Objective To conduct analyses to determine the extent to which YouTube videos posted specific to smoking cessation were actually about quitting smoking and if so, whether or not they portrayed evidence-based practices (EBPs).
Methods In August 2008, researchers identified YouTube videos by search strategies, ‘relevance’ and ‘view count’ using the following three search terms: ‘stop smoking’, ‘quit smoking’ and ‘smoking cessation (n=296 for full sample and n=191 for unique videos).
Results Overall, almost 60% of videos contained a message about quitting smoking. Differences were found across search terms for videos about quitting smoking, with 'stop smoking’ yielding the highest percentage (80.8%) of videos about quitting smoking. Almost half of the videos (48.9%) contained EBPs for cessation strategies; however, a significant portion contained either non--EBPs (28.4%) or both EBPs and non-EBPs (22.7%). The number of views per an individual video across the six categories ranged from a low of 8 in the ‘relevance’ strategy and ‘smoking cessation’ search term to a high of 1 247 540 in the ‘view count’ strategy and ‘stop smoking’ search term. Of the top three most viewed videos by strategy and search term, 66.7% included a specific mention of quitting smoking and, of these, the majority included EBPs.
Conclusion Results highlight the need to develop and upload videos containing EBPs both to increase the overall proportion of EBP videos in all categories, particularly in ‘quit smoking’ and ‘stop smoking.’ Research is needed to study whether YouTube videos influence knowledge, attitudes and behaviours regarding quitting smoking.
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YouTube, Broadcast Yourself (YouTube), founded in February 2005, is a Google-owned global video sharing website and is listed as the third most viewed website after Google.com and Yahoo.com.1 In April 2009 alone, it is estimated that more than 5.5 billion videos were watched on YouTube worldwide2 and every minute, an estimated 20 hours of new videos are uploaded to YouTube.3 YouTube reaches approximately 23–25% of all global internet users in any given month with 24% of YouTube users from the USA. Japan, Germany and India are the second, third and fourth most prevalent countries of YouTube users with 6.9%, 4.7% and 4.4%, respectively.4 In 2009, the distribution across age groups among YouTube viewers was approximately 20% across all age groups,5 and all age groups have increased use of video sharing sites since 2006.6
Although YouTube was initially designed for entertainment, health organisations have subsequently created channels on YouTube in recognition of its popularity and importance as a means for communication.7–9 Given the rapid growth of YouTube and the creation of YouTube channels by formal organisations, it is important to assess the quantity and quality of videos on YouTube to understand how to design health messages that will ‘cut through the noise’ and, in this case, will catch the attention of smokers seeking information about quitting smoking. The Pew Internet & American Life Project reported that 80% of American internet users searched for at least one of 17 health topics on the web in 2006, with 9% of these internet users searching for information about how to quit smoking.10
To date, few published reports have analysed health-related information on YouTube. Keelan and colleagues reported that less than half of the videos (48%) depicted immunisation in a positive light, whereas a third (32%) depicted immunisation in a negative light, and the remaining (20%) was ambiguous.11 This study found that the negatively portrayed immunisation videos were more probably viewed than the positive portrayals of immunisation. Freeman and Chapman conducted a content analysis of the top 50 ‘smoking’ videos with the search term ‘smoking’ sorted by relevance as well as view count and found that the majority of the videos depicted smoking in a positive manner.12 Only a small percentage of videos contained an antismoking or smoking-cessation message.
Social cognitive theory posits that individuals are actively engaged in making decisions about their behaviour as influenced by the dynamic interplay among personal factors, behavioural patterns and environmental events.13 YouTube, as a mass communications technology, is one source of information that may influence behaviour. Given this relatively new communications medium and its potential as a dissemination tool for health messages that may influence behaviour, we undertook an analysis to determine the extent to which YouTube videos specific to smoking cessation were posted and searched by users were actually about quitting smoking and, if so, whether they portrayed evidence-based practices (EBPs).
In August 2008, a search was conducted of the top 60 videos in two YouTube search strategies: the default category of ‘relevance’ and the category of ‘view count’ using the following three search terms: ‘stop smoking’, ‘quit smoking’ and ‘smoking cessation’. These three search terms were selected because the study's focus was to analyse videos specifically regarding smoking cessation and not a broad range of tobacco-related videos. Data from a Google trends analysis found that there is a higher proportion of web traffic searching for ‘quit smoking’ compared with ‘stop smoking’ and ‘smoking cessation’, with ‘smoking cessation’ having the lowest web traffic.
The initial sample included 360 videos: 60 each for the three search terms in each of the two search strategies. We chose the top 60 videos by search term and strategy because 95% of people conducting an online search will look no further than the first three pages of output (each page on YouTube searches contains 20 videos).14
Inclusion criteria were that the video was in English and not blocked by NIH (n=296, 82.2%). NIH blocks YouTube videos that include sexual content and illicit drug use and only nine were blocked from view. Fifty-five videos were not in English. Of the 296 videos, 105 (35.5%) were duplicates so that 191 videos were uniquely coded and reflected in each of the six categories: stop smoking search term by relevance category (Stop/Relevance), quit smoking search term by relevance category (Quit/Relevance), smoking cessation search term by relevance category (Cessation/Relevance), stop smoking search term by view count category (Stop/View), quit smoking search term by view count category (Quit/View) and smoking cessation search term by view count category (Cessation/View). Each video was coded by two Master's-level coders who were trained by the lead investigator. They were trained by first discussing definitions in each coding term together and then independently watching and coding five videos representative of the range of videos in the sample. The lead investigator then met with the two coders to discuss and reach consensus on any coding discrepancies. In-person training took approximately four hours. Each video was coded as addressing smoking cessation or not and, if not, the video's general message. For purposes of this study, the authors developed a narrow definition of a video that addressed smoking cessation—that is, if it contained a specific call to quit smoking or specifically mentioned methods to quit smoking. The kappa agreement between the two coders of the 191 uniquely coded videos for whether a video addressed smoking cessation or not (‘yes’ or ‘no’) was 0.86. Videos that addressed smoking cessation were then coded for specific cessation method and whether the methods were EBPs, non-EBPs or contained both EBPs and non-EBPs, based on the 2008 update of the Public Health Service Clinical Practice Guidelines, ‘Treating Tobacco Use and Dependence’.15 All data were entered into Microsoft Excel and discrepancies between coders were flagged. For those videos where there was a disagreement, the lead investigator watched the videos for resolution.
Of the 191 unique videos, 59.7% (n=114) included content that mentioned quitting smoking. Of those videos about quitting, 49.1% (n=56) included only EBPs, 29.8% (n=34) included only non-EBPs (n=34) and 21.1% (n=24) included both EBPs and non-EBPs. Among EBP videos the most frequently mentioned methods were other behavioural strategies (37.7%), websites (35.1%), medications (29.8%) and quitlines (27.2%). Among non-EBP videos, the most frequently mentioned methods were ‘other techniques’ (36.0%) and hypnosis (18.4%).
Among the sample of 296 videos, the majority of videos (59.5%) posted on YouTube from all three search terms addressed quitting smoking, with the largest proportion contained in the Stop/Relevance category (figure 1). The category of Quit/View, however, had a majority proportion of videos that were not about quitting smoking. Cessation/Relevance and Cessation/View had the highest proportion of videos containing EBPs compared with videos containing non-EBPs and those containing both. Stop/Relevance contained the fewest proportions of videos with EBPs.
Of the 120 videos not about quitting smoking, the majority were unrelated to smoking (figure 2). Of those relating to smoking or tobacco use but not related to quitting smoking, most of the videos portrayed the negative health consequences of using tobacco or smoking, contained images of smoking and/or people smoking or portrayed smoking images in general. Cessation/Relevance had the largest proportion of videos unrelated to smoking among videos not about quitting smoking.
Overall, behavioural strategies (34.5%), followed by medications (23.8%) were the most frequently mentioned EBPs. Within the six categories by search term and strategy, ‘other behavioural methods’ were the most frequently mentioned EBPs within Stop/Relevance, Quit/Relevance and Cessation/View, 45.5%, 25% and 24.1%, respectively. The most frequently mentioned EBPs were medications in Cessation/Relevance (27.1%), websites in Quit/View (19.5%) and websites and quitlines in Stop/View (17.0% each).
Among non-EBPs, the single most common practice, hypnosis, was mentioned across all categories with a high of 12% in Stop/Relevance. Cessation/Relevance had acupuncture as the most frequently mentioned non-EBPs (10.2%). Examples of non-EBPs in the category of other methods included emotional freedom techniques, reducing the body's acidity, using biorhythms and using graphic imagery to highlight the negative consequences of smoking.
Table 1 provides the range of views per individual video by search term and category. The number of views per an individual video across the six categories ranged from a low of 8 in Cessation/Relevance to a high of 1 247 540 in Stop/View. The categories that received the highest and lowest overall number of views that included only EBPs were Stop/View with a total of 1 479 152 and Cessation/Relevance with a total 72 379, respectively. The categories that received the highest and lowest overall number of views that included only non-EBPs were Quit/View with 782 903 and SCR with 894, respectively. Stop/View and Quit/View contained the highest overall number of views that included both EBPs and non-EBPs (table 1).
The most popular video, based overall on number of views, was from the Stop/View category, ‘Ghetto Science—Smoking.’ The three and a half minute video features a young man in Australia blowing cigarette smoke into a tissue to show the brown tar that gets into one's lungs and then stating that it ‘can be something that helps you quit’ with a total of 1 247 540 views.16 The next two most popular videos were ‘NicoDerm Commercial’ in the Stop/View category with 391 629 views17 and ‘You Don't Always Die From Tobacco,’ one of American Legacy Foundation's truth® ads in the Cessation/View category with 366 359 views.18 Of the top three most viewed videos in each of the six categories (n=18), 12 or 66.7% included a specific mention to quit smoking. Of those videos that mentioned quitting smoking (n=12), seven (58.3%) included EBPs and five (41.7%) included non-EBPs. Half of these 18 videos were developed by healthcare or public health organisations.
In this analysis, we sought to determine whether videos uploaded to and searched in YouTube contained evidence-based smoking cessation messages. Because the term ‘smoking cessation’ is commonly used by health professionals, it may be that health professionals are more likely to post videos on YouTube with the tag ‘smoking cessation’, which may help explain why a higher proportion of videos tagged as ‘smoking cessation’ contained EBPs compared with other search terms. Consequently, because internet users are more likely to search for quitting smoking using the terms ‘quit smoking’ or ‘stop smoking’ rather than ‘smoking cessation’, they might be exposed to a higher proportion of non-EBPs. Our results highlight the need to develop videos containing EBPs to upload to YouTube using the tags of ‘quit smoking’ and ‘stop smoking,’ in addition to ‘smoking cessation.’ In addition, videos to directly counter non-EBPs should be developed and posted on YouTube.
Few studies have been conducted researching media effect on quitting. Biener et al studied nine mass media advertisements promoting smoking cessation in Massachusetts and found that those ads that addressed the negative consequences of smoking using negative emotions were perceived as significantly more effective than the other ads by adults who viewed the ads.19 Biener and colleagues also reported that recent quitters in Massachusetts found anti-tobacco ads that depicted illness from smoking and those providing inspirational tips were helpful in quitting.20 Research summarised in the 2008 National Cancer Institute's monograph, ‘The Role of Media in Promoting and Reducing Tobacco Use’ (NCI Media Monograph), found that media that induce negative emotions perform better in terms of attention and recollection than those that do not. Research is needed to determine the effective components for smoking cessation.21
As one would assume, videos searched by relevance were viewed less often compared with videos searched by view count. Of the 10 videos that were viewed more than 100 000 times in this analysis, six addressed the negative health consequences of smoking. These findings are in alignment with the numerous studies summarised in the NCI Media Monograph consistently reporting that ads with strong negative health consequences are better attended to by target audiences than other forms of ads.21 Although these videos addressed the negative health consequences of smoking, often in an emotionally evocative manner, it is not clear whether these videos prompted smokers to attempt to quit. When an individual goes to YouTube to conduct a search, the default is to show results by ‘relevance’, it is not known whether people searching for YouTube videos about quitting smoking are more likely to use the default search or are interested in viewing more popular videos, and search by ‘view count’. Research is needed to determine the impact of the most watched viewed videos on quitting smoking.
One important limitation to this analysis is how we chose to define a video as addressing quitting smoking. Given that we narrowly defined a quitting smoking video as one with an explicit message to quit or that mentioned specific methods to quit smoking, we may have missed videos that could provide motivation to quit even though they did not specifically mention quitting. For example, several videos were TV ads addressing the negative health impact of smoking, but did not provide a specific quitting message and were not included as quitting smoking videos. Another limitation is that data from videos were captured on one specific day and it is unknown how quickly both view count and relevance change over time. The number of unique viewers of individual videos is also not known. This analysis was exploratory in nature and may not reflect how YouTube viewers find videos about quitting smoking. Unlike public service announcements or paid media regarding smoking cessation where viewers do not actively seek out these media, YouTube represents a proactive search. People may watch smoking cessation videos for a variety of reasons such as friends' referral to a particular video because of its entertainment value regardless of their smoking status or as a perceived effective method for quitting smoking. Smokers may also actively search for smoking cessation information by relevance of the video, popularity of a video based on view count, the rating of the video and/or comments posted by previous viewers.
Given that YouTube is a relatively new medium for communicating about health issues, and in this case, quitting smoking, it is not clear whether YouTube effectively provides smokers with sufficient messages about both the importance of quitting smoking and EBPs to help them quit. Videos on YouTube may negatively or positively impact smoking behaviour depending on the nature of the video. Some of the videos tagged as ‘quit smoking’, ‘stop smoking’ and ‘smoking cessation’ contained images of smoking and/or people smoking, and these videos may provide cues to smoke.
Analyses are needed to address other components of YouTube videos that may impact quitting such as source of video, setting and messenger characteristics. Additional research needs to address how and why both smokers and non-smokers search for videos regarding quitting smoking, as well as knowledge, attitudes and subsequent behaviours as a result of watching YouTube videos.
What this paper adds
Although YouTube is a popular video viewing and sharing website, it is not known the extent to which there are evidence-based smoking cessation videos on YouTube. This paper adds to the small, but growing literature by examining the videos uploaded as addressing smoking cessation.
This study assessed videos by YouTube search categories: ‘relevance’ and ‘view count’ and the search terms: ‘stop smoking’, ‘quit smoking’ and ‘smoking cessation.’ Analyses of both the unique videos and full sample found that while the majority of videos were in fact about quitting smoking, many videos were unrelated to smoking at all or were about smoking in general. Of those videos about smoking cessation, almost half contained evidence-based practices to quit; however, more than half contained either non-evidence-based methods or both non-evidenced-based practices and evidence-based practices in the same video. The most viewed videos, however, were about quitting smoking and included evidence-based practices.
This study is the first to assess smoking cessation videos on YouTube. Results highlight the need to conduct additional research to understand the utility of YouTube as a communications tool for providing quitting smoking motivation, information and evidence-based practices.
We thank Kourtney Marshall, DB Consulting Group, Inc, for his support in preparing data for analysis.
Funding Funding for this study was provided by the National Cancer Institute, Tobacco Control Research Branch.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.