AUGUST 2007 VOLUME 1, ISSUE 6 A PHYSICIAN LEARNING RESOURCE FROM THE MINTO PREVENTION AND REHABILITATION CENTRE, UNIVERSITY OF OTTAWA HEART INSTITUTE AND THE ADDICTION MEDICINE SERVICE, CENTRE FOR ADDICTION AND MENTAL HEALTH, UNIVERSITY OF TORONTO
Using Information Technology to Support Smoking-related Behaviour Change: Web-Assisted Tobacco Interventions
U N I V E R S I T Y O F O T TA W A H E A R T I N S T I T U T E INSTI TUT DE CAR DIOLOGIE D E L’ U N I V E R S I T É D ’ O T TAWA
BY CAMERON NORMAN, PH.D.
Probably, like the majority of Canadians over the age of 12, you regularly use the internet – email, the World Wide Web, interactive chatlines, and other features – and you have also sought out health information online for yourself or family members that extends beyond your clinical practice. Sixty-five percent of Canadian households1 and 64% of Americans2 report recent use of the Internet for health information. The use of information technology for health is on the rise and continues to be one of the most sought-after topics on the internet.2 Consumer use of information technology for health (or eHealth3) has grown in popularity, with eHealth journals now ranking among the top academic publications. Although popular with consumers and professionals alike, the healthcare sector is still unclear on how to adequately and effectively use technology as an intervention medium and unsure about what evidence exists to guide program delivery. This issue of Smoking Cessation Rounds highlights how information technology can assist Canadian smokers to quit. It also describes how healthcare practitioners can effectively extend the clinical encounter beyond the consultation room.
Web-assisted tobacco interventions: An overview Web-assisted tobacco interventions (WATI) are a class of technology-enabled behavioural change interventions that are in use throughout the world. WATI is a promising medium for delivering smoking cessation programming and supporting health professional training in tobacco control. The acronym, WATI, was first proposed by Peter Selby, MD, and Scott McIntosh, PhD. Since 2004, it has been used to frame a growing community of practice around the development, study, and implementation of technology-based interventions that support tobacco control. The Web part of WATI refers not only to World Wide Web information accessible from a desktop, but also to other networked technologies (eg, cell phones and personal digital assistants [PDAs]). As information becomes more tightly integrated across technologies, this will remain an important distinction, particularly since much of the developing world (where the burden of smoking-related disease is most likely to be felt in the coming decades) does not have sufficient access to the internet through conventional means,4 and relies on cell phones and other tools or media for health information. WATI resources have been developed to focus on 4 key areas: cessation, prevention, social support, and professional development/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. Research on WATI has quickly become a leading area within eHealth in general, as evidenced by the large number of tobacco-related manuscripts published in the Journal of Medical Internet Research,5-11 the leading eHealth peerreviewed publication in the world. WATI has greatly influenced tobacco control as evidenced by a special issue of the journal, Nicotine and Tobacco Research, that was devoted to WATI. Why WATI ? Tobacco use is a global phenomenon that requires control strategies that are equal in reach and appeal. The World Health Organization estimates that half of the current
Available on the Internet at
www.smokingcessationrounds.ca
UNIVERSITY OF TORONTO
The Minto Prevention and Rehabilitation Centre University of Ottawa Heart Institute A N D R E W P I P E , CM, MD, M E D I CA L D I R E C TO R C O -E D I TO R , S M O K I N G C E S S AT I O N R O U N D S DAVID DAVIDSON, MD, CCFP M ICHÉLE
DE
M ARGERIE , MD, CCFP
ROBERT S WENSON, MD, F RCPC G EORGE F ODOR , MD, P H D, F RCPC ROBERT R EID, MBA, P H D D OUG W ILKINS, MD, FRCPC
Centre for Addiction and Mental Health University of Toronto Addictions Program, Nicotine Dependence Clinic P ETER S ELBY, MBBS, CCFP C LINICAL D IRECTOR AND H EAD C O -E DITOR , S M O K I N G C E S S AT I O N R O U N D S TONY G EORGE , MD, FRCPC B ERNARD L E F OLL , MD, P H D C URTIS H ANDFORD, MD, CCFP The editorial content of Smoking Cessation Rounds is determined solely by the Minto Prevention and Rehabilitation Centre, University of Ottawa Heart Institute and the Addiction Medicine Service, Centre for Addiction and Mental Health, University of Toronto.
smokers today (about 650 million people) will die as a result of tobacco use.12 Tobacco use accounts for 22% of all disease-related deaths in Canada13 and the premature death of 4.9 million people worldwide.12 Given the scope of the problem, cessation support services must be available in settings beyond the clinical encounter if substantive decreases in smoking-related morbidity and mortality are to be achieved. In order to achieve such wide-scale reductions in smoking-attributable disease, interventions must be developed that are effective, plausible, affordable, and available at the population level.14 Web-assisted tobacco interventions offer these benefits. In addition, they have the added benefits of being relatively low-cost per smoker served and accessible 24-hours/day, every day of the year, for those with access to an internet connection. Web-assisted behaviour-change tools have had small and medium-sized effects on changing behaviour across a variety of health conditions,15-18 with tobacco control becoming one of the leaders in developing and evaluating interventions for the internet.19-23 The evidence base, while small, is strong in suggesting that eHealth interventions are effective at changing behaviour17,18,24 and, given the high proximal levels of internet access in many countries, a small shift in behaviour attributed to an accessible Web intervention can translate into a large population health effect.
• A survey of all attendees at the 3rd WATI workshop held as a pre-conference event and part of the World Congress on Internet and Medicine (MEDNET) in October 2006, where participants were asked to list all of the WATI resources they were aware of in any language. • A comprehensive Web search using both Google.ca and the metasearch engines Ixquick and Metacrawler, and deep-Web search tools such as CompletePlanet. The search yielded 35 unique, interactive tools worldwide;31 the majority of these sites were based in North America (N=25) and over 80% were in English. Two wireless phone interventions were also identified, while 3 interventions used variants of the same WATI platform created by V-CC Systems, a private, for-profit company, with support and guidance from the Centre for Addiction and Mental Health (CAMH) in Toronto, University of Toronto. An examination of this catalogue of resources (http://www.wati.net) will reveal that the majority of interactive resources are devoted to smoking cessation, while those with a focus on prevention and training are the next most popular. Social support is an aspect that is embedded in all 3 types of interventions and also offered on its own through self-organized electronic forums on Yahoo! Groups, Facebook, MySpace, and similar platforms.
Cessation information online
Using WATI to support smoking cessation: Three orders of intervention
Quality and access are among the greatest concerns expressed about using eHealth.25-28 Bock and colleagues29 reviewed the findings from an online search of cessation information resources using US Public Health Service (US PHS) and National Cancer Institute guidelines to determine the relative quality of sites most likely to be accessed by the public. The study examined sites identified through the first 10 pages retrieved by major search engines (eg, Google) to reflect the sites a health consumer would likely find when searching for these terms: smoking, quit smoking, stop smoking, and smoking cessation. Of the 46 sites that met the search criteria, over 80% did not cover one or more of the key components of tobacco treatment recommended in the US PHS guidelines, suggesting that practitioners should be cautious when relying on websites as a source of information on smoking cessation. This review has since been updated and, although the quality of some sites has improved, the authors still recommend, “buyers beware.”30
Interactive Web-assisted tobacco interventions Following Bock’s review of health information resources, in 2007, a review was conducted for Health Canada to locate and catalogue those resources that were interactive and designed as stand-alone interventions, or Web-assisted tobacco interventions.31 WATIs were identified through three methods: • A review of the published literature, using the databases PubMed, PsycInfo, ERIC, Social Science Abstracts, and Web of Science for Web-assisted tobacco interventions and related technology and tobacco control articles.
Most examples of WATI and use of the internet for health issues, focus on some version of a stand-alone website that features information, links, and perhaps a type of interactive component. The most common WATI resources are designed as self-contained resources; however, there are examples of technologies that complement existing treatments or are integrated within a larger program. These different strategies reflect 3 orders of behavioural eHealth interventions: • First order: Stand-alone • Second order: Complementary • Third order: Integrated The following sections explore each order of intervention, using examples drawn from the Canadianbased WATI resources focused on smoking cessation and prevention.
First-order WATI: Stand-alone resources The website or tool designed to operate independently of any other resource is considered a first-order eHealth intervention. It is the most common of the available interactive technologies. Although such resources may refer to others through links to other websites or references to other options (eg, books or telephone services), a first-order intervention is designed to be used independently of any other source of support. Additional supports may include: pharmacotherapy, counseling, telephone quitlines, or various self-help approaches. Smokers may wish to (and may be encouraged to) use multiple methods to quit but, from a design perspective, first-order interventions are created to provide a resource that could
Table 1. Smoking “Quitlines” CCS Quitline
Phone
Hours of Operation
Alberta Quits QuitNow Smoker’s Helpline Smoker’s Helpline Smoker’s Helpline Smoker’s Helpline Smoker’s Helpline Smoker’s Helpline
Alberta British Columbia Manitoba New Brunswick Newfoundland/Labrador Nova Scotia Nunavut Ontario
Province
1-866-332-2322 1-877-455-2233 1-877-513-5333 1-877-513-5333 1-800-363-5864 1-877-513-5333 1-866-877-3845 1-877-513-5333
Smoker’s Helpline Ligne J'arrête Ligne poumons-9
Prince Edward Island Québec Québec
Smoker’s Helpline
Saskatchewan
1-888-818-6300 1-866-527-7383 1-888-768-6669 poste 232 1-877-513-5333
not listed not listed M - Th 8a-8p; F 8a-4p M - Th 9a-9p; F 9a-5p M - Th 9a-9p; F 9a-5p M - Th 9a-9p; F 9a-5p M - F 8:30a-5:00p M - Th 8a-9p; F 8-6; Sat/Sun 9a-5p M - Th 9a-9p; F 9a-5p M - F 8a-8p M - F 8:30a-4:30p
Organisation The Stop Smoking Center
Website www.stopsmokingcenter.net
Smoker's Helpline Online Go Smokefree SmokeFree QuitNow
http://www.smokershelpline.ca www.gosmokefree.ca http://www.smokefree.gov/ http://quitnow.ca
Website http://alberta.quitnet.com/ http://quitnow.ca http://www.smokershelpline.ca http://www.smokershelp.net/
http://www.smokershelpline.ca
http://pq.lung.ca/sections/ poumon9/en/index.php
M - Th 7a-7p; F 7a-4p
Free to all smokers. Has self help and moderated mutual aid. Evaluated and evidence based. For Ontario Residents only Auto-reroutes to: http://www.hc-sc.gc.ca/hl-vs/tobac-tabac/index_e.html National Cancer Institute site for smokers in BC
potentially serve as the sole source of support. The information, tools, and other features are not designed for use with additional formalized supports such as quitlines or physician assessments, although some encourage and advise the user to seek out physician help. These tools typically offer a wide range of options including assessments, information, social support methods (eg, discussion boards), access to online quit specialists and, in some circumstances, opportunities to purchase cessation aids directly through the website. One example of this type of resource is the Stop Smoking Centre developed by V-CC and the CAMH (http://www.stopsmokingcenter.net). This resource supports quitters with a 24-hour accessible, personalized, and community-driven smoking cessation program. It requires users to register (for free) with the website to facilitate tailoring and personalized support (although this may be done using an anonymous email address to protect privacy). The program is designed around an online support group that enables users to provide peer support and guidance to one another. Further, they are supported by trained “Support Specialists” and a series of tools to develop quit plans and assess health risks. An Instant Messenger feature enables users to immediately communicate with “Quitting Buddies” for rapid cessation-related peer support. A series of quit-plan exercises builds specific, tailored action steps for users to follow that is supported by tools like the downloadable Quit Meter. The Quit Meter tracks the amount of money that users save (or have saved to date), along with estimates on the amount of health (years lived) that they have gained by stopping cigarette use. For health practitioners, first-order interventions are the easiest to recommend as options for patients to explore on their own and, in many cases, they are free-of-charge. First-order WATIs are the most flexible
because they are exclusively internet-driven and, thus, provide 24-hour/day support options. In websites where live support groups are present, there may be some limitations in the numbers and types of services available during certain hours, but basic functionality and scope of resources are not significantly affected by time-of-day restrictions. The same is not always true for second- or third-order WATIs.
Second-order WATI: Complementary resources A second-order WATI is designed to be used in conjunction with another type of resource (eg, a telephone helpline) or as an adjunct to clinical treatment. Unlike first-order interventions, however, these types of WATI are explicitly designed to complement other methods. The second-order WATI may include areas where users input information from other resources or they may provide more detailed levels of information than another medium. One such example is the Canadian Cancer Society’s (CCS) Smokers’ Helpline website in Ontario (http://www. smokershelpline.ca). This resource was designed to complement the existing telephone quitline and serve as an additional means of support, particularly during the hours when the phoneline is unavailable (Table 1). The Helpline provides information, quitting tips, and links to support via the website in a manner that is self-driven. It complements the use of the telephone service, which is widely promoted by the CCS. For the Helpline, telephone counseling is the primary vehicle for intervention; however, by adding the website component, the CCS is able to provide a trustworthy option for callers to use when the phones are not in operation, as well as a source of additional information not considered practical for inclusion in a telephone call (eg, because it is too detailed or not critical). In this case, the website supplements and complements the phone-based intervention.
With this CCS telephone-based service, callers speak one-on-one with a trained “Quit Specialist” who works with the caller to: • develop a personalized quit plan • formulate strategies to cope with cravings • provide information on quitting methods • explore the potential for withdrawal symptoms and plan for them • support stress management • inform callers of available services and resources that go beyond the helpline (including the CCS Smokers’ Helpline website). To complement this resource, the helpline website provides discussion forums for users to connect with other users (peer support). It also provides similar services as the Stop Smoking Centre because the platform is the same as the one provided by V-CC. The difference here is that the website is a secondary resource to the telephone line but, otherwise, it functions in exactly the same manner as a stand-alone WATI. The CCS Smokers’ Helpline illustrates how WATIs can be used differently depending on the context. It also indicates the flexibility of Web resources by demonstrating how a tool designed as a stand-alone website can function as a supportive adjunct to alternate treatment modalities and the resources scaled up to first- or second-order formats. The next example illustrates the further enhancement of such approaches into an integrated delivery model as part of a third-order intervention.
Third-order WATI: Integrated interventions A WATI is considered a third-order intervention when it is part of an integrated program of delivery where the information technology tool is but one component. Unlike second-order interventions, a third-order WATI is embedded within a larger program structure and the resource is not viewed as complementary or stand-alone, but integral to the larger initiative. These are the least-common forms of WATI, but also the most sophisticated and intensive programs of the group. The Virtual Classroom on Tobacco Control, developed by Youth Voices Research at the University of Toronto and TakingITGlobal, a youth-oriented nongovernmental organization (NGO), is one example of a third-order intervention. The Virtual Classroom is designed for both young smokers and nonsmokers (aged 12-24 years), and is intended for delivery in educational settings (http://www.taking itglobal.org/tiged/projects/tobacco//). This comprehensive classroom intervention is designed to facilitate learning about tobacco in a global context beyond health and contains 4 interrelated units: • Facts & Figures – examines the health effects of tobacco, from both a first-hand and second-hand perspective • The Smoking Zine – an interactive Web tool that allows students to explore their smoking behav-
iours and intentions and is designed to support healthy decision-making about using cigarettes • Denormalization – investigates the tobacco industry’s marketing campaigns that target youth, and highlights avenues for youth action • Global and Social Justice – focuses on the tobacco industry’s exploitive practices in developing regions of the world. It is also unique in that it provides options for smokers and nonsmokers alike. The Virtual Classroom on Tobacco Control also contains interactive discussion boards and online student galleries and tools to support educators and health practitioners who use this resource with classes or support groups. Professionals can post their own unique ideas in a special area and comment on the areas that were the most wellreceived by learners and/or helpful to classroom needs. The program is designed to facilitate networked knowledge between educators and students alike by offering ways to connect individuals or entire classrooms together and provide a shared learning experience. This enables the participants in the intervention to actively learn from one another and supports one of the most powerful means of learning new material. A practitioner toolkit is designed to accompany the electronic classroom environment and can be viewed online, downloaded and printed, or ordered free-of-charge from Youth Voices. The guide allows professionals to go through each section of the Virtual Classroom on Tobacco Control to decide which lessons and/or subjects would be most beneficial to their students. Each section includes a topicoverview, learning objectives, individual and group activities, as well as links to other evidence-informed online resources. Tools such as the Smoking Zine were originally developed as first-order interventions and evolved into second-order interventions before becoming part of the integrated Virtual Classroom. The Smoking Zine has been evaluated in a longitudinal randomized trial with >1400 young people. It was found to be an effective method of engaging highrisk smokers and preventing nonsmokers from starting to smoke,23 although no formal evaluation has been conducted on the integrated Virtual Classroom format. The Smoking Zine is still available as a stand-alone first-order intervention: http://www. smokingzine.org. Each of the 3 orders of intervention offers advantages and disadvantages. First-order interventions are often simple and require relatively little user skill to access. Generally, they can be used with little professional assistance, while second- and thirdorder interventions often necessitate some type of navigational support by the intervention provider. Although accessible, first-order interventions are limited to the medium of the internet, whereas second- and third-order interventions allow the
application of additional resources in a meaningful, coherent manner that facilitates interventions of greater intensity. All 3 orders offer advantages and it is important to understand the skill-set of the patient before recommending one of these options. An assessment of eHealth-related skills, the eHealth Literacy Scale, is publicly available.32 The needs, preferences, and skills of the patient, and the resources available to both the patient and the attending health practitioners should determine which model of WATI is best suited for supporting smoking cessation.
The future for WATI Information technologies are rapidly evolving, both in their functionality and in the manner in which they are used. The internet experience is becoming more social in nature, with content, individuals, and ideas being networked in ways that surpass the initial World Wide Web. Perhaps this is why these new methods of networking knowledge through information technology are called Web 2.0.33 This consumer-centered approach to knowledge creation and transfer allows users to create, edit, and share information among themselves via a website that is provided without an intermediary. Most importantly, these tools are often free-ofcharge and require little technical skill to operate, enabling any Web-user to operate them with ease. This new approach to internet use is led by “social media� tools such as blogs (customizable web diaries),34 wikis (easily editable web pages),35 podcasting (audio or video broadcasts),36 and social network websites like MySpace.com37 that present new opportunities to engage smokers in cessation activities. These tools enable users not only to create content, but also to network their collective knowledge in ways beyond a typical website and they are currently in use by millions of young adults in North America.38-40 The social networking website, Facebook, alone, has more than 30 million users and is among the most widely visited websites on the internet.41 Groups have already developed that promote and denounce smoking, creating a microcosm of society within its electronic boundaries. These tools provide new strategies to engage the public and deliver consumer-driven interventions. Just as WATI approaches have not replaced the physician as an important contributor to cessation efforts, these new technologies and tools add to the available options rather than cast them aside. In addition to the role played by these technologies in aiding tobacco control, they also provide opportunities to engage hard-to-reach populations such as youth, pregnant smokers (www.pregnets. org), and young adults. They also forecast methods to engage future generations. In terms of internet use, young Canadians comprise one of the most connected populations in the world and they frequently use it as a source of health information.42-44 Research with Youth Voices Research (formerly TeenNet)45-50
has explored strategies to engage young adults in smoking prevention and cessation efforts through technology and found that they like the media-based approach, and also appreciate the convenience and accessibility of a Web-based service. This is the population that will become the patients of tomorrow and developing ways to engage them, as well as those in other age groups, is an important step for providing the most appropriate smoking cessation resources possible. WATI can offer a strategy that is flexible enough to stand on its own and support the more intensive work of clinic-based care and treatment. By considering the options available and the level of treatment desired, health professionals can develop or use a myriad of Web tools to deliver first-, second-, or third-order WATI options in supporting their cessation efforts, combining high tech with high touch in helping people quit smoking. Cameron Norman, Ph.D., is an Assistant Professor in the Department of Public Health Sciences, Faculty of Medicine, University of Toronto. References 1. Statistics Canada. Canadian Internet Use Survey. Ottawa, ON: Statistics Canada; 2006. 15 August 2006. 2. Fox S. Online health search 2006. Washington, DC: Pew Internet and American Life Project; 2006. 3. Oh H, Rizo C, Enkin M, Jadad A. What is eHealth (3): A systematic review of published definitions. J Med Internet Res 2005;7(1):e1. 4. Whitehead LC. Methodological and ethical issues in Internetmediated research in the field of health: An integrated review of the literature. Soc Sci Med 2007;65:782-91. 5. Koo M, Skinner HA. Improving web searches: case study of quitsmoking web sites for teenagers. J Med Internet Res 2003;5(4):e28. 6. Etter J-F. Comparting the efficacy of two Internet-based, computer tailored smoking cessation programs: A randomized trial. J Med Internet Res 2005;7(1):e2. 7. Norman CD. CATCH-IT Report: Evaluation of an Internet-based smoking cessation program: Lessons learned from a pilot study. J Med Internet Res 2005;6(4):e47. 8. Cobb KN, Graham LA. Characterizing Internet searchers of smoking cessation information. J Med Internet Res 2006;8(3):e17. 9. McClure BJ, Greene MS, Wiese C, Johnson EK, Alexander G, Strecher V. Interest in an online smoking cessation program and effective recruitment strategies: Results from project Quit. J Med Internet Res 2006;8(3):e14. 10. Eng TR. Emerging technologies for cancer prevention and other population health challenges. J Med Internet Res 2005;7(3):e30. 11. Doolittle GC, Spaulding A. Online cancer services: Types of services offered and associated health outcomes. J Med Internet Res 2005;7(3):e35. 12. Shafey O, Dolwick S, Guindon GE, eds. Tobacco Control Country Profiles 2003. Atlanta, GA: American Cancer Society; 2003. 13. Makomaski Illing EM, Kaiserman MJ. Mortality attributable to tobacco use in Canada and its regions, 1994 and 1996. Chronic Dis Can 1999;20(3):111-117. 14. Niaura R, Abrams DB. Smoking cessation: Progress, priorities, and prospectus. J Consult Clin Psychol 2002;70(3):494-509. 15. Evers KE, Prochaska JM, Prochaska JO, Driskell M, Cummins CO, Velicer WF. Strengths and weaknesses of health behavior change programs on the Internet. J Health Psychol 2003;8(1): 63-70. 16. Christensen H, Griffiths KM, Korten A. Web-based cognitive behavior therapy: Analysis of site usage and changes in depression and anxiety scores. J Med Internet Res 2002;4(1):e3. 17. Ritterband LM, Gonder-Frederick LA, Cox DJ, Clifton AD, West RW, Borowitz SM. Internet interventions: In review, in use, and into the future. Prof Psychol Res Pr 2003;34(5):527-534.
18. Norman CD, Skinner HA. Internet-based behavior change: A systematic review. Unpublished manuscript, Toronto, ON: University of Toronto; 2004. 19. Feil EG, Noell J, Lichtenstein E, Boles SM, McKay HG. Evaluation of an Internet-based smoking cessation program: lessons learned from a pilot study. Nicotine Tob Res 2003;5:189-194. 20. Etter J-F. Comparing the efficacy of two-Internet-based, computertailored smoking cessation programs: a randomized trial. J Med Internet Res 2005;7(1):e2. 21. Norman CD. The web of influence: Evaluating the impact of Internet interventions on adolescent smoking cessation and eHealth literacy [Dissertation]. Toronto, ON: University of Toronto; 2005. 22. Etter J-F, le Houezec J, Landfeldt B. Impact of messages on concomitant use of nicotine replacement therapy and cigarettes: a randomized trial on the Internet. Addiction 2003;98:941-950. 23. Norman CD, Maley O, Li X, Skinner HA. Using the Internet to initiate and assist smoking prevention and cessation in schools: A randomized controlled trial. Unpublished manuscript. Toronto, ON: University of Toronto, 2005. 24. Griffiths F, Lindenmeyer A, Powell J, Lowe P, Thorogood M. Why are health care interventions delivered over the Internet? A systematic review of the published literature. J Med Internet Res 2006;8(2):e10. 25. Eysenbach G. Infodemiology: The epidemiology of (mis)information. Am J Med 2002;113(9):740-745. 26. Eysenbach G, Diepgen TL. Patients looking for information on the Internet and seeking teleadvice: motivation, expectations, and misconceptions as expressed in e-mails sent to physicians. Arch Dermatol 1999;135(2):151-156. 27. Norman CD, Skinner HA. eHealth literacy: Essential skills for consumer health in a networked world. J Med Internet Res 2006;8(2):e9. 28. Skinner HA, Biscope S, Poland B. Quality of Internet access: barrier behind Internet use statistics. Soc Sci Med 2003;57(5):875-880. 29. Bock BC, Graham AL, Sciamanna CN, et al. Smoking cessation treatment on the Internet: Content, quality, and usability. Nicotine Tob Res 2004;6(2):207-219. 30. Selby P, McIntosh S, Norman CD, Bock BC. Global eHealth innovation through tobacco control. Paper presented at: The 8th International Conference of Human Services Information Technology Applications (HUSITA 8). August 26-29, 2007; Toronto, ON. 31. Norman CD. Web-assisted tobacco interventions: A global resource review. Final report submitted to Health Canada. Toronto, ON; 2007. 32. Norman CD, Skinner HA. eHEALS: The eHealth Literacy Scale. J Med Internet Res 2006;4:e27. 33. Wikipedia. Web 2.0. 2007 [cited 2007 01 Sept]; Available from: http://en.wikipedia.org/wiki/Web_2. Accessed: September14, 2007. 34. Wikipedia. blog. 2006 [cited 2006 23 Sept]; Available from: http://en. wikipedia.org/wiki/Blog. Accessed: September 14, 2007. 35. Wikipedia. wiki. 2006 [cited 2006 23 Sept]; Available from: http://en. wikipedia.org/wiki/Wiki. Accessed: September 14, 2007. 36. Wikipedia. podcasting. 2006 [cited 2006 23 Sept]; Available from: http://en.wikipedia.org/wiki/Podcast. Accessed: September 14, 2007. 37. MySpace. MySpace Homepage. 2006 [cited 2006 23 Sept]; Available from: http://www.myspace.com/. Accessed: September 14, 2007. 38. Lenhart A, Fox S. Bloggers: A portrait of the Internet’s new storytellers. Washington, DC: Pew Internet & American Life Project; 2006. 39. Lenhart A, Horrigan JB, Fallows D. Content creation online. Washington, DC: Pew Internet and American Life Project; 2004. 40. Lenhart A, Madden M. Social networking websites and teens: An overview. Washington, DC: PEW Internet and American Life Project; 2007. 41. Environics Research Group. Young Canadians in a wired world: what are youth doing online, and what do their parents need to know? Toronto, ON: Environics Research Group; 2001 6/2001. Report No.: pn4737.
42. 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(6):545-553. 43. Lenhart A, Horrigan JB, Rainie L, et al. The ever-shifting Internet population: A new look at Internet access and the digital divide. Washington, DC: The PEW Internet & American Life Project; 2003 April 23, 2003. 44. Skinner HA, Biscope S, Poland B, Goldberg E. How adolescents use technology for health information: implications for practitioners. J Med Internet Res 2003;5(4):e32. 45. Flicker S, Goldberg E, Read S, et al. HIV-positive youth’s perspectives on the Internet and e-health. J Med Internet Res 2004;6(3):e32. 46. Skinner HA, Morrison M, Bercovitz K, et al. Using the Internet to engage youth in health promotion. Int J Health Promot Educ 1997;4: 23-5. 47. Skinner HA, Maley O, Norman CD. Developing Internet-based eHealth promotion programs: the spiral technology action research (STAR) model. Health Promot Pract 2006;7(4):406-417. 48. Skinner HA, Maley O, Smith L. New frontiers: Using the Internet To Engage Teens In Substance Abuse Prevention and Treatment. In: Monti P, Colby S, eds. Adolescence, Alcohol, and Substance Abuse: Reaching Teens through Brief Interventions. New York: Guilford Press; 2001:297318. 49. Skinner HA, Maley O, Smith L, Morrison M, Goldberg E. TeenNet: using the Internet for e-health. In: Skinner HA, ed. Promoting health through organizational change. San Francisco, CA: Benjamin Cummings; 2002:293-314. 50. Norman CD, Maley O, Skinner HA. CyberIsle: Using information technology to promote health in youth. CyberMed Catalyst 2000;1(2).
Upcoming Meeting 27 February – 1 March 2008 Society for Research on Nicotine and Tobacco (SRNT) 14th Annual Meeting Hilton Portland and Executive Tower Portland, Oregon USA Contact: www.srnt.org
Disclosure Statement: Dr. Norman is the principal investigator of Youth Voices Research; however, he does not obtain any financial benefit from the use and distribution of the resources promoted in this article. Dr. Norman is a new investigator fellow with the Canadian Institutes of Health Research (CIHR) Transdisciplinary Training Program in Tobacco Use in Special Populations.
This publication is made possible by an educational grant from
Pfizer Canada Inc. © 2007 The Minto Prevention and Rehabilitation Centre, University of Ottawa Heart Institute and the Addiction Medicine Service, Centre for Addiction and Mental Health, University of Toronto, which is solely responsible for the contents. Publisher: SNELL Medical Communication Inc. in cooperation with the Minto Prevention and Rehabilitation Centre, University of Ottawa Heart Institute and the Addiction Medicine Service, Centre for Addiction and Mental Health, University of Toronto. ®Smoking Cessation Rounds is a registered trade mark of SNELL Medical Communication Inc. All rights reserved. The administration of any therapies discussed or referred to in Smoking Cessation Rounds should always be consistent with the approved prescribing information in Canada. SNELL Medical Communication Inc. is committed to the development of superior Continuing Medical Education.
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