Health Canada Smoking Cessation Study:

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Health Canada Smoking Cessation Study:

Online Tools & Information to Help People Quit Smoking

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Stay Smoke- Free

(POR-04-06)

December 2004

Submitted to Health Canada

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111'11oe11ix 7 Str ~teSic Perspectives 111c.

Phoenix Strategie Perspectives Ine. \

1678 Bank Street, Ste. 2, Ottawa, Ontario K1V 7Y6

Tel: (613) 260-1700 Fax: (613) 260-1300 Email: info@phoenixspi.èa

www.phoenixspi.ear--Ll-S-RA-R-Y-O-F-P-A-RL-L-AM-E-N-r-

JUN 2 0 2005

BIBLIOTHÈQUE DU PARLEMENT

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Health Canada Smoking Cessation Study (December 2004)

ON-LINE DELIVERY - EFFECTIVE W A y TO ACCESS INFORMATION 34 MOST SMOKERS, SOME FORMER SMOKERS SAY SITE WILL HELP THEM QUIT/REMAIN QUIT 34 ONE SMOKER 'QUITS' USING TOOLS DURING RESEARCH, SOME CUT DOWN 34

REVlEW OF PARTICIPANT TRAC KING SHEETS 35

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ApPENDICES:

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• Recruitment screener

• Overview note for recruiters

• Letters to participants

• Instructions to participants

• Interview guide

• Participant activity tracking form

• Website Screen Shot

• W orksheets

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Executive Summary

• Health Canada commissioned Phoenix SPI to undertake qualitative research to assess the effectiveness of a set of online tools to help current/former smokers develop long- term strategies for staying smoke-free. Representatives of the target audience (i.e.

CUITent sm ok ers and recent quitters) were recruited to read and use the tools and information over a three-week work period and then to take part in a phone interview.

In total, 24 participants took part in this study, conducted September-November 2004.

Overall Impression of Information & Tools

• Participants responded positively, in sorne cases very positively, to the set of on-line tools and information. Most described the materials as useful or helpful in trying to quit smoking or remain smoke-free.

• The structured approach to quitting or remaining smoke-free was identified most often as what participants liked most about the online materials. Sorne also identified the worksheets (in general, or specifie ones), and strategies or suggestions provided.

• Duplication of information was identified most often as what participants liked least.

Sorne pointed to the amount of information to read or 'wade through', while others cited their beliefthat the site is not very engaging (i.e. somewhat dry, not interactive).

Review of Creating a Quit Plan

Everyone was asked to read the Creating a quit plan section, including an sub-sections.

• Nearlyall the participants reacted positively to this section. Those who did not tended to be neutral as opposed to negative.

• There was virtual unanimity that the information is clear and easy to understand, with very few sections/phrases seen as potentially confusing. Participants were also unanimous that the information is easy to follow and linked in a logical way.

• Most participants identified things that helped them develop plans and strategies for creating/maintaining a quit plan as what was particularly useful or relevant to them.

While most participants felt that much/most of the information in this section is not new to them, many still tended to view it as useful or relevant, mainly in validating their experiences and efforts in trying to quit smoking or remain smoke-free.

• While the information in this section was seen to be comprehensive, sorne identified things that they would like to see added, including information to address weight gain, more focus on motivations to quit, information on other methods for quitting, and more information on withdrawals and cravings.

Review ofWorksheets in Creating a Quit Plan

• Overall, participants reacted positively to the worksheets associated with this section.

There was a general consensus that they were useful, at least in the aggregate.

However, sorne worksheets were seen to be much more useful than others.

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• There was a general consensus that the worksheets are well integrated with the information provided in this section. With few exceptions, participants said they understood the purpose of the worksheets and what they were being asked to do.

Review of Additional Information Sections & Worksheets

• OveraIl, reaction to the additional information and worksheets was consistent with impressions of Creating a quit plan and related worksheets.

• Regardless of the sections read, participants were most likely to identify concrete plans and strategies as the type of information that was most useful to them. However, a number of them qualified the usefulness of the information for reasons such as prior familiarity with the strategies (i.e. lack ofnew ideas), suggestions being too general to be of real use, and repetition.

Re1ated Issues

• No participants experienced any technica1 prob1ems accessing the information online or downloading/printing the worksheets. There was a near consensus that the site was easy to navigate.

• Most participants said that if they came to this site on their own, they wou1d adapt it to their own style or specifie needs. Approximately ha1f said they would scan the site to identify things of interest or relevance to them. Most would not read all the materia1 nor complete all the worksheets, but wou1d pick and choose.

• The extent to which the too1s he1ped participants understand their persona1 obstacles to quitting varied. Whi1e sorne described their experience as reve1atory, most said it he1ped confirmlclarify what they a1ready knew. Former smokers were more like1y to emphasize confirmation as opposed to revelation. Most described the materia1s as at least somewhat effective in helping them quit smoking or remain smoke-free.

• Approximately half said they would return to the site to use it again. Participants were near1y unanimous in saying they wou1d recommend it to others, and were unanimous that having this set of too1s on1ine is the most effective way for them to access it.

Conclusions & Implications

Health Canada's online too1s/information were generally well regarded by participants and resonated positively with them. The too1s and information were routine1y described as clear and easy to understand, comprehensive and coherent (i.e. well organized and linked).

It appears that one of the most significant strengths of the online materia1s is their abi1ity to he1p peop1ebetter understand their personal obstacles to quitting or staying quit, and, in particular, the pattern to their smoking (for current smokers) or cravings (former smokers).

Despite the 1arge1y favourab1e reaction to the materials, participants drew attention to characteristics which counterba1anced or qualified their generally positive impressions.

They frequently pointed to perceived repetition or duplication on the site, the amount of

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information to read, the 1ack of new ideas and the 10w interactivity of the site. These perceptions cou1d potentially affect the overall effectiveness of the materia1s.

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The potentia1 impact of these factors is underscored by additiona1 feedback provided by participants. For this study, participants were specifically recruited and paid to review the too1s and information. When asked what they wou1d have do ne if they had come to the website on their own (i.e. not recruited to review it), most said they wou1d on1y have browsed or scanned the site, looking for information of interest or re1evance to them. As such, the site may have tested better under research conditions than it wou1d in the 'rea1 world', where there is so much competition among websites to attract and retain interest, and where peop1e's judgements ofwebsites are often quick1y made ..

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The overall positive reaction to the site during this 'testing' may be due, in part, to the time and effort that participants devoted to reviewing it. In other words, the more time they spend reviewing the site, the more 1ike1y they are to appreciate what it offers (or parts of it), even though they may perceive shortcomings as well. The site's strengths may be 1ess evident to people quickly browsing the site.

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An additional consideration is the routinely-made observation that the site could be useful to others. While genuinely intended to reflect positively on the site, an implication is that it is not, or may not be, particularly useful to the participants themselves that offered this feedback. This was captured most clearly in the fact that many participants said they would not retum to the site, although virtually all them would recommend it to others.

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In summary, participants reacted positively to the set of tools and information. However, their favourable reaction tended to be moderately favourable, not strongly so. Moreover, sorne of the deficiencies that they identified with the online materials do have central relevance in the competition for attention among websites in the online world.

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In reviewing the numerous suggestions made to strengthen the site, attention should be devoted to those that would improve the effectiveness of the tools and information.

Particular attention should be given to suggested changes that affect what people first see when they access the site. Key suggestions in this regard include:

• Cutting down on the repetition and making the site less text heavy.

• Making the site more interactive and engaging (i.e. videos, pictures, chatrooms, interactive worksheets).

• Adding 'missing' content, particu1arly addressing the issue ofweight gain.

• Pulling the materials together in one location (e.g. for those who want easy access to everything).

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In addition, there were a range of other suggestions offered to improve the effectiveness of different aspects of the tools and information that warrant review and consideration by Health Canada.

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Introduction

Phoenix Strategie Perspectives Inc. was commissioned by Health Canada to undertake qualitative research to assess the effectiveness of a set of online tools and information to help current and former smokers develop long-term strategies for staying smoke-free.

Background and Objectives

As part of the Federal Tobacco Control Strategy (FTCS), Health Canada has launched a number of cessation initiatives to motivate and support Canadian smokers of all ages to quit. This work includes the expansion and enhancement of the gosmokefree website to provide smokers with a comprehensive, one-stop online resource on smoking cessation.

The expansion of the website was undertaken as a result of research indicating that web- based interventions have significant potential because they can reach a high number of Canadians at relatively low cost and also allow smokers to work at their own pace.

Health Canada has worked with the Centre for Applied Health Research at the University of Waterloo to develop On the Road to Quitting (OTRTQ), an interactive, web-based, self-help smoking cessation pro gram. It provides individuals with personalized information on their readiness to quit, features evidence-based strategies to deal with obstacles and build motivation and skills, helps people to plan and carry-out quit attempts, provides information on effective methods for quitting, and provides referral to other sources of information and resources on quitting.

The OTRTQ pro gram is based on the stages-of-change model, recognizing that smokers generally go through five successive stages in the process of quitting, each involving different issues and challenges:

• Pre-contemplation (not thinking about quitting);

• Contemplation (thinking about quitting, but not ready to quit);

• Preparation (getting ready to quit);

• Action (quitting);

• Maintenance (remaining a non-smoker). Relapses generally occur within three months after quitting, and most people try several times before they finally quit..

Recognizing that relapse prevention (maintenance) is often the longest and most challenging stage of quitting smoking, Health Canada's Tobacco Control Program developed additional web-based messaging to complement its existing web-based cessation information. These messages were developed by Dr. Patricia Smith, University of Waterloo, using a basic cognitive-behavioural framework of self-directed change. The relapse prevention messages are closely based on other Health Canada programs, such as OTRTQ, e-Quit and Quit4Life. All messages were peer-reviewed for accuracy, content and suitability by Dr. Paul McDonald, University of Waterloo, Dr. Peter Selby, Centre for Addiction and Mental Health, and Carol McDonald (R.N.) with the City of Ottawa.

The overall goal of this initiative is to provide addition al support to current and former smokers through the development of targeted messages to help them develop long-term

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strategies for staying smoke-free. This information will be added to the "Quitting" page of the website to complement the existing self-help tools and resources on smoking cessation. The information contained in these messages is not intended to be read as a publication, but rather to be accessed by the user on a topic-by-topic basis. The users may click on are as of concérn or interest specifie to their personal situation.

With the foregoing in mind, the research objectives ofthis study were to:

• Validate and verify the set of relapse prevention information and tools (i.e.

worksheets) ;

• Explore the perceived effectiveness of the relapse information and tools; and

• Explore and better understand how adult smokers would like to receive and use this type of information, including on-line usage issues.

Research Activities

To address the research objectives, 30 individuals were recruited from the target audience to review the on-line tools and information related to quitting smoking and staying smoke- free, and take part in a phone interview about their impressions of, and experience with, the online materials. In total, 24 participants completed all stages of this research process.

Target Audience

For this study, the foIlowing types of participants were recruited:

• Canadian residents 18 years of age or older, who were CUITent smokers, and who have made at least one attempt to quit smoking and were seriously considering quitting within the next six months. We also recruited a mix of participants by the number, length and success of previous quit attempts.

• Canadian residents 18 years of age or older, who were former smokers. AU participants in this category had quit smoking within the previous year.

• Overall, there was a mix of participants by age, gender, level of education (appropriate to the demographies of smokers), and region. Participants were recruited from a number of cities across the country; specifically, Vancouver, Calgary, Winnipeg, Peterborough, Toronto, Montreal, and Quebec City.

• In total, 10 of the recruited participants were French-speaking.

• AIl participants had access to and made regular use of the Internet.

Overview of Research Process

While qualitative research was judged to be most appropriate for this research, focus groups were considered inappropriate for a number of reasons. Principal arnong these were the idiosyncratic nature of the relapse information and tools and the need for research participants to view and work with the information and tools of specifie relevance to them and their circumstances. The individualistic nature of this requirement is not well accommodated by the group discussion format of focus groups.

Participants were recruited using similar procedures to those used to recruit focus group participants. A detailed recruitment screener was developed in both official languages,

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with questions to ensure that the right mix of participants was recruited. During the recruitment process, recruiters were provided with a one-page overview note to share with potential recruits (orally or through email) describing the requirements of participation in this study (i.e. the tasks they would have to do).

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Once recruitment was completed, Phoenix contacted all participants by phone to establish contact, confirm their participation and email address, and notify them that detailed instructions would be sent to them by email that would inform them of what was required of them. They were invited to call or email the Phoenix team member who contacted them if they had any questions, difficulties, etc.

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Following this, research participants were sent via email an instruction sheet. The instruction sheet described the tasks that the participants would need to perform and contained a link to the web pages where the information was located. Participants were required to confirm receipt of the email. In addition, the instructions provided the timeframe for completion, information on completing and retuming worksheets, contact coordinates for use if problems were encountered, and arrangements for the interview.

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In terms of tasks, participants were asked to read all of the information in the section Creating a quit plan (of the Staying Quit portion of Health Canada's website) and at least two other information sections of their choice that seemed most relevant or interesting to them personally. They were also asked to complete an of the following worksheets associated with the section Creating a quit plan:

• Confidence Questionnaire (that automatically generates Create Your Difficulty Ladder)

• Daily Record (to be completed by former smokers only)

• Tracking Form (to be completed by current smokers only)

• Rewards List

• Graph

• Motivation

• Associations

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In addition, they were asked to choose and complete one other worksheet that seemed most relevant or interesting to them from among the following:

• Problem Solving

• What would you buy?

• Dealing with Lack of Support

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The 'work period' covered a three-week period (approximate). Between one week and the approximate mid-point of this work period, Phoenix checked in with participants by email (and phone if the email was not acknowledged) to see how things were proceeding.

At the end of the work period, Phoenix contacted participants by email (and phone if necessary) to tell them that the work period was over, and remind them to send in their completed worksheets. Participants faxed, emailed (PDF or scanned file) or mailed their worksheets to Phoenix for Phoenix researchers to review. Participants who did not have the ability to make a PDF or scanned version of their worksheets to send by email, or had

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no access to a secure fax, were sent a Business Reply Envelope by Phoenix so that they could return the worksheets by mail.

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Following review of all completed forms, Phoenix researchers called participants for an in-depth interview (approximately 45 minutes) using a discussion guide developed in consultation with Health Canada officials, The guide was designed to assess the effectiveness of the online information and worksheets, explore potential areas of confusion, problems or concerns, and investigate a range of related issues. Any problems or are as of uncertainty identified through a review of the participant's worksheets were raised and discussed with that participant.

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In addition, the following specifications applied to this study:

• The information/tools were accessed by research participants online to replicate the actual delivery system to be used;

• Participants were paid $200 to take part in the study. This amount was deemed to be reasonable given the volume of work that participants were required to do.

Incentives were mailed to participants once their telephone interview was completed;

• The first five interviews served as a pre-test of the discussion guide, where researchers were attentive to the functioning of the instrument to determine whether any adjustments were required;

• During the recruitment pro cess, participants were informed that there might be a six-month follow-up interview. This interview would explore issues with a longitudinal dimension (e.g. Did they continue to use the tools? Did they try to quit smoking for real [those who hadn't] and use the tools? Did they recommend the website to others? etc.). The results ofthis interview stage would be presented in a separate summary report.

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As noted, 24 of the 30 participants recruited for this study completed all the requirements . (14 smokers, 10 former smokers). This represents a completion rate of 80%. The study

was conducted in September to November, 2004.

This research was qualitative in nature, not quantitative. As such, the results provide an indication of participants' views about the issues explore d, but cannot be generalized to the full population of smokers or former smokers.

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Note on findings: OveraIl, differences between current smokers and former smokers were small and infrequent. Wherever these differences manifested themselves, they are identified and discussed in the report.

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Participants' comments are provided in italics, and are either actual verbatim comments or have been paraphrased to reflect the intent of the remark. For editorial purposes, the set of online too1s and information that were the object of this research are sometimes referred to as 'website' in this report since this is how they were delivered to and viewed by participants.

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The principal investigator for this study was Stephen Kiar, who conducted sorne of the interviews and wrote the final report. Philippe Azzie and Alethea Woods also conducted interviews and contributed to the report.

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Appended to this report are the following (in both official languages):

• Recruitrnent screener

• Overview note for recruiters

• Letters to participants

• Instructions to participants

• Interview guide

• Participant activity tracking form

• Website screen shot

• W orksheets

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Overall Impression of Information and Tools

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This section reports on participants' overall reaction to the set of on-line information and tools that they reviewed and used.

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Positive Overall Reaction to On-Line Tools & Information

Participants responded positively, in sorne cases very positively, to the set of on-line tools and information. Most explained their reaction by describing the materials as useful or helpful in trying to quit smoking or remain smoke-free. A number focussed specifically on sorne of the worksheets when saying this.

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In specifying why they perceived the materials to be useful, participants tended to focus on the approach underlying the tools and information. More specifically, they identified the following aspects:

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• Thoughtful/reflective approach: Sorne participants found the materials to be useful because they are designed to make people think or reflect on their smoking and smoking-related behaviour. Raising this to the level of conscious or reflective activity not only helped them to understand their behaviour, but also helps them deal with it (i.e. control it) in a pro active as opposed to a reactive way. One participant described the approach underlying the materials as 'therapeutic' and compared it to the psychoanalytical approach whose basic goal is to raise unconscious determinants to the level of consciousness in order to deal with them.

• Structuredlmethodical approach: Sorne described the materials as useful because they are structured in a methodical manner. The materials focus on specifie issues and problems related to smoking and smoking-related behaviour and address them in a systematic, step-by-step way. They also allow users to focus on issues that are most relevant to them.

• Serious treatment of issues: A few participants described the materials as helpful because they treat the issues and problems associated with smoking in a serious way. By that they meant that there is a recognition that trying to quit smoking or remain smoke-free can be very difficult and complicated. The materials recognize this or take it for granted, and do not propose any 'quick-fix' solutions.

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• Non-judgmental: A few found it helpful that the materials are non-judgmental (i.e.

do not censure or rebuke smokers). It was noted that this is often not the case in the public at large, where smokers can sometimes be perceived or portrayed as

"bad" people as opposed to people with a problem or bad habit.

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• Motivational support: It was noted that the information and tools provide motivation and encouragement to try to quit smoking.

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Other reasons for participants' positive overall reaction to the online information and tools were identified less often. These included:

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• Volume of information: Sorne participants focussed on the amount of information available through the site to explain their overall positive impression. It was seen to be voluminous and relatively comprehensive.

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• Ease of understanding, clarity: A few described the information as easy to understand, straightforward, and clear.

• Well laid out site: A few described the site as well set up and laid out, making it easy to access and use the information.

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While overall reactions tended to be positive, sorne participants did include comments of a more critical or cautionary nature. Here, the focus was on the following issues:

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• Repetition/duplication: Sorne participants felt that there was too much repetition of information at times. It was noted that this could be good to the extent that it serves to emphasize certain points, and may be necessary in part because things are linked together. That said, a few participants said they were a little frustrated at coming upon sorne of the same information repeatedly.

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• Too much information: A few participants felt that while there is a lot of information available, there might in fact be too much and that this might limit the extent to which people will use the site. One participant noted that he was recruited and paid to review the site but was not sure he would do this otherwise because of the large amount of information to go through.

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• Lack of new information: Sorne participants said they found little that was new or original on the site. They said that they already knew about or were familiar with muchJmost of this information and these approaches in general.

• Lack of overview: Sorne felt that it is not immediately clear how all the materials link together (i.e. information and worksheets). This becomes more clear as one begins to use the site, but one participant noted that people not recruited to review the site might get frustrated trying to figure this out and might abandon their browsing before determining this.

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Finally, a few participants, while generally positive about the tools and information, added a cautionary note regarding the usefulness of the site or the likelihood that people will use it. One explained that while it is not politically correct to point this out, many smokers are from low-income groups and tend to have less formal education. Such people are less likely to take the time or devote the effort necessary to work through such a site or even take it seriously. Another added that because smokers tend to be from low- income groups, many may not have a computer to access these materials.

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Another participant noted that while the tools and information can be useful and helpful, most people who really want to quit are going to do it regardless. While it is not simply a

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Health Canada Smoking Cessation Study (December 2004)

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matter of willpower, he felt that the most important decision is the decision to quit.

Related to this, it was felt that many people who are trying to quit smoking or remain smoke-free are looking for the quick-fix solution and will not want to follow the slower, more methodical approach outlined by the site. He thought this was sad because the site could probably help them quit or remain smoke free in the long run.

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Structured, Detailed Approach & Worksheets - Most Positive Features

Participants identified a number of features when asked what they liked most about this set of tools and information. While no single feature or aspect dominated, participants were most likely to draw attention to the structured approach to quitting or remaining smoke- free and to the worksheets.

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Positive features were seen to include:

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• Structured approach: Participants who referred to the structured approach tended to focus on one or more of the foUowing three things:

oThe ability to proceed systematically: The material is organized so as to deal with issues in a structured, step-by-step manner.

o You can choose what applies to you: The materials and information are set up in such a way that us ers can focus on issues that are relevant or most important to them.

o You can proceed at your own pace: The approach, while structured in a step- by-step manner allows users to proceed at their own pace and rhythm.

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• Worksheets: Sorne participants identified the worksheets in general, or sorne of the specifie worksheets, as what they liked most about the site. A few specified that what they liked most about the worksheets is that they make one think and reflect. Specifie worksheets singled out at this point in the interview included the

'Tracking Form' (for smokers), the 'Difficulty Ladder', and the 'Rewards List'.

• Strategies/suggestions: Sorne participants said that what they liked most were the strategies or suggestions contained in the information. Specifie examples included sections B ('Controlling Cravings') and E ('Techniques to Remain Smoke-Free') of the website.

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A smaU number of participants, typically only a couple of people, identified the foUowing as things that they liked most about the online tools and information:

• Lay-out/navigation: The site was seen to be welllaid out and easy to navigate.

• Ease of access: AU the information is available in one location and is accessible on demand (i.e. users can access it when they want or need to and are not dependent on anyone for accessing the information).

• Amount of information: The information was seen to be comprehensive.

• Clarity: The information was seen to be presented in a clear and easy-to- understand manner. There is no jargon or technicallanguage.

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Health Canada Smoking Cessation Study (Decernber 2004)

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FinaIly, a few participants said they liked everything about the site, and did not focus on anything specificaIly.

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Duplication, Amount of Reading - Main Perceived Weaknesses

While sorne participants indicated that there was nothing they disliked or liked less about the online tools and information, most did identify something. Two things were identified most often:

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• Duplication/repetition: Numerous participants identified duplication or repetition of information as what they liked least about the online tools and information.

There were two aspects to this: repetition or duplication in sorne of the worksheets and repetition in the information provided:

o Worksheets: Participants who drew attention to repetition or duplication in the worksheets all identified the same thing. They felt that the 'Motivations' and 'Association' worksheets tended to cover the same things and that it was not necessary to have both. See the more detailed discussion of these worksheets below.

o Information: Sorne participants pointed to repetition in the information sections. A few felt that this may be intentional since the same information may be relevant or pertinent in different sections, but nevertheless found it to be annoying to come across the same information more than once.

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• Too much information: Sorne participants said that what they liked least was the sheer volume or amount of information to read or 'wade through' .

Things identified less often as something that participants did not like about the site included:

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• Lack of room to write: It was felt that it is difficult to use sorne of the worksheets because of the limited space provided for writing. Specifie worksheets identified included the 'Daily Record', the 'Tracking Form', and 'Problem Solving'.

• Lack of overvie'w: Participants who had mentioned this earlier repeated that there is nothing that links aIl the materials together or provides an overview of the tools and information.

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• Worksheets: A few participants identified specifie worksheets as what they liked least about the on-line tools and information. The worksheets identified included 'Association', the 'Graph', and 'Dealing with lack of Support'. The' Association' worksheet was described as repetitive, the 'Graph' as not very helpful, and 'Dealing with Lack of Support' as unrealistic. See the more detailed discussion of these worksheets below.

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1 Review of Information in Creating a Quit Plan

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This section reports on participants' impressions of the information presented in the section Creating a Quit Plan. AlI participants were asked to read this section, including all sub-sections. They were asked to read the information as if they had come to it on their own and based on their own reading habits.

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Participants Read AlI Required Information

AU participants said that they had read the entire section, including all subsections. A few indicated that they read this section twice, or that they had referred back to parts of this section, as needed.

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Overall Impression - Very Comprehensive

Nearlyall the participants reacted positively to this section, describing it as "good" and in sorne instances "very good". Those who did not react positively tended to be neutral as opposed to critical or negative in their overall assessment. Approximately half the participants explained their positive reaction by saying that the section was comprehensive or thorough in terms of the information it contains.

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Other reasons, identified by smaller numbers, inc1uded:

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o Utility of the information: Sorne participants, primarily smokers, described the information in this section as useful. Various reasons were given to explain its utility. These included the practical strategies/plans offered for quitting smoking or dealing with triggers, clarification of issues/problems, a better understanding or awareness of their own smoking habits, and validation/confirmation of smoking- re1ated experiences. The latter was described as useful because it let people know that the things they experience when they try to quit smoking or remain smoke- free are not uncommon. This can help solidify their commitment to quitting.

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o Clarity, ease of understanding of the information: Sorne described the information as very c1ear and easy to understand.

o Organization of information: A few participants liked the way the information was presented and organized thematically under the various bullets. This made it easy to follow.

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A few participants reacted to this section by noting that there is a lot of information, but nothing or very little that is new to them, that they did not know already. One participant described the section as good overall, but added that sorne key pieces of information were missing (see discussion below).

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Information Seen to be Clear & Easy to Understand, Few Areas of Confusion

There was virtual unanimity that the information in this section is clear and èasy to understand. Participants volunteered this assessment routinely, without hesitation.

Moreover, very few sections or phrases were identified as being unclear or potentially confusing. This, in fact, was clearly one of the strengths of this set of online tools and information.

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At the beginning of the study, participants were told to note anything that is unclear or about which they would like to ask a question or make a comment during the phone interview. Only two participants drew attention to specifie passages in this section.

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One said that the relationship between the worksheets and the information should be clarified. Specifically, it was noted that the first actual reference and link to a worksheet in this section is to the 'Rewards List' in the sub-section Make the short-term rewards of quitting worthwhile. However, the 'Rewards List' is not identified as a worksheet, while the 'Motivation' and 'Associations' worksheets which appear at the end of the same section are identified as such.

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Another participant was confused by (and disagreed with) part of the following passage which appears at the beginning of the sub-section Common reasons quit plans don ^'t work:

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People don't start smoking again just because they don't have enough willpower. Willpower has nothing to do with quitting. The most common reason people can't quit smoking is because they don't do the work they need to do to quit.

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This participant felt that while the first and last sentences are accurate, the second sentence is at the very least an exaggeration and at most sheer nonsense. He felt that while willpower is not the only factor, it is certainly an important one since many people, including himself, do quit smoking "cold turkey" and remain smoke-free.

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Finally, one participant made a general statement saying that while the section was clear and easy to understand, it could be even more clear if it were made more concise.

According to this participant, the section as a whole was too wordy and could be condensed.

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Section Seen to be Easy to Follow, WeIl Structured

There was again a consensus that the information in this section is easy to follow and that the various sub-sections link together in a logical, coherent way. However, it was felt that there can be sorne confusion about how the links to the worksheets are related to the information, but that the connection becomes clear relatively quickly.

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One participant described this as the best section in terms of coherence and ease of navigation because the various sub-sections do not include additional subsections (i.e.

one is not burrowing down into one section after another) as is the case in sorne of the other sections on the site.

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No suggestions were made for improving this section in terms oflogic or coherence.

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Information to Support Plans & Strategies Judged to be Particularly Useful

Asked what information was particularly useful or relevant to them, most participants identified things that helped them develop concrete, practical plans and strategies. for creating and maintaining a quit plan. That is, things that helped them bring order and structure to their own needs and efforts in this area.

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More specifically, participants identified the following sections or types of information as being particularly useful:

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• Keep a record: Approximately one-in-five identified this section or parts of it as particularly useful to them. The main reason given was that this information helped them understand their smoking-related behaviour, including triggers, and thereby helped them develop strategies or plans to deal with them.

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• Crea te smoke-free strategies: Almost as many identified this section as particularly useful because it helps them develop plans and strategies tailored specifically to their particular situation. This helps them confront situations in a pro active as opposed to a reactive way.

• Create a difficulty ladder: A few participants described this as particularly useful because it helped them gauge their confidence and coping skills.

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• Plan to prevent a relapse & Common reasons why quit plans don 't work: A few non-smokers identified both these sections as particularly useful. They indicated that they had only very recently quit smoking and were preoccupied with a possible relapse. They were therefore particularly interested in information on this topic and possible plans to deal with it.

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A few participants said that aIl the information in this section was useful to them. One said this because all the sections were tied together and inter-related as part of an overall strategy, as opposed to being distinct and separate sections dealing with different issues.

Another explained that all the information was useful because of the underlying emphasis on writing things down. It was felt that actually putting pen to paper and seeing what you write brings you to a new level of awareness. Finally, one participant said all the information was useful because it demonstrates that there is no quick and easy solution to living smoke- free.

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Convers el y, a few participants, all but one of them former smokers, said that nothing or very little was useful to them. One felt that the information is tailored mainly for CUITent smokers, another said it was not particularly useful because there was nothing new, and two others said they no longer have any cravings so they have no need for this information.

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Much Information Not New, But Useful Nevertheless

While most participants said that there was at least sorne specifie type of information in this section that was new to them or provided ideas they would not have thought of, most also indicated that, generally speaking, much of the information was not really new to them. That said, most still tended to view the information as useful or relevant in sorne way:

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• Confirms/validates experience: A number of participants said that while most or much of the information is not new to them, it validates or confirms their own experiences and efforts in trying to quit smoking or remain smoke- free.

According to sorne, it shows that they are on the right track and serves as a motivation to continue.

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• Good reminder: Sorne participants said that even if they knew much of this already, it is good to be reminded of it since it works as positive reinforcement.

• Good for others: Sorne said that while the information was not necessarily new for them, they thought it would be new to others who had not yet tried to quit smoking.

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• Information set out clearly and systematically: A few participants said that while much of this information was known to them, this section has the virtue of pulling many things together in a clear and systematic way.

• Easy accessibility: A few said that having all this information easily accessible in one location and at one' s fingertips is helpful even if it is not newinformation.

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Information that was most likely to be identified as new tended to revolve around the idea of writing things down and keeping records/tracking. While sorne participants said that they were familiar with this approach in trying to quit smoking, others said this was new to them.

The following specifie things were identified as new, but none was identified by more than a few participants. Note that many are specifie worksheets:

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• Worksheets (in general).

• 'Tracking Form'.

• 'Rewards List'.

• 'Difficulty Ladder'.

• 'Graph'.

• 'Confidence Questionnaire'.

• 'Daily Record'.

• Writing down strategies.

• Writing things down immediately (i.e. not waiting).

• Identifying risks and ways of coping with them, and then writing them down.

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A few participants were definitive in saying that there was no new information, and tended to be disappointed with this. The lack of new information bored sorne people, and undermined the usefulness of the website. As one person stated, "1 guess l've seen and done it all". Sorne participants would have liked to see more new information and ideas that were less well known, particularly examples of things that they could act on.

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Section Described as Comprehensive

Most participants described the information in this section as comprehensive. That is, they did not think anything was missing in terms of information on how to create and maintain a quit plan. As noted, the sheer volume and perceived comprehensiveness of the site as a whole was identified as one of its strengths. That applied specifically to this section as well.

Nevertheless, sorne participants did identify information that they would like to see added. This included:

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• Information to address weight gain: Sorne participants, all women, said they would like to see information on, or a discussion about, weight gain. One said that this is an important issue for woman and the main reason she took up smoking in the first place (i.e. she would rather smoke than eat). These participants articulated a need for information and strategies on how to cope with this, not only concems about it and ways to avoid it, but also how to deal with actual weight gain.

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• More focus on motivations to quit: A couple of participants said there should be more information or tools to strengthen people's motivation for wanting to quit.

This could include documents talking about the risk of smoking, scientific research, videos of the 'horrors of not quitting', health-related information on the damage caused by smoking, or links to other non-smoking sites (sorne of which are said to graphically show the horrors associated with smoking). One participant felt that the site needs to create more of a motivation in people who want to quit, or at least to help firm up the motivational aspect of quitting smoking. At present, the site mostly assumes that people are motivated to quit. He felt there needs to be more focus on the dangers of smoking and why people need to quit.

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• Information on other methods for quitting: A couple of participants suggested that information on other ways of quitting should be added to this section (e.g. the Patch, Zyban, Nicorette). While one of them noted that such information is available on the site, as well as links to more information on the web, this information was seen to be "buried" in section C and should be pulled forward.

The reason given for pulling it forward into this section was that people need this information to make an informed decision about the options available to them when they decide to quit.

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• Information on withdrawals and cravings: It was suggested that there should be more information on withdrawals and cravings that addresses the health and

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physiological effects of quitting. For ex ample, what will happen to your body as you quit, and what side effects are normal or to be expected?

One participant said that the information was comprehensive but not necessarily useful.

Another said that it was comprehensive, but that the most important thing is the person's mindset (i.e. whether or not they really want to quit).

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Suggestions for Improvement

Slightly more than half of the participants made suggestions for improving this section.

While numerous suggestions were identified, none was identified by more than a few participants.

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Sorne suggestions involved cuts or deletions:

• Cut superfluous information: It was suggested that an effort be made to del ete or remove superfluous or useless information. The foliowing passage in Make the short-term rewards of quitting worthwhile was provided as an example: "There aren't many projects in life that make you feel happy from start to finish". This was described as a "no brainer" that did not need to be stated.

• Avoid repetition: While sorne things can be repeated for the sake of emphasis, try to ensure that there is as little repetition as possible.

• Cut the sentence "Willpower has nothing to do with quitting": This was described as untrue and possibly offensive to sorne former smokers who have quit "cold turkey".

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Sorne suggestions involved formatting or design issues:

• Add a site map: This could help prevent people from getting lost.

• Pro vide difJerent sections for difJerent users: Have one access point for current smokers and one for former smokers so that they are immediately streamed to the information that is pertinent to them. It was noted that sorne language is for smokers only (or non-smokers only), and that this can confuse readers.

• Reorganize the information: Divide the information into three sections - 'You're thinking about quitting', 'You're quitting', 'You've quit'. The information could be presented to address the issues of particular relevance to each group.

• Pro vide links to other non-smoking sites: The site should also be a gateway or portal to other non-smoking sites. These links should be in the first section on the site.

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• Use difJerent fonts and colors: Ali of the information uses the same colour pattern, the same format, etc. Consider using different colours for the different sections to help differentiate them (i.e. colour code the sections). This might make it easier for readers, by breaking the information down into parts and more c1early labelling them.

• Add sub-sections: Make this section more like the others at the site by breaking the information into more specifie, well-defined sub-groups.

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^HealthCanada Smoking Cessation Study (December 2004)

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Sorne suggestions involved adding information or ernphasis:

• Provide information on the good effects of quitting: Let people know what types of positive health impacts they will begin to feel once they've quit (e.g. easier to breathe).

• Add an overview section. This would help users understand the purpose of this section, and how the various elernents link together.

• Add information on what to do after a relapse: Currently there is information on how to prevent a relapse but nothing on what to do when or if you suffer a relapse.

• Provide more examples of things that people might not have thought of on their own. For instance, this could include creativelirnaginative ideas that could be acted on.

• Clarify pur pose of the worksheets: Provide an introduction to the worksheets, including information on how they relate to the information.

• Provide more information or detail in 'Plan to prevent relapse ': This section was described as a little too general.

• Create and maintain sense of urgency about quitting: There's a need to balance the carrot (i.e. rewards, what would you buy) with the stick (i.e. the health-related effects of smoking).

• Have morefocus on what you can buy: Have versions of 'What would you buy?' in multiple places on the site. This would reinforce the financial savings aspect of quitting.

• Provide information or tips on how to handle 'panic attacks ' related to smoking.

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Finally, sorne suggestions had to do with rnaking the site more attractive or engaging:

• Include pictures, video clips: The section was seen by sorne to be 'text heavy'. To address this, it was suggested that pictures or video clips be added to explain sorne ofwhat is presently dealt with through text.

• Add a timeline for implementing a quit plan: Provide a sample timeline or implernentation plan that could be modified by users to enable them to rnake their own 'game plan'. A related idea is for the site to provide, as a tool, a rnodel or ternplate that could be filled in by users to do this. This rnight identify the stages of quitting, with tirnelines associated with the various stages.

•. Add more interesting and fun things, like 'What would you buy?' A few participants noted that the information in this section is relatively 'dry', and that efforts to make it more interesting or engaging would help strengthen it.

• Add stories or anecdotes: This rnight rnake the information easier to relate to because people would be able to personify and personalize the information.

• Pro vide a chat room: This would allow people to share their experiences and

encourage one another. .

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• Encourage people to quit smoking: In addition to providing people with techniques to quit or remain quit, encourage them to quit. This might involve having people sign-up or pledge to try to quit. Periodic email messages could be sent to them to see how they are doing, answer their questions, and encourage them.

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Review of Worksheets for Creating a Quit Plan

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This section reports on participants' impressions of the worksheets associated with the Creating a quit plan section, including their experiences in completing the worksheets.

Relevant worksheets include:

• Confidence Questiomiaire (to Create Your Difficulty Ladder)

• Daily Record (completed by former smokers only)

• Tracking Form (completed by CUITent smokers only)

• Rewards List

• Graph

• Motivation

• Associations

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Positive Impression of Worksheets, Seen to Foster/Encourage Reflection

OveraIl, participants reacted positively, and in sorne instances very positively, to the worksheets associated with this section. There was a general consensus that the worksheets were useful, at least in the aggregate. However, sorne participants felt that sorne worksheets were much more useful than others. As weIl, sorne people said that while the worksheets were perhaps not very useful to them personaIly, they would probably be useful to others, particularly smokers who have taken the decision to quit but have not yet done so.

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In explaining their overall positive impression, most participants made reference to the fact that the worksheets encourage or foster reflection. This has the effect of raising awareness or making one conscious of such things as smoking patterns, the number or frequency of cigarettes smoked, the 'types' of cigarettes smoked (e.g. cigarettes with a

'purpose' vs. those smoked out of boredom), risks, cravings, etc. A few participants felt

that the worksheets allow one to begin to take control by developing strategies to deal with their smoking-related behaviour based on increased understanding of their smoking behaviour. One participant described the worksheets as serving a purpose and having an effect similar to a diary.

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Sorne participants described the worksheets as clear or straightforward, and easy to complete. On the more critical side, a few noted that there is sorne repetition in the worksheets. While one participant felt that such repetition can help to add emphasis or

"drive a point home", others were annoyed or frustrated by repetition in the worksheets.

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Worksheets Well Linked to Section Content

There was a general consensus that the worksheets are weIl integrated with the information provided in this section (i.e. that they complement one another). A few participants elaborated on what they meant by this by noting that the worksheets address and deal with issues discussed in the section and that the links to the worksheets appear at appropriate places throughout the section. Despite the foregoing, it was suggested that while the worksheets are weIl integrated with the information, it would help if there were

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sorne sort of introductory note clarifying the relationship between the text and the

worksheets.

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Feedbaek on Specifie Worksheets Generally Positive, Sorne Seen to be Less Useful Overall, participants tended to have generally favourable or positive impressions of the

various worksheets. Asked for their overall impression of each worksheet, they tended to

comment on each one's perceived usefulness. In doing so, most made it clear that they rated sorne as better or more useful than others (see discussion of specifie worksheets for more detail). The most frequently voiced overall impression related to specifie worksheets had to do with the perceived similarity or duplication between the 'Motivation' and 'Associations' worksheets. Almost half the participants drew attention to this when asked for their overall impression of these two worksheets.

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Purpose ofWorksheets Generally Understood

With few exceptions, participants said they clearly understood the purpose of the various worksheets, what they were being asked to do, and why they were being asked to do it.

However, sorne worksheets were identified by a few participants as lacking clarity or involving confusion. These included 'Motivation', 'Associations', 'Rewards List', and 'Daily Record'. While relatively few participants described any of these worksheets as unclear, those who did tended to focus on the 'Motivation' and/or 'Associations' worksheets. Their questions included:

• Why do they ask about the long-term advantages or good things about smoking?

• Why ask about the long-term disadvantages of quitting?

• What do they mean by positive or negative "associations" with smoking or quitting?

• What's the difference between these two worksheets?

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A couple of participants described the instructions for the 'Daily Record' as unc1ear.

SpecificaIly, they pointed to the table that is provided as an example of information that can be collected. It was not c1ear to them whether in completing their form they were to deal with each of the questions in a separate cell or all of them within the sarne cell. They suspected the latter but since the exarnple table places each question in a separate cell they were not entirely clear about this. As well, one participant was unc1ear whether users needed to complete the table going across or up and down, since sorne of the questions in the table were the sarne in each column (e.g. "what were you saying to yourself?").

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FinaIly, a couple of participants said they did not understand the purpose of sorne of the questioris asked in the 'Rewards List'. They inc1uded questions 6 (What makes you feel good?), 9 (What do you enjoy doing?), Il (Who do you like to spend time with?), and 13 (Are there any movies you would like to see?).

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W orksheets Genetally Seen to be Easy to Complete, Sorne Diffieulties Cited

Participants had no real difficulties completing any of the worksheets. A number even volunteered that the worksheets were easy or straightforward. Moreover, their ability to successfully complete the worksheets was confirmed by a review of the completed worksheets undertaken by Phoenix researchers.

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^Nevertheless, sorne participants did identify difficulties completing specifie worksheets.

These difficulties fell into four categories: difficulty conceiving or conceptualizing, difficulty quantifying, cumbersome nature of the activity, and difficulty understanding what was being asked (see above for the latter).

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• Difficulty conceiving or conceptualizing: A few participants said they had sorne di ffi cult y providing responses or answers to things they had not thought of before.

They were referring specifically to the 'Motivation' and 'Associations' worksheets, which asked them questions they had not previously considered, such as the 'short and long-term disadvantages of quitting' and the 'long-term good things about smoking'.

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• Difficulty quantifying: A few found it difficult to quantify or rate certain things asked for in various worksheets. This included describing their mood and rating the extent to which they needed a cigarette in the 'Tracking Form', quantifying cravings as asked in the 'Graph', and rating confidence to resist the urge to smoke in various situations, as asked in the 'Confidence Questionnaire'.

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• Cumbersome nature of activity: A couple of participants described completing the 'Daily Record' as difficult because it was cumbersome to complete an entry for each craving or trigger.

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Usefulness of Specifie Worksheets Varies

As noted, participants' impressions of the different worksheets tended to vary in terms of their usefulness in helping them develop strategies for quitting smoking or remaining smoke- free. That is, they tended to distinguish between the various worksheets, viewing sorne as more useful than others. A majority of participants described most of these worksheets as useful, but those most likely to be described as such included the 'Tracking Form', 'Rewards List', and 'Confidence Questionnaire', while those less likely to be described as such included 'Associations' and the 'Graph'. A more detailed and fulsome description of the perceived usefulness of each worksheet is provided below.

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The various worksheets are presented below, in approximate order of their perceived usefulness, from the most useful to the least.

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Tracking Form:

Virtually all of the CUITent smokers who completed the 'Tracking Form' described it as useful, and many as very useful. Sorne volunteered that it was the most useful of the worksheets. Sorne said it enabled them to become aware of how much they smoked in a way they had not been aware before. Not only could they quantify the number of

Health Canada Smoking Cessation Study:

aOO'f-I",

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Health Canada Smoking Cessation Study:

&

December 2004

Submitted to Health Canada

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111'11oe11ix 7 Str ~teSic Perspectives 111c.

JUN 2 0 2005

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Executive Summary

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Introduction

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