Tobacco use is a major cause of morbidity and mortality worldwide, with more than 8 million deaths each year due to tobacco use or exposure to second-hand smoke [1]. In the United States, more than 480,000 deaths a year are attributable to cigarette smoking; of these, 33% are due to cardiovascular diseases, 27% lung cancer, 23% pulmonary diseases, 9% second-hand smoke, and 7% cancers other than lung [2]. Through multifaceted tobacco control efforts, significant progress has been made over the past several decades to reduce the overall prevalence of cigarette smoking among adults from 40% in 1964 to 14.0% in 2019 [3]. In recent years, however, the emergence of alternative nicotine delivery systems (ANDS; eg, e-cigarettes and other vaping methods) [4] has been reversing the downward trend of tobacco use, with 4.5% of adults reporting current use of e-cigarettes [3] and 20.8% currently using one or more forms of tobacco or ANDS. As such, tobacco use remains a public epidemic, predisposing individuals to an increased risk for developing diseases of virtually every organ system in the body and contributing to rising health care costs [2]. For each pack of cigarettes sold in the United States, the societal costs due to smoking-related health care costs and lost productivity are estimated at US $19.16 per pack, which is around 3 times the cost of the cigarettes [5].

It is well established that clinicians have a proven positive impact on their patients’ ability to quit [6]. To achieve reductions in the public health burden of tobacco, the 2020 Surgeon General’s report on smoking cessation highlights the importance of clinical interventions by health care providers of all disciplines [7]. Three factors should be considered when attempting to improve quit rates: (1) the efficacy of interventions on patients’ ability to quit, (2) fidelity to implementing tobacco cessation interventions in clinical settings, and (3) clinicians’ knowledge and skills for treating tobacco use and dependence. In regards to efficacy, research shows that clinician interventions that are based on the 5 A's (Ask, Advise, Assess, Assist, and Arrange) are effective and increase quit rates among patients and thus is considered a gold standard for comprehensive counseling [6]. Fidelity considers the extent to which the 5 A's are integrated into practice, in the face of challenges such as lack of time, competing demands, and lack of providers’ self-efficacy for tobacco cessation counseling [8]. To mitigate these challenges, investigators have explored creative approaches to enhance the delivery of care (eg, Satterfield and colleagues [9] found that a computer-facilitated 5 A's approach performs better than usual care). The third aspect that can influence quit rates is clinicians’ knowledge and skills for providing tobacco cessation interventions. To address this, the “Rx for Change Clinician-Assisted Tobacco Cessation” curriculum was designed, and its corresponding website [10] was launched to host the tobacco cessation teaching and counseling materials. The Rx for Change curriculum, and the website described here, aim to enhance the quality and quantity of tobacco counseling that occurs in clinical practice.

Historically, the extent of tobacco cessation content has been inadequate in all health professional school curricula, including medical [11-15], nursing [16-19], pharmacy [20,21], dental hygiene [22], physical therapy [23], physician assistant [24], and respiratory therapy [25,26]. The evidence-based Rx for Change curriculum was a practical solution to address this decades-long gap [27]. The term “Rx” means prescription, and a “curriculum” is defined as “the totality of student experiences that occur in the educational process” [28]. As such, Rx for Change is a curriculum about tobacco cessation that was designed to teach health professional students and licensed clinicians. Rogers’ Diffusion of Innovations Theory [29] served as a guiding framework for program design, aiming to enhance the adoptability of the curricular innovation and structure future dissemination strategies. A key strategy for dissemination of Rx for Change occurred via targeted in-person and virtual train-the-trainer workshops for faculty at health professional schools (pharmacy, nursing, medicine, and respiratory care).

To facilitate integration of the Rx for Change curriculum at health professional schools, a public-access website was created to host all of the Rx for Change curricular materials (Figure 1). Several versions of the curriculum exist, each addressing a different clinical specialty for which patients can benefit from tobacco cessation interventions. Learning objectives are provided for each of the program’s modules. PowerPoint slides, with detailed instructor notes, and learner handouts are downloadable and can be used by educators to teach in a lecture-based format. Additional teaching materials include dozens of videos (Figure 2), case materials for role playing, ancillary handouts for clinicians and patients, and a suite of tobacco-specific virtual patients. To facilitate assessment of counseling competencies, 6 standardized patient cases were created with associated scoring rubrics for conducting objective structured clinical examinations (OSCEs). Tools are also available to assist faculty with implementation of all aspects of the curriculum. The U.S. Surgeon General provides a 3-minute introductory video, highlighting the importance of integrating tobacco cessation into clinical practice (Figure 1).

Educational experts have placed much value on developing effective training programs and have also emphasized the need for program evaluation [30]. Unfortunately, when websites are created to host educational materials, these resources are often short-lived before becoming outdated and dormant after institutional support or grant funds expire. Launched in 2004, the Rx for Change website teaching content is updated at least annually and also when needed to address changes in clinical practice (eg, postlaunch of a new medication, inclusion or removal of a boxed warning). However, its usage has yet to be characterized. Such knowledge would be helpful to understand the impact of providing shared curricular materials through a public access website and to inform future curriculum developers about potential usage and benefits of hosting shared materials online. Therefore, the purpose of this study was to conduct a longitudinal analysis of user characteristics and utilization of the Rx for Change website over a period of 15 years.

User and utilization data have been collected prospectively via the Rx for Change website since its launch in 2004. For the purpose of this study, data were extracted for a period of 15 years, ranging from the public launch date on April 1, 2004 to March 31, 2019. Individuals who registered on the website provided contact information, including their state and country, their primary discipline (medicine, nursing, pharmacy, respiratory care, dentistry, health educator/peer counselor, social work, other), and whether they were a student or resident. Additional information included how they heard about the Rx for Change program (conference/meeting/workshop; faculty member/colleague; internet LISTSERV; newsletter or publication; surfing the internet; University of California San Francisco Smoking Cessation Leadership Center; other) and their intended use of the materials (enhance own knowledge/skills; teach health professional students; teach licensed health professionals; not sure). In addition to user characteristics, prospectively collected data included various utilization measures: files downloaded (frequency and type), number of file downloads per user, number of logins, and trends in utilization over time. All video files on the website are permitted to be streamed directly on the website, and these occurrences were not linkable to individual users and therefore were not captured along with the number of file downloads.

With respect to data interpretation, it is important to note that not all programmatic materials were available at the launch of the website in 2004 — a version addressing brief counseling (Ask-Advise-Refer) was launched in November 2007, and new discipline-specific versions (eg, psychiatry, respiratory care, peer counselor, cardiology, and surgical care) became available over time. Along with the annual updates, new videos and role-playing case materials were added periodically, and all were modified as needed to be consistent with evolving clinical practice guidelines. In 2019, a suite of 6 standardized patient cases with scoring rubrics for OSCEs were added along with a link to a suite of tobacco-specific virtual patients [31]. No proactive efforts were made (eg, no email notifications) to alert users of the availability of new or updated content, and at no time during the 15-year period was the website inaccessible for more than a few hours at a time during updates or server maintenance.

Data cleaning occurred at the individual user level, which included combining duplicate registrants (eg, identical users who established separate accounts with different email addresses), reclassifying disciplines where appropriate, and recategorizing data response options labeled as “other” (eg, user checked “other” for the discipline field but provided information consistent with existing response options). Combining duplicate registrants was done by manually reviewing registrations that appeared to belong to the same person, and after extensive investigation through internet search engines and LinkedIn profiles, discussion, and consensus, the team determined when it was appropriate to attribute multiple registrants to the same user. Data were analyzed using SPSS, version 26 [32]. The study was approved by the University of California, San Francisco and Purdue University Institutional Review Boards for the protection of human subjects.