Cigarette smoking, the most preventable cause of morbidity, mortality, and excess health cost in the United States, accounts for 480,000 premature deaths yearly [1]. At 22%, American Indian (AI)/Alaska Native (AN) persons have the highest US smoking prevalence; and within this group, AN residents of Alaska (AK) have a prevalence of smoking more than double that of Alaskan whites (42% vs 17%) [2]. Accordingly, AN people who smoke experience more tobacco-related diseases and mortality compared with non-Native people living in AK or US whites [3-6]. A national public health objective is to reduce tobacco-caused health disparities [7,8]. The state of AK developed its own health improvement plan, Healthy Alaskans 2020, that identifies priority health indicators. Decreasing smoking prevalence among AN adults to 17% is one of the priorities [9]. We will address both objectives by developing effective strategies to decrease tobacco use within AN communities across the state of AK and among AN people as a whole. With approximately 20% of the state’s population self-identifying as AN race [10], substantial reductions in tobacco use will greatly contribute to reducing statewide tobacco use rates.

Quitlines have proven efficacy [11] but remain underutilized by AN people [12,13]. In addition, only 4% to 7% of unaided quit attempts are successful among AN smokers compared with 10% among non-Native smokers. Evidence-based counseling and medication treatments could boost quit rates to as high as 30% to 40% [14,15]. Therefore, a need exists to increase utilization of available, low/no cost, and evidence-based smoking cessation resources such as AK’s Tobacco Quitline or Tribal tobacco cessation resources.

The Alaska Native Tribal Health Consortium (ANTHC), a consortium of regional Tribal health leaders, represents diverse AN people in AK. ANTHC co-owns and comanages the Alaska Native Medical Center (ANMC) in Anchorage. ANMC provides specialty care to AN people statewide, serving as the AK Tribal Health System’s only tertiary care facility. ANTHC’s Community Health Services Tobacco Prevention and Control Program provides tobacco cessation counseling and nicotine replacement therapy (NRT) to inpatients at ANMC. Upon discharge, patients are referred to cessation services at their regional Tribal health organization, which vary widely, or to AK’s Tobacco Quitline. AK’s Tobacco Quitline, operated by the state, is available to all Alaskans but provides free NRT for only 1 month. Given these barriers, the ANTHC Tobacco Prevention and Control Program appealed to ANTHC’s Clinical and Research Services to explore ways to expand capacity for support of AN Tribal members’ cessation efforts statewide.

Although our study with AN pregnant women and youth demonstrated that face-to-face interventions had limited reach and efficacy [16,17], Web-based social networks, such as Facebook (FB), are potentially powerful tools for reaching, engaging, and connecting AN people who smoke in cessation efforts [18] because of their large reach, relatively low cost, and potential for greater adoption and sustainability. The following section reviews the literature on the topic of social media use for health promotion with ANs and, generally, in the area of tobacco cessation. Utilization of the internet to access health information and social media use have increased among AN people, even in remote regions. In a representative survey of 340 households in rural southwest AK (73% AN adults), 87% had at least 1 cell phone, 60% had a smartphone, and 81% used FB, Twitter, or other social media sites [19,20]. A survey of 362 AN females from a rural census area reported that 80% used internet, 78% had smartphones, and 90% used FB [21]. Although the potential of social media to enhance smoking cessation is understudied, it remains a priority research area [18,22,23], with some trials using social media platforms for smoking cessation reporting effectiveness [24-27].

An intervention with both a website and an FB group evaluated quasi-experimentally among 238 young adult smokers resulted in greater self-reported 7- and 30-day smoking abstinence rates and quit attempts, compared with an unmatched comparison group of quitline users at a 3-month follow-up [24]. Participants interacted significantly more with FB than the website; of FB users, 56% were men and 44% were women, with women more actively posting and engaging than men. An analysis of sex differences in communication styles revealed that women emphasized support and connecting, whereas men expressed strong assertions about quitting smoking [25].

Another study evaluated a 100-day Twitter intervention [26]. Among 160 smokers aged 18 to 59 years, Tweet2Quit doubled the rate of self-reported sustained abstinence at 2 months post quit date compared with a control condition (smokefree.gov cessation website referral plus nicotine patches), 40% versus 20%. Sex, but not age, was related to treatment outcome, with women less likely to quit smoking than men in both study conditions.

An uncontrolled FB study for young adult smokers tested whether monetary incentives enhanced FB intervention engagement [27]. FB engagement was high, did not differ by incentive, and self-reported smoking abstinence at 6 months was 18%. Another observational study evaluated social media to support smoking cessation efforts among participants enrolled in a state-run cessation program in Saudi Arabia. Investigators found that WhatsApp- and Twitter-based social media support groups were more likely to report a decrease in smoking frequency compared with those not using social media [27].

A total of 3 other feasibility studies examined FB use among smokers. Haines-Saah et al [28] found more postings to the Picture Me Smokefree FB page among women than men (ie, 189 total photos posted among women, mean 9.5, vs 94 posted by men, mean 4.2). Content analysis revealed that postings were of similar quality for both sexes; sharing of photos and captions about experiences with tobacco use and struggles with quitting in the context of family life and relationships were the main themes. Evaluation of the FB page smokefreewomen.gov [29] found that increased frequency of moderator postings to facilitate dialogue and provide support engaged existing and new users, resulting in a marked increase in user postings and reach. Finally, an FB intervention using health communication messaging and supportive moderator postings was associated with a decrease in cigarettes smoked per day from baseline to 2-week follow-up; increased engagement was associated with greater smoking reduction [30].

To overcome barriers of geography, climate, and scalability, we proposed to create and pilot-test a culturally salient social media (ie, FB) intervention to promote evidence-based smoking treatment utilization and cessation for AN people that will eventually be maintained by ANTHC’s Tobacco Prevention and Control Program. The project builds on ANTHC and Mayo Clinic’s longstanding tobacco control research partnership with the AN community and is informed by our understanding of cultural factors that can both impede (eg, stress and adverse childhood experiences) and encourage (eg, close family ties and community values) cessation in this population. The goal of this formative study is to develop an FB intervention that will be a hidden and closed FB group. The goal of the randomized pilot trial is to obtain effect size estimates to adequately power a larger scale efficacy trial. For this phase of the research, the main outcome measures will be intervention feasibility (treatment acceptability and program satisfaction) and verified smoking abstinence. Secondary outcome measures will be self-reported other tobacco abstinence, smoking treatment utilization, and interdependence as a culturally relevant mediator of intervention effectiveness. Additional feasibility measures such as social media engagement, usability, and satisfaction will also be addressed.

The goal of the pilot trial is to obtain effect size estimates to adequately power a larger scale stage 2 efficacy trial.

We used cultural variance and surface/deep structure frameworks [31,32] to address the influence of culture in designing health messages. Cultural variance framework considers AN cultural influences on health behaviors, including beliefs and norms (ie, communication styles and social acceptance of tobacco use), values (eg, interdependence), and AN knowledge systems/ways of knowing [33-38]. Surface and deep structure inform content and format of messages. Surface structure matches materials/messages to observable social and behavioral characteristics (eg, AN people, music, and clothing), and deep structure incorporates cultural beliefs and values. Surface structure generally enhances receptivity, comprehension, and acceptance of messages, whereas deep structure conveys salience. We will also use a planning framework based on the National Cancer Institute [39] and Centers for Disease Control (CDC) [40] recommendations for developing social media and other digital health communication tools, addressing key components of message construction [41,42] that are also consistent with stage 1 of the 3-stage model of behavioral therapies development [43] that includes intervention development, refinement, modification/adaptation, and pilot testing. In summary, we will conduct the research in 4 phases. In phase 1, we will use qualitative in-depth interviews and then in phase 2, quantitative methods to develop/refine message concepts. Next, in phase 3, we will develop and beta-test the intervention prototype; and finally, in phase 4, we will conduct a randomized pilot trial of the intervention (Figure 1).

Content for our FB intervention is culturally relevant, adapting the storytelling approach used in both the ANTHC digital stories about smoking cessation from AN people and the CDC Tips mass media campaign [44]. On the basis of factual health communication messaging, Tips features graphic, emotional, true stories from former smokers to increase awareness of smoking harms and encourage quitting. It includes the call to use free, evidence-based statewide quitline numbers and smoking cessation website resources (smokefree.gov). The campaign increased quitline utilization and quit attempts on a population level [44,45].

Tips stories promote salience and reduce tendency for smokers to discount adverse health outcomes as uncommon because stories feature real people [46]. Numerous studies, including a previous study by our team [33], suggest that storytelling is congruent with AN culture (strong oral storytelling tradition) [47-49], making the Tips format ideal for social media content development. Digital storytelling and other narrative forms of communication (eg, photonovela and photovoice) have emerged as important tools for health behavior change [50-52]. The communication forms reinforce traditional knowledge systems and cross-generational learning and build social connections [36,38]. Also relevant to the Tips campaign is the study conducted by our team indicating that AN adults preferred graphic, factual messages on tobacco use harms compared with other appeals, although this research was limited to interventions communicating risks during pregnancy [53,54].

The intervention will comprise an FB group moderated by a facilitator. To address potential concerns about FB privacy [55], we will utilize a closed and hidden FB group and a group policy/guideline that emphasizes confidentiality of all content. A hidden group is defined as invitation only, with the group and content not visible to anyone on FB except participants. Thus, anyone searching on FB would not find the group nor be able to request to join. Also, group membership or postings through news feeds will not be visible on the participants’ personal FB page.

We chose to use a moderated group based on research indicating that moderators play a critical role in directing and tailoring content to the group and enhancing overall social media engagement [25,56]. Also, the frequency of moderator FB postings is associated with increased participant engagement [29].

This study was reviewed and approved by the Institutional Review Boards for the AK area and Mayo Clinic. Tribal approval for the study was received from ANTHC. Our study fulfills objectives for stage 1 of the National Institute on Drug Abuse (NIDA) behavioral integrative treatment development program, where the intervention is developed in stage 1a and then evaluated for feasibility in 1b (Figure 1) [43].

For all study phases, we will recruit AN men and women who smoke, statewide, using targeted and paid FB ads (ie, digital targeting) based on the following: (1) aged >19 years, (2) self-reported AN race/ethnicity, and (3) keywords related to tobacco use. FB ads are a successful method of recruiting for research studies, especially among hard-to-reach populations [57,58]. We developed ads that include an image and short text consistent with FB’s advertising guidelines. We will partner with organizations that have a large FB following, such as the Alaska Federation of Natives, along with community-specific FB pages to advertise the study. We will also advertise in Tribal newsletters, newspapers, and websites and hand out flyers.

Eligibility criteria for participation are as follows: (1) AN person (male or female); (2) aged >19 years; (3) smoked at least 1 cigarette per day over the past 7-day period; (4) person with cigarettes as main tobacco product used; (5) considering or willing to make a quit attempt; (6) has access to broadband (high speed) internet on a mobile phone, at home, work, or other location; (7) has an FB account or willing to set one up before study enrollment; and (8) has not been enrolled in a program or using pharmacotherapy to stop smoking over the last 3 months. Participants will participate in the study only once, not in multiple phases (Table 1).

Enrollment will occur online and by phone. All advertisements will contain the study toll-free phone number, email address, and a website link to Qualtrics, where interested participants can verify eligibility and enroll. Individuals emailing or calling will receive a brief description of the study and a link to the study website. The website will contain a short description of the study and eligibility criteria. Participants will receive a US $25 Visa gift card as appreciation for their participation for each assessment they complete.

For all phases, we will ask the same sociodemographic and tobacco use questions: sex, age, Tribal affiliation, cultural identity (eg, language and traditionalism) [34], region of residence, marital status, education, employment, and current frequency of use of FB and other social media platforms. Tobacco use measures will include cigarettes per day, readiness to quit (Contemplation Ladder) [64], use of other tobacco and nicotine products, time to first cigarette after waking (<30 min vs >30 min) [65-67].

Sample characteristics will be summarized using descriptive statistics including means, percentages, and frequencies. Further analyses are described later by phase.

For all phases, we use the same coordination and communication procedures successfully utilized in our previous study that include regular study team meetings held via teleconference and a systematic plan for following up with participants to ensure as high a follow-up rate as possible is achieved with regard to key outcomes. First, to track follow-up (number and type) and reasons for attrition, the study coordinator keeps a database of all contacted and consented participants. Generally, subjects are contacted up to about 3 times (with actual contact) before being considered lost to follow-up. This same process is followed for mailed saliva collection kits that include a self-addressed, stamped return envelope with every mailing. For survey data, missing data will be minimized through Web-based assessments using Qualtrics. An email link will be sent automatically by the Mayo Clinic Survey Research Center to complete the assessment. If a participant does not complete Web-based assessments, he/she will be contacted through email or by phone by the project coordinator and prompted to complete the assessment. The baseline and follow-up surveys will be done on the Web or by phone, or the survey will be mailed with a postage-paid return envelope depending on participant preference. These surveys will take about 15 to 30 min each to complete. Participants will be mailed a US $25 Visa gift card as remuneration for completing each assessment, including returned saliva cotinine kits (Mayo Clinic Laboratories).

We evaluated existing content using a mixed method approach, beginning with qualitative work to refine intervention content and a quantitative survey to evaluate the perceived effectiveness (PE) of selected content (phases 1-2). Once content was evaluated both qualitatively and quantitatively, a content library and moderator guide were developed, group moderators were trained, and the FB group prototype was developed. The complete FB group is now being beta-tested for final refinement (phase 3) using quantitative measures.

This multistage pilot project will develop a social media intervention to promote smoking cessation among AN people through utilization of existing evidence-based approaches, such as AK’s Tobacco Quitline.

The proposed study, focusing on AN smokers, advances the methods of published social media intervention studies through the use of biochemical verification of smoking abstinence and extended duration of follow-up. Previously, most studies have targeted only young adults, whereas we plan to include a wide age range. We will also explore potential sex, age, and regional (urban/rural) effects on FB engagement and quitting, as there is limited research exploring these variables within the context of social media platforms for smoking cessation [24,26]. Within smoking cessation intervention efficacy and effectiveness trials generally, a recent literature review on sex/gender differences found that of 126 tests conducted, only 2 observed that women were significantly more likely to quit smoking than men, compared with 59 that found women were significantly less likely to quit smoking than men; the remaining 65 studies reported no difference by gender [87].

This pilot project is innovative for using social media communication tools that are culturally relevant and have already been adopted and that create statewide intervention access, thus promoting a scalable and sustainable approach that is tailored to the culture of AN people. The study is significant because it will advance research on population-specific treatments for ANs, an underserved, tobacco-use disparity group. If the pilot intervention is successful, we will have a blueprint to conduct a large randomized controlled efficacy trial.

Despite our strong mixed method experimental design, there are some limitations to our approach. First of all, although FB adoption is high among AN people overall, those not using social media will not be reached by this intervention. It is possible that some age groups will be more represented in this study than others because of possible gender-based differences in FB use and engagement. Finally, from the study design, we will not be able to assess the relative contribution of each component to intervention efficacy. Furthermore, FB utilizes certain algorithms to notify their users about topics that may be of interest to them based on their usage. However, as this is a hidden and closed group, none of the page posts will be added to a user’s news feed. Despite this, it is possible that exposure to Quitline-related ads or posts may be increased among those who participate in the group—an aspect to an FB intervention that the authors will have no control over. To explore these possible exposures, we will query intervention participants at the close of the FB group, a question about the perceptions about whether or not they received more than normal notifications, posts, or ads related to smoking, smoking cessation, or quitlines.

The described intervention has potential for promoting engagement with evidence-based smoking cessation treatment including AK’s Tobacco Quitline and Tribal cessation programs statewide and holds promise for AN people because it is scalable and sustainable. It utilizes a popular channel of communication and an existing, evidence-based treatment that could be considered for other remote AN communities to enhance the reach of evidence-based tobacco cessation treatments.