Elsevier

Addictive Behaviors

Volume 32, Issue 9, September 2007, Pages 1769-1786
Addictive Behaviors

Evaluation of an Internet virtual world chat room for adolescent smoking cessation

https://doi.org/10.1016/j.addbeh.2006.12.008Get rights and content

Abstract

The goal of this longitudinal study was to test an innovative approach to smoking cessation that might be particularly attractive to adolescent smokers. The study was a participatory research effort between academic and school partners. The intervention used an Internet-based, virtual reality world combined with motivational interviewing conducted in real-time by a smoking cessation counselor. Participants were 136 adolescent smokers recruited from high schools randomized to the intervention or a measurement-only control condition. Those who participated in the program were significantly more likely than controls to report at the immediate post-intervention assessment that they had abstained from smoking during the past week (p  .01), smoked fewer days in the past week (p  .001), smoked fewer cigarettes in the past week (p  .01), and considered themselves a former smoke (p  .05). Only the number of times quit was statistically significant at a one-year follow-up assessment (p  .05). The lack of longer-term results is discussed, as are methodological challenges in conducting a cluster-randomized smoking cessation study.

Introduction

Smoking among adolescents has significant public health importance. Onset of smoking occurs primarily in adolescence, and because tobacco is highly addictive, regular use in adolescence develops into nicotine dependency. Smoking among adolescents is likely to continue into the adult years, increasing the risk of numerous long-term negative health consequences (USDHHS, 2000a). Yet, after three decades of efforts to prevent smoking among children, rates of adolescent smoking remain unacceptably high. Adult smoking rates have declined steadily over the last several decades; however, smoking rates among adolescents have not shown a comparable pattern of steady decline (Johnston, O'Malley, & Bachman, 2003).

Smoking cessation clearly has major and immediate health benefits (US Department of Health and Human Services, 2000a, US Department of Health and Human Services, 2000b). Even among adolescent smokers, most report they would like to quit smoking (Lantz et al., 2000, Mermelstein, 2003, Vuckovic et al., 2003). Although many adolescents attempt to quit, most relapse quickly (Prokhorov, Hudmon, & Stancic, 2003), probably in part because they lack effective support and skills (Vuckovic et al., 2003). Previous research has shown that adolescent smokers trying to quit experience withdrawal symptoms that parallel those experienced by adults, suggesting addictive processes in adolescent smoking in addition to well-documented social factors (O'Loughlin et al., 2003, Prokhorov et al., 2003, Vuckovic et al., 2003). Also, as for many adults, adolescent smokers appear to benefit from social support in the quitting process (Vuckovic et al., 2003). However, other findings indicate unique aspects of adolescent smoking and cessation. Adolescents may be more influenced by (a) social–psychological cues to smoke, (b) tobacco advertising, (c) self-perceptions and low self-efficacy related to cessation, (d) perceptions of invulnerability to smoking's health effects, (e) perceived advantages of smoking including those related to coping and stress reduction, and (f) lack of recognition of the benefits of cessation (Pallonen et al., 1990, Turner et al., 2004, Vuckovic et al., 2003).

Most school-based tobacco use programs have been classroom-based prevention programs designed to reduce the incidence of adolescent tobacco use. Whereas some have realized positive effects especially in delaying the initiation of smoking, the results are somewhat limited and less likely to reach minority and high-risk adolescents (Spruijt-Metz et al., 2004, Unger et al., 2000). Further, these programs have not been successful in smoking reduction or cessation among adolescents who have already begun to smoke (Backinger et al., 2003). A few studies have evaluated programs designed specifically for adolescent smoking cessation, although findings have been mixed (Mermelstein, 2003, Rohde et al., 2001). Cognitive-behaviorally oriented cessation interventions that have been effective with adults, when tried with adolescents in clinics and classrooms, have not shown much promise (USDHHS, 2000a). Furthermore, adolescents are difficult to recruit and retain in smoking cessation interventions (Mermelstein, 2003, US Department of Health and Human Services, 2000a). The absence of effective intervention for young smokers is cause for concern, as adolescent smokers will likely continue on to become adult smokers. Innovative interventions are needed to engage teen smokers and to motivate interest in making quit attempts (DuRant and Smith, 1999, Sussman et al., 1999). Many believe that advances in health among young people will focus on use of interesting technologies, such as computer information and communication (Borzekowski and Rickert, 2001, Fotheringham et al., 2000, McTavish et al., 1995, Rhodes et al., 1997, Stivers et al., 1995, Weinberg et al., 1996).

Computer technology has been used for smoking cessation by creating tailored, cessation materials based on individual data (Escoffery et al., 2004, Strecher, 1999, Strecher et al., 2005, Velicer and Prochaska, 1999, Walters et al., 2006), and by building powerful, compelling, and flexible learning environments in which users interact with “smart” programs or are free to interact with one another from remote sites (Burling et al., 1994, Lenert et al., 2003, Pallonen et al., 1998, Schneider et al., 1990, Scott and McIlvain, 2000, Takahashi et al., 1999). Computer-based smoking cessation support to date has primarily employed educational websites, expert systems, games on CD-ROM, or electronic bulletin boards.

Although some of these programs are interactive in that they involve the user and can tailor support based on the user's needs, they typically have not used real-time discussion. Real-time interactive discussion (between smokers and professional change agents, and among smokers themselves) could potentiate the effectiveness of computerized communication for smoking cessation. For example, numerous studies have validated the assumptions that high school students look to their peers for emotional and social support and believe that their peers are capable of providing help (Mattey, 2003, Valente et al., 2003, Whiist, 2004). Other studies have well documented the positive effects of social support on smoking cessation outcomes both for adults and adolescents (Chassin et al., 1985, Cohen and Lichtenstein, 1990, Fisher et al., 1993, Gruder et al., 1993, Lacey et al., 1993, Myers, 1999). The use of a trained smoking cessation counselor or facilitator has also been shown to be associated with cessation and long-term abstinence (Fisher et al., 1993, Lichtenstein and Glasgow, 1992, Viswesvaran and Schmidt, 1992) and may be more successful than self-help programs alone specifically among adolescents and young adults (Charlton et al., 1990, Viswesvaran and Schmidt, 1992).

The rationale for this study derived from the fact that traditional school-based programs (e.g., clinic-based, face-to-face, and classroom-based prevention programs) have had limited success in helping adolescent smokers quit, and new strategies and technologies need to be explored. The present study tested a web-based counseling program, Breathing Room, in which young smokers interacted with a trained cessation counselor and other teen smokers in real-time in an Internet “virtual world.” The effectiveness of the real-time Breathing Room Internet intervention for smoking cessation was evaluated by comparing intervention participants with teens who participate in a measurement-only control group.

Section snippets

Design

The primary goal of this study was to test an innovative approach to smoking cessation that might be particularly attractive to adolescent smokers. The intervention used an Internet-based, virtual reality world combined with motivational interviewing conducted by a smoking cessation counselor. Participants were adolescent smokers recruited from high schools in San Diego County. Participants in the intervention condition were recruited to participate in seven 45-minute virtual world sessions

Results

Over 300 students showed interest in the program by contacting school liaisons or project staff. About 200 eligible smokers completed and returned consent/assent forms, although only 136 took the baseline survey. Of these 136 actual participants, 77 participated as intervention subjects and 59 as control subjects. The number of participants at individual schools ranged from 2 to 36, with a mean of 9.7 participants (mean of 11 participants per intervention school, and 8.4 per control school).

Discussion

Expert smoking cessation guidance via the Internet holds promise because of its accessibility, visual appeal, use of multiple media, potential anonymity, interactivity, and nonreliance on school classroom time or resources (Parlove et al., 2004, Woodruff et al., 2001). Results of this innovative study suggest that the Internet virtual world real-time counseling intervention was effective in helping adolescent smokers stay off cigarettes or reduce their consumption, at least in the short-term.

Acknowledgements

This research was funded by California's Tobacco-related Disease Research Program (TRDRP), grant number 11HT-3301.

The authors wish to acknowledge the invaluable contribution of Dr. Lynn Covarrubias, Summer Lambert, Chellie Stoffel, Elizabeth “Liz” Garcia, Dr. Sharon Snyder, and Dr. Phil Gardiner.

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