Philippe Boucher's Rendez-vous with . . .Chris Cartter

Rendez-vous with . . .Chris Cartter

President & Chief Operating Officer of, Inc.
Boston, Massachusetts, USA

By Philippe Boucher

Rendez-vous 113
Saturday, October 27 2001

PB : Thank you Chris for accepting our rendez-vous.
May I ask you to introduce yourself ?

Chris Cartter: I supervised the original implementation of QuitNet when it was a project of Join Together at Boston University and have been leading the business and program development effort since July 2000. From 1993 to 2000, I was the director of the team that built and made Join Together's websites (see JTO at and associated services the widely recognized leader in using the Web for community work. JTO won the Global Information Infrastructure Award in 1999. Previously, I co-founded Grassroots International in 1983, an international aid agency, and served as its Associate Director until 1990. During that time, I led numerous media tours into war and famine areas in several Third World countries and established electronic news services in Ethiopia, the Philippines and Haiti. I hold a BA from Bowdoin College.

Q1. Can you tell us about quitnet's history from its creation in 1995 by 3 co-founders within a Join Together project to the transition into a for-profit venture in May 2001?

CC: Nate Cobb, MD developed the idea for QuitNet in 1995 when he was a smoking cessation counselor in a neighborhood clinic in Boston. (Nate is now at the Beth Israel Deaconess Medical Center in Boston.) Smokers were not getting the help they needed to succeed because they found it inconvenient and uncomfortable to participate in group sessions on a fixed schedule. Cobb, who had worked as a programmer doing computerized health risk assessments, developed a prototype website which broke new ground as a tool capable of providing real-time support to smokers worldwide. Seeing an opportunity for advancing the field of smoking cessation and reaching a global audience with a low cost support tool, Join Together, a national substance abuse resource center based at Boston University School of Public Health, hired Cobb and adopted QuitNet in late 1995 when it launched on the Web. Partial funding to develop QuitNet came from Boston University (BU) and from grants to BU by The Robert Wood Johnson Foundation and the National Cancer Institute.

QuitNet has been frequently updated and the current and upcoming upgrade are implementations of the Surgeon General's guidelines for effective cessation. The site has been visited nearly 5 million times and has become a widely known support site. Thousands of links from websites and search engines were cultivated, but growth has largely been fueled by the QuitNet user community itself. QuitNet gives smokers an opportunity to work through their addiction with the help of tailored resources, peer support, expert advice and pharmaceutical product support - in a non-judgemental environment and in total privacy if they so choose.

By mid-1999, we needed to consider the best way to meet the growing demand for QuitNet because there was no source of continuing support for a large scale service program. In consultation with the Boston University Community Technology Fund,, Inc. was founded in January 2000. We believed that the partnerships an independent company was capable of forming were crucial if we were to succeed in building a self-sustaining service. Our commitment has been and continues to be to provide a free service. We do plan to add additional services, like professional counseling, which will be fee based.

In May 2001, BU transferred the QuitNet program and assets to, Inc., which is owned by the University, QuitNet employees and a small number of socially motivated individual investors.

Q2. I read that two reasons for the change of status (from non-profit to commercial) were an attempt to make QuitNet self-supporting and expand its offerings. I have not seen that much advertising on the site and so far New Jersey appears to be the only state that went for a customized QuitNet. Do you still think a commercial approach is viable? Why was the non-profit status limiting? You still operate "in association" with Boston University, what does this "association" mean?

CC: We believe that developing a national infrastructure of quit smoking services that is effective, accessible and affordable to anyone who wants to quit should be a top public health priority. To achieve that goal, a variety of service models will need to be deployed so that everyone's needs can be met. And, creative payment mechanisms will need to be negotiated that involve state and county health departments, health plans, employers and individuals themselves. We think that QuitNet is already an important element of such an infrastructure, and as such, will be commercially viable. In addition to the partnership we already have with the New Jersey Department of Health & Senior Services (New Jersey QuitNet), we have an agreement with the Colorado Department of Public Health & Environment to provide tobacco cessation services to Colorado residents via the Web. Colorado QuitNet will launch in November and will operate in association with Colorado's Quitline service (run by ACS). Additional state, county and national service agreements are under discussion.

As part of these agreements, our partners commit to promoting their customized site locally, often in conjunction with ads they are running to promote their "Quitline," thereby amplifying the impact of their ad dollars. QuitNet provides partners with detailed reporting on site usage and registered user demographics and activity. And, we implement six and twelve month follow-up surveys and manage the data collection and reporting. You mention advertising. On the main QuitNet site, we do accept advertising for FDA approved cessation pharmaceuticals and other non-cessation products and services. These revenues help support our free service, but are not sufficient to finance the entire program. Most of the websites that depend on advertising are broke or in deep trouble. QuitNet already implements key elements of the PHS Guidelines: social support, expert counseling, support for the effective use of pharmaceutical products and tailored information. And, it is about to get even better. We are developing new services and expect to launch a major upgrade of QuitNet later this year. As I mentioned earlier, some of these services will only be available to subscribers or to users who are paid for by a sponsor (our NJ and CO QuitNet users for example).

We are pleased to continue the association with Boston University School of Public Health. BU has been very generous as a supporter of QuitNet. The University was an early investor in the company, provides infrastructure support and offers policy guidance through their representative on QuitNet's board.

Q3. The monthly number of visitors to the site would be around 65000 (in May 2001) with about 4500 registering as members who come on average 13 times during the first 3 months. Are those figures still accurate? How do you explain the big difference between the visitors and the subscribers?

CC: You're right, we do get about 4,500 new registrants each month, but the number of registered users in the site in any particular month is much greater because of returning users.

Let me try to paint a picture of how this works because it is very different than a traditional cessation program. One of QuitNet's chief advantages is its ability to provide assistance to users at any stage, at any time of the day or night and from any net-accessible location in the world. Depending on the time of year, QuitNet has served between 50,000 and 75,000 unique individuals per month. Promotional programs that are already in place will increase this number sharply in 2002. Many QuitNet visitors come back multiple times, so the total number of visits has been around 150,000 to 220,000 per month. Our visitors read a lot of content - between two and three million pages per month - and post many support messages - about 2,000 per day.

(In describing web activity, many people use the term "hit" interchangeably with visits and sometimes with visitors. Technically though, a "hit" is recorded any time a page element like a graphic is transferred to a browser. QuitNet records about 8 million hits/month, but for general purposes this is a meaningless measure.)

In any given month, the site is a complex milieu of new visitors who are browsing the site's resources and reading support messages, newly registered users who use the personalized services and post messages in the forums and old timers who are either in maintenance mode or returning months after their quits to help the "newbies." So, while there are typically over 4,000 new registrants per month, there are in fact tens of thousands of registered users in the site.

Q4. On line cessation services are certainly useful and QuitNet is very active and dynamic but the number of users remain low compared to the number of smokers and potential quitters. The demographics of the users also appear quite selective: 92% white, 67% with some college education. Do you think the numbers could be expanded to reach out other segments of the population or should other services be created to target other groups?

CC: When you rely on word of mouth to spread the word, as we have done until recently, you will tend to see the same kind of people. Sustained promotion to additional target audiences will bring them online. The New York Times reported today that more than 60% of all US households own a computer and are online. The number gets even bigger when you include those that access the Internet from work. (QuitNet has many users who access it from the workplace.)

That's not everybody, but it marks a huge sea change in the way Americans access health information and should prompt new thinking about how to build a national infrastructure to help smokers quit. At the moment, net access is skewed towards higher income brackets (72% of those making $50k-$75k are online). But, there is movement at the lower end, with 38% of those earning under $30k online at the end of 2000 - an increase of 10% in six months. (The Pew Internet & American Life Project is a great resource for this information.)

With New Jersey QuitNet, we launched the first Spanish language versions of some of our services. With 47% of the U.S. Hispanic population online, we think this is an important direction.

We believe that QuitNet employed in combination with traditional Quitlines and face-to-face programs makes good sense in terms of a comprehensive cessation strategy. Our experience to date in New Jersey confirms this - the Quitline clearly services lower income groups and there is very little overlap between Quitline and QuitNet users. This last point is important: most people who choose QuitNet would never call a Quitline or walk into a clinic. QuitNet significantly expands the market for smoking cessation services making a state's advertising program much more cost effective if both services are advertised simultaneously. Our early experience indicates that visits to QuitNet can be expected to outnumber calls to a phone service by large multiples.

Q5. Have you been contacted by groups outside the US to develop similar services in other countries? What are your relations with the Quitlines organizations that recently met in Barcelona? Aren't the phone based Quitlines and the internet based services, two intrinsically joined facets of the same cessation coin?

CC: Yes, we have gotten inquiries from other countries, especially where we have concentrated user activity. We think that QuitNet may already be the largest smoking cessation program in the world. People from over 160 countries have registered. About 15% of daily use is from outside the U.S. There is not a minute of the day or night when the site is empty. If you check out the forums at 3am you'll find people from South Africa, the Philippines and Germany. Right now however, we are very focused on building a strong program in the U.S.

Two years ago I had the pleasure of presenting at the Quitline meeting in London. There was growing interest in the Web's potential, even though Internet penetration in Europe and elsewhere lags behind the U.S.. Both Quitlines and QuitNet are effective methods, but they differ in many ways. We look forward to delineating and quantifying some of these differences through some research opportunities that are coming up.

Q6. Is there anything else you would like to add?

CC: Just a word about research. Last year when QuitNet was asked to host a live chat session with Michael Fiore, MD around the release of the PHS Guidelines, we had the opportunity to ask whether his committee, which had reviewed thousands of documents in preparing the Guidelines, had reviewed any research concerning a Web-based intervention. The answer was no -- because there wasn't any. We aim to change that. We conducted our own survey of 25,000 QuitNet users in March 2000. A logistic regression showed that intensity of logins, participation in the support community and the length of time someone uses the service to be significant predictors of not smoking.

A study of the QuitNet implementation in New Jersey has recently been funded and we are in discussions with other groups about additional studies. There is a great opportunity here and a significant challenge. On the one hand, we have a tremendous ability to gather data of all kinds, rapidly implement web and email follow-up surveys and provide real-time analysis tools. On the other hand, the Internet is new terrain which will demand new research approaches. It is an exciting time.

PB: Thank you Chris for taking the time to be with us today.

Rendez-vous is supported by a contract from the Robert Wood Johnson Foundation
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