Background
Health effects among smokers and non-smokers of tobacco consumption are well-established including principally respiratory and cardiovascular diseases and cancer [
1]; in fact is one of the leading preventable causes of death worldwide and mainly in occidental societies [
2]. In Spain, for instance, smoking is the health problem that causes more mortality and morbidity [
3], and therefore originates one of the higher health costs. According to the last national survey conducted in Spain in 2006 the percentage of daily smokers aged 16 or older was 26.44% [
4]. The vast majority of smokers declare a willingness to quit smoking and approximately 60% have tried it [
3], although only 3 to 5% of them per year accomplished smoking cessation [
3,
5,
6].
Several cost-effectiveness studies worldwide have shown that both low and high impact care interventions to reduce tobacco consumption are cost-effective measured in cost per year of life gained and quality of life [
3,
7]. Moreover, under a public health view probably these interventions represent the most cost-effective method to improve population’s health. Minimum advice on quitting smoking among the general population achieves an average of 5% cessation per year [
8,
9]. In contrast, more intense interventions, can reach more than 20% of abstinence [
10,
11]; in general, it is well established that the more intensive the intervention, the best rates of smoking cessation are obtained [
10]. The inclusion of those treatments that have demonstrated its efficacy in systematic reviews and metanalysis, has been confirmed to be useful [
7].
Therapeutic intensive interventions for smoking cessation have been used in primary care, such as the one of the ISTAPS study [
12], but none have been based in Information and Communication Technologies (ICTs). These interventions are based on the hypothesis that smokers that do not quit smoking but are aware of its harmful effects underestimate the health risk to due to its consumption [
13]. So, these interventions could provide motivational feedback to promote risk awareness and accelerate changes on smoking behavior [
14]. Some smokers who quit smoking have been identified as susceptible to damaging adverse effects of tobacco consumption or seen seriously threaten his or her health [
15,
16].
The vast majority of non-pharmacological use the Prochaska and DiClemente’s Transtheoretical Model of Change [
17] that describes a succession of stages (precontemplation, contemplation, preparation, action and maintenance) each one indicating a different type of intervention. Other studies in our country have used this model among diabetic smokers patients attended in primary care and to confirm smoking abstinence using cooximetry [
18] and another where information gathered by cooximetry is the main element to motivate smokers to quit [
19].
The use of electronic mail and internet is increasing worldwide. In Spain, according to the National Statistics Institute, in 2010, 57% of households had Internet access; moreover there are 20 million estimated regular users and those who log at least once a week represent 58.4% of the population (7.1% increase over the previous year). Seventy-eight percent of the Spanish population between 16 and 74 uses the electronic mail, with an increase of those who access it via mobile devices [
20].
Internet and E-mail use is also increasing in medicine and can be mostly useful in appointment citations and remainders, analytical results, computerized medical history, prescription refills, regular follow-up and access to health information. The advantages derived from professional-patient E-mail communication include: time and cost saving for hospitals, primary care centers, primary care professionals and patients (e.g. patients who frequently travel and sanitary professional of rural areas can easily contact with physicians and patients respectively) [
21,
22] and convenience since it does not have a simultaneous nature (the person can check the messages at his or her convenience) [
21]. Several patients also refer that E-mail communication can facilitate the contact with the sanitary professional; in face to face interviews they could not feel enough comfortable to rise certain issues or may have forgotten to ask important questions. Some of them deem a useful and satisfactory use E-mail communication in a secure and private environment [
21]. A revision undertaken on the impact of e-therapies, Hsiung concluded that E-mail tracking is useful if preceded by a personal and direct relationship with the patient [
23]. Finally, in the global crisis context these types of interventions can diminish visits to the primary care center. Limitations comprise unwillingness to use the E-mail, perception of lack of time and experience to use the new technologies [
21,
24], an abuse by an overriding number of messages on non urgent matters, and the development of a private and secure website and a specific deontological code could increase the economic costs [
25].
Internet use in quitting smoking is becoming more evident, since it is necessary to recruit more smokers to fight smoking regardless of race or culture [
26]. Several studies have published about the virtual communities in this field [
27] and internet as a support to phone lines (quitlines) [
28]. It has been established that it is a way that enriches the sanitary professional-patient relationship and that the dissemination of patient’s successful experiences can improve their self-esteem and generate positive attitudes [
25] although further research is needed [
29].
The 2008 the Treating Tobacco Use and Dependence Guideline, pointed out that online tools to quit smoking are promising tools that have not achieved its own potential to undertake interventions; results have been shown to be only favorable if online interventions are developed in very complex programs or if were carried out when the help was more intensive among intervention groups than in controls. Nevertheless, it also encourages depending on those characteristics that needs to be improved [
7]. In Spain, the National Committee to Prevent Smoking Cessation (CNPT in Spanish) also supports these types of interventions to help smokers to quit [
3].
Characteristics of smokers who seek help on the Internet to quit smoking were female sex (59%) and younger individuals. Generally are subjects who are trying to quit smoking (53%) and search information on how or medication to quit, whilst those who have already quit search information on how to face abstinence [
30].
Twenty studies have been found to be registered at Clinical Trial when using keywords: E-mail AND smoking, none undertaken in Primary Care environment with personalized follow-up (Clinical Trials, 2012). In 2010 the Cochrane library published a revision that included the most relevant articles on internet interventions for quitting smoking. Ten out of twenty compared an internet based intervention with others not based on this media. The revision concluded that personalized and interactive internet based interventions, especially if there is an individualized tracking, can be more effective than those standardized protocols on smoking cessation. However, long-term smoking cessation is less effective when using these interventions compared to other interventions [
31].
Te Poel and collaborators published in 2009 a clinical essay to evaluate the efficacy of an E-mail computer-tailored smoking cessation intervention. At six months post intervention 21.5% and 20.4% of intervention group reported not having smoked in the last 24 hours and in the 7 days, respectively compared to the control group (9.8 and 7.8%, respectively); follow-up lost were quite high in both control and intervention groups [
32]. Polosa et al. demonstrated the utility of an E-mail consultation messages in a smoking-cessation program although the number of included patients was somewhat low [
33]. Lenert and collaborators determined the effectiveness of an automated educational E-mail messaging system individually sent in the framework of smoking cessation intervention. The OR for quitting smoking among the intervention group at 30 days post-intervention was 2.6 (95% CI: 1.3-5.3) [
34]. An increased smoking and reduced frequency of smoking was observed in young adults after an online peer support via E-mail [
35] and in adolescents after a home based internet intervention [
36,
37].
In Spain there are two online initiatives to help smokers to quit. The first one, the Madrid City Council Giving-up smoking on-line Programme, that combined automated interaction with the user and personal E-mail consultations that included 4865 smokers. After the treatment period the smoking cessation rate was 17.8% and at six months post intervention the abstinence achieved was 10% [
38]. The second one is undertaken by the Psychology Faculty of the National Distance Education University (UNED) but not results have been published yet [
39].
In Barcelona, Spain, the study
E-
consulta in Primary Care setting is being undertaken. Its main objective is to develop a secure web environment for sanitary professional-patient communication via E-mail (e.g. acute health problems, laboratory results, health measurement reports, or prescription refills) to avoid unnecessary face to face visits. The sanitary professional committed to answer patients E-mail on the following 48 working hours. The study is carried out in twelve primary care centers and includes 19 physicians, 16 nurses and 647 patients. This initiative has been positively evaluated by both sanitary professionals and patients and it is planned to spread it to all territorial setting [
40].
Both, The
E-
consulta and the experience described by Wallwiener and collaborators in 2009 [
22,
40], allow to think that better service and satisfaction of primary care services will be achieved by reducing resources of primary care addressed to smoking cessation. If sanitary systems facilitated E-mail based interventions on smoking cessation, and other sanitary problems, costs could be reduced and medical care and patient and sanitary professional satisfaction could be improved.
Acknowledgements
Supported by research grants from Fondo de Investigación Sanitaria (PI11/00817), Instituto de Salud Carlos and from III Gerencia Regional de Salud de la Consejería de Sanidad de Castilla y León (Resolución 3 de Marzo 2011) Ejecución 1/04/2011 a 30/03/2012. The authors gratefully acknowledge technical and scientific assistance provided by Primary Healthcare Research Unit of Barcelona, Primary Healthcare University Research Institute IDIAP-Jordi Gol. We would also thank the Network of Preventive Activities and Health Promotion in Primary Care (Red de Actividades Preventivas y Promoción de la Salud en Atención Primaria; redIAPP), Programa Atenció Primària Sense Fum (PAPSF) and Societat Catalana de Medicina Familiar i Comunitària (CAMFIC) for the diffusion of the study among sanitary professionals.
We would also thank all the participants of the two associated studies to the TABATIC project: the descriptive study entitled ‘Use of Communication and Information Technologies among smokers attended in Primary Care’ and the qualitative one which aims to describe barriers and facilitators of Communication and Information Technologies to help smokers to quit.
TABATIC Project investigators:
Abad Hernandez, David; Abad Polo, Laura; Abadía Taira, María Begoña; Aguado Parralejo, Maria del Campo; Alabat Teixido, Andreu; Alba Granados, José Javier; Alegre, Immaculada; Alfonso Camús, Jordi; Álvarez Fernández, Sandra; Álvarez Soler, María Elena; Andres Lorca, Anna; Anglada Sellares, Inmaculada; Araque Pro, Marta; Arnaus Pujol, Jaume; Arribas Arribas, MªAngeles; Baixauli Hernandez, Montserrat; Ballvé Moreno, José Luis; Bara Gallardo, MªJesús; Barbanoj Carruesco, Sara; Barbera Viala, Julia; Barcelo Torras, Anna Maria; Barrera Uriarte, Maria Luisa; Bartolome Moreno, Cruz; Belmonte Calderon, Laura; Benedí Palau, Maria Antonia; Benedicto MªRosa; Bernués Sanz, Guillermo; Bertolin Domingo, Nuria; Blasco Oliete, Melitón; Bobé Armant, Francesc; Bonaventura Sans, Cristina; Bravo, Luisa; Bretones, Olga Mariblanca; Briones Carcedo, Olga; Bueno Brugués, Albert; Buñuel Granados, José Miguel; Camats Escoda, Eva; Camos Guijosa, Maria Paloma; Campama Tutusaus, Inmaculada; Campanera Samitier, Elena; Canals Calbet, Gemma; Cantó Pijoan, Ana Mª; Cañadas Crespo, Silvia; Carmela Rodríguez, Mª; Carrascós Gómez, Montserrat; Carrés Piera, Marta; Casals Felip, Roser; Casas Güell, Gisel; Casas Moré, Ramon; Casasnova Perella, Ana; Cascón García, Miguel; Casellas López, Pilar; Castaño, MªCarmen; Castaño, Yolanda; Castellano Iralde, Susana; Chillon Gine, Marta; Chuecos Molina, Marta; Cifuentes Mora, Esther; Claveria, Magí; Clemente Jiménez, MªLourdes; Clemente Jiménez, Silvia; Cobacho Casafont, Rosa; Cólera Martín, Maria Pilar; Comerma Paloma, Gemma; Correas Bodas, Antonia; Cort Miró, Isabel; Cortés García, MªIsabel; Cristel Ferrer, Laura; Crivillé Mauricio, Silvia; Cruz Domenech, Jose Manuel; Cunillera Batlle, Meritxell; Danta Gómez, Mari Carmen; de Cabo, Angela; De Juan Asenjo, Jose Ramon; de Pedro Picazo Belén; Del Pozo Niubo Albert; Delgado Diestre Carmen; Díaz Espallardo Trinidad; Díaz Gete Laura; Díaz Juliano, Fernando; Diez Diez M Amparo; Digón Blanco Clarisa; Digon Garcia Escelita; Domènech Bonilla MªEncarnacion; Erruz Andrés Inmaculada; Escusa Anadón Corina; Espejo Castaño, MªTeresa; Espin Cifuentes, Pietat; Esteban Gimeno, Ana Belén; Esteban Robledo, Margarita; Fabra Noguera, Anna; Fanlo De Diego, Gemma; Farre Pallars, Francisca; Felipe Nuevo, Maria Dolores; Fernandez Campi, Maria Dolores; Fernandez de la Fuente Perez, Maria Angeles; Fernandez Gregorio, Yolanda; Fernández Maestre, Soraya; Fernandez Martinez, Mar; Fernandez Moyano, Juan Fernando; Fernández Parcés, MªJesús; Ferre, Antonia; Ferrer Vilarnau, Montserrat; Figuerola Garcia, Mireia; Florensa Piro, Carme; Flores Santos, Raquel; Gabriel, Cesáreo; Galbe Royo, Eugenio; Garcia Esteve, Laura; García Minguez, Maria Teodora; Garcia Rueda, Beatriz; Garcia Sanchon, Carlos; Gardeñes Moron, Lluisa; Gasulla, Griselda; Gerhard Perez, Jana; Gibert Sellarés, MªÀngels; Giné Vila, Anna; Gómez, Esmeralda; Gómez Santidrian, Fernando; Gómez-Quintero Mora, Ana Mª; Gonzalez Casado, Almudena; González Fernéndez, Yolanda María; Grasa Lambea, Inmaculada; Grau Majo, Inmaculada; Grive Isern, Montserrat; Güerri Ballarin, Inmaculada; Guillem Mesalles, Mónica Victoria; Guillén Antón, MªVictoria; Guillén Lorente, Sara; Hengesbach Barios, Esther; Hernandez Aguilera, Alicia; Hernandez Martin, Teodora; Hernández Moreno, Ana Consuelo; Hernandez Rodriguez, Trinidad; Herranz Fernandez, Marta; Herrera Garcia, Adelina; Herrero Rabella, Maria Àngels; Huget Bea, Nuria; Ignacio Recio, Jose; Inza Henry, Carolina; Jareño, MªJose; Jericó Clavería, Laura; Jimenez Gomez, Alicia; Jou Turallas, Neus; Laborda Ezquerra, Katherina; Laborda Ezquerra, MªRosario; Lafuente Martínez, Pilar; Lasaosa Medina, MªLourdes; Lera Omiste, Inmaculada; Llorente, Mercedes; Llort Sanso, Laia; López Barea, Antonio Jose; López Borràs, Esther; López Carrique, Trinidad; Lopez Castro, Maite; Lopez Luque, Maite; López Mompó, MªCristina; Lopez Pavon, Ignacio; Lopez Torruella, Dolors; Lorén, Maria Teresa; Lorente Zozaya, Ana Maria; Lozano Enguita, Eloisa; Lozano Moreno, Maribel; Lucas Sánchez, Roque; Manzano Montero, Mónica; Marco Aguado, MªAngles; Marco Navarro, Maria Jose; Marín Andrés, Fernando; Marsa Benavent, Eva; Martín Cantera, Carlos; Martin Montes, Esperanza; Martín Royo, Jaume; Martín Soria, Carolina; Martinez, Nuria; Martínez, Esther; Martínez Abadías, Blanca; Martínez García, Mireya; Martinez Gomez, Alberto; Martinez Iguaz, Susana; Martínez Pérez, Maria Trinidad; Martínez Picó, Angela; Martínez Romero, MªRocio; Mas Sanchez, Adoración; Masip Beso, Meritxell; Massana Raurich, Anna; Mata Segues, Francesca; Mayolas Saura, Emma; Mejía Escolano, David; Mejias Guaita, MªJesus; Mendioroz, Lorena; Mestre Ferrer, Jordi; Mestres Lucero, Jordi; Migueles García, Susana; Molina Albert, MªLluisa; Moliner Molins, Cristina; Monreal Aliaga, Isabel; Morella Alcolea, Nuria; Moreno Brik, Beatriz; Morilla Tena, Isabel; Mostazo Muntané, Alícia; Mulero Rimbau, Isabel; Munné González, Gemma; Munuera Arjona, Susana; Navarro Echevarria, MªAntonia; Navarro Picó, Montserrat; Nevado Castejón, Jorge; Nosas Canovas, Asuncion; Ortega, Raquel; Padín Minaya, Cristina; Palacio Lapuente, Jesús; Pallás Espinet, M.Teresa; Parra Gallego, Olga; Pascual Gonzalez, Carme; Pastor Santamaria, MªEncarnacion; Pau Pubil, Mercedes; Paytubi Jodra, Marta; Pedrazas López, David;Perez Lucena, M Jose; Perez Rodriguez, Dolores; Pinto, Lucio; Pinto Rodriguez, Raquel; Plana Mas, Alexandra; Planas, Ruth; Portillo Gañán, Maria José; Pueyo Val, Olga Maria; Quesada Almacellas, Alba; Quintana Velasco, Carmen; Rafecas Garcia, Veronica; Rafols Ferrer, Nuria; Rambla Vidal, Concepción; Ramos Caralt, Maria Isabel; Rando Matos, Yolanda; Rascon Garcia, Ana; Rebull Santos, Cristina; Redondo, Estibaliz; Redondo, Magdalena; Reig Calpe, Pere; Rengifo Reyes, Gloria del Rosario; Riart Solans, Marissa; Ribatallada Diez, Ana Maria; Robert, Angelique; Roca Domingo, Mariona; Rodero Perez, Estrella; Rodrigo De Pablo, Fani; Rodriguez Morán, MªJosep; Rodríguez Sánchez, Sonia; Roura Rovira, Núria; Rozas Martinez, Mariano; Rubiales Carrasco, Ana; Rubio Muñoz, Felisa; Rubio Ripolles, Carles; Ruiz Comellas, Anna; Ruiz Pino, Santiago; Sabio Aguilar, Juan Antonio; Sánchez, Ana Maria; Sánchez, Benigna; Sánchez Giralt, Maria; Sanchez Rodriguez, MªBelen; Sánchez Sánchez-Crespo, Àngela; Sancho Domènech, Laura; Sans Corrales, Mireia; Sans Rubio, Merce; Santsalvador Font, Isabel; Sarrà Manetas, Núria; Serrano Morales, Cristina; Servent Turo, Josefina; Server Climent, Maria; Silvestre Pérez Julià; Sola Casas, Gemma; Solà Cinca, Teresa; Solé Brichs, Claustre; Solé Lara, M Pilar; Soler Carne, MªTeresa; Solis i Vidal, Silvia; Tajada Vitales, Celia; Tàpia López, Montserrat; Tarongi Saleta, Ana; Telmo Huesco, Sira; Tenas i Bastida, Maria Dolors; Trillo Calvo, Eva; Trujillo Gómez, José Manuel; Urpi Fernández, Ana M; Valbuena Moreno, M Gracia; Valdes Pina, Laura; Vallduriola Calbó, MªCarme; Valverde Trillo, Pepi; Vazquez Muñoz, Immaculada; Vendrell Antentas, Ana Maria; Vera Morell, Anna; Vicente García Rovés, Irene; Vidal Cupons, Anabel; Vila Borralleras, Montse; Villagrasa Garcia, Maria Pilar; Viñas Viamonte, MªCarmen; Wilke, Asunción.