Effectiveness and Acceptability of Conversational Agents for Smoking Cessation: A Systematic Review and Meta-analysis

The Feasibility and Acceptability of Using a Digital Conversational Agent (Chatbot) for Delivering Parenting Interventions: Systematic Review

BACKGROUND

Parenting interventions are crucial for promoting family well-being, reducing violence against children, and improving child development outcomes; however, scaling these programs remains a challenge. Prior reviews have characterized the feasibility, acceptability, and effectiveness of other more robust forms of digital parenting interventions (eg, via the web, mobile apps, and videoconferencing). Recently, chatbot technology has emerged as a possible mode for adapting and delivering parenting programs to larger populations (eg, Parenting for Lifelong Health, Incredible Years, and Triple P Parenting).

OBJECTIVE

This study aims to review the evidence of using chatbots to deliver parenting interventions and assess the feasibility of implementation, acceptability of these interventions, and preliminary outcomes.

METHODS

This review conducted a comprehensive search of databases, including Web of Science, MEDLINE, Scopus, ProQuest, and Cochrane Central Register of Controlled Trials. Cochrane Handbook for Systematic Review of Interventions and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used to conduct the search. Eligible studies targeted parents of children aged 0 to 18 years; used chatbots via digital platforms, such as the internet, mobile apps, or SMS text messaging; and targeted improving family well-being through parenting. Implementation measures, acceptability, and any reported preliminary measures of effectiveness were included.

RESULTS

Of the 1766 initial results, 10 studies met the inclusion criteria. The included studies, primarily conducted in high-income countries (8/10, 80%), demonstrated a high mean retention rate (72.8%) and reported high acceptability (10/10, 100%). However, significant heterogeneity in interventions, measurement methods, and study quality necessitate cautious interpretation. Reporting bias, lack of clarity in the operationalization of engagement measures, and platform limitations were identified as limiting factors in interpreting findings.

CONCLUSIONS

This is the first study to review the implementation feasibility and acceptability of chatbots for delivering parenting programs. While preliminary evidence suggests that chatbots can be used to deliver parenting programs, further research, standardization of reporting, and scaling up of effectiveness testing are critical to harness the full benefits of chatbots for promoting family well-being.

Chatbot-Led Support Combined With Counselor-Led Support on Smoking Cessation in China: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

China has a large population of smokers, with half of them dependent on tobacco and in need of cessation assistance, indicating the need for mobile health (mHealth) to provide cessation support.

OBJECTIVE

The study aims to assess the feasibility and preliminary effectiveness of combining chatbot-led support with counselor-led support for smoking cessation among community smokers in China.

METHODS

This is a 2-arm, parallel, assessor-blinded, pilot randomized controlled trial nested in a smoke-free campus campaign in Zhuhai, China. All participants will receive brief face-to-face cessation advice and group cessation support led by a chatbot embedded in WeChat. In addition, participants in the intervention group will receive personalized WeChat-based counseling from trained counselors. Follow-up will occur at 1, 3, and 6 months after treatment initiation. The primary smoking outcome is bioverified abstinence (exhaled carbon monoxide <4 parts per million or salivary cotinine <30 ng/mL) at 6 months. Secondary outcomes include self-reported 7-day point prevalence of abstinence, smoking reduction rate, and quit attempts. Feasibility outcomes include eligibility rate, consent rate, intervention engagement, and retention rate. An intention-to-treat approach and regression models will be used for primary analyses.

RESULTS

Participant recruitment began in March 2023, and the intervention began in April 2023. The data collection was completed in June 2024. The results of the study will be published in peer-reviewed journals and presented at international conferences.

CONCLUSIONS

This study will provide novel insights into the feasibility and preliminary effectiveness of a chatbot-led intervention for smoking cessation in China. The findings of this study will inform the development and optimization of mHealth interventions for smoking cessation in China and other low- and middle-income countries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05777005; https://clinicaltrials.gov/study/NCT05777005.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/58636.

Co-Designing a Smoking Cessation Chatbot: Focus Group Study of End Users and Smoking Cessation Professionals

BACKGROUND

Our prototype smoking cessation chatbot, Quin, provides evidence-based, personalized support delivered via a smartphone app to help people quit smoking. We developed Quin using a multiphase program of co-design research, part of which included focus group evaluation of Quin among stakeholders prior to clinical testing.

OBJECTIVE

This study aimed to gather and compare feedback on the user experience of the Quin prototype from end users and smoking cessation professionals (SCPs) via a beta testing process to inform ongoing chatbot iterations and refinements.

METHODS

Following active and passive recruitment, we conducted web-based focus groups with SCPs and end users from Queensland, Australia. Participants tested the app for 1-2 weeks prior to focus group discussion and could also log conversation feedback within the app. Focus groups of SCPs were completed first to review the breadth and accuracy of information, and feedback was prioritized and implemented as major updates using Agile processes prior to end user focus groups. We categorized logged in-app feedback using content analysis and thematically analyzed focus group transcripts.

RESULTS

In total, 6 focus groups were completed between August 2022 and June 2023; 3 for SCPs (n=9 participants) and 3 for end users (n=7 participants). Four SCPs had previously smoked, and most end users currently smoked cigarettes (n=5), and 2 had quit smoking. The mean duration of focus groups was 58 (SD 10.9; range 46-74) minutes. We identified four major themes from focus group feedback: (1) conversation design, (2) functionality, (3) relationality and anthropomorphism, and (4) role as a smoking cessation support tool. In response to SCPs' feedback, we made two major updates to Quin between cohorts: (1) improvements to conversation flow and (2) addition of the "Moments of Crisis" conversation tree. Participant feedback also informed 17 recommendations for future smoking cessation chatbot developments.

CONCLUSIONS

Feedback from end users and SCPs highlighted the importance of chatbot functionality, as this underpinned Quin's conversation design and relationality. The ready accessibility of accurate cessation information and impartial support that Quin provided was recognized as a key benefit for end users, the latter of which contributed to a feeling of accountability to the chatbot. Findings will inform the ongoing development of a mature prototype for clinical testing.

Roles, Users, Benefits, and Limitations of Chatbots in Health Care: Rapid Review

BACKGROUND

Chatbots, or conversational agents, have emerged as significant tools in health care, driven by advancements in artificial intelligence and digital technology. These programs are designed to simulate human conversations, addressing various health care needs. However, no comprehensive synthesis of health care chatbots' roles, users, benefits, and limitations is available to inform future research and application in the field.

OBJECTIVE

This review aims to describe health care chatbots' characteristics, focusing on their diverse roles in the health care pathway, user groups, benefits, and limitations.

METHODS

A rapid review of published literature from 2017 to 2023 was performed with a search strategy developed in collaboration with a health sciences librarian and implemented in the MEDLINE and Embase databases. Primary research studies reporting on chatbot roles or benefits in health care were included. Two reviewers dual-screened the search results. Extracted data on chatbot roles, users, benefits, and limitations were subjected to content analysis.

RESULTS

The review categorized chatbot roles into 2 themes: delivery of remote health services, including patient support, care management, education, skills building, and health behavior promotion, and provision of administrative assistance to health care providers. User groups spanned across patients with chronic conditions as well as patients with cancer; individuals focused on lifestyle improvements; and various demographic groups such as women, families, and older adults. Professionals and students in health care also emerged as significant users, alongside groups seeking mental health support, behavioral change, and educational enhancement. The benefits of health care chatbots were also classified into 2 themes: improvement of health care quality and efficiency and cost-effectiveness in health care delivery. The identified limitations encompassed ethical challenges, medicolegal and safety concerns, technical difficulties, user experience issues, and societal and economic impacts.

CONCLUSIONS

Health care chatbots offer a wide spectrum of applications, potentially impacting various aspects of health care. While they are promising tools for improving health care efficiency and quality, their integration into the health care system must be approached with consideration of their limitations to ensure optimal, safe, and equitable use.

Mobile Health Interventions for Substance Use Disorders

Substance use disorders (SUDs) have an enormous negative impact on individuals, families, and society as a whole. Most individuals with SUDs do not receive treatment because of the limited availability of treatment providers, costs, inflexible work schedules, required treatment-related time commitments, and other hurdles. A paradigm shift in the provision of SUD treatments is currently underway. Indeed, with rapid technological advances, novel mobile health (mHealth) interventions can now be downloaded and accessed by those that need them anytime and anywhere. Nevertheless, the development and evaluation process for mHealth interventions for SUDs is still in its infancy. This review provides a critical appraisal of the significant literature in the field of mHealth interventions for SUDs with a particular emphasis on interventions for understudied and underserved populations. We also discuss the mHealth intervention development process, intervention optimization, and important remaining questions.

Smoking Cessation Counseling in Practice: A Qualitative Analysis of Quitline Conversations in Queensland, Australia

Telephone-based services are a practical and effective behavioral support for smoking cessation, yet no in-depth analyses of this counseling have been conducted. Understanding the general content of Quitline conversations can help to improve current practices and may inform future interventions. Therefore, we aimed to independently explore conversation themes, topics, and client questions during Quitline counseling sessions with Quitline clients in Queensland, Australia. A purposive sample of 30 recorded counseling sessions, completed between January and March 2019, were de-identified, transcribed, and thematically analyzed. Seven themes, encompassing 35 topics, were derived from 26 initial calls and four follow-up calls: (1) Client details and building rapport; (2) Client history and motivation to quit; (3) Pharmacotherapy; (4) Behavioral aspects of quitting and relationship with smoking; (5) Understanding nicotine dependence and other important considerations; (6) Additional support and smoking cessation resources; and (7) Planning, goal setting and follow-up. Three themes emerged from 18 client questions including (1) Pharmacotherapy safety and contraindications; (2) Pharmacotherapy instructions and mechanism of action; and (3) Physiology of nicotine dependence. This is the first qualitative analysis of the content of Quitline counseling sessions in Australia. Counselors collect and deliver a breadth of information to provide tailored, evidence-based health care, while building rapport and trust. Findings may be translatable into personalized self-help interventions that are more accessible or appealing to people reluctant to contact Quitline. Harnessing educational opportunities regarding pharmacotherapy adherence and misconceptions can improve client confidence in the product and smoking cessation outcomes. Further research will map conversations to motivational interviewing and behavior change techniques.

Exploring the characteristics of conversational agents in chronic disease management interventions: A scoping review

Objective

With the increasing global burden of chronic diseases, there is the potential for conversational agents (CAs) to assist people in actively managing their conditions. This paper reviews different types of CAs used for chronic condition management, delving into their characteristics and the chosen study designs. This paper also discusses the potential of these CAs to enhance the health and well-being of people with chronic conditions.

Methods

A search was performed in February 2023 on PubMed, ACM Digital Library, Scopus, and IEEE Xplore. Studies were included if they focused on chronic disease management or prevention and if systems were evaluated on target user groups.

Results

The 42 selected studies explored diverse types of CAs across 11 health conditions. Personalization varied, with 25 CAs not adapting message content, while others incorporated user characteristics and real-time context. Only 12 studies used medical records in conjunction with CAs for conditions like diabetes, mental health, cardiovascular issues, and cancer. Despite measurement method variations, the studies predominantly emphasized improved health outcomes and positive user attitudes toward CAs.

Conclusions

The results underscore the need for CAs to adapt to evolving patient needs, customize interventions, and incorporate human support and medical records for more effective care. It also highlights the potential of CAs to play a more active role in helping individuals manage their conditions and notes the value of linguistic data generated during user interactions. The analysis acknowledges its limitations and encourages further research into the use and potential of CAs in disease-specific contexts.

The Chatbots Are Invading Us: A Map Point on the Evolution, Applications, Opportunities, and Emerging Problems in the Health Domain

The inclusion of chatbots is potentially disruptive in society, introducing opportunities, but also important implications that need to be addressed on different domains. The aim of this study is to examine chatbots in-depth, by mapping out their technological evolution, current usage, and potential applications, opportunities, and emerging problems within the health domain. The study examined three points of view. The first point of view traces the technological evolution of chatbots. The second point of view reports the fields of application of the chatbots, giving space to the expectations of use and the expected benefits from a cross-domain point of view, also affecting the health domain. The third and main point of view is that of the analysis of the state of use of chatbots in the health domain based on the scientific literature represented by systematic reviews. The overview identified the topics of greatest interest with the opportunities. The analysis revealed the need for initiatives that simultaneously evaluate multiple domains all together in a synergistic way. Concerted efforts to achieve this are recommended. It is also believed to monitor both the process of osmosis between other sectors and the health domain, as well as the chatbots that can create psychological and behavioural problems with an impact on the health domain.