Tobacco Use: Internet-based Cessation Interventions

The CPSTF uses recently published systematic reviews to conduct accelerated assessments of interventions that could provide program planners and decision-makers with additional, effective options. The following published review was selected and evaluated by a team of specialists in systematic review methods, and in research, practice, and policy related to tobacco use cessation.

McCrabb S, Baker AL, Attia J, Skelton E, Twyman L, et al. Internet-based programs incorporating behavior change techniques are associated with increased smoking cessation in the general population: a systematic review and meta-analysis. Annals of Behavioral Medicine 2019:53(2):180-95.

The review included 45 studies (search period through September 2017). The team examined each of the studies included in the systematic review and abstracted supplemental information about study, intervention, and population characteristics.

The CPSTF finding is based on results from the published review, additional information from the included studies, and expert input from team members and the CPSTF. This recommendation updates and replaces the 2011 finding of insufficient evidence for internet-based tobacco cessation interventions [PDF – 294 kB].

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians ask all adults about tobacco use, advise tobacco users to stop using tobacco, and provide them with behavioral interventions and U.S. Food and Drug Administration approved pharmacotherapy (A grade recommendation; USPSTF 2015).

Smoking Cessation: A Report of the Surgeon General concluded there is sufficient evidence to infer that web or internet-based interventions increase smoking cessation. The report further noted that interventions are more effective when they contain behavior change techniques and interactive components (U.S. Department of Health and Human Services 2020).

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review included 45 studies; 31 of these evaluated differences in tobacco use cessation when measured 6 or more months following intervention.

• Internet-based interventions increased tobacco use cessation rates by a median of 1.2 percentage points overall (31 studies).
  • Differences in cessation rates were slightly larger when internet-based interventions were compared to no intervention, usual care, printed materials, or basic website content (median increase of 1.3 percentage points; 17 studies).
  • Differences in cessation rates were smaller when internet-based interventions were compared to other interventions that provided interactive content, cessation counseling, or evidence-based cessation medications (median increase of 0.8 percentage points; 14 studies).
  • Of this subset, 13 studies were conducted in the United States.
    • The median difference in cessation rates for U.S. studies was 0.1 percentage points (13 studies).
    • Two factors contributed to small and inconsistent effects in this subset.
      • Most studies provided internet, cessation counseling, or medication interventions to participants in the comparison group.
      • Participants in both intervention and comparison groups quit at meaningful rates, which minimized differences.

A systematic review of economic evidence has not been conducted.

Based on the overall results from the review, findings should be applicable to the general population of tobacco users in the United States who are interested in quitting. Additional research is warranted for specific U.S. population groups and settings.

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• How do intervention effects vary by participant characteristics, including income, level of education, and race/ethnicity in U.S. populations and settings?
• How do intervention effects vary by internet-based content? Simplified comparisons would also allow assessments of the effectiveness of various specific behavior change techniques, alone or in combination.
• How do internet-based interventions that use automated, interactive, and tailored guidance compare with interventions that use static websites or printed materials in U.S. populations and settings?
• What are the most effective and efficient ways to increase recruitment and enhance retention?
• What is the impact of these intervention approaches on long-term cessation outcomes (12 months or more following intervention)?
• Are these interventions effective with clients who want to quit using e-cigarettes?

• All of the included studies were randomized controlled trials (45 studies).
• Twenty-four of the included studies were conducted in the United States. The remaining studies came from Europe, the United Kingdom, Australia, and Canada.
• Of the 45 included studies, 15 provided web-based content only and the remaining offered combinations of web-based content and other components. Additional components included email messages, cessation medications, text messages, telephone calls or telephone support lines, one-on-one cessation counseling, and printed materials.
• Studies from the United States reported demographic characteristics of participants. Study samples were generally representative across age (18+), gender, racial/ethnic background, and education.

Effectiveness Review

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

• Logic Model [PDF (Print Only) – 208 kB]
• Text Description [PDF – 86 kB]

Effectiveness Review

A summary evidence table for this Community Guide review is not available because the CPSTF finding is based on the following published systematic review:

McCrabb S, Baker AL, Attia J, Skelton E, Twyman L, et al. Internet-based programs incorporating behavior change techniques are associated with increased smoking cessation in the general population: a systematic review and meta-analysis. Annals of Behavioral Medicine 2019:53(2):180-95.

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Following are studies from the published review (McCrabb et al.) that evaluated tobacco use cessation at follow-up periods of six months or longer.

Bolman C, Eggers SM, van Osch L, et al. Is action planning helpful for smoking cessation? Assessing the effects of action planning in a web-based computer-tailored intervention. Substance Use and Misuse 2015;50:1249-60.

Borland R, Balmford J, Benda P. Population-level effects of automated smoking cessation help programs: a randomized controlled trial. Addiction 2013;108:618-28.

Borland R, Balmford J, Swift E. Effects of encouraging rapid implementation and/or structured planning of quit attempts on smoking cessation outcomes: a randomized controlled trial. Ann Behav Med 2015;49:732-42.

Brendryen H, Drozd F, Kraft P. A digital smoking cessation program delivered through internet and cell phone without nicotine replacement (happy ending): randomized controlled trial. J Med Internet Res 2008;10:e51.

Brendryen H, Kraft P. Happy ending: a randomized controlled trial of a digital multi-media smoking cessation intervention. Addiction 2008;103:478-84.

Brown J, Michie S, Geraghty AW, et al. Internet-based intervention for smoking cessation (StopAdvisor) in people with low and high socioeconomic status: a randomised controlled trial. Lancet Respiratory Medicine 2014;2:997-1006.

Burford O, Jiwa M, Carter O, Parsons R, Hendrie D. Internet-based photoaging within Australian pharmacies to promote smoking cessation: randomized controlled trial. Journal of Medical Internet Research 2013;15.

*Calhoun PS, Datta S, Olsen M, et al. Comparative effectiveness of an internet-based smoking cessation intervention versus clinic-based specialty care for veterans. Journal of Substance Abuse Treatment 2016;69:19-27.

*Choi SH, Waltje AH, Ronis DL, et al. Web-enhanced tobacco tactics with telephone support versus 1-800-QUIT-NOW telephone line intervention for operating engineers: randomized controlled trial. J Med Internet Res 2014;16:e255.

Elfeddali I, Bolman C, Candel MJ, Wiers RW, de Vries H. Preventing smoking relapse via web-based computer-tailored feedback: a randomized controlled trial. Journal of Medical Internet Research 2012;14:87-102.

Emmons KM, Puleo E, Sprunck-Harrild K, et al. Partnership for health-2, a web-based versus print smoking cessation intervention for childhood and young adult cancer survivors: randomized comparative effectiveness study. Journal of Medical Internet Research 2013;15.

*Graham AL, Cobb NK, Papandonatos GD, et al. A randomized trial of Internet and telephone treatment for smoking cessation. [Erratum appears in Arch Intern Med 2011;171(5):395]. Archives of Internal Medicine 2011;171:46-53.

*Harrington KF, Kim YI, Chen M, et al. Web-based intervention for transitioning smokers from inpatient to outpatient care: an RCT. American Journal of Preventive Medicine 2016;51:620-9.

Haug S, Meyer C, John U. Efficacy of an internet program for smoking cessation during and after inpatient rehabilitation treatment: a quasi-randomized controlled trial. Addictive Behaviors 2011; 36:1369-72.

*Houston TK, Sadasivam RS, Allison JJ, et al. Evaluating the QUIT-PRIMO clinical practice ePortal to increase smoker engagement with online cessation interventions: a national hybrid type 2 implementation study. Implementation Science 2015;10:154.

*Humfleet GL, Hall SM, Delucchi KL, Dilley JW. A randomized clinical trial of smoking cessation treatments provided in HIV clinical care settings. Nicotine & Tobacco Research 2013;15:1436-45.

*Japuntich SJ, Zehner ME, Smith SS, et al. Smoking cessation via the internet: a randomized clinical trial of an internet intervention as adjuvant treatment in a smoking cessation intervention. Nicotine & Tobacco Research 2006;8 Suppl 1:S59-67.

Leykin Y, Aguilera A, Torres LD, Perez-Stable EJ, Munoz RF. Interpreting the outcomes of automated Internet-based randomized trials: Example of an international smoking cesstion study. J Med Internet Res 2012;14:102-14.

Mavrot C, Stucki I, Sager F, Etter J-F. Efficacy of an Internet-based, individually tailored smoking cessation program: a randomized-controlled trial. Journal of Telemedicine and Telecare 2016;23:521-8.

*McDonnell DD, Kazinets G, Lee HJ, Moskowitz JM. An internet-based smoking cessation program for korean americans: results from a randomized controlled trial. Nicotine & Tobacco Research 2011; 13:336-43.

*McKay H, Danaher BG, Seeley JR, Lichtenstein E, Gau JM. Comparing two web-based smoking cessation programs: randomized controlled trial. J Med Internet Res 2008;10:68-81.

*Moskowitz JM, McDonnell DD, Kazinets G, Lee H-J. Online smoking cessation program for Korean Americans: randomized trial to test effects of incentives for program completion and interim surveys. Preventive Medicine 2016;86:70-6.

*Munoz RF, Lenert LL, Delucchi K, et al. Toward evidence-based Internet interventions: a Spanish/English web site for international smoking cessation trials. Nicotine & Tobacco Research 2006;8:77-87.

Munoz RF, Barrera AZ, Delucchi K, et al. International Spanish/English internet smoking cessation trial yields 20% abstinence rates at 1 year. Nicotine & Tobacco Research 2009;11:1025-34.

*Simmons VN, Heckman BW, Fink AC, Small BJ, Brandon TH. Efficacy of an experiential, dissonance-based smoking intervention for college students delivered via the Internet. Journal of Consulting and Clinical Psychology 2013;81:810-20.

Skov-Ettrup LS, Dalum P, Bech M, Tolstrup JS. The effectiveness of telephone counselling and internet- and text-message-based support for smoking cessation: results from a randomized controlled trial. Addiction 2016;111:1257-66.

Smit ES, de Vries H, Hoving C. Effectiveness of a Web-based multiple tailored smoking cessation program: a randomized controlled trial among Dutch adult smokers. J Med Internet Res 2012;14:e82.

Smit E, Candel M, Hoving C, de Vries H. Results of the PAS study: a randomized controlled trial evaluating the effectiveness of a web-based multiple tailored smoking cessation program combined with tailored counseling by practice nurses. Health Communication 2016;31:1165-73.

*Swan GE, McClure JB, Jack LM, et al. Behavioral counseling and varenicline treatment for smoking cessation. American Journal of Preventive Medicine 2010;38:482-90.

Following are studies from the published review (McCrabb et al.) that evaluated tobacco use cessation at follow-up periods of less than six months.

*An LC, Klatt C, Perry CL, et al. The RealU online cessation intervention for college smokers: a randomized controlled trial. Preventive Medicine 2008;47:194-9.

*Berg CJ, Stratton E, Sokol M, et al. Novel incentives and messaging in an online college smoking intervention. American Journal of Health Behavior 2014;38:668-80.

*Bricker J, Wyszynski C, Comstock B, Heffner JL. Pilot randomized controlled trial of web-based acceptance and commitment therapy for smoking cessation. Nicotine & Tobacco Research 2013; 15:1756-64.

*Dezee KJ, Wink JS, Cowan CM. Internet versus in-person counseling for patients taking varenicline for smoking cessation. Military Medicine 2013;178:401-5.

Etter J-F. Comparing the efficacy of two Internet-based, computer-tailored smoking cessation programs: a randomized trial. Journal of Medical Internet Research 2005;7:e2.

*Graham AL, Zhao K, Papandonatos GD, et al. A prospective examination of online social network dynamics and smoking cessation. PLoS One 2017;12(8).

*Linke SE. Intermittent exercise in response to nicotine cravings in the context of an Internet-based smoking cessation program. Mental Health and Physical Activity 2012;5:85-92.

Mason D, Gilbert H, Sutton S. Effectiveness of web-based tailored smoking cessation advice reports (iQuit): a randomized trial. Addiction 2012;107:2183-90.

Mehring M, Haag M, Linde K, Wagenpfeil S, Schneider A. Effects of a guided web-based smoking cessation program with telephone counseling: a cluster randomized controlled trial. J Med Internet Res 2014;16:e218.

*Pechmann C, Delucchi K, Lakon CM, Prochaska JJ. Randomised controlled trial evaluation of Tweet2Quit: a social network quit-smoking intervention. Tob Control. 2017;26(2):188 194.

*Pike KJ, Rabius V, McAlister A, Geiger A. American Cancer Society’s QuitLink: randomized trial of Internet assistance. Nicotine & Tobacco Research 2007;9:415-20.

*Shuter J, Morales DA, Considine-Dunn SE, An LC, Stanton CA. Feasibility and preliminary efficacy of a web-based smoking cessation intervention for HIV-infected smokers: a randomized controlled trial. Journal of Acquired Immune Deficiency Syndromes 2014;67:59-66.

Stanczyk NE, Smit ES, Schulz DN, et al. An economic evaluation of a video- and text-based computer-tailored intervention for smoking cessation: a cost-effectiveness and cost-utility analysis of a randomized controlled trial. PLoS One 2014;9:e110117.

*Stoddard J, Augustson E, Moser R. Effect of adding a virtual community (bulletin board) to smokefree. gov: randomized controlled trial. Journal of Medical Internet Research 2008;10:e53.

Strecher VJ, Shiffman S, West R. Randomized controlled trial of a web-based computer-tailored smoking cessation program as a supplement to nicotine patch therapy. Addiction 2005;100:682-8.

*Swartz LH, Noell JW, Schroeder SW, Ary DV. A randomised control study of a fully automated internet based smoking cessation programme. Tobacco Control 2006;15:7-12.

*Studies conducted entirely in the United States

Effectiveness Review

Refer to the existing systematic review for information about the search strategy:

McCrabb S, Baker AL, Attia J, Skelton E, Twyman L, et al. Internet-based programs incorporating behavior change techniques are associated with increased smoking cessation in the general population: a systematic review and meta-analysis. Annals of Behavioral Medicine 2019:53(2):180-95.

Bricker J, Wyszynski C, Comstock B, Heffner JL. Pilot randomized controlled trial of web-based acceptance and commitment therapy for smoking cessation. Nicotine & Tobacco Research 2013; 15:1756-64.

McCrabb S, Baker AL, Attia J, Skelton E, Twyman L, et al. Internet-based programs incorporating behavior change techniques are associated with increased smoking cessation in the general population: a systematic review and meta-analysis. Annals of Behavioral Medicine 2019:53(2):180-95.

Stoddard J, Augustson E, Moser R. Effect of adding a virtual community (bulletin board) to smokefree. gov: randomized controlled trial. Journal of Medical Internet Research 2008;10:e53.

The following considerations for implementation are drawn from McCrabb et al., studies included in the review, the previous CPSTF recommendation for internet-based interventions, and expert opinion from the CPSTF, as noted below.

• Internet-based interventions require ongoing advertising, service promotion, and website enhancements to attract and engage clients.
• Advertising, cross-promotion, and coordinated web-linkages can also help tobacco users access the evidence-based cessation intervention which best suits their needs.
• Implementers should address identified barriers including technological concerns (e.g., matching program, network, and client capabilities) and requirements to ensure confidentiality of participant information.
• Studies included in the review (Bricker et al. 2013, Stoddard et al. 2008) and the CPSTF support use of the following web-based resources that provide or link to cessation interventions with interactive, dynamic content:
  • smokefree.gov is a website from the National Cancer Institute that provides evidence-based cessation information and assistance to tobacco users who want to quit
    • SmokefreeVET is a section of this page dedicated to helping veterans who want to quit smoking
  • The Tips From Former Smokers website is designed to support CDC’s national tobacco education campaign, and seeks to motivate quit attempts through stories of real people with smoking-related diseases and to help people succeed in quitting smoking by connecting them to cessation resources.
    • How to Quit Smoking
  • BecomeAnEX is a free digital resource from The Truth Initiative designed to help tobacco users quit.

Evidence-Based Cancer Control Programs (EBCCP)

Find programs from the EBCCP website that align with this systematic review. (What is EBCCP?)

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce current tobacco use in adults — TU‑01
• Reduce current cigarette smoking in adults — TU‑02
• Reduce current cigarette, cigar, and pipe smoking in adults — TU‑03
• Reduce current tobacco use in adolescents — TU‑04
• Reduce current cigarette smoking in adolescents — TU‑06
• Reduce current cigar smoking in adolescents — TU‑07
• Reduce current use of smokeless tobacco products among adolescents — TU‑08
• Increase past-year attempts to quit smoking in adults — TU‑11
• Increase use of smoking cessation counseling and medication in adults who smoke — TU‑13
• Increase successful quit attempts in adults who smoke — TU‑14