Feasibility of a Smartphone App with Mindfulness Training for Adolescent Smoking Cessation: Craving to Quit (C2Q)-Teen

Behavioral Precursors of Nicotine Product Use Trajectories Among Youth

INTRODUCTION

Preventing nicotine use among youth is a public health priority. Nicotine use emerges from complex relationships between numerous factors. This project used network analysis to model behavioral precursors of nicotine use (knowledge, attitudes, perceptions, intentions) among youth who had never used nicotine and determine which predicted future trajectories of use across multiple nicotine products.

METHODS

Data were from the Population Assessment of Tobacco and Health study (2013-2018; analyzed 2023-2024), youth ages 12-17, who reported never using nicotine at Wave 1. Network structure was determined for behavioral precursors at Wave 1 and central network nodes were identified (N=5,087). Central nodes were then tested as predictors of trajectories of use across multiple nicotine products during Waves 1-4 (N=3,851).

RESULTS

Central nodes of the Wave 1 network were harm perception, expectancy that tobacco would calm anger/reduce stress, and intention to try. Those with lower intent to try at Wave 1 had lower odds of being in an Experimentation or Use class versus a Nonuse class during Waves 1-4 (p<0.0001). Those with more accurate harm perception had lower odds of being in an Experimentation versus Nonuse class (p=0.004). Those with positive expectancies had higher odds of being in an Experimentation versus Nonuse or Use class (p=0.04, 0.02).

CONCLUSIONS

Findings suggest a network model of behavioral precursors of nicotine use that can be tested, including central nodes that predicted trajectories of use across multiple nicotine products, and therefore may be priority intervention targets.

Adolescent Tobacco/Nicotine Use and the Potential Role of Contingency Management-based Interventions

ABSTRACT

The high prevalence of tobacco/nicotine use among youth, including e-cigarettes, is a public health problem in the United States. Early exposure leads to an increased risk of dependence and health consequences in adulthood. We reviewed the literature on current treatment approaches for nicotine/tobacco use in adolescents/young adults and highlighted underexplored areas of treatment research. There are no current Food and Drug Administration-approved medications for treatment of nicotine/tobacco use disorders in adolescents. However, in research settings and on a case-to-case basis, clinical practice medications (including nicotine replacement therapy, bupropion, and varenicline) have been prescribed to this population with consideration of risk-benefit analysis when behavioral treatments are not sufficient to address dependence. Among the nonpharmacological interventions, there is evidence to support the potential for expanded use of contingency management in youth. Neural differences predisposing adolescents to substance use, along with higher attentiveness to value of options in decision making (flexible reward system) may enhance the effectiveness of reward-based approaches for treatment of substance use disorders in this population. The overall high rates of nonresponders across psychosocial and pharmacological treatments highlight the importance of considering novel strategies to improve existing interventions. We suggest that future research be done that considers unique characteristics of today's adolescents, such as high social activism and engagement with digital rewards to tailor contingency management for this age group and assess its effectiveness. Adolescents could potentially benefit from rewards administered through digital media (eg, video games, computer-based apps, and social media influencers).

Smartphone Apps Targeting Youth Tobacco Use Prevention and Cessation: An Assessment of Credibility and Quality

Purpose of Review

The goals of this study were to identify smartphone apps targeting youth tobacco use prevention and/or cessation discussed in the academic literature and/or available in the Apple App Store and to review and rate the credibility of the apps. We took a multiphase approach in a non-systematic review that involved conducting parallel literature and App Store searches, screening the returned literature and apps for inclusion, characterizing the studies and apps, and evaluating app quality using a standardized rating scale.

Recent Findings

The negative consequences of youth tobacco use initiation are profound and far-reaching. Half of the youth who use nicotine want to quit, but quit rates are low. The integration of smartphone apps shows promise in complementing and enhancing evidence-based youth tobacco prevention and treatment methods.

Summary

Consistent with prior reviews, we identified a disconnect between apps that are readily accessible and those that have an evidence base, and many popular apps received low quality scores. Findings suggest a need for better integration between evidence-based and popular, available apps targeting youth tobacco use.

User evaluation and feasibility test of an app designed for smoking cessation in Italian people who smoke: preliminary findings from an uncontrolled pre-test post-test open study

BACKGROUND

mHealth is a public health practice that exploits the use of mobile devices, including smartphone applications. We will describe an uncontrolled pre-test post-test open pilot study concerning the feasibility evaluation of a smartphone App designed to help in smoking cessation. The aim of this study is to evaluate the feasibility of a smartphone app as a tool for smoking cessation. This study is necessary to the literature because smoking is a major public health concern and has been linked to various health issues such as cardiovascular disease, respiratory disease, and cancer. While there are several smoking cessation interventions available, the use of mobile devices to aid in smoking cessation is a relatively new and innovative approach that requires further investigation.

METHODS

The App "Smoke Free" was configured on the devices of N = 30 participants who smoked combustible cigarette, 13 males and 17 females aged 18 to 55 years, with the indications to use it for 90 days, describe their experience, suggest new features, and report any critical aspect. The study consisted of an initial screening visit to select participants that reflected the inclusion criteria and 4 study visits: a baseline visit, two follow-up visits, and one final visit. We used descriptive stats to summarize results. Repeated measures ANOVA and Wilcoxon test were used to test differences in smoking consumption, self-reported craving, and measured eCO level. Statistical software Jamovi was used for analysis. Interviews were conducted via phone or in-person and analyzed using qualitative description principles.

RESULTS

Participants evaluated the app as having good aesthetic appeal and user-friendliness but being moderately useful, despite some quitting or reducing their smoking behavior. To improve it, participants have proposed features such as more notifications, social network integration, and damage caused by smoking to the body over time for future app updates.

CONCLUSIONS

The application was moderately useful with good feasibility, with several suggestions for future updates that could improve its effectiveness.

Rates of attrition and engagement in randomized controlled trials of mindfulness apps: Systematic review and meta-analysis

Randomized controlled trials (RCT) have established the efficacy of mindfulness apps for numerous mental health and behavioral outcomes. However, studies of this kind are characterized by significant problems with attrition and engagement, making it challenging to interpret these findings and realize the full potential of mindfulness app-based solutions. This systematic review and meta-analysis aimed to examine rates of attrition from, and engagement in, mindfulness apps in 70 RCTs located through four databases. The weighted meta-analytic attrition rate from 9258 participants allocated to a mindfulness app was 24.7%. This estimate was higher (38.7%) when restricting analyses to larger studies (n ≥ 100 per condition) and for specific target samples (e.g., general population of adults). Studies that offered participants monetary compensation and required in-person enrolment methods were associated with the lowest attrition rates. Attrition was higher in mindfulness app conditions relative to waitlists, but was not different to placebo or active apps. Although engagement data were inadequately reported, qualitative synthesis highlighted clear problems with sustained user engagement with mindfulness apps. Findings have implications for powering, designing and appraising research trials of mindfulness apps, as well as the development of potentially effective retention and engagement strategies worthy of evaluation in future work.

The effectiveness of digital health technologies for reducing substance use among young people: a systematic review & meta-analysis

BACKGROUND

Substance use amongst young people poses developmental and clinical challenges, necessitating early detection and treatment. Considering the widespread use of technology in young people, delivering interventions digitally may help to reduce and monitor their substance use.

AIMS

We conducted a systematic review and two meta-analyses to assess the effectiveness of digital interventions for reducing substance use (alcohol, smoking, and other substances) among young people aged 10 to 24 years old.

METHOD

Embase, Global Health, Medline, PsychINFO, Web of Science and reference lists of relevant papers were searched in November 2020. Studies were included if they quantitatively evaluated the effectiveness of digital health technologies for treating substance use. A narrative synthesis and meta-analysis were conducted.

RESULTS

Forty-two studies were included in the systematic review and 18 in the meta-analyses. Digital interventions showed small, but statistically significant reductions in weekly alcohol consumption compared to controls (SMD= -0.12, 95% CI= -0.17 to -0.06, I2=0%), but no overall effect was seen on 30-day smoking abstinence (OR = 1.12, 95% CI = 0.70 to 1.80, I2=81%). The effectiveness of digital interventions for reducing substance use is generally weak, however, promising results such as reducing alcohol use were seen. Large-scale studies should investigate the viability of digital interventions, collect user feedback, and determine cost-effectiveness.

PRISMA/PROSPERO

This systematic review was conducted following Cochrane methodology PRISMA guidelines. The review was registered with PROSPERO in November 2020 (CRD42020218442).

A systematic review of digital interventions for smoking cessation in patients with serious mental illness

Tobacco smoking is highly prevalent among patients with serious mental illness (SMI), with known deleterious consequences. Smoking cessation is therefore a prioritary public health challenge in SMI. In recent years, several smoking cessation digital interventions have been developed for non-clinical populations. However, their impact in patients with SMI remains uncertain. We conducted a systematic review to describe and evaluate effectiveness, acceptability, adherence, usability and safety of digital interventions for smoking cessation in patients with SMI. PubMed/MEDLINE, EMBASE, CINAHL, Web of Science, PsychINFO and the Cochrane Tobacco Addiction Group Specialized Register were searched. Studies matching inclusion criteria were included and their information systematically extracted by independent investigators. Thirteen articles were included, which reported data on nine different digital interventions. Intervention theoretical approaches ranged from mobile contingency management to mindfulness. Outcome measures varied widely between studies. The highest abstinence rates were found for mSMART MIND (7-day point-prevalent abstinence: 16-40%). Let's Talk About Quitting Smoking reported greater acceptability ratings, although this was not evaluated with standardized measures. Regarding usability, Learn to Quit showed the highest System Usability Scale scores [mean (s.d.) 85.2 (15.5)]. Adverse events were rare and not systematically reported. Overall, the quality of the studies was fair to good. Digitally delivered health interventions for smoking cessation show promise for improving outcomes for patients with SMI, but lack of availability remains a concern. Larger trials with harmonized assessment measures are needed to generate more definitive evidence and specific recommendations.

The Impact of Mobile Technology-Delivered Interventions on Youth Well-being: Systematic Review and 3-Level Meta-analysis

BACKGROUND

Rates of mental health problems among youth are high and rising, whereas treatment seeking in this population remains low. Technology-delivered interventions (TDIs) appear to be promising avenues for broadening the reach of evidence-based interventions for youth well-being. However, to date, meta-analytic reviews on youth samples have primarily been limited to computer and internet interventions, whereas meta-analytic evidence on mobile TDIs (mTDIs), largely comprising mobile apps for smartphones and tablets, have primarily focused on adult samples.

OBJECTIVE

This study aimed to evaluate the effectiveness of mTDIs for a broad range of well-being outcomes in unselected, at-risk, and clinical samples of youth.

METHODS

The systematic review used 5 major search strategies to identify 80 studies evaluating 83 wellness- and mental health-focused mTDIs for 19,748 youth (mean age 2.93-26.25 years). We conducted a 3-level meta-analysis on the full sample and a subsample of the 38 highest-quality studies.

RESULTS

Analyses demonstrated significant benefits of mTDIs for youth both at posttest (g=0.27) and follow-up (range 1.21-43.14 weeks; g=0.26) for a variety of psychosocial outcomes, including general well-being and distress, symptoms of diverse psychological disorders, psychosocial strategies and skills, and health-related symptoms and behaviors. Effects were significantly moderated by the type of comparison group (strongest for no intervention, followed by inert placebo or information-only, and only marginal for clinical comparison) but only among the higher-quality studies. With respect to youth characteristics, neither gender nor pre-existing mental health risk level (not selected for risk, at-risk, or clinical) moderated effect sizes; however, effects increased with the age of youth in the higher-quality studies. In terms of intervention features, mTDIs in these research studies were effective regardless of whether they included various technological features (eg, tailoring, social elements, or gamification) or support features (eg, orientation, reminders, or coaching), although the use of mTDIs in a research context likely differs in important ways from their use when taken up through self-motivation, parent direction, peer suggestion, or clinician referral. Only mTDIs with a clear prescription for frequent use (ie, at least once per week) showed significant effects, although this effect was evident only in the higher-quality subsample. Moderation analyses did not detect statistically significant differences in effect sizes based on the prescribed duration of mTDI use (weeks or sessions), and reporting issues in primary studies limited the analysis of completed duration, thereby calling for improved methodology, assessment, and reporting to clarify true effects.

CONCLUSIONS

Overall, this study's findings demonstrate that youth can experience broad and durable benefits of mTDIs, delivered in a variety of ways, and suggest directions for future research and development of mTDIs for youth, particularly in more naturalistic and ecologically valid settings.

Mindfulness for smoking cessation

BACKGROUND

Mindfulness-based smoking cessation interventions may aid smoking cessation by teaching individuals to pay attention to, and work mindfully with, negative affective states, cravings, and other symptoms of nicotine withdrawal. Types of mindfulness-based interventions include mindfulness training, which involves training in meditation; acceptance and commitment therapy (ACT); distress tolerance training; and yoga.

OBJECTIVES

To assess the efficacy of mindfulness-based interventions for smoking cessation among people who smoke, and whether these interventions have an effect on mental health outcomes.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's specialised register, CENTRAL, MEDLINE, Embase, PsycINFO, and trial registries to 15 April 2021. We also employed an automated search strategy, developed as part of the Human Behaviour Change Project, using Microsoft Academic.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs that compared a mindfulness-based intervention for smoking cessation with another smoking cessation programme or no treatment, and assessed smoking cessation at six months or longer. We excluded studies that solely recruited pregnant women.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. We measured smoking cessation at the longest time point, using the most rigorous definition available, on an intention-to-treat basis. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of intervention and type of comparator. We carried out meta-analyses where appropriate, using Mantel-Haenszel random-effects models. We summarised mental health outcomes narratively.

MAIN RESULTS

We included 21 studies, with 8186 participants. Most recruited adults from the community, and the majority (15 studies) were conducted in the USA. We judged four of the studies to be at low risk of bias, nine at unclear risk, and eight at high risk. Mindfulness-based interventions varied considerably in design and content, as did comparators, therefore, we pooled small groups of relatively comparable studies. We did not detect a clear benefit or harm of mindfulness training interventions on quit rates compared with intensity-matched smoking cessation treatment (RR 0.99, 95% CI 0.67 to 1.46; I² = 0%; 3 studies, 542 participants; low-certainty evidence), less intensive smoking cessation treatment (RR 1.19, 95% CI 0.65 to 2.19; I² = 60%; 5 studies, 813 participants; very low-certainty evidence), or no treatment (RR 0.81, 95% CI 0.43 to 1.53; 1 study, 325 participants; low-certainty evidence). In each comparison, the 95% CI encompassed benefit (i.e. higher quit rates), harm (i.e. lower quit rates) and no difference. In one study of mindfulness-based relapse prevention, we did not detect a clear benefit or harm of the intervention over no treatment (RR 1.43, 95% CI 0.56 to 3.67; 86 participants; very low-certainty evidence). We did not detect a clear benefit or harm of ACT on quit rates compared with less intensive behavioural treatments, including nicotine replacement therapy alone (RR 1.27, 95% CI 0.53 to 3.02; 1 study, 102 participants; low-certainty evidence), brief advice (RR 1.27, 95% CI 0.59 to 2.75; 1 study, 144 participants; very low-certainty evidence), or less intensive ACT (RR 1.00, 95% CI 0.50 to 2.01; 1 study, 100 participants; low-certainty evidence). There was a high level of heterogeneity (I² = 82%) across studies comparing ACT with intensity-matched smoking cessation treatments, meaning it was not appropriate to report a pooled result. We did not detect a clear benefit or harm of distress tolerance training on quit rates compared with intensity-matched smoking cessation treatment (RR 0.87, 95% CI 0.26 to 2.98; 1 study, 69 participants; low-certainty evidence) or less intensive smoking cessation treatment (RR 1.63, 95% CI 0.33 to 8.08; 1 study, 49 participants; low-certainty evidence). We did not detect a clear benefit or harm of yoga on quit rates compared with intensity-matched smoking cessation treatment (RR 1.44, 95% CI 0.40 to 5.16; 1 study, 55 participants; very low-certainty evidence). Excluding studies at high risk of bias did not substantially alter the results, nor did using complete case data as opposed to using data from all participants randomised. Nine studies reported on changes in mental health and well-being, including depression, anxiety, perceived stress, and negative and positive affect. Variation in measures and methodological differences between studies meant we could not meta-analyse these data. One study found a greater reduction in perceived stress in participants who received a face-to-face mindfulness training programme versus an intensity-matched programme. However, the remaining eight studies found no clinically meaningful differences in mental health and well-being between participants who received mindfulness-based treatments and participants who received another treatment or no treatment (very low-certainty evidence).

AUTHORS' CONCLUSIONS

We did not detect a clear benefit of mindfulness-based smoking cessation interventions for increasing smoking quit rates or changing mental health and well-being. This was the case when compared with intensity-matched smoking cessation treatment, less intensive smoking cessation treatment, or no treatment. However, the evidence was of low and very low certainty due to risk of bias, inconsistency, and imprecision, meaning future evidence may very likely change our interpretation of the results. Further RCTs of mindfulness-based interventions for smoking cessation compared with active comparators are needed. There is also a need for more consistent reporting of mental health and well-being outcomes in studies of mindfulness-based interventions for smoking cessation.

Feature-level analysis of a smoking cessation smartphone app that uses a positive psychology approach (Preprint)

Background

Smoking cessation smartphone apps have emerged as highly accessible tools to support smoking cessation efforts. It is unknown how specific app features contribute to user engagement over time and relate to smoking outcomes.

Objective

To provide a feature-level analysis of the Smiling Instead of Smoking app (version 2) and to link feature use to subsequent smoking cessation.

Methods

Nondaily smokers (N=100) used the app for a period of 49 days (1 week before quitting and 6 weeks after quitting). Participants self-reported 30-day point-prevalence abstinence at the end of this period and at a 6-month follow up (the survey response rate was 94% and 89% at these points, respectively). Self-reported 30-day point prevalence abstinence rates were 40% at the end of treatment and 56% at the 6-month follow up. The app engaged users in both positive psychology content and traditional behavioral smoking cessation content. The app sent push notifications to prompt participants to complete prescribed content (ie, a “happiness exercise” every day and a “behavioral challenge” to use the app’s smoking cessation tools on 15 out of 49 days). Actions that participants took within the app were timestamped and recorded.

Results

Participants used the app on 24.7 (SD 13.8) days out of the 49 prescribed days, interacting with the happiness content on more days than the smoking content (23.8, SD 13.8 days vs 17.8, SD 10.3 days; t₉₉=9.28 [2-tailed]; P<.001). The prescribed content was frequently completed (45% of happiness exercises; 57% of behavioral challenges) and ad libitum tools were used on ≤7 days. Most participants used each ad libitum smoking cessation tool at least once, with higher use of personalized content (≥92% used “strategies,” “cigarette log,” “smoke alarms,” and “personal reasons”) than purely didactic content (79% viewed “benefits of quitting smoking”). The number of days participants used the app significantly predicted 30-day point-prevalence abstinence at the end of treatment (odds ratio [OR] 1.05, 95% CI 1.02-1.09; P=.002) and at the 6-month follow up (OR 1.04, 95% CI 1.008-1.07; P=.01). The number of days participants engaged with the happiness content significantly predicted smoking abstinence at the end of treatment (OR 1.05, 95% CI 1.02-1.08; P=.002) and at the 6-month follow up (OR 1.04, 95% CI 1.007-1.07; P=.02). This effect was not significant for the number of days participants engaged with the smoking cessation content of the app, either at the end of treatment (OR 1.04, 95% CI 0.996-1.08, P=.08) or at the 6-month follow up (OR 1.02, 95% CI 0.98-1.06; P=.29).

Conclusions

Greater app usage predicted greater odds of self-reported 30-day point-prevalence abstinence at both the end of treatment and over the long term, suggesting that the app had a therapeutic benefit. Positive psychology content and prescriptive clarity may promote sustained app engagement over time.

Trial Registration

ClinicalTrials.gov NCT03951766; https://clinicaltrials.gov/ct2/show/NCT03951766

Update on Cyber Health Psychology: Virtual Reality and Mobile Health Tools in Psychotherapy, Clinical Rehabilitation, and Addiction Treatment

(1) Background: we investigated and analyzed the most recent implementations of technology in the fields of psychotherapy, clinical rehabilitation, and addiction treatment. (2) Methods: from December 2021 to January 2022, we conducted a review aimed at identifying the recent implementations of technology in cyber health psychology, with particular reference to Virtual Reality in psychotherapy, mHealth tools in clinical rehabilitation, and smartphone applications in the treatment of addiction to substances of abuse, searching for relevant studies in the databases PubMed, Web of Science, Google Scholar, Health & Medical Collection, and APA PsycArticles. (3) Results: the tools analyzed are in constant development and are increasingly used, with good results, and further technological progress could lead to even better treatment outcomes; as far as mHealth tools and smartphone applications are concerned, anti-smoking Apps are the most widespread, followed by those for the treatment of alcohol use disorder, and there is no presence of Apps for the treatment of heroin, cocaine, or crack addiction. (4) Conclusions: the results of the review indicate that these technological tools are increasingly used and are, in principle, effective and have numerous advantages, including low cost and versatility.

Feasibility of a Smoking Cessation Smartphone App (Quit with US) for Young Adult Smokers: A Single Arm, Pre-Post Study

While smartphone applications (apps) have been shown to enhance success with smoking cessation, no study has been conducted among young adult smokers aged 18-24 years in Thailand. Quit with US was developed based on the 5 A's model and self-efficacy theory. This single arm, pre-post study was conducted aiming to assess results after using Quit with US for 4 weeks. The primary outcome was a biochemically verified 7-day point prevalence of smoking abstinence. The secondary outcomes included smoking behaviors, knowledge and attitudes toward smoking and smoking cessation, and satisfaction and confidence in the smartphone app. A total number of 19 young adult smokers were included; most participants were males (68.4%) with the mean (SD) age of 20.42 (1.46) years. After 4 weeks of study, the primary outcome demonstrated a smoking cessation rate of 31.6%. All 19 participants expressed better smoking behaviors and better knowledge and attitudes toward smoking and smoking cessation. Further, they were satisfied with the smartphone app design and content and expressed confidence in using it. These findings provided preliminary evidence that Quit with US was found to be a potentially effective smoking cessation smartphone app for young adult smokers.

EmoTIC: Impact of a game-based social-emotional programme on adolescents

INTRODUCTION

Technologies provide a brilliant opportunity to promote social-emotional competences, well-being and adjustment in adolescence. Game-based programmes and serious games are digital tools that pursue an educational goal in an attractive environment for adolescents. The purpose of this study was therefore to determine the effectiveness of emoTIC, a game-based social-emotional programme designed according to Mayer, Caruso, and Salovey's model of emotional intelligence.

MATERIALS AND METHODS

The participants were 119 adolescents between 11 and 15 years, randomly assigned to the experimental group and the control group. The adolescents completed questionnaires to assess their emotional intelligence, self-esteem, affect balance, difficulties, prosocial behaviour, depression, anxiety and stress.

RESULTS

The MANCOVA results showed that adolescents who completed the game-based programme had improved self-esteem, affect balance, emotional symptoms, behavioural problems, and hyperactivity (Wilks' λ = .77; F = 2.10; p = .035). Hierarchical multiple regression indicated that adolescents in the experimental group had a greater change in self-esteem and affect balance (positive β), while their emotional problems and hyperactivity decreased (negative β). Anxiety moderated the influence of the intervention on self-esteem (b = .04; t = -2.55; p ≤ .05; LLCI = -0.43, ULCI = -0.05). Adolescents with low or medium anxiety improved their self-esteem with the intervention, while those with high anxiety did not develop it.

CONCLUSIONS

The use of technology in social-emotional programmes could be the first step in increasing adolescents' interest in emotions and emoTIC could be considered a useful programme which influences their personal, emotional and social factors.

TRIAL REGISTRATION

Clinical Trial identifier: NCT04414449.