Challenging Dogma - Spring 2009

Tuesday, May 5, 2009 Tries Too Hard And Not At All - Jasmine Lopez

Approximately 10,000 smokers and second hand victims die annually in the state of Massachusetts, and billions of dollars are exhausted on smoking-related health care needs (1). The Make Smoking History Campaign and the Massachusetts Department of Health acknowledge these health and economic impacts of cigarette smoking in the state. “Quitting smoking is hard, but you can do it. You can win the Fight 4 Your Life (2).” The website makes these claims throughout its pages, but this cyber intervention is likely being passed by many smokers because of its flaws.

The site is like a large warehouse of tips, video clips, statistics, questions and more. A potential quitter must find his way through the halls, rooms, stairways and levels of the warehouse with only an idea of what his final destination might look like. This is not an intervention for everyone.

In this critique I will focus on the Quit Wizard which is a part of the campaign (3). It is an internet based support intended to guide smokers who would like to quit become nonsmokers. Its content and method of behavior change provide little guidance, discipline or encouragement to smokers who are thinking about quitting. This intervention is based on the Transtheoretical Model of Behavior Change (TTM), which is a model of behavior change in which individuals seeking to complete a change will progress or digress through five stages. That movement depends upon the process of change which includes catalysts to motivate individuals to progress (4).

The Quit Wizard is flawed in its assumption that individuals who start the program will have high levels of self efficiency to get them through the six stages. In addition, it does not clearly assign which stage an individual begins the intervention or when movement is appropriate; forward or backwards. Finally, Quit Works presents weak and contradictory messages; “Make Smoking History” and “Try to Stop.”

Too Little Motivation

Individuals procrastinate. They set goals and struggle to follow through. It is an issue of self control (5). Ariely demonstrates the need for some authority in meeting deadlines. He conducted an experiment in his classes to explore the effect of deadlines on goal attainment. One class set their own deadlines throughout a semester. A second class had some guidelines in setting deadlines, and the third class had to follow the deadlines set by the professor. Ariely concluded that the class with the most flexibility had the lowest scores and the class that had no flexibility had the highest scores. Ariely also included penalties for late work and found that factor to have some effect on the outcome as well.

Ariely presents evidence that individuals need motivation in order to complete tasks; even if it is in the form of penalties. Quit Works does not motivate smokers to choose an attainable quit date or deadline. Smokers set their own date and Quit Wizard records it on a calendar. This date can be the next day or the following year. Upon return to the site, smokers may change their quit date to be sooner or later, and it has been determined that smokers will change their minds about quitting often (6). The site does not impose a firm deadline on smokers; they may adjust the quit date everyday if they so choose.

The tone of the text and tips to keep smokers on the path to quitting are not authoritative or encouraging. In fact, smokers may click through pages and messages without reading any of the content. Quit Works relies on the self efficacy of smokers to get through the intervention. This intervention assumes that site users have high level of self efficacy and therefore sufficient motivation to carry out all of the prompts and suggestions. This will not be the case, however, as the Transtheoretic Model recognizes that individuals need tailored interventions. In order to quit smoking with this intervention, individuals must expect that they can complete each task presented and attain the expected outcome (7). Quit Works presents tasks at every level, but does not offer incentives to motivate smokers to complete the tasks.

The absence of instant gratification and an unstable belief in one’s ability to complete a goal set individuals up for a long experience within the stages; possibly a to complete standstill that is never approached again. There is no element of reward or punishment in the intervention (8). The Transtheoretic Model allows individuals to move between stages in a forward or backward direction for as long as it takes the individual to complete the intervention (8, 9). Quit Works fails to keep motivation and self efficacy elevated.

Too Much To Navigate

Another flaw of this intervention is that site users are presented with too much information. Using education as a tool to create change is ineffective by itself. Providing an excess amount of information does not change that. This website has dozens of tabs and hyperlinks. There is so much information available on this website that it is easy for potential quitters to become overwhelmed. So overwhelmed that they might reach for a cigarette before they find their way to the Quit Wizard; where they will encounter many more tabs and links! There are tabs along the vertical and horizontal edges of each page.

Quit Wizard follows the Transtheoretic Model of Behavior Change which is based on movement through five stages: precontemplation, contemplation, preparation, action and maintenance (9, 10). Quit Works’ corresponding stages are: Taking a Look, Getting Ready, Counting Down, Early Days, Making Progress, Becoming a Nonsmoker. There is no guidance through the site or the stages. In addition, the intervention lacks the processes of change that sift smokers to appropriate base stage and then on toward the final stage or back to a previous stage (11).

The Transtheoretic Model is a strong model of behavior change because of its ability to mold to the individual. In other words, individuals may begin an intervention at any stage and fluctuate through the stages until the behavior change occurs. However, Quit Works does not personalize the starting point. Moreover, it does not adapt the individual’s movement through the stages. The site tracks the sections that are completed by the individual, but does not change content to reflect the individual’s return to that stage. It is easy for site users to skip through the sections and become lost.

Too Passive

The campaign title alone demonstrates how passive the Quit Wizard and other site content are. The message is to “Try” to Stop. This implies that it is acceptable for smokers to visit the site, read the intro to the Quit Wizard and move on; another failed attempt at breaking the habit. The message does not invite smokers to consider their optimal level of self efficacy, nor does it attract smokers to be a part of the intervention. Without such a pull, smokers will miss out on the quit attempt. Quit Wizard recognized that some individuals may respond better to personal assistance so it presents information about a phone line. Again, this information is barely suggested. It is up to the individual to recognize the need and take action.

The intervention is uninvolved in the quitting process. It is dry and unpleasant. The sections have checklists and tips that are easily forgettable. There is an “emergency” button should the individual crave or smoke a cigarette during the intervention. The Quit Wizard makes some suggestions for both the emergency craving and smoking scenarios. Such as drink a glass of water, tell yourself “No smoking!,” and repeat the phrase: “Just don’t smoke.” However, should the individual find himself in that emergency again, he will receive the same advice from Quit Wizard. This would be an appropriate situation for a reward or consequence, however, the Quit Wizard does not include these in the intervention.

Quit Wizard Summary

Quit Wizard is a flawed intervention based on the Transtheoretic Model and aimed at helping smokers become nonsmokers. It is hidden in a website overflowing with information. Smokers who open the webpage at all must then click their way through the site to make it to Quit Wizard. They are then linked into a six stage, impersonal, multi-part program. It has repetitive sections and long check lists. This adds to the lack of motivation, as progress through the stages could serve as a type of gratification or reward and improve self efficacy. Quit Wizard does not incorporate rewards or consequences to help smokers move through the stages. This program is ineffective in helping smokers who need an extra push or regular guidance to meet their goals. The flexible calendar and dull suggestions will not accomplish that. Quit Wizard tries to help smokers but falls short in these areas. Moreover, it is based on the Transtheoretic Model of Behavior which has been criticized in studies for being weak in defining its stages and lacking incentives. Quit Wizard may help many “Try to Stop” but it will not “Make Smoking History” in Massachusetts.

Counter Proposal to Quit Wizard

The Quit Wizard on has three flaws that my intervention does not. First, it assumes that individuals have a high level of self efficacy. Second, it does not individualize the baseline stage or determine when stage movement is necessary. Third, it presents weak and contradictory messages. I propose the implementation of a different kind of Quit Wizard. This cyber intervention, Butt In, would provide the motivation, guidance and encouragement throughout the quitting process that is missing. It would be accessed as an application through social networking sites Facebook and Myspace. Butt In incorporates elements from some social behavior models discussed in SB 721: Transtheoretical Model of Behavior Change, Framing Theory, Marketing Theory, Self Control, and Social Network Theory.

Butt In to Back Up Low Self-Efficacy

Butt In pulls elements from both individual and group focused interventions to create a program that is effective whether the smoker quits alone or with other smokers. Quit Works assumed that all participants have a high level of self-efficacy. Butt In utilizes a combination of group-focused and individual-focused social behavior theories to account for the fact that some participants will not have strong levels of self-efficacy. Incorporation of the group-focused Social Network Theory is the main method used to account for participants’ low self-efficacy.

Research shows that individuals behave differently when they are in groups, and that closely related groups of people (relatives, coworkers, friends) often quit smoking together(12). In fact, Christakis and Fowler studied networks of 12,067 individuals from the Framingham cohort and found that smoking cessation by a sibling decreased a person’s chances of smoking by 25%; by a friend, 36%; and by a coworker, 34%. Furthermore, they determined that decisions to quit smoking “reflect choices made by groups of people connected to each other both directly and indirectly at up to three degrees of separation. People appeared to act under collective pressures within niches in the network” (12). These findings are in line with the premise of the Social Network Theory(13).

With more and more communication and interaction between these groups via social websites as opposed to in person(14), Facebook and Myspace are the most appropriate places to implement Butt In. Moreover, these media are available 24/7 to smokers with internet or mobile phone access. So smokers can rely upon Butt In throughout their entire quitting experience. This is a motivational aspect of the intervention that lacked.

The individual-based theory of Self Control essentially claims that people procrastinate. Individuals do not often do what they set out to do. This is indicative of the spontaneous changes in behavior that individuals constantly make(8). The calendar, reminder emails, regular updates, and progress widget components will keep individuals on track.

Butt In will include another motivational component: ownership. In order to change behavior, we must offer some significant, tangible exchange or reward(5, 16). Participants who progress through the stages of Butt In will be rewarded with access to new social networks, popular widgets (15), and encouraging praise from individuals within their network. The use of widgets to calculate dollar savings attributed to quitting smoking is a way to provide some tangible benefit to the behavior change.

Butt Out of One Stage and Into the Next

The Transtheoretical Model of Behavior Change is typically used in smoking cessation interventions because its framework allows individuals to personalize their quitting experience(17); the same reason it is employed as the basic theory for Butt In. The aim of Butt In, however, is to guide participants to their endpoint with as few relapses as possible. It will individualize each participant’s baseline stage according a pre-start assessment and attempt to recognize the processes of change that transfer participants from one stage to another(4). Some of these processes are dramatic relief, social liberation, self reevaluation, and reinforcement management.

At the start of Butt In, a participant a completes and submits a short assessment that is reviewed by a professional who determines that person’s base stage. This occurs live via an online chat with the professional. Like the Quit Wizard, the participant will then be prompted to log goals and smoking habits on his/her profile. The difference here is that the baseline stage will actually be individualized and the participant will have guidance towards the action and maintenance stages of TTM.

The processes of change are the pathways through the TTM stages, yet some are difficult to recognize. Ideally, the accessibility of Butt In and the culture of its medium will allow for better recognition of the participants’ progress. Myspace and Facebook are about sharing up to the date news about personal accomplishments, challenges and activities. The intervention will call for brief, routine status updates on the participants’ quitting successes and drawbacks. Theses updates, like the initial assessment, will be evaluated by professionals, and summary details will be posted on the participants’ profiles so that their peers may add encouraging comments and advice.

Butt In Now

While Quit Works is tied to a passive message “try to stop,” Butt In sends a stronger message through framing and marketing strategies. It is framed in a positive and assertive tone that invites smokers to at least explore the intervention and share their quitting experience. It has an attractive and fun feel that appeals to the compelling values of youth and freedom. The use of virtual networking sites is a way of branding the intervention as a popular thing to do with friends, family and coworkers. The message is to quit and help your network become smoke-free too. An individual may be invited to join Butt In and then invite dozens of his/her online friends to join too. This adds to the individualized feel while promoting a social strategy.


We will not see a flawless intervention for smoking cessation; each approach will affect a specific audience and have its set backs. Butt In is an intervention for smokers who utilize social networking sites, and it is focused on motivation, guidance, and encouragement. These are three areas in which Quit Works needs improvement. Quit Works tries too hard to provide a large amount of information to smokers following an individual-based theory of behavior change. However, the information is not individualized and smokers get lost in the text. Butt In has live, personalized information from health professionals, electronic mechanisms to track appropriate movement through TTM stages, and instant connection with peers who can view progress made by the participants and add support. This counter-proposal takes one strong model of behavior change (TTM), and partners it with the Social Network Theory, another model that has been studied and deemed a strong base for smoking cessation interventions. Butt In is also supported by the benefits of Framing and Marketing Theory, and Ownership. These are implemented to keep smokers on the track to smoking cessation. For those who nonetheless relapse, the TTM foundation allows them to review their progress and get back on track at an appropriate stage.


1. Massachusetts Department of Public Health. Annual Report of the Massachusetts Tobacco Control Program Fiscal Year 2007. MA: Massachusetts Tobacco Control Program, 2007.

2. Massachusetts Department of Public Health. Make Smoking History. MA: Massachusetts Tobacco Control Program.

3. Massachusetts Department of Public Health. Quit Wizard. MA: Massachusetts Tobacco Control Program.

4. Cancer Prevention Research Center. Summary Overview of the Transtheoretical Model. Kingstown, RI: University of Rhode Island.

5. Ariely, Dan. The Problem of Procrastination and Self-Control: Why We Can’t Make Ourselves Do What We Want to Do (pp. 109-126). In: Ariely, Dan. Predictably Irrational. New York, NY: 2008.

6. Werner, J., Lovering, A., & Herzog, T. (2004, February). Measuring time frames for intentions to quit smoking. Paper presented at the Annual Meeting of the Society for Research on Nicotine and Tobacco, Phoenix, AZ.

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8. Society for the Study of Addiction. Time for a change: putting the Transtheoretical (Stages of Change) Model to Rest. London: University College London Department of Epidemiology, 2005.

9. Kim, Joseph. Smoking Behavior and the transtheoretical Model of the Stages of Change. BioPsychoSocial Health. Jan 25, 2009.

10. Baum, Andrew. Transtheoretical Model of Behavior Change (pp. 181). In: Baum, Andrew. Cambridge Handbook of Psychology, Health and Medicine. Cambridge, MA: Cambridge University Press, 1997.

11. Aveyard, Paul et al. The effect of Transtheoretical Model based interventions on smoking cessation Social Science & Medicine. 2009; 68(3): 397-403.

12. Christakis, Nicholas A.,, Fowler, James H. The Collective Dynamics of Smoking in a Large Social Network. New England Journal of Medicine. Volume 358:2249-2258. May 22, 2008. Number 21.

13. Northeastern University. Current Research in Social Network Theory. Boston, MA: Northeastern University College of Computer Science.

14. CNN Technology. All in the Facebook family: older generations join social networks. CNN, 2009.

15. Tech Terms. Computer Dictionary. 2006.

16. Health Education Through Extension Program. Monitor Your Progress and Reward Success. KY: University of Kentucky.

17. Bridle, C. et al. Systematic review of the effectiveness of health behavior interventions based on the Tran theoretical model. Psychology and Health. 2005; 20(3): 283-301.

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