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A key factor in successfully reducing and quitting smoking, as well as preventing smoking relapse is access to and engagement with social support. Recent technological advances have made it possible for smokers to access social support via online community forums. While community forums associated with smoking cessation interventions are now common practice, there is a gap in understanding how and when the different types of social support identified by Cutrona and Suhr (1992) (emotional, esteem, informational, tangible, and network) are exchanged on such forums. Community forums that entail “superusers” (a key marker of a successful forum), like QuitNow, are ripe for exploring and leveraging promising social support exchanges on these platforms.
The purpose of this study was to characterize the posts made on the QuitNow community forum at different stages in the quit journey, and determine when and how the social support constructs are present within the posts.
A total of 506 posts (including original and response posts) were collected. Using conventional content analysis, the original posts were coded inductively to generate categories and subcategories, and the responses were coded deductively according to the 5 types of social support. Data were analyzed using Microsoft Excel software.
Overall, individuals were most heavily engaged on the forum during the first month of quitting, which then tapered off in the subsequent months. In relation to the original posts, the majority of them fit into the categories of sharing quit successes, quit struggles, updates, quit strategies, and desires to quit. Asking for advice and describing smoke-free benefits were the least represented categories. In relation to the responses, encouragement (emotional), compliment (esteem), and suggestion/advice (informational) consistently remained the most prominent types of support throughout all quit stages. Companionship (network) maintained a steady downward trajectory over time.
The findings of this study highlight the complexity of how and when different types of social support are exchanged on the QuitNow community forum. These findings provide directions for how social support can be more strategically employed and leveraged in these online contexts to support smoking cessation.
Tobacco use continues to be the number one cause of preventable disease and death around the world, including North America [
There are many cessation services and interventions now available to support and enhance the cessation efforts of individuals. A recommended strategy in North American best practice guidelines for smoking cessation interventions and services is the inclusion and recommendation of social support [
Social support has been broken down into the following 5 different types according to Cutrona and Suhr [
A key marker of successful community forums on health-related topics is the engagement of superusers [
QuitNow is British Columbia’s free online smoking cessation service delivered by the British Columbia Lung Association on behalf of the Government of British Columbia. It is a customized program for British Columbia residents who are looking to quit or reduce tobacco use, including smoking. On the website, there are resources for different stages of quitting (eg, thinking about quitting, preparing to quit, and staying quit). There are also resources for health professionals, families, and friends to support smokers who want to quit. Individuals are encouraged to create an account with QuitNow, which gives them access to free quit coaching, live chat with a quit coach, and a community forum. A quit coach is an individual trained and paid to provide cessation support to individuals trying to quit smoking. The community forum is the primary social support feature of QuitNow and is moderated by quit coaches. The content is publicly available, but engagement with the forum requires registration. Given that the posts examined for this study are publicly available, in consultation with the Behavioral Research Ethics Board and the University of British Columbia’s Okanagan campus, it was agreed that ethical approval was not required.
For this study, a total of 506 QuitNow community forum posts spanning the month of December 2019 were collected and entered into Excel for conventional content analysis. These posts were collected in reverse chronological order so that the most recent activity on the QuitNow community forum page was represented. Sampling was driven by saturation of codes, where posts were collected until no new categories or subcategories were identified [
Using conventional content analysis [
In total, 89 unique users are represented in this sample of posts, with 413 posts made by QuitNow users and 93 made by a Quit coach.
Of the 506 posts, 76 were original posts and 430 were responses or subresponses to these posts. The average number of responses per original post was 6, with a range of 4 to 8 responses. Each post contained an average of 46.27 words.
The data within the 76 original posts were coded (n=145); these codes were subsequently classified into the following 7 categories: (1) quit desires, (2) quit struggles, (3) updates, (4) successes, (5) quit strategies, (6) advice requests, and (7) smoke-free benefits (
The frequency of posts per category was examined. The greatest numbers of original posts were in the categories
Next, variability in user engagement over time was investigated. The 1st month entailed the most engagement, followed by the 2nd month (
Categories of original posts.
Category | Description | Exemplary quote | Total value (N=145), n |
Quit desires | Sharing their desires, plans, or intentions to quit. |
|
19 |
Quit struggles | Sharing past, current, or anticipated struggles that make quitting more difficult. |
|
26 |
Updates | Sharing an update on their quitting status. |
|
22 |
Successes | Sharing their experienced successes. |
|
33 |
Quit strategies | Sharing tips and strategies that worked for them, and strategies they will use. |
|
24 |
Advice requests | Asking for advice to navigate circumstances they are experiencing. |
|
10 |
Smoke-free benefits | Sharing benefits of being smoke free. |
|
11 |
Representation of categories at each quit stage.
Stage and category | Representation (N=145 posts) | |
|
|
|
|
Quit desires | 15 (83.3) |
|
Quit struggles | 3 (16.6) |
|
|
|
|
Quit desires | 2 (3.3) |
|
Quit struggles | 12 (19.6) |
|
Updates | 13 (17.5) |
|
Successes | 11 (18.0) |
|
Quit strategies | 12 (19.6) |
|
Advice requests | 8 (13.1) |
|
Smoke-free benefits | 3 (4.9) |
|
|
|
|
Quit struggles | 5 (13.5) |
|
Updates | 4 (10.8) |
|
Successes | 13 (35.1) |
|
Quit strategies | 10 (27.0) |
|
Smoke-free benefits | 5 (13.5) |
|
|
|
|
Quit struggles | 1 (7.1) |
|
Updates | 2 (14.3) |
|
Successes | 8 (57.1) |
|
Smoke-free benefits | 3 (21.4) |
|
|
|
|
Quit benefits | 2 (13.3) |
|
Quit struggles | 5 (33.3) |
|
Updates | 3 (20.0) |
|
Successes | 1 (6.7) |
|
Quit strategies | 2 (13.3) |
|
Advice requests | 2 (13.3) |
Trajectory of post category representation throughout the quit journey.
In relation to the 430 responses or subresponses to the original posts, 1100 codes were assigned and broken down into the following 5 social support categories: (1) emotional support, (2) esteem support, (3) informational support, (4) tangible support, and (5) network support, as well as an “other” category, the latter of which was inductively derived (
….I really admire you for remaining so positive and so proud of you for not giving up (
Out of the possible 26 social support subcategories, 14 were present within the responses. Encouragement under emotional support and compliments under esteem support were the most strongly represented at 20.9% (n=230) and 20.4% (n=224) of the 1100 codes, respectively. Suggestion/advice under informational support was the next most common at 15.6% (n=172). The least represented subcategories fell under emotional, esteem, and informational support (sympathy, relief from guilt, and teaching, respectively) at 0.9% (n=10) each.
Parallel to how the number of original posts was the highest during the 1st month, the numbers of user responses and subresponses were also at their highest during this time (
During the before quitting stage, encouragement, compliment, and suggestion/advice were the most prominent types of support offered to users. During the 1st month, these were also the most prominent but in the reverse order whereby suggestion/advice was the most prominent, followed by compliment and then encouragement. During the 2nd and 3rd months, again, these were the most prominent types of support but with compliment being the most prominent, followed by encouragement and then suggestion/advice. During the relapse stage, encouragement and suggestion/advice were the most prominent, and were equally followed by compliment and companionship. The above trends can be visualized in
Social support responses to original posts.
Code and subcode | Exemplary quote | Value (N=1100), n (%) | |
|
|
|
|
|
Encouragement |
|
230 (20.9) |
|
Sympathy |
|
10 (0.9) |
|
Understanding/empathy |
|
35 (3.2) |
|
|
|
|
|
Compliment |
|
224 (20.4) |
|
Relief of guilt |
|
10 (0.9) |
|
Validation |
|
52 (4.7) |
|
|
|
|
|
Referral |
|
44 (4.0) |
|
Situation appraisal |
|
56 (5.1) |
|
Suggestion/advice |
|
172 (15.6) |
|
Teaching |
|
11 (1.0) |
|
|
|
|
|
Companionship |
|
85 (7.7) |
|
|
|
|
|
Appreciation |
|
82 (7.5) |
|
Happy holidays |
|
89 (8.1) |
Social support responses represented in each quit stage.
Stage and category | Representation (N=1100 posts) | ||
|
|
||
|
Encouragement | 59 (25.1) | |
|
Sympathy | 4 (1.7) | |
|
Understanding/empathy | 19 (8.1) | |
|
Compliment | 35 (14.9) | |
|
Relief of guilt | 2 (0.9) | |
|
Validation | 12 (5.1) | |
|
Referral | 17 (7.2) | |
|
Situation appraisal | 15 (6.4) | |
|
Suggestion/advice | 42 (17.9) | |
|
Teaching | 6 (2.6) | |
|
Companionship | 24 (10.2) | |
|
|
||
|
Encouragement | 59 (21.1) | |
|
Sympathy | 3 (1.1) | |
|
Understanding/empathy | 10 (3.6) | |
|
Compliment | 64 (22.9) | |
|
Relief of guilt | 2 (0.7) | |
|
Validation | 18 (6.5) | |
|
Referral | 20 (7.2) | |
|
Situation appraisal | 8 (2.9) | |
|
Suggestion/advice | 66 (23.7) | |
|
Teaching | 4 (1.4) | |
|
Companionship | 25 (9.0) | |
|
|
||
|
Encouragement | 69 (27.3) | |
|
Sympathy | 3 (1.2) | |
|
Understanding/empathy | 5 (2.0) | |
|
Compliment | 85 (33.6) | |
|
Relief of guilt | 3 (1.2) | |
|
Validation | 18 (7.1) | |
|
Referral | 5 (2.0) | |
|
Situation appraisal | 15 (5.9) | |
|
Suggestion/advice | 41 (16.2) | |
|
Teaching | 1 (0.4) | |
|
Companionship | 8 (3.2) | |
|
|
||
|
Encouragement | 27 (32.1) | |
|
Compliment | 35 (41.7) | |
|
Validation | 4 (4.8) | |
|
Situation appraisal | 6 (7.1) | |
|
Suggestion/advice | 9 (10.7) | |
|
Companionship | 3 (3.6) | |
|
|
||
|
Encouragement | 16 (33.3) | |
|
Understanding/empathy | 1 (2.1) | |
|
Compliment | 5 (10.4) | |
|
Relief of guilt | 3 (6.3) | |
|
Referral | 2 (4.2) | |
|
Situation appraisal | 2 (4.2) | |
|
Suggestion/advice | 14 (29.2) | |
|
Companionship | 5 (10.4) |
Trend of social support response representation throughout each quit stage.
This study highlights the complexity of how and when different types of social support are exchanged among individuals quitting smoking on the QuitNow online community forum. Application of Catrona and Suhr’s [
The highest and most varied engagement on the forum occurred throughout the 1st month of quitting. This coincides with the biological processes that occur during cessation. Many users face withdrawal symptoms in the short term following an attempt to quit [
We also found that user engagement steadily decreases after 2 to 3 months. Again, this likely reflects the nicotine dependence trajectory, wherein receptors in the brain fully adapt to nonsmoking after 3 months due to organic reversals in brain matter; nicotine-related deficits in brain dopamine are often a consequence of chronic smoking that revert to baseline 3 months after quitting [
Forum users increasingly shared their cessation journey successes and strategies with others during the 1st and 2nd months of quitting. This may suggest that, by this time, individuals feel confident enough to share their successes and feel that they have enough personal credibility to offer advice. Previous literature has found that individuals are often reluctant to share their successes too early due to a fear of failure and a lack of confidence in their ability, which is consistent with these findings [
In response to individuals sharing successes, others primarily provide esteem support, possibly further boosting their self-efficacy, a key ingredient to behavior change overall [
Overall, the types of social support that were most consistently present included emotional and esteem support. This is in keeping with previous research, whereby nurturant support (including emotional and esteem support) was found to be most common in responses to original posts [
It is important to note that companionship demonstrated to have a steady downward trajectory over time; it was most prevalent before quitting but less so over time, with the exception of relapse. This is significant as it exemplifies the importance of letting people know that they are in this together at the beginning and particularly before the quitting process, and once again speaks to the importance of a tailored individualistic intervention process. Simply, individuals need to feel like they are not alone as they embark on the journey to quit using nicotine.
The results of this study encompass several recommendations that could benefit QuitNow, as well as smoking cessation community forums at large. One recommendation is to provide community forum users, as well as family and friends, with a tip sheet based on the findings (eg, emphasizing understanding and companionship at the before quitting stage; emphasizing encouragement and compliments during active quitting; and helping them reappraise the situation/offer relief from guilt during relapse). In addition, community forums may benefit from having discussion tags, whereby users can decide what types of content they are most interested in viewing. For example, a user who is thinking about quitting might want to know what the 1st month is like and may filter forum content through a “1st month” tag. Finally, the results have implications for the implementation of online programs in which community forums are embedded. For example, now that we know companionship is key at the beginning of the quit journey, the affiliated website would benefit from emphasizing the presence of social supports (including the forum), which may subsequently retain individuals in the program. As soon as a new user joins a forum, a quit coach could send a text or email message about being there for them and referring them to the community forum (offering companionship early on).
Future research is needed to assess how changes made to the QuitNow forum as a result of this study’s findings impact engagement and cessation outcomes among users. For example, do more strategic prompts to use the forum and to post about smaller successes result in more month-to-month engagement (eg, more original posts and responses)? Moreover, it would be interesting to determine how different groups are engaging on the forum (eg, are certain populations staying in a particular quit stage longer?). This would carry implications for more tailored support for different groups. It would also be worthwhile assessing whether posting about big successes (eg, 2 months smoke-free) can be an effective measure and possible predictor of abstinence. This could potentially lend to an innovative and nonintrusive way of determining the success of a forum in supporting cessation.
This study has several limitations. First, the frequency, duration, and number of cigarettes smoked among the various forum users could not be collected. These factors may play a role in shaping individual behaviors during a cessation attempt and/or journey. Second, we did not analyze intersections of identity (eg, gender, race/ethnicity, orientation, education level, or socioeconomic status) and their impact on how support was exchanged on the forum. In this regard, we were not able to collect data on nuances regarding what type of support is most beneficial to whom at different points in the quit trajectory. Third, it may be possible that some forum users did not update their quit status on the forum. Finally, the data collected for this study represent a specific point in time (leading up to Christmas and the new year), which may influence the type of communication and motivation of the users, and possibly atypical engagement on the forum. While this may be a limitation, it is also a strength in that these posts reflect the most recent and up-to-date posts at the time of the analysis. Another strength of the study is that data available in real-time were collected to gather insights into user engagement. Finally, this study encompassed the use of inductive qualitative methods to identify key themes and a theoretical framework to understand social support exchanges on the forum. This lends to a strong evidence base from which to move forward with recommendations.
The findings of this study highlight the complexity of how and when different types of social support are exchanged on the QuitNow community forum. These findings provide directions for how social support can be more strategically employed and leveraged in these online contexts to support smoking cessation. Both community forum end-users and service providers would benefit from understanding the nuanced support needs of those trying to quit smoking.
Social support framework.
This work was supported by funding from the British Columbia Ministry of Health, via a BC Lung Foundation Research Agreement (grant: #018471).
None declared.