status 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. Information Preferences Table 4 2 2 P 2 2 P 2 2 P Table 4 Information sought by smoking status (N = 626)       Information Current Smoker (%)  (n = 474) Quit ≤ 1 Week (%)  (n = 109) Quit > 1 Week (%)  (n = 45) 2 2 P * 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 * Note: Multiple responses were allowed, so total percentages within smoking category exceed 100%. Perceived Helpfulness of Cessation Services Table 5 Table 6 Table 5 Perceived helpfulness of Internet features by smoking status        Feature All Participants, Mean (SD) (N = 626) Current Smokers, Mean (SD) (n = 472) Quit ≤ 1 Week (n = 109) Quit > 1 Week (n = 45) Mean (SD) P * Mean (SD) P * 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 * P P Note: 1 = very helpful; 2 = helpful; 3 = somewhat helpful; 4 = not very helpful; 5 = not helpful at all Table 6 Proportion of participants (N = 626) rating Internet cessation services as helpful or very helpful    Feature Offered Helpful or Very Helpful  n % 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 Estimating Incidence of Cessation Queries 14 Discussion 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. 15 16 17 3 18 19 Limitations 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. Conclusion 2 20 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.