Mobile phone-based interventions for smoking cessation

A systematic review of the effectiveness of smoking cessation interventions among patients with tuberculosis

Smoking is a significant risk factor for morbidity and mortality, particularly among patients with tuberculosis (TB). Although smoking cessation is recommended by the World Health Organization and the International Union Against Tuberculosis and Lung Disease, there has been no published evaluation of smoking cessation interventions among people with TB. The purpose of this review was to synthesize the evidence on interventions and suggest practice, research and policy implications. A systematic review of the literature identified 14 peer-reviewed studies describing 13 smoking cessation interventions between 2007 and 2017. There were five randomized controlled trials, three non-randomized interventions, and five prospective cohort studies. The primary types of interventions were brief advice (n = 9), behavioral counseling (n = 4), medication (n = 3), and community-based care (n = 3). A variety of health care workers (HCWs) implemented interventions, from physicians, nurses, clinic staff, community health workers (CHWs), as did family members. There was significant heterogeneity of design, definition of smoking and smoking abstinence, and implementation, making comparison across studies difficult. Although all smoking interventions increased smoking cessation between 15% and 82%, many studies had a high risk for bias, including six without a control group. The implementing personnel did not make a large difference in cessation results, suggesting that national TB programs may customize according to their needs and limitations. Family members may be important supporters/advocates for cessation. Future research should standardize definitions of smoking and cessation to allow comparisons across studies. Policy makers should encourage collaboration between tobacco and TB initiatives and develop smoking cessation measures to maximize results in low-resource settings.

Cost-effectiveness analysis of smoking cessation interventions using cell phones in a low-income population

BACKGROUND

The prevalence of cigarette smoking is significantly higher among those living at or below the federal poverty level. Cell phone-based interventions among such populations have the potential to reduce smoking rates and be cost-effective.

METHODS

We performed a cost-effectiveness analysis of three smoking cessation interventions: Standard Care (SC) (brief advice to quit, nicotine replacement therapy and self-help written materials), Enhanced Care (EC) (SC plus cell phone-delivered messaging) and Intensive Care (IC) (EC plus cell phone-delivered counselling). Quit rates were obtained from Project ACTION (Adult smoking Cessation Treatment through Innovative Outreach to Neighborhoods). We evaluated shorter-term outcomes of cost per quit and long-term outcomes using cost per quality-adjusted life year (QALY).

RESULTS

For men, EC cost an additional $541 per quit vs SC; however, IC cost an additional $5232 per quit vs EC. For women, EC was weakly dominated by IC-IC cost an additional $1092 per quit vs SC. Similarly, for men, EC had incremental cost-effectiveness ratio (ICER) of $426 per QALY gained vs SC; however, IC resulted in ICER of $4127 per QALY gained vs EC. For women, EC was weakly dominated; the ICER of IC vs SC was $1251 per QALY gained. The ICER was below maximum acceptable willingness-to-pay threshold of $50 000 per QALY under all alternative modelling assumptions.

DISCUSSION

Cell phone interventions for low socioeconomic groups are a cost-effective use of healthcare resources. Intensive Care was the most cost-effective strategy both for men and women.

TRIAL REGISTRATION NUMBER

NCT00948129; Results.

Estimates of effectiveness and reach for 'return on investment' modelling of smoking cessation interventions using data from England

BACKGROUND AND AIMS

Estimating 'return on investment' (ROI) from smoking cessation interventions requires reach and effectiveness parameters for interventions for use in economic models such as the EQUIPT ROI tool (http://roi.equipt.eu). This paper describes the derivation of these parameter estimates for England that can be adapted to create ROI models for use by other countries.

METHODS

Estimates were derived for interventions in terms of their reach and effectiveness in: (1) promoting quit attempts and (2) improving the success of quit attempts (abstinence for at least 12 months). The sources were systematic reviews of efficacy supplemented by individual effectiveness evaluations and national surveys.

FINDINGS

Quit attempt rates were estimated to be increased by the following percentages (with reach in parentheses): 20% by tax increases raising the cost of smoking 5% above the cost of living index (100%); 10% by enforced comprehensive indoor public smoking bans (100%); 3% by mass media campaigns achieving 400 gross rating points (100%); 40% by brief opportunistic physician advice (21%); and 110% by use of a licensed nicotine product to reduce cigarette consumption (12%). Quit success rates were estimated to be increased by the following ratios: 60% by single-form nicotine replacement therapy (NRT) (5%); 114% by NRT patch plus a faster-acting NRT (2%);124% by prescribed varenicline (5%); 60% by bupropion (1%); 100% by nortriptyline (0%), 10) 298% by cytisine (0%); 40% by individual face-to-face behavioural support (2%); 37% by telephone support (0.5%); 88% by group behavioural support (1%); 63% by text messaging (0.5%); and 19% by printed self-help materials (1%). There was insufficient evidence to obtain reliable, country-specific estimates for interventions such as websites, smartphone applications and e-cigarettes.

CONCLUSIONS

Tax increases, indoor smoking bans, brief opportunistic physician advice and use of nicotine replacement therapy (NRT) for smoking reduction can all increase population quit attempt rates. Quit success rates can be increased by provision of NRT, varenicline, bupropion, nortriptyline, cytisine and behavioural support delivered through a variety of modalities. Parameter estimates for the effectiveness and reach of these interventions can contribute to return on investment estimates in support of national or regional policy decisions.

Smoking Cessation Following Text Message Intervention in Pregnant Women

BACKGROUND

Smoking during pregnancy has detrimental effects on mother and fetus. Text messaging has been utilized to improve patient care.

OBJECTIVE

To evaluate the impact of text messaging on smoking cessation rates among pregnant women in addition to standard of care (SOC) smoking cessation services. Our SOC includes pharmacist-driven education with or without nicotine patch or bupropion.

METHODS

This randomized, open-label, prospective trial was conducted at a maternal fetal care center from May 2014 to January 2016. Pregnant patients in the preparation stage of change were randomized to text messaging or SOC. The primary outcome was smoking cessation verified with exhaled carbon monoxide levels (eCO) 2 weeks from quit date. All received clinical pharmacist weekly calls for 3 weeks and biweekly visits until pharmacotherapy completion. The text messaging group also received predetermined motivational messages.

RESULTS

Of 49 randomized patients, 13 withdrew, and 6 were lost to follow-up. The remaining included 14 texting and 16 SOC patients. eCO-verified cessation was achieved by 57.1% in the texting group versus 31.3% in the control ( P = 0.153). Overall, 64.3% of the texting group achieved an eCO below 8 ppm at ≥1 visit versus 37.5% in the control group ( P = 0.143). No difference was found in birth outcomes. The study was underpowered because of slow enrollment and high drop-out rates.

CONCLUSIONS AND RELEVANCE

Text messaging had minimal impact on improving smoking cessation rates in the obstetric population. However, further research is warranted because of the underpowered nature of this trial. Given the detrimental effects of smoking in pregnancy, more comprehensive cessation strategies are warranted.

A novel and remote biochemical verification method of smoking abstinence: Predictors of participant compliance

INTRODUCTION

Biochemical verification of smoking abstinence remains an important validity check of cessation trial outcomes. Digital health trials rarely establish in-person contacts between participants and intervention providers, requiring novel strategies to biochemically verify outcomes. We describe remote verification of smoking abstinence via saliva cotinine and individual predictors of compliance in a digital intervention.

METHODS

Data came from a feasibility trial and randomized controlled trial of a Facebook smoking cessation intervention for young adults. In both trials, participants completed baseline and follow-up surveys at 3, 6 and 12 months. Participants indicating past 7-day point prevalence smoking abstinence were mailed a saliva cotinine kit. Participants were instructed to electronically send two photos - one of them giving a saliva sample and the other with the test results. We investigated predictors of compliance with these procedures, independent of verification results, among participants that were mailed a kit at any follow-up point (N=130; mean age = 21.3; 59.2% female) using logistic and multinomial regression.

RESULTS

A total of 189 kits were sent out, of which 97 were completed (51.3% compliance). We did not identify significant predictors of completing any vs no kits using logistic regression. We also found no significant predictors of extent of kit completion (none vs some; none vs all) using multinomial regression and controlling for number of kits sent.

CONCLUSIONS

Findings demonstrate the feasibility of this biochemical verification method and suggest low risk for bias of results. Future studies should replicate findings in larger samples and improve compliance with verification procedures.

The Usability and Effectiveness of Mobile Health Technology-Based Lifestyle and Medical Intervention Apps Supporting Health Care During Pregnancy: Systematic Review

Background

A growing number of mobile health (mHealth) technology–based apps are being developed for personal lifestyle and medical health care support, of which several apps are related to pregnancy. Evidence on usability and effectiveness is limited but crucial for successful implementation.

Objective

This study aimed to evaluate the usability, that is, feasibility and acceptability, as well as effectiveness of mHealth lifestyle and medical apps to support health care during pregnancy in high-income countries. Feasibility was defined as the actual use, interest, intention, and continued use; perceived suitability; and ability of users to carry out the activities of the app. Acceptability was assessed by user satisfaction, appreciation, and the recommendation of the app to others.

Methods

We performed a systematic review searching the following electronic databases for studies on mHealth technology–based apps in maternal health care in developed countries: EMBASE, MEDLINE Epub (Ovid), Cochrane Library, Web of Science, and Google Scholar. All included studies were scored on quality, using the ErasmusAGE Quality Score or the consolidated criteria for reporting qualitative research. Main outcome measures were usability and effectiveness of mHealth lifestyle and medical health care support apps related to pregnancy. All studies were screened by 2 reviewers individually, and the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement were followed.

Results

Our search identified 4204 titles and abstracts, of which 2487 original studies remained after removing duplicates. We performed full-text screening of 217 studies, of which 29 were included in our study. In total, 19 out of 29 studies reported on mHealth apps to adopt healthy lifestyles and 10 out of 29 studies to support medical care. The lifestyle apps evaluated in 19 studies reported on usability and effectiveness: 10 studies reported positive on acceptability, and 14 studies reported on feasibility with positive results except one study. In total, 4 out of 19 studies evaluating effectiveness showed significant results on weight gain restriction during pregnancy, intake of vegetables and fruits, and smoking cessation. The 10 studies on medical mHealth apps involved asthma care, diabetic treatment, and encouraging vaccination. Only one study on diabetic treatment reported on acceptability with a positive user satisfaction. In total, 9 out of 10 studies reported on effectiveness. Moreover, the power of most studies was inadequate to show significant effects.

Conclusions

Most studies on mHealth apps to support lifestyle and medical care for high-income countries reveal the usability of these apps to reduce gestational weight gain, increase intakes of vegetables and fruit, to quit smoking cessation, and to support health care for prevention of asthma and infections during pregnancy. In general, the evidence on effectiveness of these apps is limited and needs further investigation before implementation in medical health care.

User assessments and the use of information from MomConnect, a mobile phone text-based information service, by pregnant women and new mothers in South Africa

MomConnect was designed to provide crucial health information to mothers during pregnancy and in the early years of child rearing in South Africa. The design drew on the success of the Mobile Alliance for Maternal Action’s programme in South Africa, as well as a growing list of mobile health (mHealth) interventions implemented internationally. Services such as MomConnect are dependent on user acceptability as all engagements are voluntary, meaning that tools have to be easy to use and useful to be successful. This paper describes the evaluation of the tool by pregnant women and new mothers using the tool. A purposive sample of 32 individual semistructured interviews and 7 focus groups were conducted, across five provinces in South Africa. All the sessions were transcribed and then analysed using a contextualised interpretative approach, with the assistance of Atlas.ti. The women were consistently positive about MomConnect, attaching high value to the content of the messages and the medium in which they were delivered. The system was found to work well, with minor problems in some language translations. Respondents were enthusiastic about the messages, stating that the information was of great use and made them feel empowered in their role as a mother, with some saving the messages to use as a resource or to share with others. The most significant problems related to network coverage. There was strong support for this intervention to continue. Given the user acceptability of mHealth interventions, MomConnect appeared to meet the target of identifying and responding to the recipient’s needs.

Uptake of Tailored Text Message Smoking Cessation Support in Pregnancy When Advertised on the Internet (MiQuit): Observational Study

Background

Smoking in pregnancy is a major public health concern. Pregnant smokers are particularly difficult to reach, with low uptake of support options and few effective interventions. Text message–based self-help is a promising, low-cost intervention for this population, but its real-world uptake is largely unknown.

Objective

The objective of this study was to explore the uptake and cost-effectiveness of a tailored, theory-guided, text message intervention for pregnant smokers (“MiQuit”) when advertised on the internet.

Methods

Links to a website providing MiQuit initiation information (texting a short code) were advertised on a cost-per-click basis on 2 websites (Google Search and Facebook; £1000 budget each) and free of charge within smoking-in-pregnancy webpages on 2 noncommercial websites (National Childbirth Trust and NHS Choices). Daily budgets were capped to allow the Google and Facebook adverts to run for 1 and 3 months, respectively. We recorded the number of times adverts were shown and clicked on, the number of MiQuit initiations, the characteristics of those initiating MiQuit, and whether support was discontinued prematurely. For the commercial adverts, we calculated the cost per initiation and, using quit rates obtained from an earlier clinical trial, estimated the cost per additional quitter.

Results

With equal capped budgets, there were 812 and 1889 advert clicks to the MiQuit website from Google (search-based) and Facebook (banner) adverts, respectively. MiQuit was initiated by 5.2% (42/812) of those clicking via Google (95% CI 3.9%-6.9%) and 2.22% (42/1889) of those clicking via Facebook (95% CI 1.65%-2.99%). Adverts on noncommercial webpages generated 53 clicks over 6 months, with 9 initiations (9/53, 17%; 95% CI 9%-30%). For the commercial websites combined, mean cost per initiation was £24.73; estimated cost per additional quitter, including text delivery costs, was £735.86 (95% CI £227.66-£5223.93). Those initiating MiQuit via Google were typically very early in pregnancy (median gestation 5 weeks, interquartile range 10 weeks); those initiating via Facebook were distributed more evenly across pregnancy (median gestation 16 weeks, interquartile range 14 weeks).

Conclusions

Commercial online adverts are a feasible, likely cost-effective method for engaging pregnant smokers in digital cessation support and may generate uptake at a faster rate than noncommercial websites. As a strategy for implementing MiQuit, online advertising has large reach potential and can offer support to a hard-to-reach population of smokers.

Evaluation of Two Mobile Health Apps in the Context of Smoking Cessation: Qualitative Study of Cognitive Behavioral Therapy (CBT) Versus Non-CBT-Based Digital Solutions

BACKGROUND

Mobile health (mHealth) apps can offer users numerous benefits, representing a feasible and acceptable means of administering health interventions such as cognitive behavioral therapy (CBT). CBT is commonly used in the treatment of mental health conditions, where it has a strong evidence base, suggesting that it represents an effective method to elicit health behavior change. More importantly, CBT has proved to be effective in smoking cessation, in the context of smoking-related costs to the National Health Service (NHS) having been estimated to be as high as £2.6bn in 2015. Although the evidence base for computerized CBT in mental health is strong, there is limited literature on its use in smoking cessation. This, combined with the cost-effectiveness of mHealth interventions, advocates a need for research into the effectiveness of CBT-based smoking cessation apps.

OBJECTIVE

The objective of this study was, first, to explore participants' perceptions of 2 mHealth apps, a CBT-based app, Quit Genius, and a non-CBT-based app, NHS Smokefree, over a variety of themes. Second, the study aimed to investigate the perceptions and health behavior of users of each app with respect to smoking cessation.

METHODS

A qualitative short-term longitudinal study was conducted, using a sample of 29 smokers allocated to one of the 2 apps, Quit Genius or Smokefree. Each user underwent 2 one-to-one semistructured interviews, 1 week apart. Thematic analysis was carried out, and important themes were identified. Descriptive statistics regarding participants' perceptions and health behavior in relation to smoking cessation are also provided.

RESULTS

The thematic analysis resulted in five higher themes and several subthemes. Participants were generally more positive about Quit Genius's features, as well as about its design and information engagement and quality. Quit Genius users reported increased motivation to quit smoking, as well as greater willingness to continue using their allocated app after 1 week. Moreover, these participants demonstrated preliminary changes in their smoking behavior, although this was in the context of our limited sample, not yet allowing for the finding to be generalizable.

CONCLUSIONS

Our findings underscore the use of CBT in the context of mHealth apps as a feasible and potentially effective smoking cessation tool. mHealth apps must be well developed, preferably with an underlying behavioral change mechanism, to promote positive health behavior change. Digital CBT has the potential to become a powerful tool in overcoming current health care challenges. The present results should be replicated in a wider sample using the apps for a longer period so as to allow for generalizability. Further research is also needed to focus on the effect of greater personalization on behavioral change and on understanding the psychological barriers to the adoption of new mHealth solutions.

Mobile App Usage Patterns of Patients Prescribed a Smoking Cessation Medicine: Prospective Observational Study

Background

Cigarette smoking is the leading preventable cause of death and is responsible for more than 480,000 deaths per year in the United States. Smoking cessation is challenging for many patients. Regardless of available treatment options, most quit attempts are unaided, and it takes multiple attempts before a patient is successful. With the ever-increasing use of smartphones, mobile apps hold promise in supporting cessation efforts. This study evaluates the ease of use and user satisfaction with the Pfizer Meds app to support smoking cessation among patients prescribed varenicline (Chantix).

Objective

Study participants included varenicline users who downloaded and used the app on their personal smartphone. The main objectives were to report mobile app download frequency and usage details and to describe the participant-reported satisfaction with and usefulness of the app over the 14-week follow-up study period.

Methods

Adults aged 18 years or older who had been prescribed varenicline were identified from the Express Scripts Incorporated pharmacy claims database. After meeting privacy restrictions, subjects were sent an invitation letter and second reminder letter with instructions on how to download the Pfizer Meds mobile app. Participants received a push notification to complete a smartphone-enabled survey regarding the utility of the app 12 weeks after downloading the app. Descriptive statistics summarized sociodemographics, use of varenicline, and details of use and satisfaction with the mobile app.

Results

Of the 38,129 varenicline users who were sent invitation letters, 1281 participants (3.35%) downloaded the Pfizer Meds app. Of the 1032 users with demographic and other data, 585 (56.68%) were females, and 446 (43.22%) were males; mean age was 46.4 years (SD 10.8). The mean number of app sessions per participant was 4.0 (SD 6.8). The end-of-study survey was completed by 131 survey respondents (10.23%, 131/1281); a large number of participants (117/131, 89.3%) reported being extremely, very, or moderately satisfied with the app. A total of 97 survey respondents (97/131, 74.0%) reported setting up a quit date in the app. Of those, 74 (74/97, 76%) reported quitting on their quit date.

Conclusions

Positive patient engagement was observed in this study based on app download and usage. This study quantified how the Pfizer Meds app performed in an observational real-world data setting. The findings demonstrate the willingness of participants to set a quit date and use the app for support in medication adherence, refill reminders, and information regarding how to take the medication. This study provides real-world evidence of the contribution apps can make to the continued encouragement of smokers to improve their health by smoking cessation.

Helping Patients With ESRD and Earlier Stages of CKD to Quit Smoking

Among the many adverse effects of tobacco exposure is the increased risk for progression of kidney disease. Individuals with chronic kidney disease (CKD), who already face increased cardiovascular event rates compared to the general population, are at even greater risk if they smoke. Despite these risks and the increased focus on smoking cessation in the general population in recent years, national guidelines have not specifically targeted individuals with CKD. There are similarly sparse data specific to individuals with CKD regarding the safety and efficacy of evidence-based smoking cessation modalities. This review aims to identify the risks of nicotine dependence in individuals with CKD and the potential benefits of smoking cessation; discuss current strategies for smoking cessation, including behavioral and pharmacologic therapies such as varenicline; and extrapolate these interventions to the unique challenges of this population. Much of the data presented stem from evidence for the general population but are described with additional consideration in dosing of nicotine replacement therapy, as well as non-nicotine pharmacotherapy and treatment modality for individuals with CKD.

Pilot Randomized Trial of an Automated Smoking Cessation Intervention via Mobile Phone Text Messages as an Adjunct to Varenicline in Primary Care

OBJECTIVE

Varenicline is a safe and effective aid to smoking cessation but most trials have involved frequent visits or intensive behavioral support unlike that typically provided in primary care. The current study examined if motivational text messages, sent via cellphone, would increase quit rates in smokers being treated with varenicline and 3 brief sessions in a family practice setting.

METHODS

This study was a randomized controlled, parallel-group smoking cessation trial. Intervention group participants (n = 74) received daily motivational text messages, additional texted tips in response to keywords, and weekly study questions while control group participants (n = 76) received only weekly study questions. Both groups received individualized counseling. Self-reported non-smoking and exhaled breath CO <10ppm were used to validate smoking abstinence at 3 weeks and 12 weeks.

RESULTS

Overall, 30.7% (46/150) of participants were abstinent at the 12 week follow-up and the abstinence rate did not differ between groups (INT 31.1% v. CON 30.3%, p = .91). The only predictor of abstinence at 12 weeks was use of varenicline during a previous quit attempt (p = .01). Intervention group participants were more likely to rate the text messaging program as good or excellent (p < .01), to recommend a similar program to family or friends (p < .01), and to complete positive smoking cessation activities (p = .04), when compared with the control group.

CONCLUSION

Although there were no differences in quit rates between the intervention and control group, intervention group participants rated the text messaging system more favorably, were more likely to recommend the program to others, and were more likely to complete positive smoking cessation activities.

Developing a tailored substance use intervention for youth exiting foster care

Youth who are aging out of the foster care system face significant barriers to accessing substance use treatment. Mobile interventions have shown efficacy for several mental and physical health issues and may be helpful in overcoming barriers facing foster youth with substance use problems. A program (iHeLP) for substance use reduction was developed that used a computerized screening and brief intervention (SBI) followed by six months of dynamically-tailored text messages. The program was shown to focus groups of youth (N = 24) ages 18-19 who recently left foster care and had moderate to severe substance use risk. Focus group feedback was used to modify iHeLP prior to delivery in an open trial (N = 16). Both study phases included assessments of feasibility and acceptability; the open trial also included assessments of substance use outcomes at 3 and 6 months. Focus groups indicated a high level of acceptability for the proposed intervention components. Of those screened for the open trial, 43% were eligible and 74% of those eligible enrolled, indicating good feasibility. Retention through the final follow-up was 59%, and drop out was associated with involvement in the criminal justice system. Participant ratings for liking, ease of working with, interest in and respectfulness of the SBI were high. Satisfaction ratings for the texting component were also high. A computerized brief screening intervention for substance use risk reduction together with tailored text messaging is both feasible and highly acceptable among youth who have recently aged-out of foster care.

Trust in Health Information Sources: Survey Analysis of Variation by Sociodemographic and Tobacco Use Status in Oklahoma

Background

Modern technology (ie, websites and social media) has significantly changed social mores in health information access and delivery. Although mass media campaigns for health intervention have proven effective and cost-effective in changing health behavior at a population scale, this is best studied in traditional media sources (ie, radio and television). Digital health interventions are options that use short message service/text messaging, social media, and internet technology. Although exposure to these products is becoming ubiquitous, electronic health information is novel, incompletely disseminated, and frequently inaccurate, which decreases public trust. Previous research has shown that audience trust in health care providers significantly moderates health outcomes, demographics significantly influence audience trust in electronic media, and preexisting health behaviors such as smoking status significantly moderate audience receptivity to traditional mass media. Therefore, modern health educators must assess audience trust in all sources, both media (traditional and digital) and interpersonal, to balance pros and cons before structuring multicomponent community health interventions.

Objective

We aimed to explore current trust and moderators of trust in health information sources given recent changes in digital health information access and delivery to inform design of future health interventions in Oklahoma.

Methods

We conducted phone surveys of a cross-sectional sample of 1001 Oklahoma adults (age 18-65 years) in spring 2015 to assess trust in seven media sources: traditional (television and radio), electronic (online and social media), and interpersonal (providers, insurers, and family/friends). We also gathered information on known moderators of trust (sociodemographics and tobacco use status). We modeled log odds of a participant rating a source as “trustworthy” (SAS PROC SURVEYLOGISTIC), with subanalysis for confounders (sociodemographics and tobacco use).

Results

Oklahomans showed the highest trust in interpersonal sources: 81% (808/994) reported providers were trustworthy, 55% (550/999) for friends and family, and 48% (485/998) for health insurers. For media sources, 24% of participants (232/989) rated the internet as trustworthy, followed by 21% of participants for television (225/998), 18% for radio (199/988), and only 11% for social media (110/991). Despite this low self-reported trust in social media, 40% (406/991) of participants reported using social media for tobacco-related health information. Trust in health providers did not vary by subpopulation, but sociodemographic variables (gender, income, and education) and tobacco use status significantly moderated trust in other sources. Women were on the whole more trusting than men, trust in media decreased with income, and trust in friends and family decreased with education.

Conclusions

Health education interventions should incorporate digital media, particularly when targeting low-income populations. Utilizing health care providers in social media settings could leverage high-trust and low-cost features of providers and social media, respectively.

Feasibility of a text-based smoking cessation intervention in rural older adults

Text-based interventions are effective for smoking cessation, but have not been tested in rural older adults. The purpose of this study was to compare the feasibility, acceptability and preliminary efficacy of a text-based Scheduled Gradual Reduction (SGR) program to a non-SGR text messaging support condition among rural older adults. Adults over 60 years were randomized to either: (i) the SGR program (n = 20), a text-based program to reduce smoking over 4-weeks plus text-based support messages; or (ii) control (n = 20), receipt of text-based support messages only. Participants completed surveys at baseline and end of program to assess feasibility and acceptability of the intervention, and biochemically validated 7-day point prevalence cessation was assessed at end of treatment. Most participants (81%) reported reading all the messages they received. Participants found both interventions useful in quitting smoking (SGR = 57%, Control = 63%) and would recommend it to a friend (SGR = 72%, Control = 79%). Although not statically significant, the SGR group had a higher rate of biochemically validated cessation (SGR = 15%, Control = 5%, Cohen d = 0.67). Among those still smoking, the median percent reduction in cigarettes was 33.3% for both groups. Text-based cessation interventions are feasible, acceptable and can be easily disseminated to rural older adult tobacco users.

Smartphone Smoking Cessation Application (SSC App) trial: a multicountry double-blind automated randomised controlled trial of a smoking cessation decision-aid 'app'

OBJECTIVE

To assess the efficacy of an interactive smoking cessation decision-aid application (pp) compared with a smoking cessation static information app on continuous abstinence.

DESIGN

Automated double-blind randomised controlled trial with 6 months follow-up (2014-2015).

SETTING

Smartphone-based.

PARTICIPANTS

684 participants (daily smokers of cigarettes, 18 years old or over) recruited passively from app stores in the USA, Australia, UK and Singapore, and randomised to one of two sub-apps.

INTERVENTIONS

Behavioural, decision-aid, smartphone application.

MAIN OUTCOMES

Continuous abstinence at 10 days, 1 month, 3 months and 6 months.

RESULTS

Smokers who received the decision-aid app were more likely to be continuously abstinent at 1 month compared with the information-only app (28.5% vs 16.9%; relative risk (RR) 1.68; 95% CI 1.25 to 2.28). The effect was sustained at 3 months (23.8% vs 10.2%; RR 2.08; 95% CI 1.38 to 3.18) and 6 months (10.2% vs 4.8%; RR 2.02; 95% CI 1.08 to 3.81). Participants receiving the decision-aid app were also more likely to have made an informed choice (31.9% vs 19.6%) and have lower decisional conflict (19.5% vs 3.9%).

CONCLUSION

A smartphone decision-aid app with support features significantly increased smoking cessation and informed choice. With an increasing number of smokers attempting to quit, unassisted evidence-based decision-aid apps can provide an effective and user-friendly option to many who are making quit decisions without healthcare professionals.

TRIAL REGISTRATION NUMBER

ACTRN12613000833763.

The Impact of mHealth Interventions: Systematic Review of Systematic Reviews

Background

Mobile phone usage has been rapidly increasing worldwide. mHealth could efficiently deliver high-quality health care, but the evidence supporting its current effectiveness is still mixed.

Objective

We performed a systematic review of systematic reviews to assess the impact or effectiveness of mobile health (mHealth) interventions in different health conditions and in the processes of health care service delivery.

Methods

We used a common search strategy of five major scientific databases, restricting the search by publication date, language, and parameters in methodology and content. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews (AMSTAR) checklist.

Results

The searches resulted in a total of 10,689 articles. Of these, 23 systematic reviews (371 studies; more than 79,665 patients) were included. Seventeen reviews included studies performed in low- and middle-income countries. The studies used diverse mHealth interventions, most frequently text messaging (short message service, SMS) applied to different purposes (reminder, alert, education, motivation, prevention). Ten reviews were rated as low quality (AMSTAR score 0-4), seven were rated as moderate quality (AMSTAR score 5-8), and six were categorized as high quality (AMSTAR score 9-11). A beneficial impact of mHealth was observed in chronic disease management, showing improvement in symptoms and peak flow variability in asthma patients, reducing hospitalizations and improving forced expiratory volume in 1 second; improving chronic pulmonary diseases symptoms; improving heart failure symptoms, reducing deaths and hospitalization; improving glycemic control in diabetes patients; improving blood pressure in hypertensive patients; and reducing weight in overweight and obese patients. Studies also showed a positive impact of SMS reminders in improving attendance rates, with a similar impact to phone call reminders at reduced cost, and improved adherence to tuberculosis and human immunodeficiency virus therapy in some scenarios, with evidence of decrease of viral load.

Conclusions

Although mHealth is growing in popularity, the evidence for efficacy is still limited. In general, the methodological quality of the studies included in the systematic reviews is low. For some fields, its impact is not evident, the results are mixed, or no long-term studies exist. Exceptions include the moderate quality evidence of improvement in asthma patients, attendance rates, and increased smoking abstinence rates. Most studies were performed in high-income countries, implying that mHealth is still at an early stage of development in low-income countries.

Tobacco use disorder and treatment: new challenges and opportunities

Tobacco use remains a global problem, and options for consumers have increased with the development and marketing of e-cigarettes and other new nicotine and tobacco products, such as “heat-not-burn” tobacco and dissolvable tobacco. The increased access to these new products is juxtaposed with expanding public health and clinical intervention options, including mobile technologies and social media. The persistent high rate of tobacco-use disorders among those with psychiatric disorders has gathered increased global attention, including successful approaches to individual treatment and organizational-level interventions. Best outcomes occur when medications are integrated with behavioral therapies and community-based interventions. Addressing tobacco in mental health settings requires training and technical assistance to remove old cultural barriers that restricted interventions. There is still “low-hanging fruit” to be gained in educating on the proper use of nicotine replacement medications, how smoking cessation can change blood levels of specific medications and caffeine, and how to connect with quitlines and mobile technology options. Future innovations are likely to be related to pharmacogenomics and new technologies that are human-, home-, and community-facing.

Text Messaging, Teen Outreach Program, and Sexual Health Behavior: A Cluster Randomized Trial

OBJECTIVES

To consider whether Youth All Engaged! (a text message intervention) intensified the effects of the adolescent pregnancy prevention Teen Outreach Program (control) for youths.

METHODS

In this trial performed in Denver, Colorado, from 2011 to 2014, we randomized 8 Boys & Girls Clubs each of 4 years into 32 clubs per year combinations to ensure each club would serve as a treatment site for 2 years and a control site for 2 years. Control intervention consisted of the Teen Outreach Program only. We enrolled 852 youths (aged 14-18 years), and 632 were retained at follow-up, with analytic samples ranging from 50 to 624 across outcomes. We examined program costs, and whether the intervention increased condom and contraceptive use, access to care, and pregnancy prevention.

RESULTS

Control program costs were $1184 per participant, and intervention costs were an additional $126 per participant (+10.6%). There were no statistically significant differences in primary outcomes for the full sample. Hispanic participants in the intervention condition had fewer pregnancies at follow-up (1.79%) than did those in the control group (6.72%; P = .02).

CONCLUSIONS

Youth All Engaged is feasible, low cost, and could have potential benefits for Hispanic youths.

The effectiveness of smoking cessation, physical activity/diet and alcohol reduction interventions delivered by mobile phones for the prevention of non-communicable diseases: A systematic review of randomised controlled trials

BACKGROUND

We conducted a systematic review to assess the effectiveness of smoking cessation, physical activity (PA), diet, and alcohol reduction interventions delivered by mobile technology to prevent non-communicable diseases (NCDs).

METHODS

We searched for randomised controlled trials (RCTs) of mobile-based NCD prevention interventions using MEDLINE, EMBASE, Global Health, CINAHL (Jan 1990-Jan 2016). Two authors extracted data.

FINDINGS

71 trials were included: smoking cessation (n = 18); PA (n = 15), diet (n = 3), PA and diet (n = 25); PA, diet, and smoking cessation (n = 2); and harmful alcohol consumption (n = 8). 4 trials had low risk of bias. The effect of SMS-based smoking cessation support on biochemically verified continuous abstinence was pooled relative risk [RR] 2.19 [95% CI 1.80-2.68], I2 = 0%) and on verified 7 day point prevalence of smoking cessation was pooled RR 1.51 [95% CI 1.06-2.15], I2 = 0%, with no reported adverse events. There was no difference in peak oxygen intake at 3 months in a trial of an SMS-based PA intervention. The effect of SMS-based diet and PA interventions on: incidence of diabetes was pooled RR 0.67 [95% CI 0.49, 0.90], I2 = 0.0%; end-point weight was pooled MD -0.99Kg [95% CI -3.63, 1.64] I2 = 29.4%; % change in weight was pooled MD -3.1 [95%CI -4.86- -1.3] I2 0.3%; and on triglyceride levels was pooled MD -0.19 mmol/L [95% CI -0.29, -0.08], I2 = 0.0%. The results of other pooled analyses of the effect of SMS-based diet and PA interventions were heterogenous (I2 59-90%). The effects of alcohol reduction interventions were inconclusive.

CONCLUSIONS

Smoking cessation support delivered by SMS increases quitting rates. Trials of PA interventions reporting outcomes ≥3 months showed no benefits. There were at best modest benefits of diet and PA interventions. The effects of the most promising SMS-based smoking, diet and PA interventions on morbidity and mortality in high-risk groups should be established in adequately powered RCTs.

Feasibility of a proactive text messaging intervention for smokers in community health centers

Background

Few smokers receive evidence-based cessation services during primary care visits.

Objective

We aimed to assess the feasibility of a proactive text messaging program for primary care patients who smoke.

Methods

We used electronic health records to identify smokers who had a mobile phone number listed from two community health centers in Massachusetts. Between March 2014 and June 2015, patients were screened by their primary care physician and then sent a proactive text message inviting them to enroll by texting back. Patients who opted in were asked about their readiness to quit. The text message program included messages from the QuitNowTXT library and novel content for smokers who were not ready to quit.

Results

Among 949 eligible smokers, 88 (9.3%) enrolled after receiving a single proactive text message. Compared with those who did not enroll, enrollees were more often female (54/88, 61% vs 413/861, 48.0%, P=.02), but otherwise did not differ in age, race, insurance status, or comorbidities. In all, 28% (19/67) of enrollees reported they were not ready to quit in the next 30 days, 61% (41/67) were ready to quit, and 11% (7/67) already quit. The median time in the program was 9 days (interquartile range 2-32 days). Of current smokers, 25% (15/60) sent one or more keyword requests to the server. These did not differ by readiness to quit.

Conclusions

A proactively delivered text messaging program targeting primary care patients who smoke was feasible and engaged both smokers ready to quit and those not ready to quit. This method shows promise as part of a population health model for addressing tobacco use outside of the primary care office.

A Randomized Trial of Text Messaging for Smoking Cessation in Pregnant Women

INTRODUCTION

There is a need for innovation in both the enrollment of pregnant smokers in smoking cessation treatment programs and in the types of treatments offered. The study tests whether an interactive and intensive text messaging program, Quit4baby, can promote smoking cessation for pregnant women already enrolled in a health text messaging program, Text4baby.

METHODS

Between July 2015 and February 2016, a total of 35,957 recruitment text messages were sent to Text4baby subscribers. Eligible pregnant smokers were enrolled and randomized to receive Text4baby (control) or Text4baby and Quit4baby (intervention; N=497). Participants were surveyed at 1 month, 3 months, and 6 months post-enrollment, and saliva samples were collected at 3 months for biochemical verification of smoking status. Data were collected from 2015 to 2016 and analyzed in 2016.

RESULTS

Using an intention-to-treat analysis, 28.80% of the intervention group and 15.79% of the control group reported not smoking in the past 7 days at 1 month (p<0.01), and 35.20% of the intervention group and 22.67% of the control group reported not smoking in the past 7 days at 3 months (p<0.01). Biochemical verification of smoking status at 3 months indicated no significant differences between groups (15.60% in the intervention group and 10.93% in the control group [p=0.13]), although significant differences favoring the intervention were found for older smokers (p<0.05) and for those who enrolled in their second or third trimester of pregnancy (p<0.05). Self-report of late pregnancy 7- and 30-day point prevalence abstinence favored the intervention group (p<0.001, p<0.01). No significant differences were observed at the 6-month follow-up or in the postpartum period.

CONCLUSIONS

Results provide limited support of the efficacy of the Quit4baby text messaging program in the short term and late in pregnancy, but not in the postpartum period.

An integrated digital/clinical approach to smoking cessation in lung cancer screening: study protocol for a randomized controlled trial

Background

Delivering effective tobacco dependence treatment that is feasible within lung cancer screening (LCS) programs is crucial for realizing the health benefits and cost savings of screening. Large-scale trials and systematic reviews have demonstrated that digital cessation interventions (i.e. web-based and text message) are effective, sustainable over the long-term, scalable, and cost-efficient. Use of digital technologies is commonplace among older adults, making this a feasible approach within LCS programs. Use of cessation treatment has been improved with models that proactively connect smokers to treatment rather than passive referrals. Proactive referral to cessation treatment has been advanced through healthcare systems changes such as modifying the electronic health record to automatically link smokers to treatment.

Methods

This study evaluates the impact of a proactive enrollment strategy that links LCS-eligible smokers with an evidence-based intervention comprised of a web-based (WEB) program and integrated text messaging (TXT) in a three-arm randomized trial with repeated measures at one, three, six, and 12 months post randomization. The primary outcome is biochemically confirmed abstinence at 12 months post randomization. We will randomize 1650 smokers who present for a clinical LCS to: (1) a usual care control condition (UC) which consists of Ask–Advise–Refer; (2) a digital (WEB + TXT) cessation intervention; or (3) a digital cessation intervention combined with tobacco treatment specialist (TTS) counseling (WEB + TXT + TTS).

Discussion

The scalability and sustainability of a digital intervention may represent the most cost-effective and feasible approach for LCS programs to proactively engage large numbers of smokers in effective cessation treatment. We will also evaluate the impact and cost-effectiveness of adding proven clinical intervention provided by a TTS. We expect that a combined digital/clinical intervention will yield higher quit rates than digital alone, but that it may not be as cost-effective or feasible for LCS programs to implement. This study is innovative in its use of interoperable, digital technologies to deliver a sustainable, scalable, high-impact cessation intervention and to facilitate its integration within clinical practice. It will add to the growing knowledge base about the overall effectiveness of digital interventions and their role in the healthcare delivery system.

Trial registration

ClinicalTrials.gov, NCT03084835. Registered on 9 March 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2312-x) contains supplementary material, which is available to authorized users.

Tobacco cessation interventions for young people

BACKGROUND

Most tobacco control programmes for adolescents are based around prevention of uptake, but teenage smoking is still common. It is unclear if interventions that are effective for adults can also help adolescents to quit. This is the update of a Cochrane Review first published in 2006.

OBJECTIVES

To evaluate the effectiveness of strategies that help young people to stop smoking tobacco.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register in June 2017. This includes reports for trials identified in CENTRAL, MEDLINE, Embase and PsyclNFO.

SELECTION CRITERIA

We included individually and cluster-randomized controlled trials recruiting young people, aged under 20 years, who were regular tobacco smokers. We included any interventions for smoking cessation; these could include pharmacotherapy, psycho-social interventions and complex programmes targeting families, schools or communities. We excluded programmes primarily aimed at prevention of uptake. The primary outcome was smoking status after at least six months' follow-up among those who smoked at baseline.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of candidate trials and extracted data. We evaluated included studies for risk of bias using standard Cochrane methodology and grouped them by intervention type and by the theoretical basis of the intervention. Where meta-analysis was appropriate, we estimated pooled risk ratios using a Mantel-Haenszel fixed-effect method, based on the quit rates at six months' follow-up.

MAIN RESULTS

Forty-one trials involving more than 13,000 young people met our inclusion criteria (26 individually randomized controlled trials and 15 cluster-randomized trials). We judged the majority of studies to be at high or unclear risk of bias in at least one domain. Interventions were varied, with the majority adopting forms of individual or group counselling, with or without additional self-help materials to form complex interventions. Eight studies used primarily computer or messaging interventions, and four small studies used pharmacological interventions (nicotine patch or gum, or bupropion). There was evidence of an intervention effect for group counselling (9 studies, risk ratio (RR) 1.35, 95% confidence interval (CI) 1.03 to 1.77), but not for individual counselling (7 studies, RR 1.07, 95% CI 0.83 to 1.39), mixed delivery methods (8 studies, RR 1.26, 95% CI 0.95 to 1.66) or the computer or messaging interventions (pooled RRs between 0.79 and 1.18, 9 studies in total). There was no clear evidence for the effectiveness of pharmacological interventions, although confidence intervals were wide (nicotine replacement therapy 3 studies, RR 1.11, 95% CI 0.48 to 2.58; bupropion 1 study RR 1.49, 95% CI 0.55 to 4.02). No subgroup precluded the possibility of a clinically important effect. Studies of pharmacotherapies reported some adverse events considered related to study treatment, though most were mild, whereas no adverse events were reported in studies of behavioural interventions. Our certainty in the findings for all comparisons is low or very low, mainly because of the clinical heterogeneity of the interventions, imprecision in the effect size estimates, and issues with risk of bias.

AUTHORS' CONCLUSIONS

There is limited evidence that either behavioural support or smoking cessation medication increases the proportion of young people that stop smoking in the long-term. Findings are most promising for group-based behavioural interventions, but evidence remains limited for all intervention types. There continues to be a need for well-designed, adequately powered, randomized controlled trials of interventions for this population of smokers.

Engagement Within a Mobile Phone-Based Smoking Cessation Intervention for Adolescents and its Association With Participant Characteristics and Outcomes

BACKGROUND

Although mobile phone-delivered smoking cessation programs are a promising way to promote smoking cessation among adolescents, little is known about how adolescents might actually use them.

OBJECTIVE

The aim of this study was to determine adolescents' trajectories of engagement with a mobile phone-delivered smoking cessation program over time and the associations these trajectories have with baseline characteristics and treatment outcomes.

METHODS

We performed secondary data analysis on a dataset from a study that compared a mobile phone-delivered integrated smoking cessation and alcohol intervention with a smoking cessation only intervention for adolescents recruited in vocational and upper secondary school classes (N=1418). Throughout the 3-month intervention, participants in both intervention groups received one text message prompt per week that either assessed smoking-related target behaviors or encouraged participation in a quiz or a message contest. Sequence analyses were performed to identify engagement trajectories. Analyses were conducted to identify predictors of engagement trajectory and associations between engagement trajectories and treatment outcomes.

RESULTS

Three engagement trajectories emerged: (1) stable engagement (646/1418, 45.56%), (2) decreasing engagement (501/1418, 35.33%), and (3) stable nonengagement (271/1418, 19.11%). Adolescents who were younger, had no immigrant background, perceived more benefits of quitting smoking, and reported binge drinking preceding the baseline assessment were more likely to exhibit stable engagement. Due to different reach of more engaged and less engaged participants at follow-up, three statistical models (complete-cases, last-observation-carried-forward, and multiple imputation) for the associations of engagement trajectory and smoking outcome were tested. For 7-point smoking abstinence, no association was revealed to be statistically significant over all three models. However, decreasing engagement with the program was associated over all three models, with greater reductions in daily tobacco use than nonengagement.

CONCLUSIONS

The majority of tobacco-smoking adolescents engaged extensively with a mobile phone-based smoking cessation program. However, not only stable engagement but also decreasing engagement with a program might be an indicator of behavioral change. Measures to avoid nonengagement among adolescents appear especially necessary for older smokers with an immigrant background who do not drink excessively. In addition, future studies should not only examine the use of specific program components but also users' engagement trajectories to better understand the mechanisms behind behavioral change.

The Role of Text Messaging in Cardiovascular Risk Factor Optimization

PURPOSE OF REVIEW

Many cases of CVD may be avoidable through lowering behavioural risk factors such as smoking and physical inactivity. Mobile health (mHealth) provides a novel opportunity to deliver cardiovascular prevention programs in a format that is potentially scalable. Here, we provide an overview of text messaging-based mHealth interventions in cardiovascular prevention.

RECENT FINDINGS

Text messaging-based interventions appear effective on a range of behavioural risk factors and can effect change on multiple risk factors-e.g. smoking, weight, blood pressure-simultaneously. For many texting studies, there are challenges in interpretation as many texting interventions are part of larger complex interventions making it difficult to determine the benefits of the separate components. Whilst there is evidence for text messaging improving cardiovascular risk factor levels in the short-term, future studies are needed to examine the durability of these effects and whether they can be translated to improvements in clinical care and outcomes.

User Participation and Engagement With the See Me Smoke-Free mHealth App: Prospective Feasibility Trial

BACKGROUND

The See Me Smoke-Free (SMSF) mobile health (mHealth) app was developed to help women quit smoking by targeting concerns about body weight, body image, and self-efficacy through cognitive behavioral techniques and guided imagery audio files addressing smoking, diet, and physical activity. A feasibility trial found associations between SMSF usage and positive treatment outcomes. This paper reports a detailed exploration of program use among eligible individuals consenting to study participation and completing the baseline survey (participants) and ineligible or nonconsenting app installers (nonparticipants), as well as the relationship between program use and treatment outcomes.

OBJECTIVE

The aim of this study was to determine whether (1) participants were more likely to set quit dates, be current smokers, and report higher levels of smoking at baseline than nonparticipants; (2) participants opened the app and listened to audio files more frequently than nonparticipants; and (3) participants with more app usage had a higher likelihood of self-reported smoking abstinence at follow up.

METHODS

The SMSF feasibility trial was a single arm, within-subjects, prospective cohort study with assessments at baseline and 30 and 90 days post enrollment. The SMSF app was deployed on the Google Play Store for download, and basic profile characteristics were obtained for all app installers. Additional variables were assessed for study participants. Participants were prompted to use the app daily during study participation. Crude differences in baseline characteristics between trial participants and nonparticipants were evaluated using t tests (continuous variables) and Fisher exact tests (categorical variables). Exact Poisson tests were used to assess group-level differences in mean usage rates over the full study period using aggregate Google Analytics data on participation and usage. Negative binomial regression models were used to estimate associations of app usage with participant baseline characteristics after adjustment for putative confounders. Associations between app usage and self-reported smoking abstinence were assessed using separate logistic regression models for each outcome measure.

RESULTS

Participants (n=151) were more likely than nonparticipants (n=96) to report female gender (P<.02) and smoking in the 30 days before enrollment (P<.001). Participants and nonparticipants opened the app and updated quit dates at the same average rate (rate ratio [RR] 0.98; 95% CI 0.92-1.04; P=.43), but participants started audio files (RR 1.07; 95% CI 1.00-1.13; P<.04) and completed audio files (RR 1.11; 95% CI 1.03-1.18; P<.003) at significantly higher rates than nonparticipants. Higher app usage among participants was positively associated with some smoking cessation outcomes.

CONCLUSIONS

This study suggests potential efficacy of the SMSF app, as increased usage was generally associated with higher self-reported smoking abstinence. A planned randomized controlled trial will assess the SMSF app's efficacy as an intervention tool to help women quit smoking.

Assessing the National Cancer Institute's SmokefreeMOM Text-Messaging Program for Pregnant Smokers: Pilot Randomized Trial

BACKGROUND

Automated text messages on mobile phones have been found to be effective for smoking cessation in adult smokers.

OBJECTIVE

This study aims to test the acceptability and feasibility of SmokefreeMOM, a national smoking cessation text-messaging program for pregnant smokers.

METHODS

Participants were recruited from prenatal care and randomized to receive SmokefreeMOM (n=55), an automated smoking cessation text-messaging program, or a control text message quitline referral (n=44). Participants were surveyed by phone at baseline and at 1 month and 3 months after enrollment.

RESULTS

Results indicate that the SmokefreeMOM program was highly rated overall and rated more favorably than the control condition in its helpfulness at 3-month follow-up (P<.01) and in its frequency of messaging at both 1-month and 3-month follow-ups (P<.001, P<.01, respectively). Despite the presence of technical problems, the vast majority of intervention participants read all program messages, and few participants unsubscribed from the program. There were no significant differences between groups on the use of extra treatment resources or on smoking-related outcomes. However, at the 3-month follow-up, some outcomes favored the intervention group.

CONCLUSIONS

SmokefreeMOM is acceptable for pregnant smokers. It is recommended that SmokefreeMOM be further refined and evaluated.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02412956; https://clinicaltrials.gov/ct2/show/NCT02412956 (Archived by WebCite at http://www.webcitation.org/6tcmeRnbC).

Feasibility of biochemical verification in a web-based smoking cessation study

BACKGROUND AND AIMS

Cogent arguments have been made against the need for biochemical verification in population-based studies with low-demand characteristics. Despite this fact, studies involving digital interventions (low-demand) are often required in peer review to report biochemically verified abstinence. To address this discrepancy, we examined the feasibility and costs of biochemical verification in a web-based study conducted with a national sample.

METHODS

Participants were 600U.S. adult current smokers who registered on a web-based smoking cessation program and completed surveys at baseline and 3months. Saliva sampling kits were sent to participants who reported 7-day abstinence at 3months, and analyzed for cotinine.

RESULTS

The response rate at 3-months was 41.2% (n=247): 93 participants reported 7-day abstinence (38%) and were mailed a saliva kit (71% returned). The discordance rate was 36.4%. Participants with discordant responses were more likely to report 3-month use of nicotine replacement therapy or e-cigarettes than those with concordant responses (79.2% vs. 45.2%, p=0.007). The total cost of saliva sampling was $8280 ($125/sample).

CONCLUSIONS

Biochemical verification was both time- and cost-intensive, and yielded a relatively small number of samples due to low response rates and use of other nicotine products during the follow-up period. There was a high rate of discordance of self-reported abstinence and saliva testing. Costs for data collection may be prohibitive for studies with large sample sizes or limited budgets. Our findings echo previous statements that biochemical verification is not necessary in population-based studies, and add evidence specific to technology-based studies.

Smartphones and e-tablets in perioperative medicine

Smartphones and electronic tablets (e-tablets) have become ubiquitous devices. Their ease of use, smartness, accessibility, mobility and connectivity create unique opportunities to improve quality of surgical care from prehabilitation to rehabilitation. Before surgery, digital applications (Apps), serious games and text messaging may help for a better control of risk factors (hypertension, overweight), for smoking cessation, and for optimizing adherence to preoperative recommendations (e.g., regarding anticoagulation or antihypertensive treatments). During surgery, Apps may help to rationalize fluid management and estimate blood loss. After surgery, smartphones and/or connected sensors (pulse oximeter, adhesive path, electronic tattoo, bioimpedance necklace) can be used to monitor body temperature, heart rate, heart rate variability (detection of cardiac arrhythmia), respiratory rate, arterial oxygen saturation and thoracic fluid content. Therefore, these tools have potential for the early detection of infectious, cardiac and respiratory complications in the wards and from home. When connected to echo probes, smartphones and e-tablets can also be used as ultrasound devices during central venous catheter insertion, for peripheral nerve blocks, and to perform echocardiography in patients developing cardiac complications. Finally, electronic checklists now exist as Apps to enhance communication between patients and healthcare professionals, and to track and record step by step each element of the surgical journey. Studies are now urgently needed to investigate whether this digital revolution can translate into a better outcome, an earlier detection of postoperative complications, a decrease in hospital readmissions and in health care costs.

Internet-based interventions for smoking cessation

BACKGROUND

Tobacco use is estimated to kill 7 million people a year. Nicotine is highly addictive, but surveys indicate that almost 70% of US and UK smokers would like to stop smoking. Although many smokers attempt to give up on their own, advice from a health professional increases the chances of quitting. As of 2016 there were 3.5 billion Internet users worldwide, making the Internet a potential platform to help people quit smoking.

OBJECTIVES

To determine the effectiveness of Internet-based interventions for smoking cessation, whether intervention effectiveness is altered by tailoring or interactive features, and if there is a difference in effectiveness between adolescents, young adults, and adults.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, which included searches of MEDLINE, Embase and PsycINFO (through OVID). There were no restrictions placed on language, publication status or publication date. The most recent search was conducted in August 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs). Participants were people who smoked, with no exclusions based on age, gender, ethnicity, language or health status. Any type of Internet intervention was eligible. The comparison condition could be a no-intervention control, a different Internet intervention, or a non-Internet intervention. To be included, studies must have measured smoking cessation at four weeks or longer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed and extracted data. We extracted and, where appropriate, pooled smoking cessation outcomes of six-month follow-up or more, reporting short-term outcomes narratively where longer-term outcomes were not available. We reported study effects as a risk ratio (RR) with a 95% confidence interval (CI).We grouped studies according to whether they (1) compared an Internet intervention with a non-active control arm (e.g. printed self-help guides), (2) compared an Internet intervention with an active control arm (e.g. face-to-face counselling), (3) evaluated the addition of behavioural support to an Internet programme, or (4) compared one Internet intervention with another. Where appropriate we grouped studies by age.

MAIN RESULTS

We identified 67 RCTs, including data from over 110,000 participants. We pooled data from 35,969 participants.There were only four RCTs conducted in adolescence or young adults that were eligible for meta-analysis.Results for trials in adults: Eight trials compared a tailored and interactive Internet intervention to a non-active control. Pooled results demonstrated an effect in favour of the intervention (RR 1.15, 95% CI 1.01 to 1.30, n = 6786). However, statistical heterogeneity was high (I2 = 58%) and was unexplained, and the overall quality of evidence was low according to GRADE. Five trials compared an Internet intervention to an active control. The pooled effect estimate favoured the control group, but crossed the null (RR 0.92, 95% CI 0.78 to 1.09, n = 3806, I2 = 0%); GRADE quality rating was moderate. Five studies evaluated an Internet programme plus behavioural support compared to a non-active control (n = 2334). Pooled, these studies indicated a positive effect of the intervention (RR 1.69, 95% CI 1.30 to 2.18). Although statistical heterogeneity was substantial (I2 = 60%) and was unexplained, the GRADE rating was moderate. Four studies evaluated the Internet plus behavioural support compared to active control. None of the studies detected a difference between trial arms (RR 1.00, 95% CI 0.84 to 1.18, n = 2769, I2 = 0%); GRADE rating was moderate. Seven studies compared an interactive or tailored Internet intervention, or both, to an Internet intervention that was not tailored/interactive. Pooled results favoured the interactive or tailored programme, but the estimate crossed the null (RR 1.10, 95% CI 0.99 to 1.22, n = 14,623, I2 = 0%); GRADE rating was moderate. Three studies compared tailored with non-tailored Internet-based messages, compared to non-tailored messages. The tailored messages produced higher cessation rates compared to control, but the estimate was not precise (RR 1.17, 95% CI 0.97 to 1.41, n = 4040), and there was evidence of unexplained substantial statistical heterogeneity (I2 = 57%); GRADE rating was low.Results should be interpreted with caution as we judged some of the included studies to be at high risk of bias.

AUTHORS' CONCLUSIONS

The evidence from trials in adults suggests that interactive and tailored Internet-based interventions with or without additional behavioural support are moderately more effective than non-active controls at six months or longer, but there was no evidence that these interventions were better than other active smoking treatments. However some of the studies were at high risk of bias, and there was evidence of substantial statistical heterogeneity. Treatment effectiveness in younger people is unknown.

MEMO: an mHealth intervention to prevent the onset of depression in adolescents: a double-blind, randomised, placebo-controlled trial

BACKGROUND

Depression often starts in adolescence making it an ideal time to intervene. We developed a universal cognitive behavioural therapy-based programme (MEMO CBT) to be delivered via multimedia mobile phone messages for teens.

METHODS

We conducted a prospective multicentre, randomised, placebo-controlled superiority trial in 15 high schools in Auckland, New Zealand, comparing MEMO CBT with a control programme [MEMO control] matched for intensity and type of message but with alternative content not targeting depression. The primary outcome was the change in score on the Children's Depression Rating Scale-Revised from baseline to 12 months. Secondary outcomes included the change in scores in the self-reported Reynold's Adolescent Depression Rating Scale-Second Edition, the Moods and Feelings Questionnaire, suicidal ideation using selected items from the Youth Risk Behaviour Survey, the Pediatric Quality of Life questionnaire, 12-month period prevalence of the diagnosis of depressive disorder using the Kiddie-Schedule for Affective Disorders and Schizophrenia, and students' ratings of their satisfaction with the programme.

RESULTS

Eight hundred and fifty-five students (13-17 years old, mean 14.3 years) were randomly assigned to MEMO CBT (426) or to MEMO Control (429). Participants (68% female) had a mean CDRS-R at baseline of 21.5 (SD: 5). Overall 394 (93%) from the intervention group and 392 (91%) from the control group were followed up at 12 months. At the end of the intervention (approximately 9 weeks) the mean CDRS-R scores were 20.8 in the intervention group versus 20.4 in the control group, and at 12 months they were 22.4 versus 22.4 (p value for difference in change from baseline = 0.3). There was no obvious association between the amount of the intervention viewed by participants and outcomes.

CONCLUSIONS

There was no evidence of benefit from the mobile phone CBT intervention compared with a control programme. Universal depression prevention remains a challenge.

Text messaging (SMS) as a tool to facilitate weight loss and prevent metabolic deterioration in clinically healthy overweight and obese subjects: a randomised controlled trial

OBJECTIVE

To examine whether SMS text messaging facilitates a reduction of weight and waist circumference (WC) and favourable changes in lipid profile and insulin levels in clinically healthy overweight and obese subjects.

DESIGN

A randomised controlled trial.

SETTING AND INTERVENTION

Primary care health centre in Riga, Latvia. Text messaging once in two weeks.

SUBJECTS

A total of 123 overweight and obese men and women aged 30-45 years with no cardiovascular diseases (CVDs) or diabetes.

MAIN OUTCOME MEASURES

changes in anthropometric parameters (weight, WC, body mass index (BMI)) and biochemical parameters (lipids, fasting glucose and insulin).

RESULTS

We found a statistically significant decrease in weight (2.4%), BMI and WC (4.8%) in the intervention group, while the control group showed a statistically non-significant increase in weight and BMI and decrease in WC. Between group results obtained over the course of a year showed statistically significant mean differences between weight (-3.4 kg (95% CI -5.5, -1.3)), BMI kg/m² (-1.14 (95% CI -1.9, -0.41)), WC (-4.6 cm (95% CI -6.8, -2.3)), hip circumference (-4.0 cm (95% CI -5.9, -2.0)) and fasting insulin (2.43 μU/ml (95% CI 0.6, 4.3)). Mean differences of changes in glucose and lipid levels were statistically non significant: fasting glucose (-0.01 mmol/l (95% CI -0.19, 0.17)), TC mmol/l (-0.04 mmol/l (95% CI -0.29, 0.21)), HDL-C (0.14 mmol/l (95% CI -0.65, 0.09)), LDL-C (-0.02 mmol/l (95% CI -0.22, 0.18)) and TG (0.23 mmol/l (95% CI -0.06, 0.52)).

CONCLUSIONS

SMS messaging in clinically healthy overweight and obese subjects facilitates a slight decrease in weight, BMI and WC. It is anticipated that the implications of this strategy might facilitate the design of preventive and promotive strategies among high risk groups in Latvia.

Smartphone Ownership Among US Adult Cigarette Smokers: 2014 Health Information National Trends Survey (HINTS) Data

Background

Despite increasing interest in smartphone apps as a platform for delivery of tobacco cessation interventions, no previous studies have evaluated the prevalence and characteristics of smokers who can access smartphone-delivered interventions.

Objective

To guide treatment development in this new platform and to evaluate disparities in access to smartphone-delivered interventions, we examined associations of smartphone ownership with demographics, tobacco use and thoughts about quitting, other health behaviors, physical and mental health, health care access, and Internet and technology utilization using a nationally representative sample of US adult smokers.

Methods

Data were from the National Cancer Institute’s 2014 Health Information National Trends Survey 4 (HINTS 4), Cycle 4. This mailed survey targeted noninstitutionalized individuals aged 18 years or older using two-stage stratified random sampling. For this analysis, we restricted the sample to current smokers with complete data on smartphone ownership (n=479).

Results

Nearly two-thirds (weighted percent=63.8%, 248/479) of smokers reported owning a smartphone. Those who were younger (P<.001), employed (P=.002), never married (P=.002), and had higher education (P=.002) and income (P<.001) had the highest rates of ownership. Smartphone owners did not differ from nonowners on frequency of smoking, recent quit attempts, or future plans to quit smoking, although they reported greater belief in the benefits of quitting (P=.04). Despite being equally likely to be overweight or obese, smartphone owners reported greater fruit and vegetable consumption (P=.03) and were more likely to report past-year efforts to increase exercise (P=.001) and to lose weight (P=.02). No differences in health care access and utilization were found. Smartphone owners reported better physical and mental health in several domains and higher access to and utilization of technology and the Internet, including for health reasons.

Conclusions

Smartphone ownership among smokers mirrors many trends in the general population, including the overall rate of ownership and the association with younger age and higher socioeconomic status. Apps for smoking cessation could potentially capitalize on smartphone owners’ efforts at multiple health behavior changes and interest in communicating with health care providers via technology. These data also highlight the importance of accessible treatment options for smokers without smartphones in order to reach smokers with the highest physical and mental health burden and prevent worsening of tobacco-related health disparities as interventions move to digital platforms.

Text Messaging Interventions on Cancer Screening Rates: A Systematic Review

BACKGROUND

Despite high-quality evidence demonstrating that screening reduces mortality from breast, cervical, colorectal, and lung cancers, a substantial portion of the population remains inadequately screened. There is a critical need to identify interventions that increase the uptake and adoption of evidence-based screening guidelines for preventable cancers at the community practice level. Text messaging (short message service, SMS) has been effective in promoting behavioral change in various clinical settings, but the overall impact and reach of text messaging interventions on cancer screening are unknown.

OBJECTIVE

The objective of this systematic review was to assess the effect of text messaging interventions on screening for breast, cervical, colorectal, and lung cancers.

METHODS

We searched multiple databases for studies published between the years 2000 and 2017, including PubMed, EMBASE, and the Cochrane Library, to identify controlled trials that measured the effect of text messaging on screening for breast, cervical, colorectal, or lung cancers. Study quality was evaluated using the Cochrane risk of bias tool.

RESULTS

Our search yielded 2238 citations, of which 31 underwent full review and 9 met inclusion criteria. Five studies examined screening for breast cancer, one for cervical cancer, and three for colorectal cancer. No studies were found for lung cancer screening. Absolute screening rates for individuals who received text message interventions were 0.6% to 15.0% higher than for controls. Unadjusted relative screening rates for text message recipients were 4% to 63% higher compared with controls.

CONCLUSIONS

Text messaging interventions appear to moderately increase screening rates for breast and cervical cancer and may have a small effect on colorectal cancer screening. Benefit was observed in various countries, including resource-poor and non-English-speaking populations. Given the paucity of data, additional research is needed to better quantify the effectiveness of this promising intervention.

Smoking Cessation Support by Text Message During Pregnancy: A Qualitative Study of Views and Experiences of the MiQuit Intervention

Introduction:

SMS text messaging is increasingly used for delivering smoking cessation support and pilot studies suggest this may also be useful in pregnancy. This study explores the views of women who received a tailored text messaging cessation intervention (MiQuit) during pregnancy, focusing on acceptability, perceived impact, and suggestions for improvements.

Methods:

Semi-structured interviews were undertaken with 15 purposively sampled women who had received the MiQuit intervention during pregnancy as part of a randomized controlled trial. Data were analyzed thematically.

Results:

Three main themes were identified: “impact”, “approach,” and “optimization.” Participants described an immediate, yet often short-lived, impact from the texts that distracted and delayed them from smoking and they perceived that texts focusing on the development of and risk to the baby generated more enduring emotional impacts. Most women found receiving support by text preferable to face-to-face cessation support, with participants citing the greater regularity, convenience, and non-judgmental style as particular advantages. Participants would have preferred a longer support program with increased tailoring, greater customization of text timings and consideration of cutting down as an alternative/precursor to quitting.

Conclusion:

Pregnancy-specific cessation support by text message was well received and participants considered the support increased their motivation to stop smoking. The focus on the developing baby, the regularity of contact and the provision of gentle, encouraging messages were highlighted as particularly important elements of the program.

Implications:

This study adds further evidence to the acceptability and perceived positive impact of text-messaging programs in aiding smoking cessation in pregnancy. The findings indicate that for some women, this type of support is preferable to face-to-face methods and could be utilized by health professionals, either in addition to current methods or as an alternative. This study is also relevant to researchers developing health-related text programs to consider participants’ desire for greater tailoring. Further research is required into adapting and continuing text support for women postpartum.

Using computer, mobile and wearable technology enhanced interventions to reduce sedentary behaviour: a systematic review and meta-analysis

Background

High levels of sedentary behaviour (SB) are associated with negative health consequences. Technology enhanced solutions such as mobile applications, activity monitors, prompting software, texts, emails and websites are being harnessed to reduce SB. The aim of this paper is to evaluate the effectiveness of such technology enhanced interventions aimed at reducing SB in healthy adults and to examine the behaviour change techniques (BCTs) used.

Methods

Five electronic databases were searched to identify randomised-controlled trials (RCTs), published up to June 2016. Interventions using computer, mobile or wearable technologies to facilitate a reduction in SB, using a measure of sedentary time as an outcome, were eligible for inclusion. Risk of bias was assessed using the Cochrane Collaboration’s tool and interventions were coded using the BCT Taxonomy (v1).

Results

Meta-analysis of 15/17 RCTs suggested that computer, mobile and wearable technology tools resulted in a mean reduction of −41.28 min per day (min/day) of sitting time (95% CI -60.99, −21.58, I2 = 77%, n = 1402), in favour of the intervention group at end point follow-up. The pooled effects showed mean reductions at short (≤ 3 months), medium (>3 to 6 months), and long-term follow-up (>6 months) of −42.42 min/day, −37.23 min/day and −1.65 min/day, respectively. Overall, 16/17 studies were deemed as having a high or unclear risk of bias, and 1/17 was judged to be at a low risk of bias. A total of 46 BCTs (14 unique) were coded for the computer, mobile and wearable components of the interventions. The most frequently coded were “prompts and cues”, “self-monitoring of behaviour”, “social support (unspecified)” and “goal setting (behaviour)”.

Conclusion

Interventions using computer, mobile and wearable technologies can be effective in reducing SB. Effectiveness appeared most prominent in the short-term and lessened over time. A range of BCTs have been implemented in these interventions. Future studies need to improve reporting of BCTs within interventions and address the methodological flaws identified within the review through the use of more rigorously controlled study designs with longer-term follow-ups, objective measures of SB and the incorporation of strategies to reduce attrition.

Trial registration

The review protocol was registered with PROSPERO: CRD42016038187

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-017-0561-4) contains supplementary material, which is available to authorized users.

Feasibility and Acceptability of a Text Message-Based Smoking Cessation Program for Young Adults in Lima, Peru: Pilot Study

BACKGROUND

In Peru's urban communities, tobacco smoking generally starts during adolescence and smoking prevalence is highest among young adults. Each year, many attempt to quit, but access to smoking cessation programs is limited. Evidence-based text messaging smoking cessation programs are an alternative that has been successfully implemented in high-income countries, but not yet in middle- and low-income countries with limited tobacco control policies.

OBJECTIVE

The objective was to assess the feasibility and acceptability of an short message service (SMS) text message-based cognitive behavioral smoking cessation program for young adults in Lima, Peru.

METHODS

Recruitment included using flyers and social media ads to direct young adults interested in quitting smoking to a website where interested participants completed a Google Drive survey. Inclusion criteria were being between ages 18 and 25 years, smoking at least four cigarettes per day at least 6 days per week, willing to quit in the next 30 days, owning a mobile phone, using SMS text messaging at least once in past year, and residing in Lima. Participants joined one of three phases: (1) focus groups and in-depth interviews whose feedback was used to develop the SMS text messages, (2) validating the SMS text messages, and (3) a pilot of the SMS text message-based smoking cessation program to test its feasibility and acceptability among young adults in Lima. The outcome measures included adherence to the SMS text message-based program, acceptability of content, and smoking abstinence self-report on days 2, 7, and 30 after quitting.

RESULTS

Of 639 participants who completed initial online surveys, 42 met the inclusion criteria and 35 agreed to participate (focus groups and interviews: n=12; validate SMS text messages: n=8; program pilot: n=15). Common quit practices and beliefs emerged from participants in the focus groups and interviews informed the content, tone, and delivery schedule of the messages used in the SMS text message smoking cessation program. A small randomized controlled pilot trial was performed to test the program's feasibility and acceptability; nine smokers were assigned to the SMS text message smoking cessation program and six to a SMS text message nutrition program. Participant retention was high: 93% (14/15) remained until day 30 after quit day. In all, 56% of participants (5/9) in the SMS text message smoking cessation program reported remaining smoke-free until day 30 after quit day and 17% of participants (1/6) in the SMS text message nutrition program reported remaining smoke-free during the entire program. The 14 participants who completed the pilot reported that they received valuable health information and approved the delivery schedule of the SMS text messages.

CONCLUSIONS

This study provides initial evidence that a SMS text message smoking cessation program is feasible and acceptable for young adults residing in Lima.

Tobacco smoking: Health impact, prevalence, correlates and interventions

BACKGROUND AND OBJECTIVES

Despite reductions in prevalence in recent years, tobacco smoking remains one of the main preventable causes of ill-health and premature death worldwide. This paper reviews the extent and nature of harms caused by smoking, the benefits of stopping, patterns of smoking, psychological, pharmacological and social factors that contribute to uptake and maintenance of smoking, the effectiveness of population and individual level interventions aimed at combatting tobacco smoking, and the effectiveness of methods used to reduce the harm caused by continued use of tobacco or nicotine in some form.

RESULTS AND CONCLUSIONS

Smoking behaviour is maintained primarily by the positive and negative reinforcing properties of nicotine delivered rapidly in a way that is affordable and palatable, with the negative health consequences mostly being sufficiently uncertain and distant in time not to create sufficient immediate concern to deter the behaviour. Raising immediate concerns about smoking by tax increases, social marketing and brief advice from health professionals can increase the rate at which smokers try to stop. Providing behavioural and pharmacological support can improve the rate at which those quit attempts succeed. Implementing national programmes containing these components are effective in reducing tobacco smoking prevalence and reducing smoking-related death and disease.

MapMySmoke: feasibility of a new quit cigarette smoking mobile phone application using integrated geo-positioning technology, and motivational messaging within a primary care setting

Background

Approximately 11,000 people die in Scotland each year as a result of smoking-related causes. Quitting smoking is relatively easy; maintaining a quit attempt is a very difficult task with success rates for unaided quit attempts stubbornly remaining in the single digits. Pharmaceutical treatment can improve these rates by lowering the overall reward factor of nicotine. However, these and related nicotine replacement therapies do not operate on, or address, the spatial and contextual aspects of smoking behaviour. With the ubiquity of smartphones that can log spatial, quantitative and qualitative data related to smoking behaviour, there exists a person-centred clinical opportunity to support smokers attempting to quit by first understanding their smoking behaviour and subsequently sending them dynamic messages to encourage health behaviour change within a situational context.

Methods

We have built a smartphone app—MapMySmoke—that works on Android and iOS platforms. The deployment of this app within a clinical National Health Service (NHS) setting has two distinct phases: (1) a 2-week logging phase where pre-quit patients log all of their smoking and craving events; and (2) a post-quit phase where users receive dynamic support messages and can continue to log craving events, and should they occur, relapse events. Following the initial logging phase, patients consult with their general practitioner (GP) or healthcare provider to review their smoking patterns and to outline a precise, individualised quit attempt plan. Our feasibility study consists of assessment of an initial app version during and after use by eight patients recruited from an NHS Fife GP practice. In addition to evaluation of the app as a potential smoking cessation aid, we have assessed the user experience, technological requirements and security of the data flow.

Results

In an initial feasibility study, we have deployed the app for a small number of patients within one GP practice in NHS Fife. We recruited eight patients within one surgery, four of whom actively logged information about their smoking behaviour. Initial feedback was very positive, and users indicated a willingness to log their craving and smoking events. In addition, two out of three patients who completed follow-up interviews noted that the app helped them reduce the number of cigarettes they smoked per day, while the third indicated that it had helped them quit. The study highlighted the use of pushed notifications as a potential technology for maintaining quit attempts, and the security of collection of data was audited. These initial results influenced the design of a planned second larger study, comprised of 100 patients, the primary objectives of which are to use statistical modelling to identify times and places of probable switches into smoking states, and to target these times with dynamic health behaviour messaging.

Conclusions

While the health benefits of quitting smoking are unequivocal, such behaviour change is very difficult to achieve. Many factors are likely to contribute to maintaining smoking behaviour, yet the precise role of cues derived from the spatial environment remains unclear. The rise of smartphones, therefore, allows clinicians the opportunity to better understand the spatial aspects of smoking behaviour and affords them the opportunity to push targeted individualised health support messages at vulnerable times and places.

Trial registration

ClinicalTrial.gov, NCT02932917.

Large multi-centre pilot randomized controlled trial testing a low-cost, tailored, self-help smoking cessation text message intervention for pregnant smokers (MiQuit)

AIMS

To estimate the effectiveness of pregnancy smoking cessation support delivered by short message service (SMS) text message and key parameters needed to plan a definitive trial.

DESIGN

Multi-centre, parallel-group, single-blinded, individual randomized controlled trial.

SETTING

Sixteen antenatal clinics in England.

PARTICIPANTS

Four hundred and seven participants were randomized to the intervention (n = 203) or usual care (n = 204). Eligible women were < 25 weeks gestation, smoked at least one daily cigarette (> 5 pre-pregnancy), were able to receive and understand English SMS texts and were not already using text-based cessation support.

INTERVENTION

All participants received a smoking cessation leaflet; intervention participants also received a 12-week programme of individually tailored, automated, interactive, self-help smoking cessation text messages (MiQuit).

OUTCOME MEASUREMENTS

Seven smoking outcomes, including validated continuous abstinence from 4 weeks post-randomization until 36 weeks gestation, design parameters for a future trial and cost-per-quitter.

FINDINGS

Using the validated, continuous abstinence outcome, 5.4% (11 of 203) of MiQuit participants were abstinent versus 2.0% (four of 204) of usual care participants [odds ratio (OR) = 2.7, 95% confidence interval (CI) = 0.93-9.35]. The Bayes factor for this outcome was 2.23. Completeness of follow-up at 36 weeks gestation was similar in both groups; provision of self-report smoking data was 64% (MiQuit) and 65% (usual care) and abstinence validation rates were 56% (MiQuit) and 61% (usual care). The incremental cost-per-quitter was £133.53 (95% CI = -£395.78 to 843.62).

CONCLUSIONS

There was some evidence, although not conclusive, that a text-messaging programme may increase cessation rates in pregnant smokers when provided alongside routine NHS cessation care.

A Review of the Theoretical Basis, Effects, and Cost Effectiveness of Online Smoking Cessation Interventions in the Netherlands: A Mixed-Methods Approach

BACKGROUND

Tobacco smoking is a worldwide public health problem. In 2015, 26.3% of the Dutch population aged 18 years and older smoked, 74.4% of them daily. More and more people have access to the Internet worldwide; approximately 94% of the Dutch population have online access. Internet-based smoking cessation interventions (online cessation interventions) provide an opportunity to tackle the scourge of tobacco.

OBJECTIVE

The goal of this paper was to provide an overview of online cessation interventions in the Netherlands, while exploring their effectivity, cost effectiveness, and theoretical basis.

METHODS

A mixed-methods approach was used to identify Dutch online cessation interventions, using (1) a scientific literature search, (2) a grey literature search, and (3) expert input. For the scientific literature, the Cochrane review was used and updated by two independent researchers (n=651 identified studies), screening titles, abstracts, and then full-text studies between 2013 and 2016 (CENTRAL, MEDLINE, and EMBASE). For the grey literature, the researchers conducted a Google search (n=100 websites), screening for titles and first pages. Including expert input, this resulted in six interventions identified in the scientific literature and 39 interventions via the grey literature. Extracted data included effectiveness, cost effectiveness, theoretical factors, and behavior change techniques used.

RESULTS

Overall, many interventions (45 identified) were offered. Of the 45 that we identified, only six that were included in trials provided data on effectiveness. Four of these were shown to be effective and cost effective. In the scientific literature, 83% (5/6) of these interventions included changing attitudes, providing social support, increasing self-efficacy, motivating smokers to make concrete action plans to prepare their attempts to quit and to cope with challenges, supporting identity change and advising on changing routines, coping, and medication use. In all, 50% (3/6) of the interventions included a reward for abstinence. Interventions identified in the grey literature were less consistent, with inclusion of each theoretical factor ranging from 31% to 67% and of each behavior change technique ranging from 28% to 54%.

CONCLUSIONS

Although the Internet may provide the opportunity to offer various smoking cessation programs, the user is left bewildered as far as efficacy is concerned, as most of these data are not available nor offered to the smokers. Clear regulations about the effectiveness of these interventions need to be devised to avoid disappointment and failed quitting attempts. Thus, there is a need for policy regulations to regulate the proliferation of these interventions and to foster their quality in the Netherlands.

Health App Possession Among Smartphone or Tablet Owners in Hong Kong: Population-Based Survey

Background

Health apps are increasingly used with important implications for health. Hong Kong is one of the most technologically advanced and connected cities—smartphone ownership and Internet access rates are among the highest in the world.

Objective

We investigated the prevalence of health app possession and related sociodemographic factors and health behaviors among smartphone or tablet owners in Hong Kong.

Methods

A territory-wide population-based dual (landline and mobile) telephone survey was conducted in 2016. Respondents were asked whether they had health-related apps on their smartphones or tablets and what functions were available on the apps (eg, tracking physical activity and logging health records). Logistic regression was used to calculate the adjusted odds ratio (aOR) and 95% CI of health app possession for different demographic characteristics, socioeconomic position (education, employment, and income), health behaviors (smoking, alcohol, and physical activity) and health (body mass index and chronic diseases).

Results

Of the 4129 smartphone or tablet owners (81.28%, 4129/5080 respondents), 995 (24.10%) had a health app. Tracking physical activity (67.0% of 995) and logging health records (43.0% of 995) were the most common functions of the health apps. Overall, younger age, higher education, and household income were associated with having health apps (all P<.001). Compared with physical inactivity, engaging in moderate physical activity ≥1 day/week was associated with having health apps (aOR 1.45 [95% CI 1.20-1.75] for 1-3 days/week, and aOR 1.32 [95% CI 1.07-1.62] for ≥4 days/week). Having a history of chronic diseases was associated with having health apps (aOR 1.36 [95% CI 1.11-1.68]).

Conclusions

We have shown a lower prevalence of use of information and communication technologies (ICTs) in respondents with lower education and income in the most developed Chinese city. This could be seen as a confirmation of the “Inverse information law,” which suggests that those most in need have less use of services and hence receive less benefits from advancements in medicine and health related ICTs.

Development and evaluation of the See Me Smoke-Free multi-behavioral mHealth app for women smokers

Women face particular challenges when quitting smoking, especially those with weight concerns. A multi-behavioral smoking cessation intervention addressing these concerns and incorporating guided imagery may assist women to engage in healthy lifestyle behaviors. An mHealth app can easily disseminate such an intervention. The goals of this pilot study were to develop and test the feasibility and potential of the See Me Smoke-Free™ mHealth app to address smoking, diet, and physical activity among women smokers. We used pragmatic, direct-to-consumer methods to develop and test program content, functionality, and the user interface and conduct a pre-/post-test, 90-day pilot study. We enrolled 151 participants. Attrition was 52%, leaving 73 participants. At 90 days, 47% of participants reported 7-day abstinence and significant increases in physical activity and fruit consumption. Recruitment methods worked well, but similar to other mHealth studies, we experienced high attrition. This study suggests that a guided imagery mHealth app has the potential to address multiple behaviors. Future research should consider different methods to improve retention and assess efficacy.

Effectiveness of Mobile Apps for Smoking Cessation: A Review

INTRODUCTION

Smartphone-based smoking cessation interventions are increasingly used around the world. However, the effects of smartphone applications on applicability and efficacy on cessation rate and prevention of relapses are not often evaluated. Therefore, this review aims to assess the evidence on effectiveness of smartphone applications as an intervention tool for smoking cessation support.

METHODS

We conducted the search using Ovid Medline/PubMed, CENTRAL and Scopus databases dated (January 2007-June 2016). Inclusion criteria include randomized control trials or intervention studies with mobile applications that offer smoking cessation support. Two assessors independently extracted and evaluated the data from each included study.

RESULTS

The review of eight selected studies illustrate the use of smartphone applications in increasing quit rates among smokers, however adherence to app features influences quit rates. Audiovisual features followed by a quit plan, tracking progress and sharing features are most accepted and utilised app features. However, inconsistency was observed in their association with abstinence or quit rate. App engagement features increase the statistical significance in the quit rate. Development of smartphone applications was supported by behavior change theories in all studies nevertheless; heterogeneous forms of intervention were adopted within studies. Similarly, reduction in relapse attributed to enhanced discussion among quitters using social media applications was observed.

CONCLUSIONS

Quality evidence is warranted with large sample size to measure effect size of the intervention. Future research on effectiveness and efficacy of smartphone alone and comparisons with other mHealth interventions, such as text messaging would be useful.

How do text-messaging smoking cessation interventions confer benefit? A multiple mediation analysis of Text2Quit

AIMS

To determine the degree to which the observed benefit of Text2Quit was accounted for by psychosocial mechanisms derived from its quit smoking messaging versus from the use of extra-programmatic smoking cessation treatments and services.

DESIGN

Prospective, multiple mediation model of a randomized controlled trial (RCT).

SETTING

United States nation-wide.

PARTICIPANTS

A total of 409 adult daily smokers participated. Participants were, on average, 35 years of age, predominantly female (68%), white (79%), lacked a college degree (70%), had medium nicotine dependence (average Fagerström Nicotine Dependence Score score of 5.2) and more than half (62%) had made a previous quit attempt.

INTERVENTION

Adult daily smokers browsing the web for smoking cessation support (n = 409; recruited 19 May2011-10 July 2012) were randomized to receive smoking cessation support via Text2Quit versus a smoking cessation material.

MEASUREMENTS

Mediators (i.e. changes in psychosocial constructs of health behavior change, use of extra-programmatic treatment) were assessed at 1 month using single-item measures and outcome (i.e. self-reported 7-day point prevalence abstinence) at 6-month follow-up.

FINDINGS

Mediators accounted for 35% of the effect of Text2Quit on smoking cessation. Only psychosocial mechanisms had complete mediational paths, with increases in self-efficacy [b = 0.10 (0.06-0.15)], quitting know-how [b = 0.07 (0.03-0.11)] and the sense that someone cared [b = 0.06 (0.01-0.11)], partially explaining the conferred benefit of Text2Quit. Use of outside resources, including treatments promoted explicitly by Text2Quit, i.e. medication [b = 0.001 (-0.01 to 0.01), quitline [b = -0.002 (-0.01 to 0.04)], treatments and resources not promoted by Text2Quit, i.e. online forums [b = 0.01 (-0.01 to 0.04)] and self-help materials [b = -0.01 (-0.04 to 0.02)], did not have complete mediational paths. An interaction effect existed for medication use that suggested that for participants not using medication, Text2Quit conferred substantial benefit, but not for participants using medication.

CONCLUSIONS

Text-messaging programs for smoking cessation appear primarily to confer benefit by promoting improvements in the psychosocial processes related to quitting rather than through the use of extra-programmatic smoking cessation treatments and services.

Study protocol for a pragmatic randomised controlled trial evaluating efficacy of a smoking cessation e-'Tabac Info Service': ee-TIS trial

INTRODUCTION

A French national smoking cessation service, Tabac Info Service, has been developed to provide an adapted quitline and a web and mobile application involving personalised contacts (eg, questionnaires, advice, activities, messages) to support smoking cessation. This paper presents the study protocol of the evaluation of the application (e-intervention Tabac Info Service (e-TIS)). The primary objective is to assess the efficacy of e-TIS. The secondary objectives are to (1) describe efficacy variations with regard to users' characteristics, (2) analyse mechanisms and contextual conditions of e-TIS efficacy.

METHODS AND ANALYSES

The study design is a two-arm pragmatic randomised controlled trial including a process evaluation with at least 3000 participants randomised to the intervention or to the control arm (current practices). Inclusion criteria are: aged 18 years or over, current smoker, having completed the online consent forms, possessing a mobile phone with android or apple systems and using mobile applications, wanting to stop smoking sooner or later. The primary outcome is the point prevalence abstinence of 7 days at 6 months later. Data will be analysed in intention to treat (primary) and per protocol analyses. A logistic regression will be carried out to estimate an OR (95% CI) for efficacy. A multivariate multilevel analysis will explore the influence on results of patients' characteristics (sex, age, education and socioprofessional levels, dependency, motivation, quit experiences) and contextual factors, conditions of use, behaviour change techniques.

ETHICS AND DISSEMINATION

The study protocol was reviewed by the ethical and deontological institutional review board of the French Institute for Public Health Surveillance on 18 April 2016. The findings of this study will allow us to characterise the efficacy of e-TIS and conditions of its efficacy. These findings will be disseminated through peer-reviewed articles.

TRIAL REGISTRATION NUMBER

NCT02841683; Pre-results.

Psychosocial interventions for supporting women to stop smoking in pregnancy

BACKGROUND

Tobacco smoking remains one of the few preventable factors associated with complications in pregnancy, and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and is increasing in low- to middle-income countries.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH METHODS

In this sixth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 November 2015), checked reference lists of retrieved studies and contacted trial authors.

SELECTION CRITERIA

Randomised controlled trials, cluster-randomised trials, and quasi-randomised controlled trials of psychosocial smoking cessation interventions during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, with meta-regression conducted in STATA 14.

MAIN RESULTS

The overall quality of evidence was moderate to high, with reductions in confidence due to imprecision and heterogeneity for some outcomes. One hundred and two trials with 120 intervention arms (studies) were included, with 88 trials (involving over 28,000 women) providing data on smoking abstinence in late pregnancy. Interventions were categorised as counselling, health education, feedback, incentives, social support, exercise and dissemination.In separate comparisons, there is high-quality evidence that counselling increased smoking cessation in late pregnancy compared with usual care (30 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.73) and less intensive interventions (18 studies; average RR 1.25, 95% CI 1.07 to 1.47). There was uncertainty whether counselling increased the chance of smoking cessation when provided as one component of a broader maternal health intervention or comparing one type of counselling with another. In studies comparing counselling and usual care (largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy. However, a clear effect was seen in smoking abstinence at zero to five months postpartum (11 studies; average RR 1.59, 95% CI 1.26 to 2.01) and 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), with a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77). In other comparisons, the effect was unclear for most secondary outcomes, but sample sizes were small.Evidence suggests a borderline effect of health education compared with usual care (five studies; average RR 1.59, 95% CI 0.99 to 2.55), but the quality was downgraded to moderate as the effect was unclear when compared with less intensive interventions (four studies; average RR 1.20, 95% CI 0.85 to 1.70), alternative interventions (one study; RR 1.88, 95% CI 0.19 to 18.60), or when smoking cessation health education was provided as one component of a broader maternal health intervention.There was evidence feedback increased smoking cessation when compared with usual care and provided in conjunction with other strategies, such as counselling (average RR 4.39, 95% CI 1.89 to 10.21), but the confidence in the quality of evidence was downgraded to moderate as this was based on only two studies and the effect was uncertain when feedback was compared to less intensive interventions (three studies; average RR 1.29, 95% CI 0.75 to 2.20).High-quality evidence suggests incentive-based interventions are effective when compared with an alternative (non-contingent incentive) intervention (four studies; RR 2.36, 95% CI 1.36 to 4.09). However pooled effects were not calculable for comparisons with usual care or less intensive interventions (substantial heterogeneity, I2 = 93%).High-quality evidence suggests the effect is unclear in social support interventions provided by peers (six studies; average RR 1.42, 95% CI 0.98 to 2.07), in a single trial of support provided by partners, or when social support for smoking cessation was provided as part of a broader intervention to improve maternal health.The effect was unclear in single interventions of exercise compared to usual care (RR 1.20, 95% CI 0.72 to 2.01) and dissemination of counselling (RR 1.63, 95% CI 0.62 to 4.32).Importantly, high-quality evidence from pooled results demonstrated that women who received psychosocial interventions had a 17% reduction in infants born with low birthweight, a significantly higher mean birthweight (mean difference (MD) 55.60 g, 95% CI 29.82 to 81.38 g higher) and a 22% reduction in neonatal intensive care admissions. However the difference in preterm births and stillbirths was unclear. There did not appear to be adverse psychological effects from the interventions.The intensity of support women received in both the intervention and comparison groups has increased over time, with higher-intensity interventions more likely to have higher-intensity comparisons, potentially explaining why no clear differences were seen with increasing intervention intensity in meta-regression analyses. Among meta-regression analyses: studies classified as having 'unclear' implementation and unequal baseline characteristics were less effective than other studies. There was no clear difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however there was uncertainty in the effectiveness of counselling in four dissemination trials where the focus on the intervention was at an organisational level. The pooled effects were similar in interventions provided for women classified as having predominantly low socio-economic status, compared to other women. The effect was significant in interventions among women from ethnic minority groups; however not among indigenous women. There were similar effect sizes in trials with biochemically validated smoking abstinence and those with self-reported abstinence. It was unclear whether incorporating use of self-help manuals or telephone support increased the effectiveness of interventions.

AUTHORS' CONCLUSIONS

Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy and the proportion of infants born low birthweight. Counselling, feedback and incentives appear to be effective, however the characteristics and context of the interventions should be carefully considered. The effect of health education and social support is less clear. New trials have been published during the preparation of this review and will be included in the next update.