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The Role of Facebook in Crush the Crave, a Mobile- and Social Media-Based Smoking Cessation Intervention: Qualitative Framework Analysis of Posts

The Role of Facebook in Crush the Crave, a Mobile- and Social Media-Based Smoking Cessation... Background: Social networking sites, particularly Facebook, are increasingly included in contemporary smoking cessation interventions directed toward young adults. Little is known about the role of Facebook in smoking cessation interventions directed toward this age demographic. Objective: The aim of this study was to characterize the content of posts on the Facebook page of Crush the Crave, an evidence-informed smoking cessation intervention directed toward young adults aged 19 to 29 years. Methods: Crush the Crave Facebook posts between October 10, 2012 and June 12, 2013 were collected for analysis, representing page activity during the pilot phase of Crush the Crave. Of the 399 posts included for analysis, 121 were original posts, whereas the remaining 278 were reply posts. Posts were coded according to themes using framework analysis. Results: We found that the original Crush the Crave Facebook posts served two main purposes: to support smoking cessation and to market Crush the Crave. Most of the original posts (86/121, 71.1%) conveyed support of smoking cessation through the following 7 subthemes: encouraging cessation, group stimulation, management of cravings, promoting social support, denormalizing smoking, providing health information, and exposing tobacco industry tactics. The remaining original posts (35/121, 28.9%) aimed to market Crush the Crave through 2 subthemes: Crush the Crave promotion and iPhone 5 contest promotion. Most of the reply posts (214/278, 77.0%) were in response to the supporting smoking cessation posts and the remaining 64 (23.0%) were in response to the marketing Crush the Crave posts. The most common response to both the supporting smoking cessation and marketing Crush the Crave posts was user engagement with the images associated with each post at 40.2% (86/214) and 45% (29/64), respectively. The second most common response consisted of users sharing their smoking-related experiences. More users shared their smoking-related experiences in response to the supporting smoking cessation posts (81/214, 37.9%) compared to the marketing Crush the Crave posts (11/64, 17%). With the exception of 4 posts, a moderator posted all the original posts. In addition, although 56.00% (18,937/33,815) of Crush the Crave Facebook page users were men, only 19.8% (55/278) of the reply posts were made by men. Finally, men were found to be more likely to express sarcasm or make strong assertions about quitting smoking and Crush the Crave than women. Conclusions: The CTC Facebook page presents as a unique platform for supporting young adult smoking cessation at all stages of the cessation process. The findings of this study indicate that social networking sites, especially Facebook, warrant inclusion http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 1 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville in tobacco control efforts directed towards young adults. Research on effectiveness of the Facebook page for quitting smoking is needed. (J Med Internet Res 2014;16(7):e170) doi: 10.2196/jmir.3189 KEYWORDS qualitative research; young adult; smoking cessation; Internet; social media comparative analysis of the top 5 downloaded cessation apps, Introduction and 2 rounds of focus groups with young adult smokers were used to create the content and test the usability, design, and Background functionality of Crush the Crave. Facebook has been recently included in the design and Crush the Crave is available for Android and iOS devices in development of smoking cessation initiatives directed toward both English and French. Incorporating principles of persuasive young adults. Because young adults (ages 18 to 29) are extensive technology for behavior change [9], Crush the Crave offers such users of Facebook [1], and because they represent the largest features as a customized quit plan, the tracking of cravings and population of smokers in both Canada (21%) [2] and the United smoking habits, notifications of money saved and health States (19%) [3], Facebook is increasingly included in improvements achieved, direct dial-up to telephone-based contemporary smoking cessation initiatives directed toward this support, virtual awards that credit performance toward reaching population. For example, Crush the Crave [4], a research-based milestones, evidence-informed credible information (eg, nicotine smoking cessation app developed for young adults, has been replacement therapy), and the ability to connect with a integrated into Facebook, among other social media. The community of people for social support via Facebook. personal connections that can be formed through social media can be viewed as a form of social support and social support is Crush the Crave Facebook Page effective in helping people quit smoking according to evidence The Crush the Crave Facebook page (Figure 1) is integrated gathered by the US Public Health Service expert panel [5]. within the smartphone app or can be accessed on its own through However, despite the rapid growth in use of social media, a browser. It is moderated by a social media expert and a small research is in the early stages regarding how online social team with expertise in tobacco control. Individuals principally networks and opportunities for social support might or might come to the Facebook page via the Google search engine or the not affect smoking cessation [6]. Crush the Crave app. During the period of April 2012 to April Social networking sites, particularly Facebook, remain under 2013, Crush the Crave was piloted and promoted through examined media for health promotion. Given the widespread Google and Facebook ads. Since this pilot phase, there has not uptake of Facebook among young adults, this medium warrants been any active promotion of Crush the Crave. further investigation for its role in health behavior interventions As of November 19, 2013, the Crush the Crave Facebook page directed toward this population, particularly in relation to had 34,690 likes and a total reach of 7282 people. In all, 56.00% smoking cessation. Therefore, the purpose of this study was to (4078/7282) of Crush the Crave Facebook users were men and use framework analysis to characterize the content of the Crush 44.00% (3024/7282) were women. Most people reached the Crave Facebook posts and the associated responses. (4369/7282, 60.00%) were between the ages of 18 and 34 years Crush the Crave (the intended target group) and 57.00% (4151/7282) of Crush the Crave fans were from Canada. Posts to the Facebook page In early 2012, a team of population health researchers, social took place almost daily and usually included a photo and caption media experts, and computer programmers developed and about quitting smoking. The total number of people who clicked promoted Crush the Crave as an evidence-informed smoking on, liked, commented on, or shared Crush the Crave averaged cessation smartphone and social media app designed to help 4000.4 (SD 4306.10) per week. User engagement in terms of close the gap between existing smartphone apps [7] and evidence likes, comments, and shares averaged 70.1 (SD 62.7) per post. on what works in getting young smokers to quit smoking [8]. A panel of 5 experts in social media and tobacco cessation, a http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 2 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville Figure 1. The Crush the Crave Facebook page. database. The first author coded all posts. To validate coding, Methods both authors independently coded the first 51 posts and then compared for consistency. Any discrepancies in coding were Study Sample and Data Collection discussed and resolved. In this way, each author was able to For this study, 399 Crush the Crave Facebook posts, spanning critically challenge one another on differing perspectives and from October 10, 2012 to June 12, 2013, were collected for any potential biases. analysis and entered into an NVivo version 10 qualitative After the first 51 posts were coded, a thematic framework was software database (QSR International Pty Ltd, Burlington, MA, developed by generating major themes and subthemes in relation USA). This page activity represented the pilot phase of Crush to the original posts and categorizing the associated responses. the Crave. Posts were collected in reverse chronological order This process was facilitated by asking iterative, analytic so that the most recent activity on the Crush the Crave Facebook questions (eg, What is going on here? How are these different page was represented. Sampling was driven by saturation of or the same?). Original posts were grouped according to their themes, where posts were collected until no new themes or identified purpose (eg, supporting smoking cessation) and the subthemes were identified. Of the 399 posts, 121 were original responses were categorized according to their identified type posts, whereas the remaining 278 were responses to these posts. (eg, sharing smoking-related experiences). To maintain the No direct contact with participants was sought for this study; context of the responses to the original posts, they were listed data collection occurred solely through the gathering of posts under the messages from which they were derived and then freely available on the Crush the Crave Facebook page. categorized separately as a type of response. Throughout the Data Analysis coding process, regular meetings were held between the 2 authors to discuss and refine the thematic framework. Indexing The framework approach [10] was used to qualitatively analyze was accomplished by coding each post in NVivo, with reliability the Crush the Crave Facebook posts. Central to framework checked by the second author through review of the NVivo file. analysis is a series of interconnected stages (familiarization, The constant comparison method [12] was employed throughout identifying a thematic framework, indexing, charting, and the coding process to ensure internal homogeneity of the coding mapping and interpretation) that enables the researcher to move categories [13], whereby each post was coded into 1 category. back and forth between the data until a coherent account of the phenomenon is developed [11]. This analytic approach The fourth stage of framework analysis, charting, involved facilitated refinement of themes by both authors while arranging summaries of the original posts and the associated maintaining a clear audit trail. Familiarization was achieved in responses in a table, which were grouped according to the this study through constant comparison [12] of posts in which identified themes and subthemes in relation to the purpose of coding categories were developed and entered in the NVivo http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 3 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville the original posts. This stage enabled the researchers to identify Results the range of data included in the original posts and to become familiar with the range of responses to these messages. The Characterizing the Original Crush the Crave Facebook thematic framework was refined and two tables of data were Posts developed: one that encompassed the purpose of the original posts according to each identified theme and subtheme and one Overview that encompassed the various responses to these posts, which We found that the original posts served two main purposes: to were grounded in the context of the themes and subthemes of support smoking cessation and market Crush the Crave. Most the original posts. The final stage, mapping and interpretation, posts (86/121, 71.1%) related to the major theme supporting enabled the researchers to compare and contrast the original smoking cessation, which included 7 subthemes (Table 1), and posts and responses while searching for patterns. At this stage, 35 of 121 posts (28.9%) related to the major theme marketing the original posts were grouped according to the finalized themes Crush the Crave, which included 2 subthemes (Table 2). The and subthemes, and responses were grouped together. original Crush the Crave Facebook posts were primarily initiated Representative quotes were selected from the original posts and by a Crush the Crave moderator. Only 4 of the posts were responses to illustrate key themes and subthemes. user-initiated. http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 4 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville Table 1. Posts supporting smoking cessation (N=86). Subtheme n (%) Examples of post content Encourage cessation 34 (39) Quitting is tough...but you’re tougher ;) Think of all the places a tobacco-free road can take you. Group stimulation 13 (15) Fill in the blank! It’s been ___days since my last cigarette. Cool piece from ’66. What would you rather spend your money on? Promote social support 12 (14) You gotta love your quit buddy! Good friends make quitting easier! Management of cravings 11 (13) We found your next craving distraction-playing frisbee with a friend! Next time you think about smoking, go to a mirror, take a breath, and make this face. Just try it. You’ll see. Denormalize smoking 7 (8) Hit the like button if you agree that smoking isn’t sexy. http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 5 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville Subtheme n (%) Examples of post content Fact: Not smoking makes you more kissable. Provide health information 5 (6) Get outdoors and get active! Researchers found that physically active men were 36% more likely to have tried to quit smoking within the past year, while physically active women were 37% more likely to do so than nonactive women. As soon as you stop smoking, you start repairing. (Thanks Australia!) Expose tobacco industry 4 (5) How do you feel about being labeled “a replacement”? “The truth about tobacco” tactics video [14] Why are young adults so important to tobacco companies? http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 6 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville Table 2. Posts marketing Crush the Crave (N=35). Subtheme n (%) Examples of post content Crush the Crave promotion 26 (74) The new Crush the Crave is going to be Facebook-friendly! Strut your way to a smoke-free lifestyle with Crush the Crave! iPhone 5 contest promo- 9 (26) Did someone say iPhone 5? Our contest ends on June 15th! tion Have you entered the Crush the Crave contest yet? You could WIN an iPhone 5! The supporting smoking cessation posts also entailed a focus Supporting Smoking Cessation on promoting the act of social support for those trying to quit The encourage cessation subtheme was present in many of the (11/86, 13%). The positive role that providing and receiving supporting smoking cessation posts (34/86, 39%). Posts within social support has on smoking cessation was emphasized in this subtheme contained positively framed messages offering these posts. For instance, one post read, “Find a quit buddy, encouragement to those trying to quit smoking, such as “Stay backup goes a long way.” positive! You can do this!” Denormalize smoking was another subtheme under supporting The group stimulation subtheme represented 13 of 86 (15%) smoking cessation and represented 7 of 86 posts (8%). These posts under the major theme supporting smoking cessation. posts covered the positive social outcomes of being smoke-free. Generating interaction among the Crush the Crave Facebook These positive outcomes included smelling good and looking users was the primary goal of these posts. Therefore, the posts attractive, such as “Did you know? Not smelling like cigarette consisted of questions and posting thought-provoking articles smoke=more hugs.” or images related to smoking. For example, a post contained a Posts that provided health information made up 5 of 86 (6%) link to an article on new research demonstrating a link between supporting smoking cessation posts. These posts provided facts cigarette smoking and damage to memory, learning, and about addiction, research on effective strategies for quitting reasoning, and asked users “Think there’s truth to this?” smoking, the positive health effects of quitting, and information Management of cravings was another common subtheme (12/86, about the damaging effects of smoking on the body. For 14%). Posts under this subtheme included suggestions about example, one post read, “Do you have a cigarette first thing in ways to manage cravings (eg, “Find a peaceful place when the morning? This recent study shows that smoking as soon as cravings stress you out”) and also invited users to reflect on you wake up is even more unhealthy.” their cravings (eg, “Quit Smoking Pro Tip: Reflect on your Expose tobacco industry tactics was another subtheme under triggers to understand where your habit comes from”). supporting smoking cessation (4/86, 5%). The purpose of these posts was to invite Crush the Crave Facebook users to think http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 7 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville about the recruitment strategies used by tobacco companies to I quit smoking 31 years ago. My husband had had a increase their revenue. This is demonstrated in the post: “Class heart attack, we had to get someone to wash all the is in session! How does this Newport ad try to sell cigarettes to house and carpets and upholstery so the smoke smell men?” would be gone. Because I loved him so much, and I wanted him to live with me much longer, he was my Marketing Crush the Crave reason to stop. In order to be able to stop, you need The Crush the Crave promotion subtheme represented most of a reason to help you along. Not so hard that way. And the marketing Crush the Crave posts (26/35, 74%). The purpose so worth it. Good luck all. of these posts was to promote the various mobile and social Crush the Crave Facebook users also shared their struggles with media platforms to access Crush the Crave (eg, “Did you know cessation, which was demonstrated in the following post: “I that Crush the Crave is on Google Play?”), the different features quit so many times...started again and again...last time I just of the Crush the Crave app (eg, “Watching a funny video can made up my mind...threw them away and never looked back. help distract the crave! It’s one of the features in our Quit Help It was hard but I’ve been smoke-free for 12 years now and very section in the Crush the Crave app”), as well as news related to happy I did.” Sharing personal management of cravings was Crush the Crave (eg, “We got some radio play for new version another popular response in which users would describe what of Crush the Crave today!”). they found helpful in remaining smoke-free: The iPhone 5 contest promotion subtheme made up the I used an aide called Champix and I never looked remaining 9 of 35 (26%) marketing Crush the Crave posts. The back and never will!!!! And thanks, I am very proud focus of these posts was to motivate people to join Crush the of myself. I was a very heavy smoker. I smoked 25 to Crave and download the Crush the Crave app. For instance, one 30 a day and rolled my own. So harsh lol. Good luck post read, “Looking for some motivation? Enter our contest and to whomever is quitting. IT IS WORTH IT!!!! you could win an iPhone 5!” Some Crush the Crave Facebook users also shared their smoking Characterizing the Crush the Crave User Reply Posts triggers. For example, one user described how she changed her daily routine so that she could quit smoking: Overview For me, it was after a meal with my coffee. So I Of the 278 reply posts, 214 (77.0%) were in response to the switched to tea and it made things easier. Or went supporting smoking cessation posts, whereas the remaining 64 without it and went for a walk because I never smoked (23.0%) were in response to the marketing Crush the Crave outside. It has been 32 years now. I am so proud of posts. Women posted 218 (78.4%) of the reply posts, men posted myself. 55 (19.8%), and 5 (1.8%) were posted by users that did not indicate their gender. Although seldom, some users would assert their current smoking status (eg, “Sorry, I do smoke”). Still others would express their Supporting Smoking Cessation Reply Posts intentions to quit (eg, “Well, Jan 1, 2013 will be the first day The most common response (86/214, 40.2%) to the posts under for me :) Wish me luck!”). the supporting smoking cessation major theme consisted of user Crush the Crave Facebook users also discussed tobacco control engagement with the images associated with the original posts. measures (11/214, 5.1%) in response to the supporting smoking Users primarily expressed their enjoyment of the images. For cessation posts. For example, in response to a post asking users example, in response to an image of kittens hugging associated if they thought health warnings on cigarette packages should with a post promoting social support of cessation, a user be mandatory, a user responded with the statement: “I don’t responded: “Aw, so sweet!;))” A few users expressed that the think they should have to [put health warnings on cigarette images associated with the posts spurred on their smoke-free packages]...you don’t see any warning labels on liquor bottles efforts. For example, in response to an image of puppies or beer bottles or cans!! Drunken drivers kill...” Some users associated with the caption “If I just hold your mouth shut, like expressed frustration with tobacco control efforts and suggested this, you can’t smoke” a user responded, “AH-adorable with a that a complete ban on cigarettes was needed: “...take THEM good reminder or push in the right direction.” Conversely, some OFF THE shelf then, why can they keep selling something that users indicated that although the images were appreciated, they kills you, when they pull a product off the shelf for WAY less were not enough to motivate their smoke-free efforts. For health issues...” example, a user responded, “I love this cat...but nope, won’t help me to stop smoking” to an image of a cat with the caption, Sometimes Crush the Crave Facebook users would express a “Maybe I can persuade you not to light that cigarette.” negative attitude toward smoking (9/214, 4.2%) when engaging with the supporting smoking cessation posts. For example, a The second most common response (81/214, 37.8%) to the user described the social benefits of not smelling like cigarette supporting smoking cessation posts consisted of users sharing smoke in response to a post that aimed to denormalize smoking: their smoking-related experiences at various stages of the “More dates, more lov’n, more everything! It’s not cool to smell cessation process. These responses often consisted of users like smoke!” sharing their quit successes (eg, “Day 200 for me no smoking :3”). Some users would respond in detail and elaborate on their In all, 4 of 214 responses (1.9%) consisted of tags, which are lived experiences with quitting smoking: links created by users to another person’s Facebook timeline. The people who are tagged then receive a notification and are http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 8 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville directed to the post that they were tagged in, facilitating their Of the 64 replies to the marketing Crush the Crave posts, 6 (9%) exposure to Crush the Crave content. Only 2 of 214 (0.9%) consisted of sarcastic remarks about quitting smoking and what reply posts consisted of users sharing smoking-related facts, will help people quit. For example, in response to a post such as “It takes 7 years to recover.” And 3 of 214 posts (1.4%) promoting Crush the Crave to help people quit smoking, a user consisted of users encouraging the smoking cessation efforts posted, “Maybe if they put Justin Bieber on each pack of smokes of their peers: “If I can do it, anyone can. YOU CAN!!” In then people will maybe quit smoking lol.” Of the 64 reply posts, addition, 3 of 214 posts (1.4%) consisted of users expressing 4 (6%) consisted of users expressing a negative attitude toward sarcasm. For example, in a post asking users how many days Crush the Crave, which is demonstrated in the following post: it’s been since their last cigarette, a user responded with “too “Pathetic if you need an app to help you quit smoking.” With long.” The remaining reply posts consisted of users expressing the exception of one, the reply posts consisting of sarcasm or a their misunderstanding of the posts (4/214, 1.9%) (eg, “What negative attitude toward Crush the Crave were made by men. does the aurora borealis have to do with not smoking?”), a user In addition, 3 of 64 (5%) reply posts consisted of users gathering sharing holiday wishes (1/214, 0.5%) (eg,”Happy information about Crush the Crave. For example, a user wanted Thanksgiving!”), and users posting content unrelated to the to know more about the availability of Crush the Crave on original post (12/214, 5.6%) (eg, “Do you ever have those mobile phones: “Do you have a Blackberry version? Because dreams, where a bad person is chasing you and you’re running it would be a shame if a Canadian-made app didn’t work on a in slow motion?”). Canadian phone...:).” The remaining 3 of 64 (5%) reply posts consisted of peer encouragement of cessation (eg, “Quit Marketing Crush the Crave Reply Posts smoking!! :)”), expression of a positive attitude toward Crush Many (29/64, 45%) responses to the posts under the marketing the Crave (eg, “Thumbs up”), and a comment unrelated to the Crush the Crave major theme consisted of users engaging with Crush the Crave Facebook posts (eg, “We do a free package!”). the images associated with the posts. A couple of images brought forward critiques by some of the Crush the Crave Facebook Secondary Reply Posts users. For example, the inclusion of an image portraying Of the 278 reply posts, 50 (18.0%) were secondary responses cigarettes that spelled out the word “quit” in a post promoting provided by moderators and peers. These secondary responses the Crush the Crave app received some criticism. One user made primarily consisted of the moderator offering clarification when the following critique of the image: “It would make more sense there was misunderstanding, providing redirection when user if they [cigarettes in photo] were broken.” Another user responses were not related to the topic of the posts, and expressed that the use of images depicting cigarettes did not providing positive reinforcement for users sharing motivate their cessation efforts and, in fact, had the opposite smoking-related experiences. For example, in response to a user effect: “This makes me want to smoke one.” Of the 64 reply sharing their quit success on the Crush the Crave Facebook posts in response to the marketing Crush the Crave posts, 11 page, a moderator responded, “This is a wonderful and inspiring (17%) included users sharing their smoking-related experiences. story! Thank you so much for sharing it with us.” Some Tagging others to the marketing Crush the Crave posts was responses to the original posts would prompt an ongoing another method of responding to the posts (6/64, 9%), indicating conversation between the moderator and the users, or between that users were promoting Crush the Crave to their friends. the users, as shown in Textboxes 1 and 2. Textbox 1. Sample conversation between the moderator and the users. Post: Fill in the blank! I’ve pushed the CRAVE button _____ times today. User #1 response: 3. User #2 response: 0. User #3 response: 9. Moderator (asking the users who reported pushing the CRAVE button): Did you Distract the Crave with one of the options in the app? User 1 response: Watermelon [distraction aid]. Textbox 2. Sample conversation between the users. Although seldom, some users would engage with the responses of their peers, such as this conversation: Post: Does anyone remember the Friends (TV show) episode when Chandler tries to quit smoking? Maybe he should have tried our app! User #1 response: 3 years plus now nonsmoking thanks to the help of Champix. User #2 response: Posted article about Champix being linked to suicides. User #1 response: The article forgot to mention that using tobacco kills 40,000 Canadians each year. I’d take my chances with Champix. http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 9 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville smoking-related experiences. The sharing of personal Discussion experiences on the Crush the Crave Facebook page is similar to the findings of a recent study by Brandt and colleagues [20], Principal Findings demonstrating that Facebook is used as a platform for This study addresses gaps in the literature by investigating the self-reflection and evaluation of one’s cessation efforts [20]. role of Facebook as part of a smoking cessation intervention This finding adds to increasing evidence that social networking directed toward young adults. The findings of this study reveal sites, particularly Facebook, may play a critical role in helping that social networking sites, such as Facebook, can be harnessed individuals reach their cessation goals. for supporting young adults who are trying to quit smoking or We found that Crush the Crave Facebook users often posted have become smoke-free. about their various tobacco use behaviors and experiences, from The primary purpose of the Crush the Crave Facebook page their current smoking status (eg, “Sorry, I do smoke”) to their was to support smoking cessation. The supportive nature of the success in becoming smoke-free (eg, “I quit smoking just over Crush the Crave Facebook page was first cultivated through the 1 month ago and I’ve never felt better”). Although infrequent, original posts, and then maintained through the reply posts, as members on the page would share their cessation challenges. well as through the secondary responses provided by the Crush The display of quit struggles and smoking relapses on the Crush the Crave Facebook page moderators, where positive the Crave Facebook page is similar to the findings of Ploderer reinforcement, clarification, and redirection was provided in and colleagues [15], who also found that members of a smoking response to user posts. This finding extends previous research cessation Facebook page were willing to share their quit [15] and indicates that Facebook is not only a context that can struggles. This finding adds to increasing evidence that host supportive exchanges, but also that the original posts on a Facebook pages dedicated to supporting a particular health Facebook page may play a major role in establishing a behavior, such as the Crush the Crave Facebook page, are trusted supportive context for these exchanges. Once established sources of social support. In light of evidence that individuals through the original posts, the supportive nature of the Crush are not likely to share their health behavior struggles on their the Crave Facebook page was then maintained and continued personal Facebook pages because of concern for embarrassment through the responses made by a variety of sources (eg, [21,22], the inclusion of Facebook pages as part of health moderator, smoke-free individuals, individuals trying to quit) behavior interventions provides individuals with a support in a variety of ways (eg, offering information, providing positive network that they can tap into and share a broad range of reinforcement, sharing personal experiences). Given that social experiences. support increases the likelihood of quitting and success in More frequently, users would share cessation success stories. remaining smoke-free [16,17], the supportive context established This finding is encouraging because successful quitters are a on the Crush the Crave Facebook page is encouraging. valuable resource for others who are trying to quit, and also Leadership on the Crush the Crave Facebook page was primarily provide normative influence within a social network [17,23]. provided by the Crush the Crave moderators. The moderators In addition, abstinent smokers in a social network are reminded posted almost all the original posts and continually sought to of their cessation journey, which strengthens their wish to encourage individuals in their cessation efforts, promote remain smoke-free [23]. Furthermore, individuals who are trying engagement by posing questions or topics of interest to the to quit can draw motivation and encouragement from reading group, and moderate discussions. Given that individuals on the the stories of those who have succeeded in their cessation [23], page were not likely to initiate engagement on the page, it thereby adding to the supportive nature of the Crush the Crave appears that users relied on the direction of a moderator. Facebook page. Although leadership on the page may evolve over time, this Gender differences in user engagement on the Crush the Crave finding highlights the key role that moderators play in Facebook page were highlighted in the findings. Consistent stimulating group activity and in directing and tailoring page with recent reports indicating that women are more likely than content to the group. Other researchers who have investigated men to engage on social networking sites, such as Facebook the role of social forums in health promotion interventions report [24], we found that most responses to both the original posts similar findings [15,18]. For example, Ploderer and colleagues and other user posts were made by women. Although men were [15] found that users of a Facebook page as part of a smoking found to be less active, they also represented the largest users cessation intervention also relied on the direction of a moderator of the Crush the Crave Facebook page, indicating that the Crush rather than on the contributions of its members. It has been the Crave Facebook page may be a promising avenue for suggested that moderators play a pivotal role in influencing reaching young men who smoke. In light of evidence that young health behavior change and that the absence of a moderator may adults are less likely to participate in smoking cessation discourage users and hinder their motivation and self-confidence programs [25,26], this finding highlights the potential of in changing their health behaviors [18,19]. Given increasing engaging young adults in smoking cessation interventions via evidence that a moderator plays a pivotal role in harnessing the Facebook, especially young women. benefits of including social networking sites in health promotion interventions, consideration for ongoing inclusion of moderators Gender differences in the communication styles of men and for providing support and guiding page content is warranted. women were also noted on the Crush the Crave Facebook page. Women’s communication on the Crush the Crave Facebook In relation to the reply posts, we found that individuals on the page emphasized supportiveness and connection with others, Crush the Crave Facebook page primarily shared their http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 10 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville whereas men were more likely to express sarcasm and make Future research on the effectiveness of mHealth and social media strong assertions about Crush the Crave or quitting smoking. interventions in helping people quit smoking is needed. Research This finding is consistent with the findings of previous studies on how social support moderates the relationship between use investigating communication on Facebook specifically [21], of social media and quitting smoking is also needed. In addition, and social media more broadly [27]. Although we must be given the variability in smoking rates across population cautious about falling into heteronormative assumptions when subgroups, understanding what subpopulations of smokers can approaching smoking cessation online, consideration for the benefit the most from social media and mobile-based smoking stereotypical communication styles of men and women displayed cessation interventions is needed. Furthermore, given the noted on Facebook is warranted. gender differences on the Crush the Crave Facebook page, further research is needed investigating participation of men Limitations and Future Research and women on the Facebook page and how their smoking The findings of this study need to be considered in light of behaviors are influenced through the page. Once demonstrated several limitations. We were limited in describing Crush the as cost-effective and for whom, policy makers can determine Crave Facebook users through Facebook Insights. In addition, how best to integrate mHealth and social media interventions gender and age group were the only demographics freely within comprehensive tobacco cessation systems [28,29]. available on the Crush the Crave Facebook page for the sample Conclusions of users included in this study. Because this study specifically examined Facebook, the findings may not be applicable to other Social networking sites are increasingly included in social networking platforms. Finally, it is important to be contemporary smoking cessation interventions. Given the mindful of the continuously evolving nature of the Crush the relative lack of evidence in relation to online smoking cessation Crave Facebook page over time (eg, membership, introduction initiatives, this exploratory analysis contributes to knowledge of new topics, new group leaders, new moderators, new about the ways in which social networking sites, such as promotion campaigns) and that these findings are situated in a Facebook, fit within the overall cessation picture. We found particular timeframe. In particular, the Crush the Crave that the Crush the Crave Facebook page is a useful tool for Facebook page activity for this study was representative of the providing individuals with opportunities to give and receive pilot phase of Crush the Crave to assess feasibility. Work is support throughout the smoking cessation process, thereby underway to launch a randomized controlled trial of Crush the adding a new and innovative dimension to smoking cessation Crave to determine its effectiveness in quitting smoking interventions directed toward young men and women. Acknowledgments We thank Stephanie Filsinger (Senior Manager, Propel Centre for Population Health Impact), Dr David Hammond (School of Public Health and Health Systems, University of Waterloo) and IMP Canada for their contributions in the administration and development of Crush the Crave. We also thank the users of Crush the Crave. This work was supported by a grant from Health Canada, Federal Tobacco Control Strategy (Agreement #: 6549-15-2011/8300125), a grant from the Canadian Institutes of Health Research (Grant #: MOP-130303), and a grant from the Canadian Cancer Society Research Institute (Grant #: 2011-701019). Authors' Contributions LS and NB conceived the study. NB was senior scientist and oversaw the study. NB developed the intervention in collaboration with IMP Canada, DH, and SF. LS oversaw the conduct of the analysis for the paper, preparation of the manuscript, and NB contributed. LS and NB interpreted the findings. All authors contributed to the final manuscript. All authors had full access to all data. NB is guarantor for the paper. Conflicts of Interest None declared. References 1. Duggan M, Brenner J. The demographics of social media users-2013. Washington, DC: Pew Internet & American Life Project; 2012. URL: http://pewinternet.org/Commentary/2012/March/Pew-Internet-Social-Networking-full-detail.aspx [accessed 2013-12-09] [WebCite Cache ID 6LkOCjRIN] 2. Health Canada. 2012. Canadian tobacco use monitoring survey (CTUMS) URL: http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/ research-recherche/stat/_ctums-esutc_2012/ann_summary-sommaire-eng.php [accessed 2013-12-09] [WebCite Cache ID 6LkOGztHV] 3. 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URL: http://www.publichealthontario.ca/en/eRepository/ http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 12 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville Evidence%20to%20Guide%20Action%20-%20CTC%20in%20Ontario%20SFO-SAC%202010E.PDF [accessed 2014-06-27] [WebCite Cache ID 6Qd8Ir1EX] Edited by G Eysenbach; submitted 16.12.13; peer-reviewed by B Ploderer, L Greenseid, RS Sadasivam; comments to author 03.04.14; revised version received 25.04.14; accepted 12.06.14; published 11.07.14 Please cite as: Struik LL, Baskerville NB The Role of Facebook in Crush the Crave, a Mobile- and Social Media-Based Smoking Cessation Intervention: Qualitative Framework Analysis of Posts J Med Internet Res 2014;16(7):e170 URL: http://www.jmir.org/2014/7/e170/ doi: 10.2196/jmir.3189 PMID: 25016998 ©Laura Louise Struik, Neill Bruce Baskerville. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 11.07.2014. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included. http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 13 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Medical Internet Research JMIR Publications

The Role of Facebook in Crush the Crave, a Mobile- and Social Media-Based Smoking Cessation Intervention: Qualitative Framework Analysis of Posts

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Abstract

Background: Social networking sites, particularly Facebook, are increasingly included in contemporary smoking cessation interventions directed toward young adults. Little is known about the role of Facebook in smoking cessation interventions directed toward this age demographic. Objective: The aim of this study was to characterize the content of posts on the Facebook page of Crush the Crave, an evidence-informed smoking cessation intervention directed toward young adults aged 19 to 29 years. Methods: Crush the Crave Facebook posts between October 10, 2012 and June 12, 2013 were collected for analysis, representing page activity during the pilot phase of Crush the Crave. Of the 399 posts included for analysis, 121 were original posts, whereas the remaining 278 were reply posts. Posts were coded according to themes using framework analysis. Results: We found that the original Crush the Crave Facebook posts served two main purposes: to support smoking cessation and to market Crush the Crave. Most of the original posts (86/121, 71.1%) conveyed support of smoking cessation through the following 7 subthemes: encouraging cessation, group stimulation, management of cravings, promoting social support, denormalizing smoking, providing health information, and exposing tobacco industry tactics. The remaining original posts (35/121, 28.9%) aimed to market Crush the Crave through 2 subthemes: Crush the Crave promotion and iPhone 5 contest promotion. Most of the reply posts (214/278, 77.0%) were in response to the supporting smoking cessation posts and the remaining 64 (23.0%) were in response to the marketing Crush the Crave posts. The most common response to both the supporting smoking cessation and marketing Crush the Crave posts was user engagement with the images associated with each post at 40.2% (86/214) and 45% (29/64), respectively. The second most common response consisted of users sharing their smoking-related experiences. More users shared their smoking-related experiences in response to the supporting smoking cessation posts (81/214, 37.9%) compared to the marketing Crush the Crave posts (11/64, 17%). With the exception of 4 posts, a moderator posted all the original posts. In addition, although 56.00% (18,937/33,815) of Crush the Crave Facebook page users were men, only 19.8% (55/278) of the reply posts were made by men. Finally, men were found to be more likely to express sarcasm or make strong assertions about quitting smoking and Crush the Crave than women. Conclusions: The CTC Facebook page presents as a unique platform for supporting young adult smoking cessation at all stages of the cessation process. The findings of this study indicate that social networking sites, especially Facebook, warrant inclusion http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 1 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville in tobacco control efforts directed towards young adults. Research on effectiveness of the Facebook page for quitting smoking is needed. (J Med Internet Res 2014;16(7):e170) doi: 10.2196/jmir.3189 KEYWORDS qualitative research; young adult; smoking cessation; Internet; social media comparative analysis of the top 5 downloaded cessation apps, Introduction and 2 rounds of focus groups with young adult smokers were used to create the content and test the usability, design, and Background functionality of Crush the Crave. Facebook has been recently included in the design and Crush the Crave is available for Android and iOS devices in development of smoking cessation initiatives directed toward both English and French. Incorporating principles of persuasive young adults. Because young adults (ages 18 to 29) are extensive technology for behavior change [9], Crush the Crave offers such users of Facebook [1], and because they represent the largest features as a customized quit plan, the tracking of cravings and population of smokers in both Canada (21%) [2] and the United smoking habits, notifications of money saved and health States (19%) [3], Facebook is increasingly included in improvements achieved, direct dial-up to telephone-based contemporary smoking cessation initiatives directed toward this support, virtual awards that credit performance toward reaching population. For example, Crush the Crave [4], a research-based milestones, evidence-informed credible information (eg, nicotine smoking cessation app developed for young adults, has been replacement therapy), and the ability to connect with a integrated into Facebook, among other social media. The community of people for social support via Facebook. personal connections that can be formed through social media can be viewed as a form of social support and social support is Crush the Crave Facebook Page effective in helping people quit smoking according to evidence The Crush the Crave Facebook page (Figure 1) is integrated gathered by the US Public Health Service expert panel [5]. within the smartphone app or can be accessed on its own through However, despite the rapid growth in use of social media, a browser. It is moderated by a social media expert and a small research is in the early stages regarding how online social team with expertise in tobacco control. Individuals principally networks and opportunities for social support might or might come to the Facebook page via the Google search engine or the not affect smoking cessation [6]. Crush the Crave app. During the period of April 2012 to April Social networking sites, particularly Facebook, remain under 2013, Crush the Crave was piloted and promoted through examined media for health promotion. Given the widespread Google and Facebook ads. Since this pilot phase, there has not uptake of Facebook among young adults, this medium warrants been any active promotion of Crush the Crave. further investigation for its role in health behavior interventions As of November 19, 2013, the Crush the Crave Facebook page directed toward this population, particularly in relation to had 34,690 likes and a total reach of 7282 people. In all, 56.00% smoking cessation. Therefore, the purpose of this study was to (4078/7282) of Crush the Crave Facebook users were men and use framework analysis to characterize the content of the Crush 44.00% (3024/7282) were women. Most people reached the Crave Facebook posts and the associated responses. (4369/7282, 60.00%) were between the ages of 18 and 34 years Crush the Crave (the intended target group) and 57.00% (4151/7282) of Crush the Crave fans were from Canada. Posts to the Facebook page In early 2012, a team of population health researchers, social took place almost daily and usually included a photo and caption media experts, and computer programmers developed and about quitting smoking. The total number of people who clicked promoted Crush the Crave as an evidence-informed smoking on, liked, commented on, or shared Crush the Crave averaged cessation smartphone and social media app designed to help 4000.4 (SD 4306.10) per week. User engagement in terms of close the gap between existing smartphone apps [7] and evidence likes, comments, and shares averaged 70.1 (SD 62.7) per post. on what works in getting young smokers to quit smoking [8]. A panel of 5 experts in social media and tobacco cessation, a http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 2 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville Figure 1. The Crush the Crave Facebook page. database. The first author coded all posts. To validate coding, Methods both authors independently coded the first 51 posts and then compared for consistency. Any discrepancies in coding were Study Sample and Data Collection discussed and resolved. In this way, each author was able to For this study, 399 Crush the Crave Facebook posts, spanning critically challenge one another on differing perspectives and from October 10, 2012 to June 12, 2013, were collected for any potential biases. analysis and entered into an NVivo version 10 qualitative After the first 51 posts were coded, a thematic framework was software database (QSR International Pty Ltd, Burlington, MA, developed by generating major themes and subthemes in relation USA). This page activity represented the pilot phase of Crush to the original posts and categorizing the associated responses. the Crave. Posts were collected in reverse chronological order This process was facilitated by asking iterative, analytic so that the most recent activity on the Crush the Crave Facebook questions (eg, What is going on here? How are these different page was represented. Sampling was driven by saturation of or the same?). Original posts were grouped according to their themes, where posts were collected until no new themes or identified purpose (eg, supporting smoking cessation) and the subthemes were identified. Of the 399 posts, 121 were original responses were categorized according to their identified type posts, whereas the remaining 278 were responses to these posts. (eg, sharing smoking-related experiences). To maintain the No direct contact with participants was sought for this study; context of the responses to the original posts, they were listed data collection occurred solely through the gathering of posts under the messages from which they were derived and then freely available on the Crush the Crave Facebook page. categorized separately as a type of response. Throughout the Data Analysis coding process, regular meetings were held between the 2 authors to discuss and refine the thematic framework. Indexing The framework approach [10] was used to qualitatively analyze was accomplished by coding each post in NVivo, with reliability the Crush the Crave Facebook posts. Central to framework checked by the second author through review of the NVivo file. analysis is a series of interconnected stages (familiarization, The constant comparison method [12] was employed throughout identifying a thematic framework, indexing, charting, and the coding process to ensure internal homogeneity of the coding mapping and interpretation) that enables the researcher to move categories [13], whereby each post was coded into 1 category. back and forth between the data until a coherent account of the phenomenon is developed [11]. This analytic approach The fourth stage of framework analysis, charting, involved facilitated refinement of themes by both authors while arranging summaries of the original posts and the associated maintaining a clear audit trail. Familiarization was achieved in responses in a table, which were grouped according to the this study through constant comparison [12] of posts in which identified themes and subthemes in relation to the purpose of coding categories were developed and entered in the NVivo http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 3 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville the original posts. This stage enabled the researchers to identify Results the range of data included in the original posts and to become familiar with the range of responses to these messages. The Characterizing the Original Crush the Crave Facebook thematic framework was refined and two tables of data were Posts developed: one that encompassed the purpose of the original posts according to each identified theme and subtheme and one Overview that encompassed the various responses to these posts, which We found that the original posts served two main purposes: to were grounded in the context of the themes and subthemes of support smoking cessation and market Crush the Crave. Most the original posts. The final stage, mapping and interpretation, posts (86/121, 71.1%) related to the major theme supporting enabled the researchers to compare and contrast the original smoking cessation, which included 7 subthemes (Table 1), and posts and responses while searching for patterns. At this stage, 35 of 121 posts (28.9%) related to the major theme marketing the original posts were grouped according to the finalized themes Crush the Crave, which included 2 subthemes (Table 2). The and subthemes, and responses were grouped together. original Crush the Crave Facebook posts were primarily initiated Representative quotes were selected from the original posts and by a Crush the Crave moderator. Only 4 of the posts were responses to illustrate key themes and subthemes. user-initiated. http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 4 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville Table 1. Posts supporting smoking cessation (N=86). Subtheme n (%) Examples of post content Encourage cessation 34 (39) Quitting is tough...but you’re tougher ;) Think of all the places a tobacco-free road can take you. Group stimulation 13 (15) Fill in the blank! It’s been ___days since my last cigarette. Cool piece from ’66. What would you rather spend your money on? Promote social support 12 (14) You gotta love your quit buddy! Good friends make quitting easier! Management of cravings 11 (13) We found your next craving distraction-playing frisbee with a friend! Next time you think about smoking, go to a mirror, take a breath, and make this face. Just try it. You’ll see. Denormalize smoking 7 (8) Hit the like button if you agree that smoking isn’t sexy. http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 5 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville Subtheme n (%) Examples of post content Fact: Not smoking makes you more kissable. Provide health information 5 (6) Get outdoors and get active! Researchers found that physically active men were 36% more likely to have tried to quit smoking within the past year, while physically active women were 37% more likely to do so than nonactive women. As soon as you stop smoking, you start repairing. (Thanks Australia!) Expose tobacco industry 4 (5) How do you feel about being labeled “a replacement”? “The truth about tobacco” tactics video [14] Why are young adults so important to tobacco companies? http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 6 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville Table 2. Posts marketing Crush the Crave (N=35). Subtheme n (%) Examples of post content Crush the Crave promotion 26 (74) The new Crush the Crave is going to be Facebook-friendly! Strut your way to a smoke-free lifestyle with Crush the Crave! iPhone 5 contest promo- 9 (26) Did someone say iPhone 5? Our contest ends on June 15th! tion Have you entered the Crush the Crave contest yet? You could WIN an iPhone 5! The supporting smoking cessation posts also entailed a focus Supporting Smoking Cessation on promoting the act of social support for those trying to quit The encourage cessation subtheme was present in many of the (11/86, 13%). The positive role that providing and receiving supporting smoking cessation posts (34/86, 39%). Posts within social support has on smoking cessation was emphasized in this subtheme contained positively framed messages offering these posts. For instance, one post read, “Find a quit buddy, encouragement to those trying to quit smoking, such as “Stay backup goes a long way.” positive! You can do this!” Denormalize smoking was another subtheme under supporting The group stimulation subtheme represented 13 of 86 (15%) smoking cessation and represented 7 of 86 posts (8%). These posts under the major theme supporting smoking cessation. posts covered the positive social outcomes of being smoke-free. Generating interaction among the Crush the Crave Facebook These positive outcomes included smelling good and looking users was the primary goal of these posts. Therefore, the posts attractive, such as “Did you know? Not smelling like cigarette consisted of questions and posting thought-provoking articles smoke=more hugs.” or images related to smoking. For example, a post contained a Posts that provided health information made up 5 of 86 (6%) link to an article on new research demonstrating a link between supporting smoking cessation posts. These posts provided facts cigarette smoking and damage to memory, learning, and about addiction, research on effective strategies for quitting reasoning, and asked users “Think there’s truth to this?” smoking, the positive health effects of quitting, and information Management of cravings was another common subtheme (12/86, about the damaging effects of smoking on the body. For 14%). Posts under this subtheme included suggestions about example, one post read, “Do you have a cigarette first thing in ways to manage cravings (eg, “Find a peaceful place when the morning? This recent study shows that smoking as soon as cravings stress you out”) and also invited users to reflect on you wake up is even more unhealthy.” their cravings (eg, “Quit Smoking Pro Tip: Reflect on your Expose tobacco industry tactics was another subtheme under triggers to understand where your habit comes from”). supporting smoking cessation (4/86, 5%). The purpose of these posts was to invite Crush the Crave Facebook users to think http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 7 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville about the recruitment strategies used by tobacco companies to I quit smoking 31 years ago. My husband had had a increase their revenue. This is demonstrated in the post: “Class heart attack, we had to get someone to wash all the is in session! How does this Newport ad try to sell cigarettes to house and carpets and upholstery so the smoke smell men?” would be gone. Because I loved him so much, and I wanted him to live with me much longer, he was my Marketing Crush the Crave reason to stop. In order to be able to stop, you need The Crush the Crave promotion subtheme represented most of a reason to help you along. Not so hard that way. And the marketing Crush the Crave posts (26/35, 74%). The purpose so worth it. Good luck all. of these posts was to promote the various mobile and social Crush the Crave Facebook users also shared their struggles with media platforms to access Crush the Crave (eg, “Did you know cessation, which was demonstrated in the following post: “I that Crush the Crave is on Google Play?”), the different features quit so many times...started again and again...last time I just of the Crush the Crave app (eg, “Watching a funny video can made up my mind...threw them away and never looked back. help distract the crave! It’s one of the features in our Quit Help It was hard but I’ve been smoke-free for 12 years now and very section in the Crush the Crave app”), as well as news related to happy I did.” Sharing personal management of cravings was Crush the Crave (eg, “We got some radio play for new version another popular response in which users would describe what of Crush the Crave today!”). they found helpful in remaining smoke-free: The iPhone 5 contest promotion subtheme made up the I used an aide called Champix and I never looked remaining 9 of 35 (26%) marketing Crush the Crave posts. The back and never will!!!! And thanks, I am very proud focus of these posts was to motivate people to join Crush the of myself. I was a very heavy smoker. I smoked 25 to Crave and download the Crush the Crave app. For instance, one 30 a day and rolled my own. So harsh lol. Good luck post read, “Looking for some motivation? Enter our contest and to whomever is quitting. IT IS WORTH IT!!!! you could win an iPhone 5!” Some Crush the Crave Facebook users also shared their smoking Characterizing the Crush the Crave User Reply Posts triggers. For example, one user described how she changed her daily routine so that she could quit smoking: Overview For me, it was after a meal with my coffee. So I Of the 278 reply posts, 214 (77.0%) were in response to the switched to tea and it made things easier. Or went supporting smoking cessation posts, whereas the remaining 64 without it and went for a walk because I never smoked (23.0%) were in response to the marketing Crush the Crave outside. It has been 32 years now. I am so proud of posts. Women posted 218 (78.4%) of the reply posts, men posted myself. 55 (19.8%), and 5 (1.8%) were posted by users that did not indicate their gender. Although seldom, some users would assert their current smoking status (eg, “Sorry, I do smoke”). Still others would express their Supporting Smoking Cessation Reply Posts intentions to quit (eg, “Well, Jan 1, 2013 will be the first day The most common response (86/214, 40.2%) to the posts under for me :) Wish me luck!”). the supporting smoking cessation major theme consisted of user Crush the Crave Facebook users also discussed tobacco control engagement with the images associated with the original posts. measures (11/214, 5.1%) in response to the supporting smoking Users primarily expressed their enjoyment of the images. For cessation posts. For example, in response to a post asking users example, in response to an image of kittens hugging associated if they thought health warnings on cigarette packages should with a post promoting social support of cessation, a user be mandatory, a user responded with the statement: “I don’t responded: “Aw, so sweet!;))” A few users expressed that the think they should have to [put health warnings on cigarette images associated with the posts spurred on their smoke-free packages]...you don’t see any warning labels on liquor bottles efforts. For example, in response to an image of puppies or beer bottles or cans!! Drunken drivers kill...” Some users associated with the caption “If I just hold your mouth shut, like expressed frustration with tobacco control efforts and suggested this, you can’t smoke” a user responded, “AH-adorable with a that a complete ban on cigarettes was needed: “...take THEM good reminder or push in the right direction.” Conversely, some OFF THE shelf then, why can they keep selling something that users indicated that although the images were appreciated, they kills you, when they pull a product off the shelf for WAY less were not enough to motivate their smoke-free efforts. For health issues...” example, a user responded, “I love this cat...but nope, won’t help me to stop smoking” to an image of a cat with the caption, Sometimes Crush the Crave Facebook users would express a “Maybe I can persuade you not to light that cigarette.” negative attitude toward smoking (9/214, 4.2%) when engaging with the supporting smoking cessation posts. For example, a The second most common response (81/214, 37.8%) to the user described the social benefits of not smelling like cigarette supporting smoking cessation posts consisted of users sharing smoke in response to a post that aimed to denormalize smoking: their smoking-related experiences at various stages of the “More dates, more lov’n, more everything! It’s not cool to smell cessation process. These responses often consisted of users like smoke!” sharing their quit successes (eg, “Day 200 for me no smoking :3”). Some users would respond in detail and elaborate on their In all, 4 of 214 responses (1.9%) consisted of tags, which are lived experiences with quitting smoking: links created by users to another person’s Facebook timeline. The people who are tagged then receive a notification and are http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 8 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville directed to the post that they were tagged in, facilitating their Of the 64 replies to the marketing Crush the Crave posts, 6 (9%) exposure to Crush the Crave content. Only 2 of 214 (0.9%) consisted of sarcastic remarks about quitting smoking and what reply posts consisted of users sharing smoking-related facts, will help people quit. For example, in response to a post such as “It takes 7 years to recover.” And 3 of 214 posts (1.4%) promoting Crush the Crave to help people quit smoking, a user consisted of users encouraging the smoking cessation efforts posted, “Maybe if they put Justin Bieber on each pack of smokes of their peers: “If I can do it, anyone can. YOU CAN!!” In then people will maybe quit smoking lol.” Of the 64 reply posts, addition, 3 of 214 posts (1.4%) consisted of users expressing 4 (6%) consisted of users expressing a negative attitude toward sarcasm. For example, in a post asking users how many days Crush the Crave, which is demonstrated in the following post: it’s been since their last cigarette, a user responded with “too “Pathetic if you need an app to help you quit smoking.” With long.” The remaining reply posts consisted of users expressing the exception of one, the reply posts consisting of sarcasm or a their misunderstanding of the posts (4/214, 1.9%) (eg, “What negative attitude toward Crush the Crave were made by men. does the aurora borealis have to do with not smoking?”), a user In addition, 3 of 64 (5%) reply posts consisted of users gathering sharing holiday wishes (1/214, 0.5%) (eg,”Happy information about Crush the Crave. For example, a user wanted Thanksgiving!”), and users posting content unrelated to the to know more about the availability of Crush the Crave on original post (12/214, 5.6%) (eg, “Do you ever have those mobile phones: “Do you have a Blackberry version? Because dreams, where a bad person is chasing you and you’re running it would be a shame if a Canadian-made app didn’t work on a in slow motion?”). Canadian phone...:).” The remaining 3 of 64 (5%) reply posts consisted of peer encouragement of cessation (eg, “Quit Marketing Crush the Crave Reply Posts smoking!! :)”), expression of a positive attitude toward Crush Many (29/64, 45%) responses to the posts under the marketing the Crave (eg, “Thumbs up”), and a comment unrelated to the Crush the Crave major theme consisted of users engaging with Crush the Crave Facebook posts (eg, “We do a free package!”). the images associated with the posts. A couple of images brought forward critiques by some of the Crush the Crave Facebook Secondary Reply Posts users. For example, the inclusion of an image portraying Of the 278 reply posts, 50 (18.0%) were secondary responses cigarettes that spelled out the word “quit” in a post promoting provided by moderators and peers. These secondary responses the Crush the Crave app received some criticism. One user made primarily consisted of the moderator offering clarification when the following critique of the image: “It would make more sense there was misunderstanding, providing redirection when user if they [cigarettes in photo] were broken.” Another user responses were not related to the topic of the posts, and expressed that the use of images depicting cigarettes did not providing positive reinforcement for users sharing motivate their cessation efforts and, in fact, had the opposite smoking-related experiences. For example, in response to a user effect: “This makes me want to smoke one.” Of the 64 reply sharing their quit success on the Crush the Crave Facebook posts in response to the marketing Crush the Crave posts, 11 page, a moderator responded, “This is a wonderful and inspiring (17%) included users sharing their smoking-related experiences. story! Thank you so much for sharing it with us.” Some Tagging others to the marketing Crush the Crave posts was responses to the original posts would prompt an ongoing another method of responding to the posts (6/64, 9%), indicating conversation between the moderator and the users, or between that users were promoting Crush the Crave to their friends. the users, as shown in Textboxes 1 and 2. Textbox 1. Sample conversation between the moderator and the users. Post: Fill in the blank! I’ve pushed the CRAVE button _____ times today. User #1 response: 3. User #2 response: 0. User #3 response: 9. Moderator (asking the users who reported pushing the CRAVE button): Did you Distract the Crave with one of the options in the app? User 1 response: Watermelon [distraction aid]. Textbox 2. Sample conversation between the users. Although seldom, some users would engage with the responses of their peers, such as this conversation: Post: Does anyone remember the Friends (TV show) episode when Chandler tries to quit smoking? Maybe he should have tried our app! User #1 response: 3 years plus now nonsmoking thanks to the help of Champix. User #2 response: Posted article about Champix being linked to suicides. User #1 response: The article forgot to mention that using tobacco kills 40,000 Canadians each year. I’d take my chances with Champix. http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 9 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville smoking-related experiences. The sharing of personal Discussion experiences on the Crush the Crave Facebook page is similar to the findings of a recent study by Brandt and colleagues [20], Principal Findings demonstrating that Facebook is used as a platform for This study addresses gaps in the literature by investigating the self-reflection and evaluation of one’s cessation efforts [20]. role of Facebook as part of a smoking cessation intervention This finding adds to increasing evidence that social networking directed toward young adults. The findings of this study reveal sites, particularly Facebook, may play a critical role in helping that social networking sites, such as Facebook, can be harnessed individuals reach their cessation goals. for supporting young adults who are trying to quit smoking or We found that Crush the Crave Facebook users often posted have become smoke-free. about their various tobacco use behaviors and experiences, from The primary purpose of the Crush the Crave Facebook page their current smoking status (eg, “Sorry, I do smoke”) to their was to support smoking cessation. The supportive nature of the success in becoming smoke-free (eg, “I quit smoking just over Crush the Crave Facebook page was first cultivated through the 1 month ago and I’ve never felt better”). Although infrequent, original posts, and then maintained through the reply posts, as members on the page would share their cessation challenges. well as through the secondary responses provided by the Crush The display of quit struggles and smoking relapses on the Crush the Crave Facebook page moderators, where positive the Crave Facebook page is similar to the findings of Ploderer reinforcement, clarification, and redirection was provided in and colleagues [15], who also found that members of a smoking response to user posts. This finding extends previous research cessation Facebook page were willing to share their quit [15] and indicates that Facebook is not only a context that can struggles. This finding adds to increasing evidence that host supportive exchanges, but also that the original posts on a Facebook pages dedicated to supporting a particular health Facebook page may play a major role in establishing a behavior, such as the Crush the Crave Facebook page, are trusted supportive context for these exchanges. Once established sources of social support. In light of evidence that individuals through the original posts, the supportive nature of the Crush are not likely to share their health behavior struggles on their the Crave Facebook page was then maintained and continued personal Facebook pages because of concern for embarrassment through the responses made by a variety of sources (eg, [21,22], the inclusion of Facebook pages as part of health moderator, smoke-free individuals, individuals trying to quit) behavior interventions provides individuals with a support in a variety of ways (eg, offering information, providing positive network that they can tap into and share a broad range of reinforcement, sharing personal experiences). Given that social experiences. support increases the likelihood of quitting and success in More frequently, users would share cessation success stories. remaining smoke-free [16,17], the supportive context established This finding is encouraging because successful quitters are a on the Crush the Crave Facebook page is encouraging. valuable resource for others who are trying to quit, and also Leadership on the Crush the Crave Facebook page was primarily provide normative influence within a social network [17,23]. provided by the Crush the Crave moderators. The moderators In addition, abstinent smokers in a social network are reminded posted almost all the original posts and continually sought to of their cessation journey, which strengthens their wish to encourage individuals in their cessation efforts, promote remain smoke-free [23]. Furthermore, individuals who are trying engagement by posing questions or topics of interest to the to quit can draw motivation and encouragement from reading group, and moderate discussions. Given that individuals on the the stories of those who have succeeded in their cessation [23], page were not likely to initiate engagement on the page, it thereby adding to the supportive nature of the Crush the Crave appears that users relied on the direction of a moderator. Facebook page. Although leadership on the page may evolve over time, this Gender differences in user engagement on the Crush the Crave finding highlights the key role that moderators play in Facebook page were highlighted in the findings. Consistent stimulating group activity and in directing and tailoring page with recent reports indicating that women are more likely than content to the group. Other researchers who have investigated men to engage on social networking sites, such as Facebook the role of social forums in health promotion interventions report [24], we found that most responses to both the original posts similar findings [15,18]. For example, Ploderer and colleagues and other user posts were made by women. Although men were [15] found that users of a Facebook page as part of a smoking found to be less active, they also represented the largest users cessation intervention also relied on the direction of a moderator of the Crush the Crave Facebook page, indicating that the Crush rather than on the contributions of its members. It has been the Crave Facebook page may be a promising avenue for suggested that moderators play a pivotal role in influencing reaching young men who smoke. In light of evidence that young health behavior change and that the absence of a moderator may adults are less likely to participate in smoking cessation discourage users and hinder their motivation and self-confidence programs [25,26], this finding highlights the potential of in changing their health behaviors [18,19]. Given increasing engaging young adults in smoking cessation interventions via evidence that a moderator plays a pivotal role in harnessing the Facebook, especially young women. benefits of including social networking sites in health promotion interventions, consideration for ongoing inclusion of moderators Gender differences in the communication styles of men and for providing support and guiding page content is warranted. women were also noted on the Crush the Crave Facebook page. Women’s communication on the Crush the Crave Facebook In relation to the reply posts, we found that individuals on the page emphasized supportiveness and connection with others, Crush the Crave Facebook page primarily shared their http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 10 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville whereas men were more likely to express sarcasm and make Future research on the effectiveness of mHealth and social media strong assertions about Crush the Crave or quitting smoking. interventions in helping people quit smoking is needed. Research This finding is consistent with the findings of previous studies on how social support moderates the relationship between use investigating communication on Facebook specifically [21], of social media and quitting smoking is also needed. In addition, and social media more broadly [27]. Although we must be given the variability in smoking rates across population cautious about falling into heteronormative assumptions when subgroups, understanding what subpopulations of smokers can approaching smoking cessation online, consideration for the benefit the most from social media and mobile-based smoking stereotypical communication styles of men and women displayed cessation interventions is needed. Furthermore, given the noted on Facebook is warranted. gender differences on the Crush the Crave Facebook page, further research is needed investigating participation of men Limitations and Future Research and women on the Facebook page and how their smoking The findings of this study need to be considered in light of behaviors are influenced through the page. Once demonstrated several limitations. We were limited in describing Crush the as cost-effective and for whom, policy makers can determine Crave Facebook users through Facebook Insights. In addition, how best to integrate mHealth and social media interventions gender and age group were the only demographics freely within comprehensive tobacco cessation systems [28,29]. available on the Crush the Crave Facebook page for the sample Conclusions of users included in this study. Because this study specifically examined Facebook, the findings may not be applicable to other Social networking sites are increasingly included in social networking platforms. Finally, it is important to be contemporary smoking cessation interventions. Given the mindful of the continuously evolving nature of the Crush the relative lack of evidence in relation to online smoking cessation Crave Facebook page over time (eg, membership, introduction initiatives, this exploratory analysis contributes to knowledge of new topics, new group leaders, new moderators, new about the ways in which social networking sites, such as promotion campaigns) and that these findings are situated in a Facebook, fit within the overall cessation picture. We found particular timeframe. In particular, the Crush the Crave that the Crush the Crave Facebook page is a useful tool for Facebook page activity for this study was representative of the providing individuals with opportunities to give and receive pilot phase of Crush the Crave to assess feasibility. Work is support throughout the smoking cessation process, thereby underway to launch a randomized controlled trial of Crush the adding a new and innovative dimension to smoking cessation Crave to determine its effectiveness in quitting smoking interventions directed toward young men and women. Acknowledgments We thank Stephanie Filsinger (Senior Manager, Propel Centre for Population Health Impact), Dr David Hammond (School of Public Health and Health Systems, University of Waterloo) and IMP Canada for their contributions in the administration and development of Crush the Crave. We also thank the users of Crush the Crave. This work was supported by a grant from Health Canada, Federal Tobacco Control Strategy (Agreement #: 6549-15-2011/8300125), a grant from the Canadian Institutes of Health Research (Grant #: MOP-130303), and a grant from the Canadian Cancer Society Research Institute (Grant #: 2011-701019). Authors' Contributions LS and NB conceived the study. 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URL: http://www.publichealthontario.ca/en/eRepository/ http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 12 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Struik & Baskerville Evidence%20to%20Guide%20Action%20-%20CTC%20in%20Ontario%20SFO-SAC%202010E.PDF [accessed 2014-06-27] [WebCite Cache ID 6Qd8Ir1EX] Edited by G Eysenbach; submitted 16.12.13; peer-reviewed by B Ploderer, L Greenseid, RS Sadasivam; comments to author 03.04.14; revised version received 25.04.14; accepted 12.06.14; published 11.07.14 Please cite as: Struik LL, Baskerville NB The Role of Facebook in Crush the Crave, a Mobile- and Social Media-Based Smoking Cessation Intervention: Qualitative Framework Analysis of Posts J Med Internet Res 2014;16(7):e170 URL: http://www.jmir.org/2014/7/e170/ doi: 10.2196/jmir.3189 PMID: 25016998 ©Laura Louise Struik, Neill Bruce Baskerville. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 11.07.2014. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included. http://www.jmir.org/2014/7/e170/ J Med Internet Res 2014 | vol. 16 | iss. 7 | e170 | p. 13 (page number not for citation purposes) XSL FO RenderX

Journal

Journal of Medical Internet Research – JMIR Publications

Published: Jul 11, 2014

Keywords: qualitative research; young adult; smoking cessation; Internet; social media

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