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

The Effectiveness of Text Support for Stopping Smoking in Pregnancy (MiQuit): Multi-Trial Pooled Analysis Investigating Effect Moderators and Mechanisms of Action

INTRODUCTION

Digital cessation support appeals to pregnant smokers. In two pooled RCTs, MiQuit, a pregnancy-specific tailored text messaging intervention, did not show effectiveness for validated prolonged abstinence. However, secondary outcomes and potential moderators and mediators have not been investigated. We aimed to determine, using pooled RCT data: (1) MiQuit effectiveness on a range of smoking outcomes; (2) whether baseline tobacco dependence or quit motivation moderate effectiveness; (3) whether hypothesized mechanisms of action (quitting determination, self-efficacy, baby harm beliefs, lapse prevention strategies) mediate effectiveness.

METHODS

Pooled data analysis from two procedurally identical RCTs comparing MiQuit (N = 704) to usual care (N = 705). Participants were smokers, <25 weeks pregnant, recruited from 40 English antenatal clinics. Outcomes included self-reported 7-day abstinence at 4 weeks post-baseline and late pregnancy, and prolonged abstinence. Late pregnancy outcomes were also biochemically validated. We used hierarchical regression and structural equation modeling.

RESULTS

MiQuit increased self-reported, 7-day abstinence at 4 weeks (OR = 1.73 [95% CI 1.10-2.74]) and was borderline significant at late pregnancy (OR = 1.34 [0.99-1.82]) but not for prolonged or validated outcomes. Effectiveness was not moderated by baseline dependence (heaviness of smoking "low" vs. "moderate-high") or motivation (planning to quit ≤30 days [high] vs. >30 days [low]), but effects on self-reported outcomes were larger for the high motivation sub-group. MiQuit had a small effect on mean lapse prevention strategies (MiQuit 8.6 [SE 0.17], UC 8.1 [SE 0.17]; P = .030) but not other mechanisms.

CONCLUSIONS

MiQuit increased short-term but not prolonged or validated abstinence and may be most effective for those motivated to quit sooner.

IMPLICATIONS

Digital cessation support appeals to pregnant smokers. MiQuit, a tailored, theory-guided text messaging program for quitting smoking in pregnancy, has not shown effectiveness for validated prolonged abstinence in two previous RCTs but its impact on other smoking outcomes and potential mechanisms of action are unknown. When pooling trial data, MiQuit increased self-reported short-term abstinence, including making a quit attempt and abstinence at 4-week follow-up, but not late pregnancy, sustained, or validated abstinence. MiQuit appeared effective at late pregnancy for participants with high quitting motivation, but its mechanisms of action remain uncertain. Additional support components are likely required to enhance effectiveness.

Effect of Adding Personalized Instant Messaging Apps to a Brief Smoking Cessation Model in Community Smokers in Hong Kong: Pragmatic Randomized Clinical Trial

BACKGROUND

While text messaging has proven effective for smoking cessation (SC), engagement in the intervention remains suboptimal.

OBJECTIVE

This study aims to evaluate whether using more interactive and adaptive instant messaging (IM) apps on smartphones, which enable personalization and chatting with SC advisors, can enhance SC outcomes beyond the provision of brief SC advice and active referral (AR) to SC services.

METHODS

From December 2018 to November 2019, we proactively recruited 700 adult Chinese daily cigarette users in Hong Kong. Participants were randomized in a 1:1 ratio. At baseline, all participants received face-to-face brief advice on SC. Additionally, they were introduced to local SC services and assisted in selecting one. The intervention group received an additional 26 personalized regular messages and access to interactive chatting through IM apps for 3 months. The regular messages aimed to enhance self-efficacy, social support, and behavioral capacity for quitting, as well as to clarify outcome expectations related to cessation. We developed 3 sets of messages tailored to the planned quit date (within 30 days, 60 days, and undecided). Participants in the intervention group could initiate chatting with SC advisors on IM themselves or through prompts from regular messages or proactive inquiries from SC advisors. The control group received 26 SMS text messages focusing on general health. The primary outcomes were smoking abstinence validated by carbon monoxide levels of <4 parts per million at 6 and 12 months after the start of the intervention.

RESULTS

Of the participants, 505/700 (72.1%) were male, and 450/648 (69.4%) were aged 40 or above. Planning to quit within 30 days was reported by 500/648 (77.2%) participants, with fewer intervention group members (124/332, 37.3%) reporting previous quit attempts compared with the control group (152/335, 45.4%; P=.04). At the 6- and 12-month follow-ups (with retention rates of 456/700, 65.1%, and 446/700, 63.7%, respectively), validated abstinence rates were comparable between the intervention (14/350, 4.0%, and 19/350, 5.4%) and control (11/350, 3.1% and 21/350, 6.0%) groups. Compared with the control group, the intervention group reported greater utilization of SC services at 12 months (RR 1.26, 95% CI 1.01-1.56). Within the intervention group, engaging in chat sessions with SC advisors predicted better validated abstinence at 6 months (RR 3.29, 95% CI 1.13-9.63) and any use of SC services (RR 1.66, 95% CI 1.14-2.43 at 6 months; RR 1.67, 95% CI 1.26-2.23 at 12 months).

CONCLUSIONS

An IM-based intervention, providing support and assistance alongside brief SC advice and AR, did not yield further increases in quitting rates but did encourage the utilization of SC services. Future research could explore whether enhanced SC service utilization leads to improved long-term SC outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03800719; https://clinicaltrials.gov/ct2/show/NCT03800719.

A smoking cessation smartphone app that delivers real-time 'context aware' behavioural support: the Quit Sense feasibility RCT

Background

During a quit attempt, cues from a smoker's environment are a major cause of brief smoking lapses, which increase the risk of relapse. Quit Sense is a theory-guided Just-In-Time Adaptive Intervention smartphone app, providing smokers with the means to learn about their environmental smoking cues and provides 'in the moment' support to help them manage these during a quit attempt.

Objective

To undertake a feasibility randomised controlled trial to estimate key parameters to inform a definitive randomised controlled trial of Quit Sense.

Design

A parallel, two-arm randomised controlled trial with a qualitative process evaluation and a 'Study Within A Trial' evaluating incentives on attrition. The research team were blind to allocation except for the study statistician, database developers and lead researcher. Participants were not blind to allocation.

Setting

Online with recruitment, enrolment, randomisation and data collection (excluding manual telephone follow-up) automated through the study website.

Participants

Smokers (323 screened, 297 eligible, 209 enrolled) recruited via online adverts on Google search, Facebook and Instagram.

Interventions

Participants were allocated to 'usual care' arm (n = 105; text message referral to the National Health Service SmokeFree website) or 'usual care' plus Quit Sense (n = 104), via a text message invitation to install the Quit Sense app.

Main outcome measures

Follow-up at 6 weeks and 6 months post enrolment was undertaken by automated text messages with an online questionnaire link and, for non-responders, by telephone. Definitive trial progression criteria were met if a priori thresholds were included in or lower than the 95% confidence interval of the estimate. Measures included health economic and outcome data completion rates (progression criterion #1 threshold: ≥ 70%), including biochemical validation rates (progression criterion #2 threshold: ≥ 70%), recruitment costs, app installation (progression criterion #3 threshold: ≥ 70%) and engagement rates (progression criterion #4 threshold: ≥ 60%), biochemically verified 6-month abstinence and hypothesised mechanisms of action and participant views of the app (qualitative).

Results

Self-reported smoking outcome completion rates were 77% (95% confidence interval 71% to 82%) and health economic data (resource use and quality of life) 70% (95% CI 64% to 77%) at 6 months. Return rate of viable saliva samples for abstinence verification was 39% (95% CI 24% to 54%). The per-participant recruitment cost was £19.20, which included advert (£5.82) and running costs (£13.38). In the Quit Sense arm, 75% (95% CI 67% to 83%; 78/104) installed the app and, of these, 100% set a quit date within the app and 51% engaged with it for more than 1 week. The rate of 6-month biochemically verified sustained abstinence, which we anticipated would be used as a primary outcome in a future study, was 11.5% (12/104) in the Quit Sense arm and 2.9% (3/105) in the usual care arm (estimated effect size: adjusted odds ratio = 4.57, 95% CIs 1.23 to 16.94). There was no evidence of between-arm differences in hypothesised mechanisms of action. Three out of four progression criteria were met. The Study Within A Trial analysis found a £20 versus £10 incentive did not significantly increase follow-up rates though reduced the need for manual follow-up and increased response speed. The process evaluation identified several potential pathways to abstinence for Quit Sense, factors which led to disengagement with the app, and app improvement suggestions.

Limitations

Biochemical validation rates were lower than anticipated and imbalanced between arms. COVID-19-related restrictions likely limited opportunities for Quit Sense to provide location tailored support.

Conclusions

The trial design and procedures demonstrated feasibility and evidence was generated supporting the efficacy potential of Quit Sense.

Future work

Progression to a definitive trial is warranted providing improved biochemical validation rates.

Trial registration

This trial is registered as ISRCTN12326962.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 17/92/31) and is published in full in Public Health Research; Vol. 12, No. 4. See the NIHR Funding and Awards website for further award information.

How to inform college students about meningitis B vaccine? Comparative effectiveness of an online theory-based text and video intervention

Objective The purpose of this study was to compare the effect of text and video formats of an online theory-based Meningitis B (MenB) health message intervention on college students. Participants: College freshmen and transfer students admitted at a Southern U.S. University. Methods: In a 2-arm randomized study, knowledge, perceptions, and intention to receive the vaccine were compared pre- and post-intervention. Results: Post intervention, participants in both the written and video interventions had significantly higher scores of knowledge, perceptions, and intentions. Upon comparing the change in scores pre- to post-intervention between both text and video groups, no significant differences were found between both groups. Conclusions: This study, a first in using a theory-based MenB online education intervention and questionnaire to compare text and video formats, suggests that both text and video formats are equally effective in raising young adults' awareness about the MenB vaccine.

Systematic review and meta-analysis of text messaging interventions to support tobacco cessation

OBJECTIVE

To review randomised controlled trials (RCTs) investigating the effectiveness of text message-based interventions for smoking cessation, including the effects of dose (number of text messages) and concomitant use of behavioural or pharmacological interventions.

DATA SOURCES

We searched seven databases (PubMed, CINAHL, PsycINFO, Scopus, EMBASE, Cochrane Library and Web of Science), Google Scholar and the reference lists of relevant publications for RCTs. Eligible studies included participants aged ≥15 years who smoked tobacco at enrolment.

STUDY SELECTION

One reviewer screened titles and abstracts and two reviewers independently screened full texts of articles.

DATA EXTRACTION

One of three reviewers independently extracted data on study and intervention characteristics and smoking abstinence rates using Qualtrics software.

DATA SYNTHESIS

30 of the 40 included studies reported higher rates of smoking cessation among those receiving text messaging interventions compared with comparators, but only 10 were statistically significant. A meta-analysis of seven RCTs found that participants receiving text messages were significantly more likely to quit smoking compared with participants in no/minimal intervention or 'usual care' conditions (risk ratio 1.87, 95% CI 1.52 to 2.29, p <0.001). Three trials found no benefit from a higher dose of text messages on smoking cessation. Two trials that tested the added benefit of text messaging to pharmacotherapy reported outcomes in favour of adding text messaging.

CONCLUSIONS

Findings suggest that text messaging-based interventions are effective at promoting smoking cessation. Further research is required to establish if any additional benefit is gained from an increased number of text messages or concurrent pharmacotherapy or behavioural counselling.

Efficacy of e-health interventions for smoking cessation management in smokers: a systematic review and meta-analysis

Background

Smoking is one of the major risk factors for shortened lifespan and disability, while smoking cessation is currently the only guaranteed method to reduce the harm caused by smoking. E-health is a field that utilizes information and communication technology to support the health status of its users. The emergence of this digital health approach has provided a new way of smoking cessation support for smokers seeking help, and an increasing number of researchers are attempting to use e-health for a wide range of effective smoking cessation interventions. We conducted a systematic review and meta-analysis of studies that used e-health as a smoking cessation support tool.

Methods

This systematic review and meta-analysis searched the PubMed, Embase, and Cochrane Library databases until December 2022. The included studies were randomized controlled trials (RCTs) comparing the use of e-health interventions and traditional offline smoking cessation care interventions. The primary outcome of the studies was the point smoking cessation rate (7-day and 30-day), and the secondary outcome was sustained smoking cessation rates. Studies were excluded if there was no clear e-health intervention described or if standard-compliant cessation outcomes were not clearly reported. Fixed-effects meta-analysis and meta-regression analyses were performed on the included study data to evaluate the effectiveness of the interventions. The meta-analysis outcome was the risk ratio (RR) and a 95% confidence interval. The study was registered with PROSPERO, CRD42023388667.

Findings

We collectively screened 2408 articles, and ultimately included 39 articles with a total of 17,351 eligible participants, of which 44 studies were included in the meta-analysis. The meta-analysis revealed that compared to traditional smoking cessation interventions, e-health interventions can increase point quit rates (RR 1.86, 95% CI 1.69-2.04) as well as sustained quit rates in the long-term (RR 1.79, 95% CI 1.60-2.00) among smokers. Subgroup analysis showed that text and telephone interventions in e-health significantly improved short-term quit rates for up to 7 days (RR 2.10, 95% CI 1.77-2.48). Website and app interventions also had a positive impact on improving short-term quit rates for up to 7 days (RR 1.74, 95% CI 1.56-1.94). The heterogeneity of the study results was low, demonstrating the significant smoking cessation advantages of e-health interventions.

Interpretation

We have found that personalized e-health interventions can effectively help smokers quit smoking. The diverse remote intervention methods of e-health can provide more convenient options for further customization. Additionally, further follow-up research is needed to evaluate the sustained effectiveness of interventions on smokers' continuous abstinence over a longer period (greater than one year). In the future, e-health can further optimize smoking cessation strategies.

Funding

No funding.

Effectiveness of smoking cessation interventions among pregnant women: An updated systematic review and meta-analysis

OBJECTIVE

To carry out a systematic review of systematic reviews with an update of the existing evidence relating to a broad range of smoking cessation interventions, including psycho-social, digital and pharmacologic interventions, for pregnant women.

DATA-SOURCES

Search was conducted in March 2022 in PubMed, EMBASE, and Cochrane in two stages: 1) a search of systematic reviews and meta-analyses, published from January 2012 through January 2022; 2) an update of those that fulfilled eligibility criteria reproducing the primary search strategy.

STUDY ELIGIBILITY CRITERIA

We selected randomized clinical trials (RCTs) that evaluated the effectiveness of pharmacological, digital, and psychosocial interventions in aged 18 years and over who were daily smokers, and compared these with routine care, less intense interventions or placebo.

STUDY APPRAISAL AND SYNTHESIS METHODS

Data from eligible studies were manually extracted by two authors and reviewed by a third. The quality of the reviews was evaluated using the AMSTAR scale, and risk of bias was measured with the Rob-2 tool and GRADE level of evidence.

RESULTS

The meta-analysis included 63 RCTs (n = 19849 women). The interventions found to be effective were: financial incentives (RR:1.77; 95%CI:1.21-2.58), counseling (RR:1.27; 95%CI:1.13-1.43) and long-term nicotine replacement therapy (NRT) (RR:1.53; 95%CI:1.16-2.01). Short-term NRT, bupropion, digital interventions, feedback, social support, and exercise showed no effectiveness. The GRADE level of evidence was moderate-to-high for all interventions, with the exception of long-term NRT.

CONCLUSIONS

Non-pharmacological interventions for smoking cessation are the most effective for pregnant women. The moderator analysis suggests that pregnant women of low socioeconomic status might benefit less from smoking cessation interventions than women of a high socioeconomic status. These women are usually heavier smokers that live in pro-smoking environments and could require more intensive and targeted interventions.

Effectiveness of eHealth Smoking Cessation Interventions: Systematic Review and Meta-Analysis

BACKGROUND

Rapid advancements in eHealth and mobile health (mHealth) technologies have driven researchers to design and evaluate numerous technology-based interventions to promote smoking cessation. The evolving nature of cessation interventions emphasizes a strong need for knowledge synthesis.

OBJECTIVE

This systematic review and meta-analysis aimed to summarize recent evidence from randomized controlled trials regarding the effectiveness of eHealth-based smoking cessation interventions in promoting abstinence and assess nonabstinence outcome indicators, such as cigarette consumption and user satisfaction, via narrative synthesis.

METHODS

We searched for studies published in English between 2017 and June 30, 2022, in 4 databases: PubMed (including MEDLINE), PsycINFO, Embase, and Cochrane Library. Two independent reviewers performed study screening, data extraction, and quality assessment based on the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework. We pooled comparable studies based on the population, follow-up time, intervention, and control characteristics. Two researchers performed an independent meta-analysis on smoking abstinence using the Sidik-Jonkman random-effects model and log risk ratio (RR) as the effect measurement. For studies not included in the meta-analysis, the outcomes were narratively synthesized.

RESULTS

A total of 464 studies were identified through an initial database search after removing duplicates. Following screening and full-text assessments, we deemed 39 studies (n=37,341 participants) eligible for this review. Of these, 28 studies were shortlisted for meta-analysis. According to the meta-analysis, SMS or app text messaging can significantly increase both short-term (3 months) abstinence (log RR=0.50, 95% CI 0.25-0.75; I2=0.72%) and long-term (6 months) abstinence (log RR=0.77, 95% CI 0.49-1.04; I2=8.65%), relative to minimal cessation support. The frequency of texting did not significantly influence treatment outcomes. mHealth apps may significantly increase abstinence in the short term (log RR=0.76, 95% CI 0.09-1.42; I2=88.02%) but not in the long term (log RR=0.15, 95% CI -0.18 to 0.48; I2=80.06%), in contrast to less intensive cessation support. In addition, personalized or interactive interventions showed a moderate increase in cessation for both the short term (log RR=0.62, 95% CI 0.30-0.94; I2=66.50%) and long term (log RR=0.28, 95% CI 0.04-0.53; I2=73.42%). In contrast, studies without any personalized or interactive features had no significant impact. Finally, the treatment effect was similar between trials that used biochemically verified or self-reported abstinence. Among studies reporting outcomes besides abstinence (n=20), a total of 11 studies reported significantly improved nonabstinence outcomes in cigarette consumption (3/14, 21%) or user satisfaction (8/19, 42%).

CONCLUSIONS

Our review of 39 randomized controlled trials found that recent eHealth interventions might promote smoking cessation, with mHealth being the dominant approach. Despite their success, the effectiveness of such interventions may diminish with time. The design of more personalized interventions could potentially benefit future studies.

TRIAL REGISTRATION

PROSPERO CRD42022347104; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=347104.

Effect of digital health, biomarker feedback and nurse or midwife-led counselling interventions to assist pregnant smokers quit: a systematic review and meta-analysis

OBJECTIVE

To assess the effect of digital health (DH), biomarker feedback (BF) and nurse or midwife-led counselling (NoMC) interventions on abstinence in pregnant smokers during pregnancy and postpartum.

SETTINGS

Any healthcare setting servicing pregnant women, including any country globally.

PARTICIPANTS

Pregnant women of any social, ethnic or geographical background who smoke.

METHODS

We searched Embase, Medline, Web Of Science, Google Scholar, PsychINFO, CINAHL and PubMed between 2007 and November 2021. We included published original intervention studies in English with comparators (usual care or placebo). Two independent assessors screened and abstracted data. We performed a random-effects meta-analysis, assessed risk of bias with the Cochrane Tool and used Grading of Recommendations Assessment, Development and Evaluation to assess the quality of evidence.

RESULTS

We identified 57 studies and included 54 in the meta-analysis. Sixteen studies assessed DH (n=3961), 6 BF (n=1643), 32 NoMC (n=60 251), 1 assessed NoMC with BF (n=1120) and 2 NoMC with DH interventions (n=2107). DH interventions had moderate certainty evidence to achieve continuous abstinence (CA) at late pregnancy (4 studies; 2049 women; RR=1.98, 95% CI 1.08 to 3.64, p=0.03) and low certainty evidence to achieve point prevalence abstinence (PPA) postpartum (5 studies; 2238 women; RR=1.46, 95% CI 1.05 to 2.02, p=0.02). NoMC interventions had moderate certainty evidence to achieve PPA in late pregnancy (15 studies; 16 234 women; RR=1.54, 95% CI 1.16 to 2.06, p<0.01) and low certainty evidence to achieve PPA postpartum (13 studies; 5466 women; RR=1.79, 95% CI 1.14 to 2.83, p=0.01). Both DH and BF interventions did not achieve PPA at late pregnancy, nor NoMC interventions achieve CA postpartum. The certainty was reduced due to risk of bias, heterogeneity, inconsistency and/or imprecision.

CONCLUSION

NoMC interventions can assist pregnant smokers achieve PPA and DH interventions achieve CA in late pregnancy. These interventions may achieve other outcomes.

Leveraging Digital Technology to Support Pregnant and Early Parenting Women in Recovery from Addictive Substances: A Scoping Review

Little is known about digital health interventions used to support treatment for pregnant and early parenting women (PEPW) with substance use disorders (SUD).

METHODS

Guided by the Arksey and O'Malley's Scoping Review Framework, empirical studies were identified within the CINAHL, PsycInfo, PubMed, and ProQuest databases using subject headings and free-text keywords. Studies were selected based on a priori inclusion/exclusion criteria, and data extraction and descriptive analysis were performed.

RESULTS

A total of 27 original studies and 30 articles were included. Varying study designs were used, including several feasibility and acceptability studies. However, efficacious findings on abstinence and other clinically important outcomes were reported in several studies. Most studies focused on digital interventions for pregnant women (89.7%), suggesting a dearth of research on how digital technologies may support early parenting women with SUD. No studies included PEPW family members or involved PEPW women in the intervention design.

CONCLUSIONS

The science of digital interventions to support treatment for PEPW is in an early stage, but feasibility and efficacy results are promising. Future research should explore community-based participatory partnerships with PEPW to develop or tailor digital interventions and include family or external support systems to engage in the intervention alongside PEPW.

Systematic review on the cost and cost-effectiveness of mHealth interventions supporting women during pregnancy

OBJECTIVES

The increased integration of digital health into maternity care-alongside growing use of, and access to, personal digital technology among pregnant women-warrants an investigation of the cost-effectiveness of mHealth interventions used by women during pregnancy and the methodological quality of the cost-effectiveness studies.

METHODS

A systematic search was conducted to identify peer-reviewed studies published in the last ten years (2011-2021) reporting on the costs or cost-effectiveness of mHealth interventions used by women during pregnancy. Available data related to program costs, total incremental costs and incremental cost-effectiveness ratios (ICERs) were reported in 2020 United States Dollars. The quality of cost-effectiveness studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).

FINDINGS

Nine articles reporting on eight studies met the inclusion criteria. Direct intervention costs ranged from $7.04 to $86 per woman, total program costs ranged from $241,341 to $331,136 and total incremental costs ranged from -$21.16 to $1.12 million per woman. The following ICERs were reported: $2168 per DALY averted, $203.44 per woman ceasing smoking, and $3475 per QALY gained. The full economic evaluation studies (n = 4) were moderate to high in quality and all reported the mHealth intervention as cost-effective. Other studies (n = 4) were low to moderate in quality and reported low costs or cost savings associated with the implementation of the mHealth intervention.

CONCLUSIONS FOR PRACTICE

Preliminary evidence suggests mHealth interventions may be cost-effective and "low-cost" but more evidence is needed to ascertain the cost-effectiveness of mHealth interventions regarding positive maternal and child health outcomes and longer-term health service utilisation.

Digital interventions for smoking abstinence: a systematic review and meta-analysis of randomized control trials

OBJECTIVES

Technological advancements have improved patients' health and clinical care through digital interventions. This study investigated the effects of digital interventions on smoking abstinence.

METHODS

PubMed, the Cochrane Library, and Scopus were systematically searched from inception until December 2021. Meta-analysis was carried out using a random-effects model. The degree of heterogeneity, quality, and publication bias of the selected studies was further evaluated.

RESULTS

A total of 43 randomized control trial studies were eligible for this study. 38,814 participants from 18 countries were included in the analysis. Digital interventions on seven-day point prevalence abstinence (1 month) showed increased smoking abstinence. The odds ratio was 2.02 and confidence interval (CI) was 1.67-2.43; p < 0.001; I² = 55.1%) . The result for a 30-day point prevalence abstinence (1 month) was 1.63 (CI 1.09-2.46; p = 0.018; I² = 0%). Digital intervention also had a significant effect on continuous abstinence (odds ratio = 1.68; CI 1.29-2.18; p < 0.001; I² = 70.1%) and prolonged abstinence (odds ratio = 1.60; CI 1.19-2.15; p = 0.002; I² = 53.6%). There was evidence of heterogeneity and publication bias.

CONCLUSIONS

Digital interventions led to increased smoking abstinence and can be a valuable tool in smoking cessation. Further research is required to evaluate the long-term impact of digital interventions on outcomes related to smoking cessation.

Investigating the cost-effectiveness of three cessation interventions on a national scale using the Economics of Smoking in Pregnancy (ESIP) decision analytical model

AIM

To measure the cost-effectiveness of adding text message (TMB), exercise (EB) and abstinent-contingent financial incentive-based (CFIB) stop smoking interventions to standard smoking cessation support for pregnant women in England.

DESIGN

Modelling cost-effectiveness outcomes by separately adding three cessation interventions to standard cessation care offered to pregnant women in England. English National Health Service Stop Smoking Services (NHS SSS) statistics from 2019 to 2020 were used for estimating the base quit rate. Intervention effectiveness and cost data for interventions were taken from trial reports. Cost-effectiveness was derived using the economics of smoking in pregnancy (ESIP) model from a health service and personal social services perspective. Interventions were compared with each other as well as against standard cessation care.

SETTING

English NHS SSS.

PARTICIPANTS/CASES

A total of 13 799 pregnant women who accessed NHS SSS. Interventions and comparator; comparator: standard stop smoking support comprising behavioural intervention and an offer of nicotine replacement therapy (NRT). Three additive interventions were TMB, EB and CFIB.

MEASUREMENTS

Incremental cost-effectiveness ratios per quality-adjusted life-years gained for both mothers and offspring over their life-times; return on investment (ROI); and cost-effectiveness acceptability curves (CEACs).

FINDINGS

The addition of any of the interventions compared with standard care alone was preferred, but only significant for the addition of CFIB, with the CEAC suggesting an at least 90% chance of being favoured to standard care alone. When compared against each other CFIB appeared to yield the largest returns, but this was not significant. The estimated ROI for CFIB was £2 [95% confidence interval (CI) = £1-3] in health-care savings for every £1 spent by the NHS on the cessation intervention.

CONCLUSIONS

For a health system which currently provides behavioural support and an offer of nicotine replacement therapy as standard stop smoking support for pregnant women, the greatest economic gains would be provided by operating an abstinent-contingent financial incentives scheme alongside this.

A Method to Deliver Automated and Tailored Intervention Content: 24-month Clinical Trial

Background

The use of digital technologies and software allows for new opportunities to communicate and engage with research participants over time. When software is coupled with automation, we can engage with research participants in a reliable and affordable manner. Research Electronic Data Capture (REDCap), a browser-based software, has the capability to send automated text messages. This feature can be used to automate delivery of tailored intervention content to research participants in interventions, offering the potential to reduce costs and improve accessibility and scalability.

Objective

This study aimed to describe the development and use of 2 REDCap databases to deliver automated intervention content and communication to index participants and their partners (dyads) in a 2-arm, 24-month weight management trial, Partner2Lose.

Methods

Partner2Lose randomized individuals with overweight or obesity and cohabitating with a partner to a weight management intervention alone or with their partner. Two databases were developed to correspond to 2 study phases: one for weight loss initiation and one for weight loss maintenance and reminders. The weight loss initiation database was programmed to send participants (in both arms) and their partners (partner-assisted arm) tailored text messages during months 1-6 of the intervention to reinforce class content and support goal achievement. The weight maintenance and reminder database was programmed to send maintenance-related text messages to each participant (both arms) and their partners (partner-assisted arm) during months 7-18. It was also programmed to send text messages to all participants and partners over the course of the 24-month trial to remind them of group classes, dietary recall and physical activity tracking for assessments, and measurement visits. All text messages were delivered via Twilio and were unidirectional.

Results

Five cohorts, comprising 231 couples, were consented and randomized in the Partner2Lose trial. The databases will send 53,518 automated, tailored text messages during the trial, significantly reducing the need for staff to send and manage intervention content over 24 months. The cost of text messaging will be approximately US $450. Thus far, there is a 0.004% known error rate in text message delivery.

Conclusions

Our trial automated the delivery of tailored intervention content and communication using REDCap. The approach described provides a framework that can be used in future behavioral health interventions to create an accessible, reliable, and affordable method for intervention delivery and engagement that requires minimal trial-specific resources and personnel time.

Trial Registration

ClinicalTrials.gov NCT03801174; https://clinicaltrials.gov/ct2/show/NCT03801174?term=NCT03801174

Cost-effectiveness of mental health interventions during and after pregnancy: A systematic review

BACKGROUND

Mental health problems during and after pregnancy such as depression, anxiety, post-traumatic stress disorder (PTSD), or addiction are common and can have lifelong implications for both parents and offspring. This review investigates the cost-effectiveness of interventions tackling these problems, assesses the methodological quality of included studies, and indicates suggestions for further research.

METHODS

Thirteen databases were searched for economic evaluations of interventions related to antenatal, perinatal, and postnatal mental health conditions, published between 2000 and September 2021, in high-income countries.

RESULTS

Thirty-nine studies met all inclusion criteria. Interventions considered were screening programs, pharmacological treatments, and various forms of psychosocial and psychological support. Six studies reported that the intervention was cost-saving. Eighteen were cost-effective and seven likely to be cost-effective. Only six studies included health outcomes for the child; one study considered paternal health. The time horizon for which costs and consequences were considered was for most evaluations limited to 1 year (n = 18) or 2 years (n = 11) postpartum.

CONCLUSIONS

Given the importance of the subject, a relatively low number of studies have investigated the cost-effectiveness of interventions tackling mental health problems during and after pregnancy. The scant evidence available suggests good overall value for money. Likely, cost-effectiveness is underestimated as costly long-term consequences on offspring are systematically excluded. No evidence was found for several frequently occurring conditions. Further research is required to obtain reliable, long-term effectiveness data and to address the methodological challenges related to measuring all relevant health outcomes for all parties affected.

Online randomised factorial trial of electronic Screening and Brief Intervention for alcohol use in pregnancy: a study protocol

INTRODUCTION

Approximately 1 in 7 pregnant women in the USA report past-month alcohol use. Strong evidence connects prenatal alcohol exposure with a range of adverse perinatal outcomes, including the spectrum of conditions known as fetal alcohol spectrum disorders. Screening and Brief Intervention (SBI) has been recommended for pregnant women but has proven difficult to implement. This study will test the efficacy of single-session technology-delivered SBI (electronic SBI) for alcohol use in pregnancy, while simultaneously evaluating the possible additional benefit of tailored text messages and/or booster sessions in a 3×2 factorial trial.

METHOD AND ANALYSIS

This full factorial trial will use online advertising and clinic-based flyers to recruit pregnant women meeting criteria for unhealthy alcohol use, and randomly assign them to one of six conditions crossing three levels of brief intervention (none, single 120-minute session and single session plus two 5-minute boosters) with two levels of tailored text messaging (none vs twice weekly messages). The primary analysis will test for dose-response effects of the brief intervention on alcohol abstinence, defined as no self-report of alcohol use in the 90 days prior to 34 weeks' gestation, and negative results for ethyl glucuronide analysis of fingernail samples. Secondary analyses will examine main and interaction effects of tailored text messaging as well as intervention effects on birth outcomes.

ETHICS AND DISSEMINATION

Ethical approval was provided by the Michigan State University Biomedical and Health Institutional Review Board (STUDY00005298). Results will be presented at conferences and community forums, in addition to being published in a peer-reviewed journal. Intervention content demonstrating sufficient efficacy and safety will be made publicly available.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04332172).

Promoting smoking cessation during pregnancy: A feasibility and pilot trial of a digital storytelling intervention delivered via text-messaging

OBJECTIVE

Smoking during pregnancy causes risks to mother and infant health. We investigated the feasibility and likely success of SKIP-IT, a narrative and picture-based smoking cessation intervention delivered via text messages.

METHODS

A feasibility and pilot trial. We aimed to recruit 70 pregnant women who smoked, randomised to usual care alone, or usual care and the SKIP-IT intervention, between 12 weeks of pregnancy and 6 weeks post due-date. Outcomes assessed were recruitment, retention, acceptability of, and engagement with the intervention, smoking behaviour, intentions, perceived risk, and self-efficacy.

RESULTS

Of 312 women initially approached by smoking cessation services only 54 (17%) agreed to be contacted by the research team. Twenty were then either ineligible or uncontactable and 28 (82%) participated. Most women reported texts to be entertaining and helpful. The proportion of women not smoking at follow-up was lower in the intervention group, but numbers were too small to draw conclusions about effectiveness.

CONCLUSION

The intervention was acceptable, but difficulty in making initial and follow-up contacts meant our methods were unfeasible for a larger trial.

PRACTICE IMPLICATIONS

Digital Storytelling interventions could help women quit smoking, but further research is required to identify alternative methods for studies with pregnant women who smoke.

Development of a WeChat-based Mobile Messaging Smoking Cessation Intervention for Chinese Immigrant Smokers: Qualitative Interview Study

Background

Smoking remains a major public health issue among Chinese immigrants. Smoking cessation programs that focus on this population are scarce and have a limited population-level impact due to their low reach. Mobile messaging interventions have the potential to reach large audiences and expand smokers’ access to smoking cessation treatment.

Objective

This study describes the development of a culturally and linguistically appropriate mobile messaging smoking cessation intervention for Chinese immigrant smokers delivered via WeChat, the most frequently used social media platform among Chinese people globally.

Methods

This study had 2 phases. In phase 1, we developed a mobile message library based on social cognitive theory and the US Clinical Practice Guidelines for Treating Tobacco Use and Dependence. We culturally adapted messages from 2 social cognitive theory-based text messaging smoking cessation programs (SmokefreeTXT and Decídetexto). We also developed new messages targeting smokers who were not ready to quit smoking and novel content addressing Chinese immigrant smokers’ barriers to quitting and common misconceptions related to willpower and nicotine replacement therapy. In phase 2, we conducted in-depth interviews with 20 Chinese immigrant smokers (including 7 women) in New York City between July and August 2021. The interviews explored the participants’ smoking and quitting experiences followed by assessment of the text messages. Participants reviewed 17 text messages (6 educational messages, 3 self-efficacy messages, and 8 skill messages) via WeChat and rated to what extent the messages enhanced their motivation to quit, promoted confidence in quitting, and increased awareness about quitting strategies. The interviews sought feedback on poorly rated messages, explored participant preferences for content, length, and format, discussed their concerns with WeChat cessation intervention, and solicited recommendations for frequency and timing of messages.

Results

Overall, participants reported that the messages enhanced their motivation to quit, offered encouragement, and made them more informed about how to quit. Participants particularly liked the messages about the harms of smoking and strategies for quitting. They reported barriers to applying some of the quitting strategies, including coping with stress and staying abstinent at work. Participants expressed strong interest in the WeChat mobile messaging cessation intervention and commented on its potential to expand their access to smoking cessation treatment.

Conclusions

Mobile messages are well accepted by Chinese immigrant smokers. Research is needed to assess the feasibility, acceptability, and efficacy of WeChat mobile messaging smoking cessation interventions for promoting abstinence among Chinese immigrant smokers.

A Scoping Review of Computer-Based and Telecommunication Technology Interventions to Address Drug and Alcohol Misuse and Smoking in Women

BACKGROUND

Computer-based and telecommunication technology has become increasingly common to address addiction among women. This review assessed the effect of technology-based interventions on substance misuse, alcohol use, and smoking outcomes among women.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) guideline was used to conduct the scoping review. Four databases (PubMed, Web of Science, PsycINFO, and Scopus) were used to search for peer-reviewed articles published in English on computer-based and telecommunication technology use to address substance misuse, alcohol use, and smoking among women.

RESULTS

A total of 30 articles were selected after the final full-text review from the U.S., England, Japan, and the Netherlands. The types of technology used in the interventions included computer software (standalone or web-based), mobile applications, video calling, phone, and text messaging. Intervention outcomes included alcohol and other substance misuse reduction as polysubstance misuse (n = 5), smoking cessation (n = 10), substance misuse reduction only (n = 6), and alcohol use reduction only (n = 9). The populations reached included women who were pregnant (n = 13), postpartum (n = 4), or non-pregnant (n = 14) ranging from adolescent to adulthood. Interventions that targeted polysubstance misuse showed statistically significant reductions (p < .05).

CONCLUSION

Although effective in reducing alcohol and other substance misuse, mixed findings were identified for other outcomes targeting a single substance. Technology-based interventions might maximize their effects by targeting polysubstance misuse and addressing associated contextual issues in the form of a computer-delivered module(s).

Effectiveness of offering tailored text message, self-help smoking cessation support to pregnant women who want information on stopping smoking: MiQuit3 randomised controlled trial and meta-analysis

AIMS

To test the efficacy of 'MiQuit', a tailored, self-help, text message stop smoking programme for pregnancy, as an adjunct to usual care (UC) for smoking cessation in pregnancy.

DESIGN

Multicentre, open, two-arm, parallel-group, superiority randomised controlled trial (RCT) and a trial sequential analysis (TSA) meta-analysis combining trial findings with two previous ones.

SETTING

Twenty-four English hospital antenatal clinics.

PARTICIPANTS

A total of 1002 pregnant women who were ≥16 years old, were ≤25 weeks gestation and smoked ≥1 daily cigarette and accepted information on cessation with no requirement to set quit dates.

INTERVENTIONS

UC or UC plus 'MiQuit': 12 weeks of tailored, smoking cessation text messages focussed on inducing and aiding cessation.

MEASUREMENTS

Primary outcome: biochemically validated cessation between 4 weeks after randomisation and late pregnancy.

SECONDARY OUTCOMES

shorter and non-validated abstinence periods, pregnancy outcomes and incremental cost-effectiveness ratios.

FINDINGS

RCT: cessation was 5.19% (26/501) and 4.59% (23/501) in MiQuit and UC groups (adjusted odds ratio [adj OR] for quitting with MiQuit versus UC, 95% CI = 1.15 [0.65-2.04]); other abstinence findings were similar, with higher point estimates. Primary outcome ascertainment was 61.7% (309) and 67.3% (337) in MiQuit and UC groups with 71.1% (54/76) and 69.5% (41/59) abstinence validation rates, respectively. Pregnancy outcomes were similar and the incremental cost per quality-adjusted life year was -£1118 (95% CI = -£4806-£1911). More MiQuit group women reported making at least one quit attempt (adj OR [95% CI]) for making an attempt, 1.50 (1.07-2.09). TSA meta-analysis: this found no significant difference in prolonged abstinence between MiQuit and UC (pooled OR = 1.49, adjusted 95% CI = 0.62-3.60).

CONCLUSIONS

Irrespective of whether they want to try quitting, when offered a tailored, self-help, text message stop smoking programme for pregnancy (MiQuit) as an adjunct to usual care, pregnant women are not more likely to stop smoking until childbirth but they report more attempts at stopping smoking.

Adaptive Text Messaging for Postpartum Risky Drinking: Conceptual Model and Protocol for an Ecological Momentary Assessment Study (Preprint)

Background

Risky drinking is prevalent among women of childbearing age. Although many women reduce their drinking during pregnancy, more than half return to prepregnancy levels during the early postpartum period. Risky drinking in new mothers may be associated with negative child and maternal health outcomes; however, new mothers are unlikely to seek treatment for risky drinking because of stigma and fear of child protective service involvement. SMS text messaging is a promising approach for reaching non–treatment-seeking new mothers at risk because of risky drinking. SMS text messaging interventions (TMIs) are empirically supported for alcohol use, but a tailored intervention for new mothers does not exist. This study aims to fill this gap by developing a just-in-time adaptive TMI for postpartum risky drinking.

Objective

The objectives of this paper are to present a preliminary conceptual model of postpartum risky drinking and describe the protocol for conducting an ecological momentary assessment (EMA) study with new mothers to inform the refinement of the conceptual model and development of the TMI.

Methods

This paper presents a preliminary conceptual model of postpartum risky drinking based on the motivational model of alcohol use, social cognitive theory, and temporal self-regulation theory. The model proposes three primary intervention targets: motivation, self-efficacy, and self-regulation. Theoretical and empirical literature in support of the conceptual model is described. The paper also describes procedures for a study that will collect EMA data from 30 participants recruited via social media and the perinatal Central Intake system of New Jersey. Following the baseline assessment, EMA surveys will be sent 5 times per day for 14 days. The assessment instruments and data analysis procedures are described.

Results

Recruitment is scheduled to begin in January 2022 and is anticipated to conclude in March 2022. Study results are estimated to be published in July 2022.

Conclusions

The study findings will enhance our understanding of daily and momentary fluctuations in risk and protective factors for risky drinking during the early postpartum period. The findings will be used to refine the conceptual model and inform the development of the TMI. The next steps for this work include the development of intervention components via an iterative participatory design process and testing of the resulting intervention in a pilot microrandomized trial.

International Registered Report Identifier (IRRID)

PRR1-10.2196/36849

Digital interventions in mental health: evidence syntheses and economic modelling

BACKGROUND

Economic evaluations provide evidence on whether or not digital interventions offer value for money, based on their costs and outcomes relative to the costs and outcomes of alternatives.

OBJECTIVES

(1) Evaluate and summarise published economic studies about digital interventions across different technologies, therapies, comparators and mental health conditions; (2) synthesise clinical evidence about digital interventions for an exemplar mental health condition; (3) construct an economic model for the same exemplar mental health condition using the previously synthesised clinical evidence; and (4) consult with stakeholders about how they understand and assess the value of digital interventions.

METHODS

We completed four work packages: (1) a systematic review and quality assessment of economic studies about digital interventions; (2) a systematic review and network meta-analysis of randomised controlled trials on digital interventions for generalised anxiety disorder; (3) an economic model and value-of-information analysis on digital interventions for generalised anxiety disorder; and (4) a series of knowledge exchange face-to-face and digital seminars with stakeholders.

RESULTS

In work package 1, we reviewed 76 economic evaluations: 11 economic models and 65 within-trial analyses. Although the results of the studies are not directly comparable because they used different methods, the overall picture suggests that digital interventions are likely to be cost-effective, compared with no intervention and non-therapeutic controls, whereas the value of digital interventions compared with face-to-face therapy or printed manuals is unclear. In work package 2, we carried out two network meta-analyses of 20 randomised controlled trials of digital interventions for generalised anxiety disorder with a total of 2350 participants. The results were used to inform our economic model, but when considered on their own they were inconclusive because of the very wide confidence intervals. In work package 3, our decision-analytic model found that digital interventions for generalised anxiety disorder were associated with lower net monetary benefit than medication and face-to-face therapy, but greater net monetary benefit than non-therapeutic controls and no intervention. Value for money was driven by clinical outcomes rather than by intervention costs, and a value-of-information analysis suggested that uncertainty in the treatment effect had the greatest value (£12.9B). In work package 4, stakeholders identified several areas of benefits and costs of digital interventions that are important to them, including safety, sustainability and reducing waiting times. Four factors may influence their decisions to use digital interventions, other than costs and outcomes: increasing patient choice, reaching underserved populations, enabling continuous care and accepting the 'inevitability of going digital'.

LIMITATIONS

There was substantial uncertainty around effect estimates of digital interventions compared with alternatives. This uncertainty was driven by the small number of studies informing most comparisons, the small samples in some of these studies and the studies' high risk of bias.

CONCLUSIONS

Digital interventions may offer good value for money as an alternative to 'doing nothing' or 'doing something non-therapeutic' (e.g. monitoring or having a general discussion), but their added value compared with medication, face-to-face therapy and printed manuals is uncertain. Clinical outcomes rather than intervention costs drive 'value for money'.

FUTURE WORK

There is a need to develop digital interventions that are more effective, rather than just cheaper, than their alternatives.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018105837.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 1. See the NIHR Journals Library website for further project information.

Motivational interviewing telephone counseling to increase postpartum maintenance of abstinence from tobacco

Although many women quit smoking while pregnant, rates of relapse after delivery are high. We examined the effectiveness of motivational interviewing (MI) in maintaining postpartum abstinence from smoking among pregnant women who recently quit smoking (N = 382), randomized to receive five brief MI phone counseling calls or to a prenatal and postpartum care as usual control condition. Relapse to smoking was assessed at 3, 6, and 12 months postpartum based on self-report and urine cotinine. Cox regressions compared conditions on relapse outcomes and hazard ratio of total number of MI calls was examined to probe dose-response effects. Results revealed no difference in the hazard ratio of relapse between treatment condition and no dose-response effect of total number of MI calls. Phone counseling in the prenatal and postpartum period did not facilitate maintenance of abstinence among new mothers. Considerations for future intervention development studies on relapse prevention during the postpartum period are discussed.

eHealth Interventions to Treat Substance Use in Pregnancy: A Systematic Review and Meta-Analysis

Substance use during pregnancy is associated with adverse pregnancy and neonatal outcomes; eHealth interventions offer a potential accessible treatment option. The objective of this systematic review and meta-analysis was to evaluate the effectiveness of eHealth interventions for the treatment of substance use during pregnancy. A comprehensive search of PsycINFO, Medline, CINAHL, Cochrane and Embase databases was conducted from May 2020 to April 2021. The protocol for this study was registered with Prospero (CRD42020205186) through the University of York Centre for Reviews and Dissemination. Two independent reviewers completed screening, data extraction, and quality assessment. RCTs were included if they reported: (a) administration of an eHealth intervention for (b) substance use outcomes, among (c) pregnant individuals. Comprehensive Meta-Analysis Software (CMA) was used to calculate pooled effect sizes (Odds Ratio) to determine the effect of eHealth interventions on substance use outcomes. Six studies were identified with substance use outcomes that included: smoking (n = 3), alcohol (n = 2), and other (n = 1). eHealth interventions were delivered through the internet (n = 1), computer (n = 3), telephone (n = 1), and text (n = 1). Results suggested that eHealth interventions significantly reduced substance use in pregnant individuals compared to controls (OR = 1.33, 95% CI = 1.06 to 1.65, p = 0.013). eHealth interventions offer a promising and accessible treatment option to reduce substance use during pregnancy. This work was supported by the generous donors of the Alberta Children's Hospital Foundation, the Canadian Child Health Clinician Scientist Program (CCHCSP), the Canadian Institute of Health Research and the Fonds de Recherche du Québec-Santé.

Takore i te Kai Ava'ava (Quit smoking), a mCessation Program Adapted for the Cook Islands: Indicators of Potential for Tobacco Control

Mobile phone-based smoking cessation interventions (mCessation) are an established evidence-based intervention designed to support smokers to quit. Evidence of impact to date is modestly positive but skewed in favor of high-resourced countries, with less evidence of value added to low-resourced settings. Takore i te Kai Ava'ava, a text message-based smoking cessation program, was delivered to smokers living on the island of Rarotonga in 2019. Eighty-eight smokers consented to take part. Participants completed a baseline questionnaire about current smoking behavior and previous quit attempts; follow-up measures at 2 months assess quit attempts feedback on the program. Thirty-two people completed the follow-up interviews; 10 (31%) had not smoked in the past 7 days, 23 (72%) reported a serious quit attempt, and 29 (91%) felt the program was effective for the Cook Islands. Takore i te Kai Ava'ava was deemed to be highly acceptable and potentially cost-effective.

Systematic Review and Critique of Methods for Economic Evaluation of Digital Mental Health Interventions

OBJECTIVES

Investment in digital interventions for mental health conditions is growing rapidly, offering the potential to elevate systems that are currently overstretched. Despite a growing literature on economic evaluation of digital mental health interventions (DMHIs), including several systematic reviews, there is no conclusive evidence regarding their cost-effectiveness. This paper reviews the methodology used to determine their cost-effectiveness and assesses whether this meets the requirements for decision-making. In doing so we consider the challenges specific to the economic evaluation of DMHIs, and identify where consensus and possible further research is warranted.

METHODS

A systematic review was conducted to identify all economic evaluations of DMHIs published between 1997 and December 2018. The searches included databases of published and unpublished research, reference lists and citations of all included studies, forward citations on all identified protocols and conference abstracts, and contacting authors researchers in the field. The identified studies were critiqued against a published set of requirements for decision-making in healthcare, identifying methodological challenges and areas where consensus is required.

RESULTS

The review identified 67 papers evaluating DMHIs. The majority of the evaluations were conducted alongside trials, failing to capture all relevant available evidence and comparators, and long-term impact of mental health disorders. The identified interventions are complex and heterogeneous. As a result, there are a number of challenges specific to their evaluation, including estimation of all costs and outcomes, conditional on analysis viewpoint, and identification of relevant comparators. A taxonomy for DMHIs may be required to inform what interventions can reasonably be pooled and compared.

CONCLUSIONS

This study represents the first attempt to understand the appropriateness of the methodologies used to evaluate the value for money of DMHIs, helping work towards consensus and methods' harmonisation on these complex interventions.

Using Trial Sequential Analysis for estimating the sample sizes of further trials: example using smoking cessation intervention

Background

Assessing benefits and harms of health interventions is resource-intensive and often requires feasibility and pilot trials followed by adequately powered randomised clinical trials. Data from feasibility and pilot trials are used to inform the design and sample size of the adequately powered randomised clinical trials. When a randomised clinical trial is conducted, results from feasibility and pilot trials may be disregarded in terms of benefits and harms.

Methods

We describe using feasibility and pilot trial data in the Trial Sequential Analysis software to estimate the required sample size for one or more trials investigating a behavioural smoking cessation intervention. We show how data from a new, planned trial can be combined with data from the earlier trials using trial sequential analysis methods to assess the intervention’s effects.

Results

We provide a worked example to illustrate how we successfully used the Trial Sequential Analysis software to arrive at a sensible sample size for a new randomised clinical trial and use it in the argumentation for research funds for the trial.

Conclusions

Trial Sequential Analysis can utilise data from feasibility and pilot trials as well as other trials, to estimate a sample size for one or more, similarly designed, future randomised clinical trials. As this method uses available data, estimated sample sizes may be smaller than they would have been using conventional sample size estimation methods.

Interest in and Use of Smoking Cessation Support Across Pregnancy and Postpartum

Background

Limited research exists on interest in and use of smoking cessation support in pregnancy and postpartum.

Methods

A longitudinal cohort of pregnant smokers and recent ex-smokers were recruited in Nottinghamshire, United Kingdom (N = 850). Data were collected at 8–26 weeks gestation, 34–36 weeks gestation, and 3 months postpartum and used as three cross-sectional surveys. Interest and use of cessation support and belief and behavior measures were collected at all waves. Key data were adjusted for nonresponse and analyzed descriptively, and multiple regression was used to identify associations.

Results

In early and late pregnancy, 44% (95% CI 40% to 48%) and 43% (95% CI 37% to 49%) of smokers, respectively, were interested in cessation support with 33% (95% CI 27% to 39%) interested postpartum. In early pregnancy, 43% of smokers reported discussing cessation with a midwife and, in late pregnancy, 27% did so. Over one-third (38%) did not report discussing quitting with a health professional during pregnancy. Twenty-seven percent of smokers reported using any National Health Service (NHS) cessation support and 12% accessed NHS Stop Smoking Services during pregnancy. Lower quitting confidence (self-efficacy), higher confidence in stopping with support, higher quitting motivation, and higher age were associated with higher interest in support (ps ≤ .001). A recent quit attempt and greater interest in support was associated with speaking to a health professional about quitting and use of NHS cessation support (ps ≤ .001).

Conclusions

When asked in early or late pregnancy, about half of pregnant smokers were interested in cessation support, though most did not engage. Cessation support should be offered throughout pregnancy and after delivery.

Implications

There is relatively high interest in cessation support in early and late pregnancy and postpartum among smokers; however, a much smaller proportion of pregnant or postpartum women access any cessation support, highlighting a gap between interest and engagement. Reflecting women’s interest, offers of cessation support should be provided throughout pregnancy and after delivery. Increasing motivation to quit and confidence in quitting with assistance may enhance interest in support, and promoting the discussion of stopping smoking between women and health practitioners may contribute to higher support engagement rates.

Proactively Offered Text Messages and Mailed Nicotine Replacement Therapy for Smokers in Primary Care Practices: A Pilot Randomized Trial

INTRODUCTION

Proactive, population health cessation programs can guide efforts to reach smokers outside of the clinic to encourage quit attempts and treatment use.

AIMS AND METHODS

This study aimed to measure trial feasibility and preliminary effects of a proactive intervention offering text messages (TM) and/or mailed nicotine replacement therapy (NRT) to smokers in primary care clinics. From 2017 to 2019 we performed a pilot randomized trial comparing brief telephone advice (control: BA), TM, 2 weeks of mailed NRT, or both interventions (TM + NRT). Patients were identified using electronic health records and contacted proactively by telephone to assess interest in the study. We compared quit attempts, treatment use, and cessation in the intervention arms with BA.

RESULTS

Of 986 patients contacted, 153 (16%) enrolled (mean age 53 years, 57% female, 76% white, 11% black, 8% Hispanic, 52% insured by Medicaid) and 144 (94%) completed the 12-week assessment. On average, patients in the TM arms received 159 messages (99.4% sent, 0.6% failed), sent 19 messages, and stayed in the program for 61 days. In all groups, a majority of patients reported quit attempts (BA 67% vs. TM 86% [p = .07], NRT 81% [p = .18], TM + NRT 79% [p = .21]) and NRT use (BA 51% vs. NRT 83% [p = .007], TM 65% [p = .25], TM + NRT 76% [p = .03]). Effect estimates for reported 7-day abstinence were BA 10% versus TM 26% (p = .09), NRT 28% (p = .06), and TM + NRT 23% (p = .14).

CONCLUSIONS

Proactively offering TM or mailed nicotine medications was feasible among primary care smokers and a promising approach to promote quit attempts and short-term abstinence.

IMPLICATIONS

Proactive intervention programs to promote quit attempts outside of office visits among smokers enrolled in primary care practices are needed. TM have potential to engage smokers not planning to quit or to support smokers to make a planned quit attempt. This pilot study demonstrates the feasibility of testing a proactive treatment model including TM and/or mailed NRT to promote quit attempts, treatment use, and cessation among nontreatment-seeking smokers in primary care.

CLINICALTRIALS.GOV IDENTIFIER

NCT03174158.

The impact of tobacco chemicals and nicotine on placental development

Despite decades of messages warning about the dangers of tobacco use in pregnancy, 10% to 15% of pregnant women continue to smoke. Furthermore, an increased popularity of electronic nicotine delivery systems (ENDS) over the past decade in women of childbearing age raises parallel concerns regarding the effects of vaporized nicotine use in pregnancy. While research using animal models which mimic tobacco smoke and nicotine exposure in pregnancy have largely replicated findings in humans, few studies focus directly on the effects of these exposures on the placenta. Because the placenta is a fetal derived tissue, and nicotine and other components of tobacco smoke are either processed by or transported directly through the placenta, such studies help us understand the risks of these exposures on the developing fetus. In this review, we summarize research on the placenta and placental-derived cells examining either tobacco smoke or nicotine exposure, including both histologic and subcellular (ie, epigenetic and molecular) modifications. Collectively, these studies reveal that tobacco and nicotine exposure are accompanied by some common and several unique molecular and epigenomic placental modifications. Consideration of the nature and sequelae of these molecular mediators of risk may help to better inform the public and more effectively curtail modifiable behavior.

Targeted client communication via mobile devices for improving maternal, neonatal, and child health

BACKGROUND

The global burden of poor maternal, neonatal, and child health (MNCH) accounts for more than a quarter of healthy years of life lost worldwide. Targeted client communication (TCC) via mobile devices (MD) (TCCMD) may be a useful strategy to improve MNCH.

OBJECTIVES

To assess the effects of TCC via MD on health behaviour, service use, health, and well-being for MNCH.

SEARCH METHODS

In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification.

SELECTION CRITERIA

We included randomised controlled trials that assessed TCC via MD to improve MNCH behaviour, service use, health, and well-being. Eligible comparators were usual care/no intervention, non-digital TCC, and digital non-targeted client communication.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross-checked by a second.

MAIN RESULTS

We included 27 trials (17,463 participants). Trial populations were: pregnant and postpartum women (11 trials conducted in low-, middle- or high-income countries (LMHIC); pregnant and postpartum women living with HIV (three trials carried out in one lower middle-income country); and parents of children under the age of five years (13 trials conducted in LMHIC). Most interventions (18) were delivered via text messages alone, one was delivered through voice calls only, and the rest were delivered through combinations of different communication channels, such as multimedia messages and voice calls. Pregnant and postpartum women TCCMD versus standard care For behaviours, TCCMD may increase exclusive breastfeeding in settings where rates of exclusive breastfeeding are less common (risk ratio (RR) 1.30, 95% confidence intervals (CI) 1.06 to 1.59; low-certainty evidence), but have little or no effect in settings where almost all women breastfeed (low-certainty evidence). For use of health services, TCCMD may increase antenatal appointment attendance (odds ratio (OR) 1.54, 95% CI 0.80 to 2.96; low-certainty evidence); however, the CI encompasses both benefit and harm. The intervention may increase skilled attendants at birth in settings where a lack of skilled attendants at birth is common (though this differed by urban/rural residence), but may make no difference in settings where almost all women already have a skilled attendant at birth (OR 1.00, 95% CI 0.34 to 2.94; low-certainty evidence). There were uncertain effects on maternal and neonatal mortality and morbidity because the certainty of the evidence was assessed as very low. TCCMD versus non-digital TCC (e.g. pamphlets) TCCMD may have little or no effect on exclusive breastfeeding (RR 0.92, 95% CI 0.79 to 1.07; low-certainty evidence). TCCMD may reduce 'any maternal health problem' (RR 0.19, 95% CI 0.04 to 0.79) and 'any newborn health problem' (RR 0.52, 95% CI 0.25 to 1.06) reported up to 10 days postpartum (low-certainty evidence), though the CI for the latter includes benefit and harm. The effect on health service use is unknown due to a lack of studies. TCCMD versus digital non-targeted communication No studies reported behavioural, health, or well-being outcomes for this comparison. For use of health services, there are uncertain effects for the presence of a skilled attendant at birth due to very low-certainty evidence, and the intervention may make little or no difference to attendance for antenatal influenza vaccination (RR 1.05, 95% CI 0.71 to 1.58), though the CI encompasses both benefit and harm (low-certainty evidence). Pregnant and postpartum women living with HIV TCCMD versus standard care For behaviours, TCCMD may make little or no difference to maternal and infant adherence to antiretroviral (ARV) therapy (low-certainty evidence). For health service use, TCC mobile telephone reminders may increase use of antenatal care slightly (mean difference (MD) 1.5, 95% CI -0.36 to 3.36; low-certainty evidence). The effect on the proportion of births occurring in a health facility is uncertain due to very low-certainty evidence. For health and well-being outcomes, there was an uncertain intervention effect on neonatal death or stillbirth, and infant HIV due to very low-certainty evidence. No studies reported on maternal mortality or morbidity. TCCMD versus non-digital TCC The effect is unknown due to lack of studies reporting this comparison. TCCMD versus digital non-targeted communication TCCMD may increase infant ARV/prevention of mother-to-child transmission treatment adherence (RR 1.26, 95% CI 1.07 to 1.48; low-certainty evidence). The effect on other outcomes is unknown due to lack of studies. Parents of children aged less than five years No studies reported on correct treatment, nutritional, or health outcomes. TCCMD versus standard care Based on 10 trials, TCCMD may modestly increase health service use (vaccinations and HIV care) (RR 1.21, 95% CI 1.08 to 1.34; low-certainty evidence); however, the effect estimates varied widely between studies. TCCMD versus non-digital TCC TCCMD may increase attendance for vaccinations (RR 1.13, 95% CI 1.00 to 1.28; low-certainty evidence), and may make little or no difference to oral hygiene practices (low-certainty evidence). TCCMD versus digital non-targeted communication TCCMD may reduce attendance for vaccinations, but the CI encompasses both benefit and harm (RR 0.63, 95% CI 0.33 to 1.20; low-certainty evidence). No trials in any population reported data on unintended consequences.

AUTHORS' CONCLUSIONS

The effect of TCCMD for most outcomes is uncertain. There may be improvements for some outcomes using targeted communication but these findings were of low certainty. High-quality, adequately powered trials and cost-effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCCMD. Future studies should measure potential unintended consequences, such as partner violence or breaches of confidentiality.

[N on-pharmacological management of smoking cessation during pregnancy- CNGOF-SFT Expert Report and Guidelines for Smoking Management during Pregnancy]

OBJECTIVES

To assess the benefit of non-pharmacological intervention promoting on smoking cessation, obstetric and neonatal outcomes, to offer pregnant women who smoke (PWS) optimal care.

METHODS

We searched Medline Database, Cochrane Library and consulted international guidelines.

RESULTS

"Counselling" involving globally all kind of non-pharmacological interventions has a benefit on smoking cessation (NP1) and a moderate benefit on birth weight and prematurity (NP2). The brief intervention seems ineffective on smoking cessation (NP2). The effects of motivational interviewing have not been demonstrated during pregnancy (NP2). Cognitive-behavioral interventions do not show superiority (NP2). Financial incentives have a benefit for smoking cessation and possibly for neonatal outcomes (NP1). Feedback interventions (Co tester) provide heterogeneous results (NP2). Self-help interventions (NP2) and health education (NP2) seem effective on smoking cessation. Hypnotherapy and acupuncture have been little or not studied in PWS. Moderate physical activity did not show a significant effect (NP2) on smoking cessation but seem to reduce craving for tobacco (NP3).

CONCLUSIONS

We recommend asking all PWS about their smoking consumption and detailing their smoking history, offering them different types of counselling according to their preferences and involving them multidisciplinary (grade A). The systematic use of feedback is not recommended (grade C) but experience suggests that the CO tester is important in establishing a therapeutic alliance (professional consensus). The use of self-help interventions (grade C) and health education (grade B) are recommended.

Telehealth Interventions to Improve Obstetric and Gynecologic Health Outcomes: A Systematic Review

Telehealth interventions were associated with improvements in obstetric outcomes, perinatal smoking cessation, breastfeeding, early access to medical abortion services, and schedule optimization for high-risk obstetrics.

OBJECTIVE:

To systematically review the effectiveness of telehealth interventions for improving obstetric and gynecologic health outcomes.

DATA SOURCES:

We conducted a comprehensive search for primary literature in ClinicalTrials.gov, Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE.

METHODS OF STUDY SELECTION:

Qualifying primary studies had a comparison group, were conducted in countries ranked very high on the United Nations Human Development Index, published in English, and evaluated obstetric and gynecologic health outcomes. Cochrane Collaboration's tool and ROBINS-I tool were used for assessing risk of bias. Summary of evidence tables were created using the United States Preventive Services Task Force Summary of Evidence Table for Evidence Reviews.

TABULATION, INTEGRATION, RESULTS:

Of the 3,926 published abstracts identified, 47 met criteria for inclusion and included 31,967 participants. Telehealth interventions overall improved obstetric outcomes related to smoking cessation and breastfeeding. Telehealth interventions decreased the need for high-risk obstetric monitoring office visits while maintaining maternal and fetal outcomes. One study found reductions in diagnosed preeclampsia among women with gestational hypertension. Telehealth interventions were effective for continuation of oral and injectable contraception; one text-based study found increased oral contraception rates at 6 months. Telehealth provision of medication abortion services had similar clinical outcomes compared with in-person care and improved access to early abortion. Few studies suggested utility for telehealth to improve notification of sexually transmitted infection test results and app-based intervention to improve urinary incontinence symptoms.

CONCLUSION:

Telehealth interventions were associated with improvements in obstetric outcomes, perinatal smoking cessation, breastfeeding, early access to medical abortion services, and schedule optimization for high-risk obstetrics. Further well-designed studies are needed to examine these interventions and others to generate evidence that can inform decisions about implementation of newer telehealth technologies into obstetrics and gynecology practice.

Efficacy of a Texting Program to Promote Cessation Among Pregnant Smokers: A Randomized Control Trial

INTRODUCTION

Smoking during pregnancy poses serious risks to baby and mother. Few disseminable programs exist to help pregnant women quit or reduce their smoking. We hypothesized that an SMS text-delivered scheduled gradual reduction (SGR) program plus support texts would outperform SMS support messages alone.

METHODS

We recruited 314 pregnant women from 14 prenatal clinics. Half of the women received theory-based support messages throughout their pregnancy to promote cessation and prevent relapse. The other half received the support messages plus alert texts that gradually reduced their smoking more than 3-5 weeks. We conducted surveys at baseline, end of pregnancy, and 3 months postpartum. Our primary outcome was biochemically validated 7-day point prevalence abstinence at late pregnancy. Our secondary outcome was reduction in cigarettes per day.

RESULTS

Adherence to the SGR was adequate with 70% responding to alert texts to smoke within 60 minutes. Women in both arms quit smoking at the same rate (9%-12%). Women also significantly reduced their smoking from baseline to the end of pregnancy from nine cigarettes to four; we found no arm differences in reduction.

CONCLUSIONS

Support text messages alone produced significant quit rates above naturally occurring quitting. SGR did not add significantly to helping women quit or reduce. Sending support messages can reach many women and is low-cost. More obstetric providers might consider having patients who smoke sign up for free texting programs to help them quit.

IMPLICATIONS

A disseminable texting program helped some pregnant women quit smoking.Clinical Trial Registration number: NCT01995097.

Mobile Phone-Based Behavioral Interventions in Pregnancy to Promote Maternal and Fetal Health in High-Income Countries: Systematic Review

Background

Chronic diseases have recently had an increasing effect on maternal-fetal health, especially in high-income countries. However, there remains a lack of discussion regarding health management with technological approaches, including mobile health (mHealth) interventions.

Objective

This study aimed to systematically evaluate mHealth interventions used in pregnancy in high-income countries and their effects on maternal health behaviors and maternal-fetal health outcomes.

Methods

This systematic review identified studies published between January 1, 2000, and November 30, 2018, in MEDLINE via PubMed, Cochrane Library, EMBASE, CINAHL, PsycINFO, Web of Science, and gray literature. Studies were eligible for inclusion if they included only pregnant women in high-income countries and evaluated stand-alone mobile phone interventions intended to promote healthy maternal beliefs, behaviors, and/or maternal-fetal health outcomes. Two researchers independently reviewed and categorized aspects of full-text articles, including source, study design, intervention and control, duration, participant age, attrition rate, main outcomes, and risk of bias. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, and the study was registered in PROSPERO before initiation.

Results

Of the 2225 records examined, 28 studies were included and categorized into 4 themes: (1) gestational weight gain, obesity and physical activity (n=9); (2) smoking cessation (n=9); (3) influenza vaccination (n=2); and (4) general prenatal health, preventive strategies, and miscellaneous topics (n=8). Reported sample sizes ranged from 16 to 5243 with a median of 91. Most studies were performed in the United States (18/28, 64%) and were randomized controlled trials (21/28, 75%). All participants in the included studies were pregnant at the time of study initiation. Overall, 14% (4/28) of studies showed association between intervention use and improved health outcomes; all 4 studies focused on healthy gestational weight. Among those, 3 studies showed intervention use was associated with less overall gestational weight gain. These 3 studies involved interventions with text messaging or an app in combination with another communication strategy (Facebook or email). Regarding smoking cessation, influenza vaccination, and miscellaneous topics, there was some evidence of positive effects on health behaviors and beliefs, but very limited correlation with improved health outcomes. Data and interventions were heterogeneous, precluding a meta-analysis.

Conclusions

In high-income countries, utilization of mobile phone–based health behavior interventions in pregnancy demonstrates some correlation with positive beliefs, behaviors, and health outcomes. More effective interventions are multimodal in terms of features and tend to focus on healthy gestational weight gain.

Use of Brief Messages Based on Behavior Change Techniques to Encourage Medication Adherence in People With Type 2 Diabetes: Developmental Studies

BACKGROUND

Brief messages are a promising way to improve adherence to medication for people with type 2 diabetes. However, it is often unclear how messages have been developed and their precise content, making it difficult to ascertain why certain messages are successful and some are not.

OBJECTIVE

The goal of the research was to develop messages that have proven fidelity to specified evidence-derived behavior change techniques (BCTs) and are acceptable to people with type 2 diabetes.

METHODS

Four studies were conducted: (1) a workshop (n=21) where behavioral change researchers and health care professionals developed messages based on specific BCTs or beliefs or concerns related to taking medication, (2) a focus group study with people with type 2 diabetes (n=23) to assess acceptability of the approach, (3) a survey to ascertain the acceptability of a subset of messages to people with type 2 diabetes (n=61) and, (4) a survey with behavior change researchers to assess the fidelity of a subset of messages to their intended BCT (n=18).

RESULTS

In study 1, 371 messages based on 38 BCTs and beliefs/concerns were developed. Workshop participants rated BCTs to be relevant to medication adherence (mean 7.12/10 [SD 1.55]) and messages to have good fidelity (mean 7.42/10 [SD 1.19]). In study 2, the approach of providing medication adherence support through text messages was found to be acceptable. In study 3, mean acceptability of all BCTs was found to be above the midpoint (mean 3.49/5 [SD 0.26]). In study 4, mean fidelity for all BCTs was found to be above the midpoint (mean 7.61/10 [SD 1.38]).

CONCLUSIONS

A library of brief messages acceptable to people with type 2 diabetes and representative of specific evidence-derived BCTs was developed. This approach allowed brief messages to be developed with known content that can be used to test theory.

Pilot Test of Connecting Pregnant Women who Smoke to Short Message Service (SMS) Support Texts for Cessation

INTRODUCTION

Most pregnant women know that smoking poses serious risks to baby and mother, yet many still smoke. We conducted a large randomized controlled trial and found that an SMS text-delivered program helped about 10% of these women quit smoking. In this paper, we describe the feasibility of disseminating a text-based intervention to pregnant women who smoke.

METHODS

We tested dissemination in two ways from prenatal clinics and compared recruitment rates to those found in our large randomized controlled trial. The first method involved "direct texting" where study staff identified women who smoked and sent them a text asking them to text back if they wanted to receive texts to help them quit. The second involved "nurse screening" where clinic staff from county health departments screened women for smoking and asked them to send a text to the system if they wanted to learn more about the program. Our primary outcome was feasibility assessed by the number of women who texted back their baby's due date, which served as "enrolling" in the texting program, which we compared to the recruitment rate we found in our large trial.

RESULTS

Over 4 months, we texted 91 women from the academic health system. Of those, 17 texted back and were counted as "enrolled." In the health departments, across the 4 months, 12 women texted the system initially. Of those, 10 were enrolled. This rate was similar to the rate enrolled in the randomized controlled trial.

DISCUSSION

Two different methods connected pregnant women who smoke to a texting program. One of these methods can be automated further and have the potential of helping many women quit smoking with minimal effort. Clinical Trial # NCT01995097.

Mobile phone text messaging and app-based interventions for smoking cessation

BACKGROUND

Mobile phone-based smoking cessation support (mCessation) offers the opportunity to provide behavioural support to those who cannot or do not want face-to-face support. In addition, mCessation can be automated and therefore provided affordably even in resource-poor settings. This is an update of a Cochrane Review first published in 2006, and previously updated in 2009 and 2012.

OBJECTIVES

To determine whether mobile phone-based smoking cessation interventions increase smoking cessation rates in people who smoke.

SEARCH METHODS

For this update, we searched the Cochrane Tobacco Addiction Group's Specialised Register, along with clinicaltrials.gov and the ICTRP. The date of the most recent searches was 29 October 2018.

SELECTION CRITERIA

Participants were smokers of any age. Eligible interventions were those testing any type of predominantly mobile phone-based programme (such as text messages (or smartphone app) for smoking cessation. We included randomised controlled trials with smoking cessation outcomes reported at at least six-month follow-up.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures described in the Cochrane Handbook for Systematic Reviews of Interventions. We performed both study eligibility checks and data extraction in duplicate. We performed meta-analyses of the most stringent measures of abstinence at six months' follow-up or longer, using a Mantel-Haenszel random-effects method, pooling studies with similar interventions and similar comparators to calculate risk ratios (RR) and their corresponding 95% confidence intervals (CI). We conducted analyses including all randomised (with dropouts counted as still smoking) and complete cases only.

MAIN RESULTS

This review includes 26 studies (33,849 participants). Overall, we judged 13 studies to be at low risk of bias, three at high risk, and the remainder at unclear risk. Settings and recruitment procedures varied across studies, but most studies were conducted in high-income countries. There was moderate-certainty evidence, limited by inconsistency, that automated text messaging interventions were more effective than minimal smoking cessation support (RR 1.54, 95% CI 1.19 to 2.00; I² = 71%; 13 studies, 14,133 participants). There was also moderate-certainty evidence, limited by imprecision, that text messaging added to other smoking cessation interventions was more effective than the other smoking cessation interventions alone (RR 1.59, 95% CI 1.09 to 2.33; I² = 0%, 4 studies, 997 participants). Two studies comparing text messaging with other smoking cessation interventions, and three studies comparing high- and low-intensity messaging, did not show significant differences between groups (RR 0.92 95% CI 0.61 to 1.40; I² = 27%; 2 studies, 2238 participants; and RR 1.00, 95% CI 0.95 to 1.06; I² = 0%, 3 studies, 12,985 participants, respectively) but confidence intervals were wide in the former comparison. Five studies compared a smoking cessation smartphone app with lower-intensity smoking cessation support (either a lower-intensity app or non-app minimal support). We pooled the evidence and deemed it to be of very low certainty due to inconsistency and serious imprecision. It provided no evidence that smartphone apps improved the likelihood of smoking cessation (RR 1.00, 95% CI 0.66 to 1.52; I² = 59%; 5 studies, 3079 participants). Other smartphone apps tested differed from the apps included in the analysis, as two used contingency management and one combined text messaging with an app, and so we did not pool them. Using complete case data as opposed to using data from all participants randomised did not substantially alter the findings.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that automated text message-based smoking cessation interventions result in greater quit rates than minimal smoking cessation support. There is moderate-certainty evidence of the benefit of text messaging interventions in addition to other smoking cessation support in comparison with that smoking cessation support alone. The evidence comparing smartphone apps with less intensive support was of very low certainty, and more randomised controlled trials are needed to test these interventions.

Dropout and Abstinence Outcomes in a National Text Messaging Smoking Cessation Intervention for Pregnant Women, SmokefreeMOM: Observational Study

Background

Population-level text messaging smoking cessation interventions may reduce racial and ethnic differences in smoking among pregnant women.

Objective

Our objective was to examine racial and ethnic differences in dropout, response, and abstinence rates among users of a US national, publicly available text messaging cessation intervention targeting pregnant women, SmokefreeMOM.

Methods

Participants were online subscribers to SmokefreeMOM who set a prospective quit date within the 9 months before their due date. We examined demographics, smoking frequency, number of cigarettes smoked per day, and prequit time (up to 14 days of preparation time before quit date) as correlates of response rate and abstinence at 8 time points: quit date, day 7, day 14, day 21, day 28, day 35, day 42 (intervention end), and day 72 (1-month follow-up). We conducted survival analysis of time from quit date to dropout by race and ethnicity.

Results

The mean age of the analytic sample of 1288 users was 29.46 (SD 7.11) years. Of these, 65.81% (848/1288) were white, 16.04% (207/1288) were black, 8.86% (114/1288) were Latina, and 9.29% (120/1288) were multiracial, American Indian/Alaska Native, Native Hawaiian Pacific Islander, or other; 82.68% (1065/1288) had some college education or less. Point-prevalence abstinence was 14.51% (157/1082) on quit day, 3.51% (38/1082) at intervention end, and 1.99% (21/1053) at 1-month follow-up. Black users (hazard ratio 0.68, 95% CI 0.51-0.91) and those with a high school degree or less (hazard ratio 0.66, 95% CI 0.49-0.89) or some college education (hazard ratio 0.75, 95% CI 0.57-0.99) were less likely to drop out than whites or users with a bachelor’s degree or higher. Response and abstinence rates were similar across race, ethnicity, and education.

Conclusions

Enrollment was low among racial and ethnic minority women but high among less-educated women. Abstinence at intervention end and 1-month follow-up was lower than that in controlled trials of text messaging cessation interventions for pregnant women (range 7%-20%). Increasing the reach, engagement, and effectiveness of SmokefreeMOM, especially among women with high rates of smoking during pregnancy, must be prioritized.

Predictors of Retention in an Adult Text Messaging Smoking Cessation Intervention Program: Cohort Study

Background

Mobile health tools such as text messaging programs can support smoking cessation. However, high rates of disengagement from these tools decrease their effectiveness.

Objective

The purpose of this study was to identify user characteristics associated with retention in an adult text messaging smoking cessation intervention.

Methods

Adults initiating a quit attempt using the publicly available program SmokefreeTXT between March 6 and June 21, 2016 (n=6215), were included. Data were collected to assess nicotine dependence, frequency of being around other smokers, time of the day for cigarette cravings, extrinsic and intrinsic motivation to quit smoking, confidence in quitting, and long-term intention to be smoke free. Multivariable survival analysis modeling for time to opt out was conducted to identify characteristics associated with opting out over the course of the intervention, adjusting for age, sex, and smoking frequency, reset of the quit date by the user, and the number of days enrolled before initiating the quit attempt. Among those who opted out, multivariable multinomial logistic regression analysis was used to identify predictors of opting out early (within 3 days and between 4 and 7 days into the quit attempt) compared to opting out late (more than 7 days into the quit attempt), adjusting for the same confounders.

Results

Survival analyses indicated that younger age, female sex, higher levels of nicotine dependence, lower intention to be smoke free, and enrolling in SmokefreeTXT ≤1 week before initiating the quit attempt were associated with an increased risk of opting out. For example, users who smoked within 5 minutes of waking up were 1.17 times more likely to opt out than those who smoked more than 5 minutes after waking up (95% CI 1.01-1.35). Among users who opted out from SmokefreeTXT, logistic regression modeling indicated that compared to users who were never or rarely around other smokers, those who were sometimes around other smokers had 1.96 times more likely to opt out within the first 3 days of the quit attempt (95% CI 1.18-3.25). In addition, compared to users with high levels of long-term quit intention, users with lower levels of intention had 1.80 times the odds of opting out between 4 and 7 days into the quit attempt (95% CI 1.02-3.18). Users who reset their quit date after initiating a quit attempt were less likely to opt out at either time point compared with those who did not reset their quit date.

Conclusions

Several user characteristics are associated with retention in an adult text messaging smoking cessation program. These results provide guidance on potential characteristics that should be addressed in future text messaging smoking cessation programs. Providing additional support to users with these characteristics may increase retention in text messaging programs and ultimately lead to smoking cessation.

Randomized factorial experiment of components of the SmokeFree Baby smartphone application to aid smoking cessation in pregnancy

Smartphone applications (apps) might be able to reach pregnant smokers who do not engage with face-to-face support. However, we do not know how far pregnant smokers will engage with smoking cessation apps or what components are likely to be effective. This study aimed to assess pregnant smokers' engagement with the SmokeFree Baby app (v1) and to assess the short-term efficacy of selected components ("modules") for smoking abstinence. Positive outcomes would provide a basis for further development and evaluation. SmokeFree Baby was developed drawing on behavior change theories and relevant evidence. Pregnant smokers (18+) who were interested in quitting and set a quit date were recruited. Following multiphase optimization development principles, participants (N = 565) were randomly allocated to one of 32 (2 × 2 × 2 × 2 × 2) experimental groups in a full factorial design to evaluate five modules (each in minimal and full version: identity, health information, stress management, face-to-face support, and behavioral substitution). Measures of engagement included duration and frequency of engagement with the app. Smoking abstinence was measured by self-reported number of smoke-free days up to 4 weeks from the quit date. Participants engaged with the app for a mean of 4.5 days (SD = 8.5) and logged in a mean of 2.9 times (SD = 3.1). Main effects of the modules on the number of smoke-free days were not statistically significant (identity: p = .782, health information: p = .905, stress management: p = .103, face-to-face support: p = .397, behavioral substitution: p = .945). Despite systematic development and usability testing, engagement with SmokeFree Baby (v1) was low and the app did not appear to increase smoking abstinence during pregnancy.

Feasibility of a text-messaging smoking cessation program for soldiers in Israel

BACKGROUND

Cigarette smoking is a main cause of preventable morbidity and mortality. Many young adults begin smoking in the military, with smoking rates higher among soldiers than in the general population. Among other health effects, smoking impairs performance among soldiers. Smoking cessation programs in the military are challenging due to the unique settings and low access to smoking cessation resources. Studies have shown that text-messaging smoking cessation programs are feasible and effective, but there is a lack of studies on soldiers.

OBJECTIVE

To evaluate the feasibility of a text-messaging smoking cessation program tailored for soldiers.

METHODS

We recruited 81 soldiers who smoked, 76.5% of whom were male. Following enrollment, participants filled out a baseline survey and were given a text messaging program for 6 months. Participants could send predetermined keywords and immediately receive a response from a list of messages that were constructed as a response to the specific keyword. Participants filled out a follow-up survey at 1 month. Additionally, we retrieved and analyzed program usage data, including keywords sent and received, for the entire program period. Based on the follow-up survey and the program usage data, we assessed feasibility of the recruitment methods, participants' engagement and satisfaction and technical usability of the program.

RESULTS

At 1 month, 20.6% reported that they had not smoked in the past week. A high percentage of the participants were engaged in the program, with 82.5% sending at least one valid keyword. The lowest self-efficacy group had higher chances of leaving the program (50.0%) while for the highest group there were much lower chances (4.8%). Most of the soldiers (96.8%) found the program easy to use and would recommend it to a friend (84.1%).

CONCLUSIONS

The study demonstrates that a text-messaging smoking cessation program is feasible in a military setting. Further development and evaluation of digital smoking cessation tools tailored for soldiers are warranted.

SmokefreeTXT for Homeless Smokers: Pilot Randomized Controlled Trial

Background

Homeless smokers want to quit smoking but face numerous barriers to doing so, including pervasive smoking among peers and a lack of social support for quitting. An SMS (short message service) text messaging intervention could address these challenges by providing virtual daily support for homeless smokers who are trying to quit but coping with multiple triggers to smoke.

Objective

This study aimed to assess whether a free SMS text messaging program, added to evidence-based pharmacotherapy and counseling, improved smoking abstinence among homeless adult smokers.

Methods

From October 2015 to June 2016, we conducted an 8-week pilot randomized controlled trial (RCT) of nicotine patch therapy and weekly in-person counseling with (n=25) or without (n=25) SmokefreeTXT, a free SMS text messaging service administered by the National Cancer Institute (NCI) at Boston Health Care for the Homeless Program. All participants were provided with a mobile phone and a 2-month prepaid voice and text plan at no cost. SmokefreeTXT enrollees were sent 1 to 5 automated SMS text messages daily for up to 8 weeks and could receive on-demand tips for managing cravings, mood symptoms, and smoking lapses. The primary outcome was smoking abstinence, defined as an exhaled carbon monoxide count of <8 parts per million, assessed 14 times over 8 weeks of follow-up, and analyzed using repeated-measures logistic regression with generalized estimating equations. Other outcomes were use of SmokefreeTXT, assessed by data obtained from NCI; perceptions of SmokefreeTXT, assessed by surveys and qualitative interviews; and mobile phone retention, assessed by self-report.

Results

Of the SmokefreeTXT arm participants (n=25), 88% (22) enrolled in the program, but only 56% (14) had confirmed enrollment for ≥2 weeks. Among 2-week enrollees, the median response rate to interactive messages from SmokefreeTXT was 2.1% (interquartile range 0-10.5%). Across all time points, smoking abstinence did not differ significantly between SmokefreeTXT and control arm participants (odds ratio 0.92, 95% CI 0.30-2.84). Of SmokefreeTXT enrollees who completed exit surveys (n=15), two-thirds were very or extremely satisfied with the program. However, qualitative interviews (n=14) revealed that many participants preferred in-person intervention formats over phone-based, found the SMS text messages impersonal and robotic, and felt that the messages were too frequent and repetitive. Only 40% (10/25) of SmokefreeTXT arm participants retained their study-supplied mobile phone for the 8-week duration of the trial, with phone theft being common. Storing and charging phones were cited as challenges.

Conclusions

SmokefreeTXT, added to nicotine patch therapy and in-person counseling, did not significantly improve smoking abstinence in this 8-week pilot RCT for homeless smokers. SMS text messaging interventions for this population should be better tuned to the unique circumstances of homelessness and coupled with efforts to promote mobile phone retention over time.

Trial Registration

ClinicalTrials.gov NCT02565381; https://clinicaltrials.gov/ct2/show/NCT02565381 (Archived by WebCite at http://www.webcitation.org/78PLpDptZ)

Development of a Complex Intervention for the Maintenance of Postpartum Smoking Abstinence: Process for Defining Evidence-Based Intervention

Relapse to tobacco smoking for pregnant women who quit is a major public health problem. Evidence-based approaches to intervention are urgently required. This study aimed to develop an intervention to be integrated into existing healthcare. A mixed methods approach included a theory-driven systematic review identifying promising behaviour change techniques for targeting smoking relapse prevention, and qualitative focus groups and interviews with women (ex-smokers who had remained quit and those who had relapsed), their partners and healthcare professionals (N = 74). A final stage recruited ten women to refine and initially test a prototype intervention. Our qualitative analysis suggests a lack, but need for, relapse prevention support. This should be initiated by a trusted 'credible source'. For many women this would be a midwife or a health visitor. Support needs to be tailored to individual needs, including positive praise/reward, novel digital and electronic support and partner or social support. Advice and support to use e cigarettes or nicotine replacement therapy for relapse prevention was important for some women, but others remained cautious. The resulting prototype complex intervention includes face-to-face support reiterated throughout the postpartum period, tailored digital and self-help support and novel elements such as gifts and nicotine replacement therapy (NRT).

Effectiveness and cost-effectiveness of a tailored text-message programme (MiQuit) for smoking cessation in pregnancy: study protocol for a randomised controlled trial (RCT) and meta-analysis

BACKGROUND

Smoking in pregnancy is a major international public health problem. Self-help support (SHS) increases the likelihood of women stopping smoking in pregnancy and delivering this kind of support by text message could be a cost-effective way to deliver SHS to pregnant women who smoke. SHS delivered by text message helps non-pregnant smokers to stop but the currently available message programmes are not appropriate for use in pregnancy. A randomised controlled trial (RCT) has demonstrated the feasibility and acceptability of using a programme called 'MiQuit' to text SHS support to pregnant women who smoke. Another pilot RCT has shown that it would be feasible to run a larger, multi-centre trial within the UK National Health Service (NHS). The aim of this third RCT is to complete MiQuit's evaluation, demonstrating whether or not this is efficacious for smoking cessation in pregnancy.

METHODS/DESIGN

This is a multi-centre, parallel-group RCT. Pregnant women aged over 16 years, of less than 25 weeks' gestation who smoke one or more daily cigarettes but smoked at least five daily cigarettes before pregnancy and who understand written English and are being identified in 24 English antenatal care hospitals. Participants are randomised to control or intervention groups in a 1:1 ratio stratified by gestation (< 16 weeks versus ≥ 16 weeks). All participants receive a leaflet on stopping smoking during pregnancy; they are also able to access standard NHS smoking cessation support. Intervention group women also receive the 12-week MiQuit programme of tailored, interactive text message, and self-help cessation support. Women are followed up by telephone at 4 weeks after randomisation and 36 weeks' gestation. The RCT will recruit 692 women (346 per group), enabling a 95% confidence interval for the difference in quit rates to be estimated within ± 3%. To determine whether or not MiQuit helps pregnant smokers to stop, intervention group quit rates from this trial will be combined with those from the two earlier trials in a Trial Sequential Analysis (TSA) meta-analysis to derive a pooled efficacy estimate.

DISCUSSION

If effective, MiQuit will be a cheap, cost-effective method to help pregnant women to stop smoking.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03231553 . Registered on 20 July 2017.

Combining Real-Time Ratings With Qualitative Interviews to Develop a Smoking Cessation Text Messaging Program for Primary Care Patients

Background

Text messaging (short message service, SMS) interventions show promise as a way to help cigarette smokers quit. Few studies have examined the effectiveness of text messaging (SMS) programs targeting smokers associated with primary care or hospital settings.

Objective

This study aimed to develop a text messaging (SMS) program targeting primary care smokers.

Methods

Adult smokers in primary care were recruited from February 2017 to April 2017. We sent patients 10 to 11 draft text messages (SMS) over 2 days and asked them to rate each message in real time. Patients were interviewed daily by telephone to discuss ratings, message preferences, and previous experiences with nicotine replacement therapy (NRT). Content analysis of interviews was directed by a step-wise text messaging (SMS) intervention development process and the Information-Motivation-Behavioral Skills model of medication adherence.

Results

We sent 149 text messages (SMS) to 15 patients. They replied with ratings for 93% (139/149) of the messages: 134 (96%, 134/139) were rated as clear or useful and 5 (4%, 5/139) as unclear or not useful. Patients’ preferences included the addition of graphics, electronic cigarette (e-cigarette) content, and use of first names. Regarding NRT, patients identified informational gaps around safety and effectiveness, preferred positively framed motivational messages, and needed behavioral skills to dose and dispose of NRT.

Conclusions

Patients recommended text message (SMS) personalization, inclusion of e-cigarette information and graphics, and identified barriers to NRT use.

Combining real-time ratings with telephone interviews is a feasible method for incorporating primary care patients’ preferences into a behavioral text messaging (SMS) program.

A dynamic, modifiable model for estimating cost-effectiveness of smoking cessation interventions in pregnancy: application to an RCT of self-help delivered by text message

BACKGROUND AND AIMS

Previous evaluations of smoking cessation interventions in pregnancy have several limitations. Our solution to these limitations is the Economics of Smoking in Pregnancy (ESIP) model, which estimates the life-time cost-effectiveness of smoking cessation interventions in pregnancy from a National Health Service (NHS) and personal social services perspective. We aim to (1) describe how ESIP has been constructed and (2) illustrate its use with trial data.

METHODS

ESIP links mothers' and offspring pregnancy outcomes to estimate the burdens of smoking-related disease they experience with different rates of smoking in pregnancy, both in pregnancy and throughout their life-times. Smoking rates are inputted by model users. ESIP then estimates the costs of treating disease burdens and also mothers' and offspring life-years and quality-adjusted life years (QALYs). By comparing costs incurred and healthy life following different smoking rates, ESIP estimates incremental cost-effectiveness and benefit-cost ratios for mothers or offspring or both combined. We illustrate ESIP use using data from a pragmatic randomized controlled trial that tested a smoking cessation intervention in pregnancy.

RESULTS

Throughout women's and offspring life-times, the intervention proved cheaper than usual care, having a negative incremental cost of £38.37 (interquartile range = £21.46-56.96) and it improved health, demonstrating a 0.04 increase in incremental QALYs for mothers and offspring, implying that it is 'dominant' over usual care. Benefit-cost ratios suggested that every £1 spent would generate a median of £14 (interquartile range = £8-20) in health-care savings.

CONCLUSIONS

Economics of Smoking in Pregnancy is the first economic model to link mothers' and infants' costs and benefits while reporting cost-effectiveness in readily-comparable units. Using ESIP with data from a trial which reported only short-term economic analysis showed that the intervention was very likely to be cost-effective in the longer term and to generate health-care savings.

Which eHealth interventions are most effective for smoking cessation? A systematic review

PURPOSE

To synthesize evidence of the effects and potential effect modifiers of different electronic health (eHealth) interventions to help people quit smoking.

METHODS

Four databases (MEDLINE, PsycINFO, Embase, and The Cochrane Library) were searched in March 2017 using terms that included "smoking cessation", "eHealth/mHealth" and "electronic technology" to find relevant studies. Meta-analysis and meta-regression analyses were performed using Mantel-Haenszel test for fixed-effect risk ratio (RR) and restricted maximum-likelihood technique, respectively. Protocol Registration Number: CRD42017072560.

RESULTS

The review included 108 studies and 110,372 participants. Compared to nonactive control groups (eg, usual care), smoking cessation interventions using web-based and mobile health (mHealth) platform resulted in significantly greater smoking abstinence, RR 2.03 (95% CI 1.7-2.03), and RR 1.71 (95% CI 1.35-2.16), respectively. Similarly, smoking cessation trials using tailored text messages (RR 1.80, 95% CI 1.54-2.10) and web-based information and conjunctive nicotine replacement therapy (RR 1.29, 95% CI 1.17-1.43) may also increase cessation. In contrast, little or no benefit for smoking abstinence was found for computer-assisted interventions (RR 1.31, 95% CI 1.11-1.53). The magnitude of effect sizes from mHealth smoking cessation interventions was likely to be greater if the trial was conducted in the USA or Europe and when the intervention included individually tailored text messages. In contrast, high frequency of texts (daily) was less effective than weekly texts.

CONCLUSIONS

There was consistent evidence that web-based and mHealth smoking cessation interventions may increase abstinence moderately. Methodologic quality of trials and the intervention characteristics (tailored vs untailored) are critical effect modifiers among eHealth smoking cessation interventions, especially for web-based and text messaging trials. Future smoking cessation intervention should take advantages of web-based and mHealth engagement to improve prolonged abstinence.

mHealth resources for asthma and pregnancy care: Methodological issues and social media recruitment. A discussion paper

AIMS

A discussion of methodological issues and social media recruitment to a feasibility study to investigate mHealth resources for asthma and pregnancy care.

BACKGROUND

Pregnant women with asthma are reported to be poorly supported according to an international research. We sought to establish if a mHealth intervention might be feasible and acceptable to them.

DESIGN

A Phase I or modelling study.

METHODS

A project team designed an intervention to address UK national guidelines for the management of asthma during pregnancy, using other resources already accessible on the web. This was made available on a project website optimized for mobile phone usage. Links were Tweeted and advertised on Facebook, asking participants to access the project website, which included links to the resources and before- and after-use questionnaires to establish baseline symptom data and participant views of the resources.

RESULTS

Despite 55,700 Twitter impressions in a 76-day period over winter 2016-2017, this recruitment strategy garnered 402 engagements but only seven respondents for questionnaire 1 and zero respondents for questionnaire 2.

CONCLUSIONS

We could not recruit to this study despite believing that social media recruitment would be effective and we recommend that social media recruitment be used cautiously. Apparently, we did not sufficiently address the theoretical aspects of communications theory and were not clear enough about our key messages. Publication bias may exist about the non-publication of other failed telemedicine studies using social media; this goes largely unreported in some systematic reviews and may influence researchers' decision-making about social media recruitment.

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.