Addictive Behaviors 32 (2007) 1769 – 1786

Evaluation of an Internet virtual world chat room

for adolescent smoking cessation
Susan I. Woodruff a,⁎, Terry L. Conway a , Christine C. Edwards a ,
Sean P. Elliott a , Jim Crittenden b
a
Graduate School of Public Health, San Diego State University, 9245 Sky Park Ct, Ste 120, San Diego,
CA 92123, United States
b
San Diego County Office of Education, Safe Schools Unit, 5404 Napa St., San Diego, CA 92110, United States

Abstract

The goal of this longitudinal study was to test an innovative approach to smoking cessation that might be
particularly attractive to adolescent smokers. The study was a participatory research effort between academic and
school partners. The intervention used an Internet-based, virtual reality world combined with motivational
interviewing conducted in real-time by a smoking cessation counselor. Participants were 136 adolescent smokers
recruited from high schools randomized to the intervention or a measurement-only control condition. Those who
participated in the program were significantly more likely than controls to report at the immediate post-intervention
assessment that they had abstained from smoking during the past week (p ≤ .01), smoked fewer days in the past
week (p ≤ .001), smoked fewer cigarettes in the past week (p ≤ .01), and considered themselves a former smoke
(p ≤ .05). Only the number of times quit was statistically significant at a one-year follow-up assessment (p ≤ .05).
The lack of longer-term results is discussed, as are methodological challenges in conducting a cluster-randomized
smoking cessation study.
© 2006 Elsevier Ltd. All rights reserved.

Keywords: Smoking cessation; Adolescents; Health behavior; Trial; Chat room; Internet

1. Introduction

Smoking among adolescents has significant public health importance. Onset of smoking occurs primarily
in adolescence, and because tobacco is highly addictive, regular use in adolescence develops into nicotine

⁎ Corresponding author. Tel.: +1 619 594 2787; fax: +1 619 594 3143.
E-mail address: swoodruff@projects.sdsu.edu (S.I. Woodruff).

0306-4603/$ - see front matter © 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.addbeh.2006.12.008
1770 S.I. Woodruff et al. / Addictive Behaviors 32 (2007) 1769–1786

dependency. Smoking among adolescents is likely to continue into the adult years, increasing the risk of
numerous long-term negative health consequences (USDHHS, 2000a). Yet, after three decades of efforts to
prevent smoking among children, rates of adolescent smoking remain unacceptably high. Adult smoking
rates have declined steadily over the last several decades; however, smoking rates among adolescents have
not shown a comparable pattern of steady decline (Johnston, O'Malley, & Bachman, 2003).
Smoking cessation clearly has major and immediate health benefits (USDHHS, 2000a,b). Even among
adolescent smokers, most report they would like to quit smoking (Lantz et al., 2000; Mermelstein, 2003;
Vuckovic, Polen, & Hollis, 2003). Although many adolescents attempt to quit, most relapse quickly
(Prokhorov, Hudmon, & Stancic, 2003), probably in part because they lack effective support and skills
(Vuckovic et al., 2003). Previous research has shown that adolescent smokers trying to quit experience
withdrawal symptoms that parallel those experienced by adults, suggesting addictive processes in
adolescent smoking in addition to well-documented social factors (O'Loughlin et al., 2003; Prokhorov
et al., 2003; Vuckovic et al., 2003). Also, as for many adults, adolescent smokers appear to benefit from
social support in the quitting process (Vuckovic et al., 2003). However, other findings indicate unique
aspects of adolescent smoking and cessation. Adolescents may be more influenced by (a) social–
psychological cues to smoke, (b) tobacco advertising, (c) self-perceptions and low self-efficacy related to
cessation, (d) perceptions of invulnerability to smoking's health effects, (e) perceived advantages of
smoking including those related to coping and stress reduction, and (f) lack of recognition of the benefits
of cessation (Pallonen et al., 1990; Turner, Mermelstein, & Flay, 2004; Vuckovic et al., 2003).
Most school-based tobacco use programs have been classroom-based prevention programs designed to
reduce the incidence of adolescent tobacco use. Whereas some have realized positive effects especially in
delaying the initiation of smoking, the results are somewhat limited and less likely to reach minority and
high-risk adolescents (Spruijt-Metz et al., 2004; Unger et al., 2000). Further, these programs have not
been successful in smoking reduction or cessation among adolescents who have already begun to smoke
(Backinger et al., 2003). A few studies have evaluated programs designed specifically for adolescent
smoking cessation, although findings have been mixed (Mermelstein, 2003; Rohde et al., 2001).
Cognitive-behaviorally oriented cessation interventions that have been effective with adults, when tried
with adolescents in clinics and classrooms, have not shown much promise (USDHHS, 2000a).
Furthermore, adolescents are difficult to recruit and retain in smoking cessation interventions
(Mermelstein, 2003; USDHHS, 2000a). The absence of effective intervention for young smokers is
cause for concern, as adolescent smokers will likely continue on to become adult smokers. Innovative
interventions are needed to engage teen smokers and to motivate interest in making quit attempts (DuRant
& Smith, 1999; Sussman et al., 1999). Many believe that advances in health among young people will
focus on use of interesting technologies, such as computer information and communication (Borzekowski
& Rickert, 2001; Fotheringham, Owies, Leslie, & Owen, 2000; McTavish et al., 1995; Rhodes, Fishbein,
& Reis, 1997; Stivers, Bentley, & Meccouri, 1995; Weinberg, Schmale, Uken, & Wessel, 1996).
Computer technology has been used for smoking cessation by creating tailored, cessation materials based
on individual data (Escoffery, McCormick, & Bateman, 2004; Strecher, 1999; Strecher, Shiffman, & West,
2005; Velicer & Prochaska, 1999; Walters, Wright, & Shegog, 2006), and by building powerful, compelling,
and flexible learning environments in which users interact with “smart” programs or are free to interact with
one another from remote sites (Burling, Seidner, & Gaither, 1994; Lenert et al., 2003; Pallonen et al., 1998;
Schneider, Walter, & O'Donnell, 1990; Scott & McIlvain, 2000; Takahashi, Satomura, Miyagishima, &
Nakahara, 1999). Computer-based smoking cessation support to date has primarily employed educational
websites, expert systems, games on CD-ROM, or electronic bulletin boards.
 S.I. Woodruff et al. / Addictive Behaviors 32 (2007) 1769–1786 1771

Although some of these programs are interactive in that they involve the user and can tailor support
based on the user's needs, they typically have not used real-time discussion. Real-time interactive
discussion (between smokers and professional change agents, and among smokers themselves) could
potentiate the effectiveness of computerized communication for smoking cessation. For example,
numerous studies have validated the assumptions that high school students look to their peers for
emotional and social support and believe that their peers are capable of providing help (Mattey, 2003;
Valente et al., 2003; Whiist, 2004). Other studies have well documented the positive effects of social
support on smoking cessation outcomes both for adults and adolescents (Chassin, Presson, & Sherman,
1985; Cohen & Lichtenstein, 1990; Fisher, Lichtenstein, Haire-Joshu, Morgan, & Rehberg, 1993; Gruder
et al., 1993; Lacey et al., 1993; Myers, 1999). The use of a trained smoking cessation counselor or
facilitator has also been shown to be associated with cessation and long-term abstinence (Fisher et al.,
1993; Lichtenstein & Glasgow, 1992; Viswesvaran & Schmidt, 1992) and may be more successful than
self-help programs alone specifically among adolescents and young adults (Charlton, Melia, & Moyer,
1990; Viswesvaran & Schmidt, 1992).
The rationale for this study derived from the fact that traditional school-based programs (e.g., clinic-
based, face-to-face, and classroom-based prevention programs) have had limited success in helping
adolescent smokers quit, and new strategies and technologies need to be explored. The present study
tested a web-based counseling program, Breathing Room, in which young smokers interacted with a
trained cessation counselor and other teen smokers in real-time in an Internet “virtual world.” The
effectiveness of the real-time Breathing Room Internet intervention for smoking cessation was evaluated
by comparing intervention participants with teens who participate in a measurement-only control group.

2. Methods

2.1. Design

The primary goal of this study was to test an innovative approach to smoking cessation that might be
particularly attractive to adolescent smokers. The intervention used an Internet-based, virtual reality world
combined with motivational interviewing conducted by a smoking cessation counselor. Participants were
adolescent smokers recruited from high schools in San Diego County. Participants in the intervention
condition were recruited to participate in seven 45-minute virtual world sessions over a 7-week period,
and complete 4 online surveys. Participants recruited into the measurement-only condition were asked
only to complete the 4 online surveys. Participants in both conditions were surveyed at baseline, post-
intervention, 3-months post-intervention, and 12-months post-intervention. Randomization to condition
was done by school to avoid contamination between intervention and control groups, to facilitate
recruitment and intervention implementation, and because the program, if broadly disseminated, would
likely be applied at the school level (Edwards, Braunholtz, Lilford, & Stevens, 1999).

2.2. Recruitment and program implementation

From October 2002 through April 2004, teenage smokers were recruited from 14 local high school
sites to participate in the Breathing Room study. Schools included traditional high schools, continuation
high schools, and schools from the Juvenile Court and Community School system. Seven schools
1772 S.I. Woodruff et al. / Addictive Behaviors 32 (2007) 1769–1786

participated in the control arm of the study, and seven in the intervention arm. Six of the 14 schools were
continuation/alternative high schools, and 8 were regular high schools.
Numerous strategies were employed at the school sites to recruit participants including classroom
presentations, lunch-hour sign-up tables, flyers, posters, school newspaper ads and articles, school-wide
announcements, and school liaison referrals.
At the suggestion of school personnel, the recruitment approach and materials were different for
intervention and control schools. At the control schools, Breathing Room was promoted as a research
project about teen smoking. Potential participants were asked to help researchers “learn more about teen
smoking” by completing 4 online surveys over a 15-month period, for which participants would receive
up to $50.00. Recruitment for participants at the intervention schools advertised a virtual reality Internet-
based program to help students quit smoking. Materials and presentations promoted spending about
45 min per week for 7 weeks online in a virtual reality world with other teenagers and a counselor to
explore quitting smoking. Similar to control group recruitment, intervention recruitment publicized
earning up to $50 for completing 4 online surveys over a 15-month period. Participants at the control
schools were recruited on an ongoing basis; participants at the intervention schools were recruited once
each semester to accommodate the 7-week online counseling schedule.
To participate in the study, a student must have smoked at least one cigarette within the past 30 days.
Eligible participants were given a Breathing Room project folder that contained a brief project description,
contact information, assent form, parent consent form, survey schedule, and an instruction sheet for
logging onto the Breathing Room website (to complete surveys only, or to participate in the virtual world
chat room and complete surveys). Parental consent forms described the study as a teen health project, and
did not reveal that participants necessarily were smokers. Per school liaison request, the parental consent
forms were individualized for control or intervention schools, describing specifically what would be
required by the adolescent. Completed consent and assent forms were collected by the school liaisons and
forwarded to research staff who would then set up a secure password protected account for the participant.
Intervention participants were also given instructions for logging onto and using the Breathing Room
virtual world. All procedures had full University Institutional Review Board approval.
A new Dell computer dedicated to the Breathing Room project was donated to each school, and housed
in a location where participants could take a survey or participate in the virtual world intervention without
interruption. Breathing Room surveys also could be completed at home or elsewhere with Internet access.
Each semester at the intervention schools the Breathing Room virtual world counseling was available
Monday through Thursday at four different times throughout the day for 7 weeks. Slots were available
before school, during lunch hour, and after school. All intervention participants were asked to sign up for
a specific time slot during the week for their virtual world intervention session with the counselor.
Although participants were strongly encouraged to choose a counseling time and adhere to it, they were
also told they could “drop in” on another session if they needed to make up a session.
School liaisons were an integral part of implementing the program on campus, encouraging completion of
counseling sessions and surveys, and maintaining the cohort. Liaisons were given an intervention session list
for participants, and asked to remind students to attend their assigned sessions. Participants who did not show
up for their initial intervention session were contacted by research staff by phone and reminded to attend the
next session. At the close of each week, liaisons were faxed an updated list indicating the number of sessions
participants had attended, number of sessions remaining, and when surveys were due.
Intervention and control participants were provided the same stipend amounts for completing each
survey. Stipends were tied to survey completion (not intervention sessions). Stipend amounts were $5.00
 S.I. Woodruff et al. / Addictive Behaviors 32 (2007) 1769–1786 1773

for the baseline survey, $10.00 for the immediate post-test, $15.00 for the 3-month follow-up, and $20.00
for the 12-month follow-up survey for a total of $50.00 if all surveys were completed. Upon signing up for
the study each participant was given the choice of receiving their stipends as a check or a gift card. Once
an online survey was completed, the participant was mailed the stipend, a thank you letter, and a reminder
of when the next survey was due.

2.3. Appearance and content of the Breathing Room virtual world

The Breathing Room website allowed secure entry into the online surveys (for control participants),
and to surveys and the virtual world chat room (for intervention participants). The Breathing Room virtual
world used powerful, proprietary interactive software known as ActiveWorlds that allows more
interesting features than the usual text-based chat rooms. ActiveWorlds is a virtual environment in which
participants can see each other as 3-dimensional figures (i.e., avatars) on their computer screens, move
around in the “world,” and have real-time discussions with each other. ActiveWorlds software
automatically provided approximately 20 avatars that differed in gender, race, and clothing. Avatars could
run, jump, fly, and dance at the click of a button, enabling a participant to express emotions. Although
easily changed with a click of a button, most participants chose the same avatar each session.
The Breathing Room virtual world was developed by the research staff and a graphics software engineer.
A sky mall was chosen as the setting because malls frequently serve as meeting places for teens. Within the
sky mall, there were various virtual storefronts that supported the content of the counseling. For example, a
pathology lab showing pictures of diseased organs and premature aging, provided a backdrop for discussing
the short- and long-term health effects of smoking (see Fig. 1). An art gallery facilitated discussion of the
effects of tobacco advertising, as well as appreciation of anti-tobacco art. Billboards throughout the virtual
world allowed the counselor to display topics of interest to be addressed (e.g., “Dealing with Cravings”) and

Fig. 1. Scene from pathology lab in the Breathing room virtual world.
1774 S.I. Woodruff et al. / Addictive Behaviors 32 (2007) 1769–1786

individualize messages to participants (e.g., “Guero's been quit for a month!”). A virtual pharmacy was used
to discuss biological responses to smoking and quitting, as well as pharmacological aids to quitting. A
storefront called “The Man,” pejoratively referring to the heads of the large tobacco corporations, contained
links to incriminating tobacco industry documents released as part of the Master Settlement Agreement. A
graveyard outside the sky mall displayed tombstones of celebrities and sports figures that have died from
smoking-related disease, and provided an opportunity to discuss health risks. A teen dance club and a fast
food restaurant provided settings to discuss social influences to smoke and relapse, and an amphitheater was
available for additional virtual meetings and discussions. The participants' chat content appeared real-time in
a box below the virtual world. An early version of the virtual world chat room was pilot tested with rural teen
smokers to collect their comments for refining the world and preliminary information about its effectiveness
(Woodruff, Edwards, Conway, & Elliott, 2001).
In the virtual world, up to four adolescent smokers interacted with each other as well as with the
counselor, capitalizing on the benefits of peer-to-peer interaction. All sessions were conducted by the
same counselor, an experienced smoking cessation advisor who had an undergraduate degree in
psychology. During the sessions, participants were required to stay with the group and participate in the
discussion. The counselor had the authority to “pull” participants back to the group, or to eject them
temporarily or permanently for inappropriate behavior.
Session 1 was an introductory session devoted to familiarizing participants with moving and chatting in
the virtual world, and reviewing the rules of conduct. The nature and content of the subsequent six counseling
sessions was somewhat fluid and partly driven by the participants, although the counselor worked from an
outline and attempted to cover key topics considered effective in motivating adolescents to quit smoking.
Social Learning Theory concepts (Bandura, 1986, 1997), behavioral principles and relapse prevention
concepts (Marlatt & Gordon, 1985), stage of change theory (Dino et al., 2004; Prochaska & Velicer, 1997),
and social support/group interaction (Lancaster, Stead, Silagy, & Sowden, 2000) provided guidance for the
content of these semi-structured sessions. Topics covered included motivation to quit (e.g., weighing the pros
and cons of smoking/quitting), self-efficacy for quitting, sharing experiences of quitting with each other,
identifying barriers to quitting and ideas for overcoming those barriers, setting sub-goals for quitting and
strategies for handling cravings, handling social situations and other temptations to relapse, developing a
plan for a quit attempt, peer influences and social support, cues to smoke (e.g., personal stress, tobacco
advertising), and tobacco industry tactics. Relevant practical and health issues such as smoking effects on
employability, sports performance, short-term health problems, long-term health problems (e.g., impotence,
fertility), and economics of smoking were addressed throughout the sessions.
The smoking cessation counselor used motivational interviewing techniques when chatting with
participants. Motivational interviewing is a technique and style of brief intervention derived from social
cognitive theory that is a “client-centered” non-confrontational approach to behavior change (Miller &
Rollnick, 1991; Rollnick & Miller, 1995). Motivational interviewing may be particularly effective with
adolescent smokers who might resist more “didactic” approaches to behavior change (Lawendowski,
1998; Myers, 1999). In line with this approach, the counselor explored ambivalence about behavior
change, and elicited personal goals and self-motivational statements from participants.

2.4. Participatory nature of the research study

The ultimate goal of health-related research is to improve the lives of people in the community studied.
However, in traditional research, the community (e.g., churches, neighborhoods, schools) is not actively
 S.I. Woodruff et al. / Addictive Behaviors 32 (2007) 1769–1786 1775

involved in designing or conducting the projects. In addition, community members, who frequently give
their time and energy for no compensation discover that they are left without information about the
outcome of the research or any findings that can benefit the community. Participatory research counters
these shortcomings by making the researchers and community groups partners from the early stages of the
research and throughout the process (Israel, Schulz, Parker, & Becker, 1998).
The Breathing Room study was funded by the California Tobacco-related Disease Research Program
(TRDRP) as a School and Academic Research Award (SARA). TRDRP SARAs are participatory research
studies that involve an academic/university partner and a school community partner. The primary school
partner (author J.C.) is a specialist with the San Diego County Office of Education, and additional school
partners at the district levels and schools levels were instrumental in developing and implementing the
Breathing Room study. School partners, or liaisons, played a direct role in the design and conduct of the
research study. For example, the liaisons recommended a web-based approach for evaluation surveys to
match the web-based intervention approach, determined the times and most of the logistics of the online
counseling sessions, suggested and often implemented recruitment strategies, suggested appropriate
incentives for schools and students participating in the control arm of the study, and brainstormed
approaches to disseminate research findings and garner funds for institutionalization of the Breathing
Room program. This involvement not only helped carry out the study, but also ensured that school
priorities were addressed and improved the relevance of the study to the school community.

2.5. Measures

The self-report online surveys consisted of items measuring demographic characteristics, smoking
status, smoking behavior, quitting history, and readiness to quit. Most measures were standard items used
elsewhere, particularly those from the National Youth Tobacco Survey/American Legacy Foundation, and
the California Youth Tobacco Survey.
Sociodemographic information included gender and age in years computed from birth date.
Participants reported their race/ethnic group as Hispanic, White/Non-Hispanic, African–American,
Asian/Pacific Islander, or Other.
Seven outcome variables were examined in the present study: (a) past-week abstinence (yes versus no);
(b) number of days smoked in the past 7 days ranging from 0 (0 days) to 7 (all 7 days); (c) number
cigarettes smoked per day during the past 7 days with response options of 0 (0 cigarettes), 1 (less than
1 cigarette per day), 2 (1 cigarette per day), 3 (2–5 cigarettes), 4 (6–10 cigarettes), 5 (11–15 cigarettes) 6
(16–20 cigarettes), 7 (21–25 cigarettes), 8 (26–30 cigarettes), 9 (31–35 cigarettes), 10 (36–40 cigarettes),
and 11 (more than 40 cigarettes per day); (d) number of lifetime quit attempts measured on a scale ranging
from 0 (none) to 5 (10 or more times); (e) latency to first cigarette of the day assessed on a scale ranging
from 1 (immediately after waking) to 6 (more than 2 h after waking); (f) readiness/intentions to quit
measured on an ordinal scale with the options of 1 (I don't intend to quit smoking in the next 6 months), 2
(I intend to quit smoking in the next 6 months), 3 (I intend to quit smoking in the next 30 days), and 4 (I
have already quit smoking); and (g) participant's self-described Current Smoking Category
(experimenter, occasional smoker, daily smoker, or former smoker).
For describing the smoking and quitting experience of the sample by condition, several additional
smoking/quitting history baseline variables were examined: (a) the age one started smoking regularly
measured on a scale ranging from 1 (11 years of age or younger) to 8 (18 years of age or older), (b) the last
time one smoked a cigarette ranged from 1 (Today) to 8 (5 or more years ago), (c) length of longest quit
1776 S.I. Woodruff et al. / Addictive Behaviors 32 (2007) 1769–1786

attempt ranging from 1 (less than 24 h) to 8 (1 year or more), and (d) the last time one tried to quit ranging
from 1 (1 to 7 days ago) to 7 (5 or more years ago).
Participation in sessions and satisfaction with the virtual world chat room was assessed for intervention
participants. The counselor recorded the number of sessions each participant completed. Intervention
participants were asked to complete 5 items assessing their satisfaction with the program at the end of the
post-test assessment. Ease of use of the virtual world chat room was rated on a scale ranging from 1 (very
difficult to use) to 5 (very easy to use). Similarly, liking of the chat room was rated on a 5-point scale
ranging from 1 (disliked it very much) to 5 (liked it very much). Usefulness of the chat room for “helping
you quit” smoking and for helping “other teen smokers quit” was measured on a 3-point scale ranging
from 1 (not at all useful) to 3 (very useful). A final item asked about whether the participant would
recommend the chat room program to other teen smokers (yes vs. no).

2.6. Statistical analysis

Because school was the unit of randomization rather than individuals, it was necessary to assess the
degree to which results could be affected by clustering within schools (Bland, 2004). To assess the
dependence in the data accounted for by school, design effects were computed based on baseline
variables' intraclass correlations and average cluster sizes. Intraclass correlations were generally small
(.10 or less), and the magnitude of the effect sizes was below 2, indicating that school-level clustering was
small (Hox, 2002; Muthen & Satorra, 1995). Therefore, analyses were conducted at the individual level
without a school-level cluster term.
Analyses were based on intention to treat. Differential rate of change in abstinence rates and other
measures of smoking/abstinence relied on analysis of repeated measures over time. We analyzed the
effects of Breathing Room using the generalized estimating equations approach (SAS version 6.12).
Modeling procedures in GEE (Liang & Zeger, 1986; Zeger & Liang, 1986) are superior to models based
on analysis of variance in that they do not require repeated measures to be equally spaced from one
another, and they retain cases with missing data on one or more variables. We first modeled differential
change from baseline to post-intervention to assess an immediate intervention effect. We then repeated the
GEE analysis using all 4 repeated assessments to assess the overall and long-term effect of the
intervention.

3. Results

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

3.1. Sample characteristics and equivalence of groups at baseline

Approximately 54% of the sample was male (n = 73) and 46% was female (n = 63). The average age of
the sample was 16, with a range of 14 to 19 years. The racial/ethnic composition was varied: 51% were
 S.I. Woodruff et al. / Addictive Behaviors 32 (2007) 1769–1786 1777

Hispanic, 28% were White non-Hispanic, 5% were African–American, 7% were Asian/Pacific Islander,
and 9% were of Other ethnic groups. Forty-one percent of participants were from continuation/alternative
high schools, while the remaining 59% were from regular high schools. On average, participants had been
smoking about two years, smoked 2–5 cigarettes a day, and smoked about 5 days a week. Three-fourths
had ever tried to quit. Additional characteristics of the overall sample are reported elsewhere (Woodruff,
Lee, & Conway, 2006).
Table 1 presents demographic and baseline smoking-related characteristics of the sample by condition.
The two conditions did not differ significantly in their gender, ethnic, and age characteristics, although a
significantly greater proportion of intervention subjects were alternative/continuation high school
students. The groups differed significantly on several baseline smoking variables. Compared to control
subjects, intervention participants had started smoking at a younger age, had smoked more cigarettes per
day during the previous week, and had smoked more days in the previous week. Group differences were
not statistically significant for self-described current smoking category, the last time one smoked a

Table 1
Comparison of intervention and control groups on demographic, smoking, and quitting variables
Variable % or mean category
Intervention Control χ2 or t
(n = 77) (n = 59)
Gender (%)
Male 51 58
Female 49 42 0.65
Ethnic group (%)
Hispanic 51 50
White non-Hispanic 27 28
African American 3 5
Asian/Pacific Islander 10 7
Other 9 11 0.94
Age in years (mean) 16.5 16.1 − 1.86
Alternative/continuation students (%) 50 17 16.46⁎⁎⁎
Age first started smoking regularly (mean category) 3.79 2.97 − 2.41⁎⁎
Self-described current smoking category (%)
Experimented 25 15
Occasional 34 30
Daily 32 45
Former 9 11 3.68
No. of cigarettes smoked per day in past week (mean category) 2.97 2.29 − 2.14⁎
No. of days smoked in past week (mean category) 4.63 3.47 − 2.40⁎⁎
Latency to first cigarette of the day (mean category) 4.44 4.78 1.05
Last time one smoked a cigarette (mean category) 2.00 2.22 1.37
No. of times ever quit (mean) 1.66 1.50 0.56
Longest time ever quit (mean category) 3.49 3.17 − 0.81
Last time one tried to quit (mean category) 4.06 4.78 1.70
Readiness/intentions to quit (mean category) 2.42 2.18 − 1.27
⁎p ≤ .05.
⁎⁎p ≤ .01.
⁎⁎⁎p ≤ .001.
1778 S.I. Woodruff et al. / Addictive Behaviors 32 (2007) 1769–1786

Fig. 2. Past-week abstinence rates by condition.

cigarette, or latency to first cigarette of the day. The groups did not differ significantly in their baseline
quitting history, including number of times quit, longest time ever quit, last time one tried to quit, and their
readiness/intentions to quit.

Table 2
Estimates from Generalized Estimating Equations (GEE) assessing main effects and condition-by-time interactions
GEE estimate
Condition Time Condition-
Outcome Main effect Main effect by-time
interaction
Past-week abstinence
Pre-post 2.292⁎⁎ 1.797⁎ − 1.401⁎⁎
4 time periods .516 −.111 −.106
No. cigarettes smoked per day/past week
Pre-post 1.675⁎⁎ 1.271⁎ −.989⁎⁎
4 time periods .577 .035 −.155
No. days smoked in past week
Pre-post 2.915⁎⁎ 1.763⁎⁎ − 1.753⁎⁎⁎
4 time periods .940 −.081 −.249
No. times ever quit
Pre-post .086 −.014 .084
4 time periods − .031 −.097 .170⁎
Latency to first cigarette
Pre-post − .555 −.020 .217
4 time periods − .290 .144 .065
Readiness/intentions to quit
Pre-post − .018 −.353 .255
4 time periods .389 .273⁎ −.063
Self-described former smoker
3 time periods 2.550⁎ 1.110⁎ −.720⁎
⁎p ≤ .05.
⁎⁎p ≤ .01.
 S.I. Woodruff et al. / Addictive Behaviors 32 (2007) 1769–1786 1779

Fig. 3. Amount smoked in the past week by condition.

3.2. Intervention effects

Fig. 2 presents past week abstinence rates by condition at the four assessments. Table 2 presents the GEE
estimates for the condition main effect, time main effect, and of particular interest, condition-by-time
interactions. Although intervention participants had lower past-week abstinence rates than controls at baseline,
at the post-assessment, they had significantly higher abstinence rates than controls (significant condition-by-
time interaction). The interaction term considering all 4 assessments was not significant (see Table 2). At the
final 12-month follow-up, the two conditions were nearly identical in their past-week abstinence rates.
A similar pattern was seen for the amount smoked per day in the past week (Fig. 3). Intervention
participants smoked more than controls at baseline, but by the post-intervention assessment, reported
smoking less than controls. This statistically significant condition-by-time interaction seen for the pre-to-
post change did not hold when considering all 4 repeated assessments (see Table 2).
Fig. 4 shows changes in the number of days smoked in the past week by condition. Intervention
participants showed greater change than controls at the intervention phase (i.e., pre-to-post intervention),
as indicated by a statistically significant interaction. However, the analysis using all 4 time periods was

Fig. 4. Days smoked in the past week by condition.

1780 S.I. Woodruff et al. / Addictive Behaviors 32 (2007) 1769–1786

Fig. 5. Number of times quit by condition.

not statistically significant. Fig. 5 presents changes in the number of times ever tried to quit by condition.
The number of times quit increased more steeply over the study period for intervention participants than
controls. Unlike other outcomes, the condition-by-time interaction for times quit was significant using all
4 assessments, and not for pre-post changes.
Latency to first cigarette of the day and readiness/intentions to quit did not change differentially by
condition either in the pre-post analysis or the analysis using all four assessments. However, there was a
significant time main effect for readiness/intentions to quit using all assessments, with both groups
improving over time.
Although adolescents had to have said they smoked in the past month to be eligible for the study, 9.6%
described their current smoking category on the baseline survey as “former” smoker (i.e., they quit
between volunteering to participate and going online to complete the baseline survey). Fig. 6 presents the
percent of baseline smokers (i.e., excluding baseline former smokers) who described themselves as
former smokers at the post-intervention and follow-up assessments. The GEE condition-by-time
interaction using all 3 assessments was statistically significant (Table 2), indicating differential group

Fig. 6. Percent of baseline smokers describing themselves as a former smoker.

 S.I. Woodruff et al. / Addictive Behaviors 32 (2007) 1769–1786 1781

change over time. Follow-up chi-square analysis showed that at the post-intervention assessment, a
significantly higher percent of intervention participants than controls described themselves as a former
smoker (χ2 (1) = 3.64, p = .05). However, differences at the 3- and 12-month assessments were not
statistically significant. The percent of intervention participants considering themselves former smokers
had declined by the 12-month assessment, while the percent of control participants describing themselves
as former smokers increased over time.

3.3. Attrition analysis

Cohort maintenance strategies included contacting the school liaison with a list of students due to
complete surveys, multiple telephone contact attempts to the participant to remind them of surveys,
mailed personalized reminder letters, and mailing surveys to the participant's home if he/she had moved
and had no computer available. Overall non-response or loss to follow-up was 25% for the post-
intervention survey, 21% for the 3-month follow-up survey, and 27% for the 12-month follow-up survey.
There was tendency for survey non-response to be higher among intervention participants than among
controls. For example, at the post-intervention assessment, 15% of controls did not respond compared to
33% of intervention participants. However, those who responded did not differ greatly from those who
dropped out in terms of their demographic characteristics, baseline smoking history, or baseline quitting
history. Furthermore, the characteristics of those who dropped out or remained did not differ by condition.

3.4. Participation in and satisfaction with the Breathing Room program

The 77 intervention participants averaged about 3 online sessions. About 19% (n = 15) never logged on
to any session, and 9% (n = 7) received all 7 sessions. Sixty-eight percent (n = 52) of intervention
participants completed the 5 items assessing their satisfaction with the program immediately after the
post-test assessment. Participants rated the ease of use of the chat room a 4.2 (SD = .89) on a 5-point scale.
Similarly, liking of the program averaged 4.0 (SD = .98) on a 5-point scale. Usefulness of the virtual world
chat room for both “helping you quit” smoking and for helping “other teen smokers quit” was 2.2 on a 3-
point scale (SDs = .69 and .67). A large percent of participants (89%) reported they would recommend the
program to another smoker.

4. Discussion

Expert smoking cessation guidance via the Internet holds promise because of its accessibility, visual
appeal, use of multiple media, potential anonymity, interactivity, and nonreliance on school classroom
time or resources (Parlove, Cowdery, & Hoerauf, 2004; Woodruff et al., 2001). Results of this innovative
study suggest that the Internet virtual world real-time counseling intervention was effective in helping
adolescent smokers stay off cigarettes or reduce their consumption, at least in the short-term. Those who
participated in the program were more likely than controls to report at the post-intervention assessment
that they abstained from smoking during the past week, smoked fewer days in the past week, smoked
fewer cigarettes in the past week, and considered themselves a former smoker. This pattern of findings is
notable, given the intervention group's worse smoking profile at baseline. The positive results of the
intervention, however, were generally not maintained at the follow-up assessments, a fairly consistent
1782 S.I. Woodruff et al. / Addictive Behaviors 32 (2007) 1769–1786

finding that has been documented by other researchers (Walters et al., 2006). These results suggest that
continued support, perhaps in the form of online booster sessions, is needed to reinforce what the smoker
has learned and to help deal with relapse. Booster sessions are an integral part of most adult smoking
cessation programs, and are an important component for effective tobacco use prevention programs for
youth (Pentz, 1999). Some of our own research (author S.I.W.) shows that boosters or further application
of the program have been effective in helping to maintain prevention intervention effects (Eckhardt,
Woodruff, & Elder, 1997; Elder et al., 1993). Less is known about the importance of boosters on
maintaining cessation among adolescents, although it makes sense that additional contact and activity
with participants may help to maintain abstinence or spur a quit attempt if the participant has relapsed.
Of the seven outcomes examined, only the number of times quit was statistically significant long-term
(i.e., one year post intervention). It may be that the intervention, while not resulting in protracted
abstinence or reduction in smoking, may have helped adolescent smokers continue to make quit attempts
long after the program ended. Multiple quit attempts are associated with eventual cessation success
among adult smokers, and therefore, this finding may be a positive outcome. However, experience with
quitting may not be a particularly strong predictor of eventual cessation among adolescents (Sargent,
Mott, & Stevens, 1998). The association of multiple quit attempts with cessation among young smokers is
an area needing further research.
In the present study, control participants generally improved over time, probably due to the type of
smokers that comprised the control group. Compared to intervention subjects, control participants were
lighter and less frequent smokers at baseline, an unintended difference that was likely the result of the
different recruitment methods used for the two conditions. This type of recruitment bias is common in
trials in which clusters rather than individuals are randomly assigned to treatment groups. Different types
of participants are selected into the various arms of the trial, resulting in nonequivalent groups (Torgerson,
2000). One solution is to ask for informed consent to participate in a study (rather than participation in
specific intervention or evaluation activities) and to collect baseline measures prior to notice of
randomization. However, logistical and practical considerations and suggestions of the schools led us to
inform participants of the specific intervention or evaluation activities that would be asked of them prior
to the baseline assessment. The result was that regular, “hard core” smokers were more likely to volunteer
for the intervention, and occasional, less frequent smokers were more likely to participate in the control
arm. In a related vein, a higher percent of intervention participants than controls were from alternative/
continuation high schools. These types of students are likely to have different characteristics (beyond
smoking behavior) than regular high school students (Sussman, Dent, Severson, Burton, & Flay, 1998),
that may have impacted the long-term effects of the intervention. The control group's exposure to other
tobacco programs, or reaction to simply being measured may have also contributed to their improvement
over time.
It may be that the Internet virtual world chat room may have been more effective as an adjunct to a
traditional face-to-face counseling program. The question of whether Internet technology can be used
successfully as an alternative stand-alone intervention medium is still difficult to judge (Christensen &
Griffiths, 2003).
The level of participation in the intervention was somewhat disappointing, given the advantages of the
Internet approach, and the participants' generally positive ratings of its appeal and usefulness. We believe
that there may have been barriers (e.g., counseling times) that prevented more complete participation.
Perhaps allowing participation during school hours (rather than before and after school), or allowing class
credit for participation would have improved involvement.
 S.I. Woodruff et al. / Addictive Behaviors 32 (2007) 1769–1786 1783

There were several positive aspects of the study, including the multiethnic group of smokers, the
participatory relationship with school partners, the satisfaction of the participants with the approach, and
the inclusion of all data points in the analyses. Although the attrition rate differed by condition, the
characteristics of those who dropped out did not differ greatly by condition. However, there are limitations
of the study, including the differential recruitment strategies that resulted in nonequivalent groups at
baseline. In addition, there was no objective validation of smoking/quitting, although collection of this
type of information was not feasible or desirable in the context of an Internet-based study. Despite the
limitations, this study suggests that real-time Internet communication may be an appealing and effective
approach to help young smokers quit or reduce smoking in the short term, but that additional support is
probably needed for longer-term success. One area of interest to us is the relative impact of the virtual
world chat room technology compared to a more traditional chat room. In addition, we are interested in
how interactive chat room approaches compare to lower-cost, education-oriented smoking cessation
websites for teen smokers.

Acknowledgements

This research was funded by California's Tobacco-related Disease Research Program (TRDRP), grant
number 11HT-3301.
The authors wish to acknowledge the invaluable contribution of Dr. Lynn Covarrubias, Summer
Lambert, Chellie Stoffel, Elizabeth “Liz” Garcia, Dr. Sharon Snyder, and Dr. Phil Gardiner.

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