Online support for smoking cessation: a systematic review of the literature

Individual Predictors of Response to A Behavioral Activation-Based Digital Smoking Cessation Intervention: A Machine Learning Approach

Background: Depression is prevalent among individuals who smoke cigarettes and increases risk for relapse. A previous clinical trial suggests that Goal2Quit, a behavioral activation-based smoking cessation mobile app, effectively increases smoking abstinence and reduces depressive symptoms. Objective: Secondary analyses were conducted on these trial data to identify predictors of success in depression-specific digitalized cessation interventions. Methods: Adult who smoked cigarettes (age = 38.4 ± 10.3, 53% women) were randomized to either use Goal2Quit for 12 weeks (N = 103), paired with a 2-week sample of nicotine replacement therapy (patch and lozenge) or to a Treatment-As-Usual (TAU) control (N = 47). The least absolute shrinkage and selection operator was utilized to identify a subset of baseline variables predicting either smoking or depression intervention outcomes. The retained predictors were then fitted via linear regression models to determine relations to each intervention outcome. Results: Relative to TAU, only individuals who spent significant time using Goal2Quit (56 ± 46 min) were more likely to reduce cigarette use by at least 50% after 12 weeks, whereas those who spent minimal time using Goal2Quit (10 ± 2 min) did not exhibit significant changes. An interaction between educational attainment and treatment group revealed that, as compared to TAU, only app users with an educational degree beyond high school exhibited significant reductions in depression. Conclusions: The findings highlight the importance of tailoring depression-specific digital cessation interventions to individuals' unique engagement needs and educational level. This study provides a potential methodological template for future research aimed at personalizing technology-based treatments for cigarette users with depressive symptoms.

An umbrella review of the benefits and risks associated with youths' interactions with electronic screens

The influence of electronic screens on the health of children and adolescents and their education is not well understood. In this prospectively registered umbrella review (PROSPERO identifier CRD42017076051 ), we harmonized effects from 102 meta-analyses (2,451 primary studies; 1,937,501 participants) of screen time and outcomes. In total, 43 effects from 32 meta-analyses met our criteria for statistical certainty. Meta-analyses of associations between screen use and outcomes showed small-to-moderate effects (range: r = -0.14 to 0.33). In education, results were mixed; for example, screen use was negatively associated with literacy (r = -0.14, 95% confidence interval (CI) = -0.20 to -0.09, P ≤ 0.001, k = 38, N = 18,318), but this effect was positive when parents watched with their children (r = 0.15, 95% CI = 0.02 to 0.28, P = 0.028, k = 12, N = 6,083). In health, we found evidence for several small negative associations; for example, social media was associated with depression (r = 0.12, 95% CI = 0.05 to 0.19, P ≤ 0.001, k = 12, N = 93,740). Limitations of our review include the limited number of studies for each outcome, medium-to-high risk of bias in 95 out of 102 included meta-analyses and high heterogeneity (17 out of 22 in education and 20 out of 21 in health with I2 > 50%). We recommend that caregivers and policymakers carefully weigh the evidence for potential harms and benefits of specific types of screen use.

A Christian Faith-Based Facebook Intervention for Smoking Cessation in Rural Communities (FAITH-CORE): Protocol for a Community Participatory Development Study

BACKGROUND

Tobacco smoking remains the leading cause of preventable morbidity and mortality in the United States, with significant rural-urban disparities. Adults who live in rural areas of the United States have among the highest tobacco smoking rates in the nation and experience a higher prevalence of smoking-related deaths and deaths due to chronic diseases for which smoking is a causal risk factor. Barriers to accessing tobacco use cessation treatments are a major contributing factor to these disparities. Adults living in rural areas experience difficulty accessing tobacco cessation services due to geographical challenges, lack of insurance coverage, and lack of health care providers who treat tobacco use disorders. The use of digital technology could be a practical answer to these barriers.

OBJECTIVE

This report describes a protocol for a study whose main objectives are to develop and beta test an innovative intervention that uses a private, moderated Facebook group platform to deliver peer support and faith-based cessation messaging to enhance the reach and uptake of existing evidence-based smoking cessation treatment (EBCT) resources (eg, state quitline coaching programs) for rural adults who smoke.

METHODS

We will use the Integrated Theory of Health Behavior Change, surface or deep structure frameworks to guide intervention development, and the community-based participatory research (CBPR) approach to identify and engage with community stakeholders. The initial content library of moderator postings (videos and text or image postings) will be developed using existing EBCT material from the Centers for Disease Control and Prevention Tips from Former Smokers Campaign. The content library will feature topics related to quitting smoking, such as coping with cravings and withdrawal and using EBCTs with faith-based message integration (eg, Bible quotes). A community advisory board and a community engagement studio will provide feedback to refine the content library. We will also conduct a beta test of the intervention with 15 rural adults who smoke to assess the recruitment feasibility and preliminary intervention uptake such as engagement, ease of use, usefulness, and satisfaction to further refine the intervention based on participant feedback.

RESULTS

The result of this study will create an intervention prototype that will be used for a future randomized controlled trial.

CONCLUSIONS

Our CBPR project will create a prototype of a Facebook-delivered faith-based messaging and peer support intervention that may assist rural adults who smoke to use EBCT. This study is crucial in establishing a self-sufficient smoking cessation program for the rural community. The project is unique in using a moderated social media platform providing peer support and culturally relevant faith-based content to encourage adult people who smoke to seek treatment and quit smoking.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52398.

Personalized feedback intervention for individuals with low distress tolerance who smoke cigarettes: A randomized controlled trial of a digital intervention

INTRODUCTION

Cigarette smoking remains the leading preventable cause of death and disability in the United States and frequently co-occurs with anxiety and depressive symptoms. A novel and integrative, theory-driven approach to address the heterogeneity of mood-related symptoms associated with cigarette use is to focus on transdiagnostic processes, such as distress tolerance, that underpin both mood-related symptoms and smoking behavior. The current study sought to develop and examine the feasibility, acceptability, and initial efficacy of a digitally delivered integrated personalized feedback intervention (PFI) that addresses smoking-distress tolerance relations.

METHODS

Participants included 121 adults (71.1 % male; Mage = 29.33 years, SD = 7.52) who smoked cigarettes daily and reported low distress tolerance. The study randomized participants to the Active PFI (feedback on distress tolerance and smoking) or the Control PFI (feedback on smoking only).

RESULTS

Results indicated feasibility and acceptability demonstrated by the ability to retain participants through the 1-month follow-up (98.2 % retention rate) and positive feedback from participants, including satisfaction regarding the Active PFI. The Active PFI (vs. Control PFI) was also a statistically significant predictor of change in motivation and intention to quit smoking and willingness to use adaptive coping strategies from baseline to 1-month follow-up.

CONCLUSIONS

For individuals with low distress tolerance who smoke cigarettes, this study's findings suggest that the current intervention may be a first-step to aid in increasing motivation/intention to quit smoking and willingness to use adaptive coping strategies.

Use of e-Cigarettes in Cigarette Smoking Cessation: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Many adults use e-cigarettes to help them quit cigarette smoking. However, the impact of self-selected use of e-cigarettes on cigarette smoking cessation, particularly when concurrently receiving app-based behavioral interventions, remains unexplored.

OBJECTIVE

This study used data from a randomized trial of 2 smartphone apps to compare 12-month cigarette smoking cessation rates between participants who used e-cigarettes on their own (ie, adopters: n=465) versus those who did not (ie, nonadopters: n=1097).

METHODS

The study population included all participants who did not use e-cigarettes at baseline. "Adopters" were those who self-reported the use of e-cigarettes at either 3- or 6-month follow-ups. "Nonadopters" were those who self-reported no use of e-cigarettes at either follow-up time point. The primary cessation outcome was self-reported, complete-case, 30-day point prevalence abstinence from cigarette smoking at 12 months. Secondary outcomes were missing-as-smoking and multiple imputation analyses of the primary outcome, prolonged abstinence, and cessation of all nicotine and tobacco products at 12 months. In logistic regression models, we first examined the potential interaction between e-cigarette use and treatment arm (iCanQuit vs QuitGuide) on the primary cessation outcome. Subsequently, we compared 12-month cigarette smoking cessation rates between adopters and nonadopters separately for each app.

RESULTS

There was suggestive evidence for an interaction between e-cigarette use and treatment arm on cessation (P=.05). In the iCanQuit arm, 12-month cigarette smoking cessation rates were significantly lower among e-cigarette adopters compared with nonadopters (41/193, 21.2% vs 184/527, 34.9%; P=.003; odds ratio 0.55, 95% CI 0.37-0.81). In contrast, in the QuitGuide arm, 12-month cigarette smoking cessation rates did not differ between adopters and nonadopters (46/246, 18.7% vs 104/522, 19.9%; P=.64; odds ratio 0.91, 95% CI 0.62-1.35).

CONCLUSIONS

The use of e-cigarettes while concurrently receiving an app-based smoking cessation intervention was associated with either a lower or an unimproved likelihood of quitting cigarette smoking compared to no use. Future behavioral treatments for cigarette smoking cessation should consider including information on the potential consequences of e-cigarette use.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02724462; https://clinicaltrials.gov/study/NCT02724462.

Non-pharmacological interventions for smoking cessation: analysis of systematic reviews and meta-analyses

BACKGROUND

Although non-pharmacological smoking cessation measures have been widely used among smokers, current research evidence on the effects of smoking cessation is inconsistent and of mixed quality. Moreover, there is a lack of comprehensive evidence synthesis. This study seeks to systematically identify, describe, and evaluate the available evidence for non-pharmacological interventions in smoking populations through evidence mapping (EM), and to search for best-practice smoking cessation programs.

METHODS

A comprehensive search for relevant studies published from the establishment of the library to January 8, 2023, was conducted in PubMed, Web of Science, Embase, the Cochrane Library, CNKI, CBM, Wan Fang, and VIP. Two authors independently assessed eligibility and extracted data. The PRISMA statement and AMSTAR 2 tool were used to evaluate the report quality and methodology quality of systematic reviews/meta-analyses (SRs/MAs), respectively. Bubble plots were utilized to display information, such as the study population, intervention type, evidence quality, and original study sample size.

RESULTS

A total of 145 SRs/MAs regarding non-pharmacological interventions for smoking cessation were investigated, with 20 types of interventions identified. The most commonly used interventions were cognitive behaviour education (n = 32, 22.07%), professional counselling (n = 20, 13.79%), and non-nicotine electronic cigarettes (e-cigarettes) (n = 13, 8.97%). Among them, counselling and behavioural support can improve smoking cessation rates, but the effect varies depending on the characteristics of the support provided. These findings are consistent with previous SRs/MAs. The general population (n = 108, 74.48%) was the main cohort included in the SRs/MAs. The total score of PRISMA for the quality of the reports ranged from 8 to 27, and 13 studies (8.97%) were rated as high confidence, and nine studies (6.21%) as moderate confidence, in the AMSTAR 2 confidence rating.

CONCLUSIONS

The abstinence effect of cognitive behaviour education and money incentive intervention has advantages, and non-nicotine e-cigarettes appear to help some smokers transition to less harmful replacement tools. However, the methodological shortcomings of SRs/MAs should be considered. Therefore, to better guide future practice in the field of non-pharmacological smoking cessation, it is essential to improve the methodological quality of SRs and carry out high-quality randomized controlled trials (RCTs).

Effectiveness of social video platforms in promoting smoking cessation among youth: A content-specific analysis of smoking cessation topic videos on the social platform Bilibili

INTRODUCTION

Smoking cessation is a significant public health issue for young people. Social media provide the public with health knowledge through various types of videos. Bilibili is a trendy social video platform among the young population in China, and the number of smoking cessation videos on this platform is continuously increasing. Different content creators advocating smoking cessation through videos may influence young people's attitudes and behaviors towards tobacco and smoking. This study aims to measure the message sensation value (MSV) and the information appeals in smoking cessation videos on Bilibili, examining their impact on communication effectiveness.

METHODS

This study collected 337 videos from Bilibili and conducted a content analysis regarding the content creator's information, video presentation, MSV, and message appeals. The communication effectiveness of the videos was defined as a dependent variable and was divided into three dimensions: communication breadth, recognition, and participation.

RESULTS

The average MSV (rated on a scale of 0 to 11) for smoking cessation-themed videos was 4.49 (SD=2.23). Chi-squared analysis revealed significant differences among different types of videos in the use of threat appeal (p<0.001), humor appeal (p<0.001), and psychological benefit (p<0.05). Additionally, different types of creators showed differences in the use of threat appeal (p<0.05), humor appeal (p<0.001), and psychological benefit (p<0.05). ANOVA results indicated significant differences in the level of MSV among different smoking cessation videos (F=39.775, p<0.001). Linear regression analysis showed that MSV, threat appeal, humor appeal, and economic benefit positively impacted dissemination effects (p<0.001).

CONCLUSIONS

The results indicate that young people are likelier to watch smoking cessation videos with higher MSV and information appeal. These elements can enhance persuasion and the effectiveness of communication. Therefore, when video creators aim to promote smoking cessation among young people, they can consider factors such as MSV, threat appeal, humor appeal, and economic benefit to enhance communication effects.

Study protocol for the description and evaluation of the "Habit Coach" - a longitudinal multicenter mHealth intervention for healthy habit formation in health care professionals

BACKGROUND

The adoption of a healthy lifestyle plays a crucial role for the health and well-being of health care professionals. Previous e- and mHealth interventions relied on deliberative psychological processes (e.g., intention, planning) to target lifestyle changes, while revealing mixed efficacy. The additional potential of non-deliberative, automatic processes (i.e., habits) for behavior change has been understudied in interventions so far. The Habit Coach mHealth intervention combines deliberative and non-deliberative processes to support health care professionals in forming healthy physical activity, nutrition and mindfulness habits in daily life. The aim of this paper is to outline the study protocol including a detailed description of the mHealth intervention, evaluation plan, and study design. The purpose of this trial is to understand healthy habit formation in health care professionals over time.

METHODS

A one-arm, multicenter mHealth intervention study will be conducted. Behavioral and psychosocial predictors will be collected via within-app questionnaires across a 100-day period at baseline, post, as well as at weekly assessments. To understand habit formation across time, linear mixed models will be used.

DISCUSSION

This trial aims to unravel the role of motivational and volitional determinants for healthy habit formation across multiple health behaviors in health care professionals embedded in a mHealth intervention.

TRIAL REGISTRATION

This trial is registered in the German Clinical Trials Register, DRKS-ID DRKS00027156. Date of registration 17 November 2021.

HIV patients’ perceptions of a potential multi-component mindfulness-based smoking cessation smartphone application intervention

Objectives

Cigarette smoking rates among people living with HIV (PLWH) in the US is triple that of the general population. PLWH smokers are a high-risk group for smoking-related health disparities and should be a prime focus for smoking cessation efforts. Our team has developed a novel evidence-based Mindfulness Training (MT) smoking cessation smartphone application (app), “Craving-to-Quit.” Using qualitative focus groups among PLWH smokers, this study aims to tailor and optimize the app’s content and design to PLWH’s unique psychosocial profile and needs.

Methods

We conducted 8 focus groups among PLWH smokers (n = 59; 47.5% females; ≥18 years) to gain insight into participants’ perceptions about the app, MT, and the feasibility and acceptability of adding two additional strategies (CM: Contingency Management; self-monitoring of anti-retroviral therapies intake [ART]) to further optimize the app. Participants were asked to practice MTs and watch videos from the app presented on a screen in the conference room to discuss their experience. Sessions were audio-taped, transcribed verbatim, and analyzed thematically using NVivo.

Results

Most participants were non-Hispanic black (67.8%), on a federal health insurance program (61.0%). Participants considered it easy to learn the app and thought that MT is helpful in reducing stress and motivating quit attempts and were supportive of adding CM and recommended providing $20-$50 weekly cash incentives to help in quitting. Participants felt that adding self-monitoring of ART is helpful but were concerned about confidentiality in case they lost their phone. Participants recommended making the app cost-free and adding information about smoking cessation medications and the negative effects of smoking among PLWH.

Conclusions

Findings will guide the development of a novel multi-component smoking cessation intervention app integrating MT, CM, and ART self-monitoring strategies. This intervention has the potential to address several barriers to quitting in PLWH. Further clinical research is needed to test this intervention.

Characterizing Participant Perceptions about Smoking-Cessation Pharmacotherapy and E-Cigarettes from Facebook Smoking-Cessation Support Groups

The prevalence of smoking among young adults aged 19-28 years old in the United States persists at rates of 14.3%. Young adults underutilize pharmacotherapy for smoking cessation, and the use of e-cigarettes has increased. We analyzed comments from online smoking-cessation support groups to understand young-adult smokers' views of pharmacotherapy and e-cigarettes, to provide a more in-depth insight into the underutilization of pharmacotherapy. A qualitative analysis was performed on comments about pharmacotherapy and e-cigarettes from participants enrolled in online smoking-cessation support groups in 2016-2020. A codebook was developed with a deductive approach to code the comments, followed by thematic analysis. Eighteen themes were identified, with four dominant themes: interest, benefit, knowledge, and flavor. Participants expressed less interest in both nicotine-replacement therapy and e-cigarettes; moreover, they expressed unfamiliarity with and misconceptions about pharmacotherapy, and recognized the enticing flavors of e-cigarettes. Participants often felt e-cigarettes were not useful for smoking cessation, but the flavors of e-cigarettes were appealing for use. Participants had mixed opinions about the use of e-cigarettes for smoking cessation, but predominantly felt e-cigarettes were not useful for smoking cessation. The use of social media may be an effective way to address misconceptions about pharmacotherapy for smoking cessation and increase willingness to accept assistance.

Effectiveness of a smoking cessation decision-making electronic tool (Pare de Fumar Conosco): A randomized clinical trial

There is an underutilization of smoking cessation treatment among patients with chronic conditions, which indicates a need for new strategies to engage them. Web-based smoking cessation decision-making tools can be beneficial. This study assessed the effectiveness of the Pare de Fumar Conosco software at increasing engagement to smoking cessation counseling groups among Brazilian smokers with chronic conditions. Clinical trial participants were randomized to Pare de Fumar Conosco or standard of care. Engagement in the smoking cessation counseling group was the primary outcome. Secondary outcomes included motivation level, cessation rate, completion, and treatment adherence. The t-tests and Chi-square analyzed baseline differences between groups and the Poisson models, the effects of the intervention. Engagement rates were higher in the Pare de Fumar Conosco (IR=2.22; 95% CI: 1.06 - 4.63) concerning the standard of care. Pare de Fumar Conosco group was more adherent to treatment over time (6.4% versus 4.2% in the final week). Cessation rate was 26.3% in standard care and 23.1% in Pare de Fumar Conosco. Both interventions maintained significant motivation levels to quit smoking. The Pare de Fumar Conosco intervention effectively increases the engagement in the smoking cessation counseling groups. There is a need to improve the smoking cessation rate.

Smoking cessation interventions in South Asian Region: a systematic scoping review

Background

Cigarette smoking is one of the most preventable causes of morbidities and mortalities. Since 2005, the World Health Organization Framework Convention for Tobacco Control (WHO-FCTC) provides an efficient strategic plan for tobacco control across the world. Many countries in the world have successfully reduced the prevalence of cigarette smoking. However, in developing countries, the prevalence of cigarette smoking is mounting which signifies a need of prompt attention. This scoping review aims to explore the extent and nature of Smoking Cessation (SmC) interventions and associated factors in South Asian Region (SAR) by systematically reviewing available recently published and unpublished literature.

Methods

The Joanna Briggs Institute (JBI) framework frames the conduct of this scoping review.

PubMed, EBSCO CINAHL Complete, Cochrane Library, ProQuest Dissertation and Theses, and local websites as well as other sources of grey literature were searched for relevant literature. In total, 573 literature sources were screened. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram, finally, 48 data sources were included for data extraction and analysis.

We analyzed the extracted SmC interventions through the FCTC. Factors that affect smoking cessation interventions will be extracted through manual content analysis.

Results

Regarding FCTC recommended smoking cessation strategies (articles), most of the articles were either neglected or addressed in a discordant way by various anti-smoking groups in SAR. Key barriers that hamper the effectiveness of smoking cessation interventions included lack of awareness, poor implementation of anti-smoking laws, and socio-cultural acceptance of tobacco use. Conversely, increased levels of awareness, through different mediums, related to smoking harms and benefits of quitting, effective implementation of anti-smoking laws, smoking cessation trained healthcare professionals, support systems, and reluctance in the community to cigarette smoking were identified as facilitators to smoking cessation interventions.

Conclusion

The ignored or uncoordinated FCTC’s directions on smoking cessation strategies have resulted in continued increasing prevalence of cigarette smoking in developing countries, especially SAR. The findings of this review highlight the need for refocusing the smoking cessation strategies in SAR.

Strengths

The review was conducted by a team of expert comprising information specialists, and senior professors bringing rich experience in systematic and scoping reviews. Every effort was made to include all available literature sources addressing cigarette SmC and associated factors in SAR. The review findings signal the need and direction for more SmC efforts in SAR which may contribute to development of effective policies and guidelines for the control of smoking prevalence.

Limitations

Despite efforts, potentially relevant records may have been missed due to unpublished or inaccessible articles, unintended selection bias, or those published in local languages, etc. Moreover, the exclusion of literature on under 18 participants and mentally ill smokers may limit the generalizability of findings.

The Stop-tabac smartphone application for smoking cessation: a randomized controlled trial

AIMS

To test whether the Stop-tabac smartphone application (app) increased smoking cessation rates.

DESIGN

A two-arm, parallel-group, individually randomized, double-blind, controlled trial.

SETTING AND PARTICIPANTS

A total of 5293 daily smokers (Stop-tabac = 2639, control = 2654) enrolled on app stores and on the internet in 2019-20, who lived in France or Switzerland.

INTERVENTION AND COMPARATOR

The Stop-tabac application includes immediate feedback during episodes of craving and withdrawal; individually tailored counseling messages with notifications sent during 6 months; a discussion forum; fact sheets; modules on nicotine replacement therapy and e-cigarettes; and calculators of cigarettes not smoked, money saved and days of life gained since quitting. The control application included five brief pages and calculators as above.

MEASUREMENTS

Primary outcome: self-reported smoking cessation after 6 months (no puff of tobacco in the past 4 weeks), with non-responders counted as smokers.

SECONDARY OUTCOME

self-reported use of nicotine medications.

FINDINGS

Participants were aged 36 years on average; 66% were women who smoked 15 cigarettes/day, and 64% screened positive for depression. Stop-tabac participants used the app over a longer period than control participants (23 versus 11 days, P < 0.001). Smoking cessation rates after 6 months were 9.9% in the Stop-tabac group versus 10.3% in the control group (odds ratio = 0.96, 95% confidence interval = 0.80-1.45, P = 0.63). Rates of use of nicotine medications after entry in the study were 38 versus 30% after 6 months (χ²  = 8.3, P = 0.004) in the Stop-tabac and control groups. After 6 months, 26% of participants in the Stop-tabac group and 8% in the control group said that the app helped them 'a lot' or 'enormously' to quit smoking (χ²  =  113, P < 0.001).

CONCLUSIONS

In smokers enrolled on the app stores and the internet, allocation to the Stop-tabac smoking cessation app did not increase smoking cessation rates, but increased rates of use of nicotine medications.

The Behavior Change Techniques Used in Canadian Online Smoking Cessation Programs: Content Analysis

BACKGROUND

Smoking rates in Canada remain unacceptably high, and cessation rates have stalled in recent years. Online cessation programs, touted for their ability to reach many different populations anytime, have shown promise in their efficacy. The Government of Canada has therefore funded provincial and national smoking cessation websites countrywide. However, little is known about the behavior change techniques (BCTs) that underpin the content of these websites, which is key to establishing the quality of the websites, as well as a way forward for evaluation.

OBJECTIVE

The purpose of this study, therefore, is to apply the BCTTv1 taxonomy to Canadian provincial and federal websites, and to determine which BCTs they use.

METHODS

A total of 12 government-funded websites across Canada were included for analysis. Using deductive content analysis and through training in applying the BCTTv1 taxonomy, the website content was coded according to the 93 BCTs across the 16 BCT categories.

RESULTS

Of the 16 BCT categories, 14 were present within the websites. The most widely represented BCT categories (used in all 12 websites) included goals and planning, social support, natural consequences, and regulation. Implementation of BCTs within these categories varied across the sites.

CONCLUSIONS

Analyzing the content of online smoking cessation websites using the BCTTv1 taxonomy is an appropriate method for identifying the behavior change content of these programs. The findings offer programmers and researchers tangible directions for prioritizing and enhancing provincial and national smoking cessation programs, and an evaluation framework to assess smoking cessation outcomes in relation to the web-based content.

Effect of Electronic Portal Messaging With Embedded Asynchronous Care on Physician-Assisted Smoking Cessation Attempts: A Randomized Clinical Trial

IMPORTANCE

Despite the substantial health and financial burdens of smoking and the availability of effective, evidence-based interventions in primary care settings, few smokers and physicians use these strategies for smoking cessation.

OBJECTIVE

To evaluate whether electronic outreach to smokers with embedded asynchronous care increases the number of quit attempts and explore the roles of the message sender (ie, primary care physician [PCP] vs health care system) and patient-related characteristics.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement randomized clinical trial was designed to measure 2 factors: (1) electronic outreach messaging with and without a survey link to asynchronous care and (2) messaging by a personal PCP or health system. The study was conducted within the electronic health record and portal messaging platform of a large health system in the South Central US. Participants were adult patients 18 years or older who were designated as smokers in their electronic health records. Data were collected from January 13 to February 24, 2020, with participating PCPs surveyed in July 2020.

INTERVENTIONS

Portal messages encouraging a quit attempt and offering physician assistance were sent to smokers who were randomly selected and assigned to 1 of 4 conditions (message with or without embedded asynchronous care and PCP or system as sender). Half of the messages contained an invitation to come to clinics and the other half contained a link to access asynchronous care.

MAIN OUTCOMES AND MEASURES

The primary outcome was electronic health record-documented quit attempts (1 indicates quit attempt; 0, no quit attempt), which were tracked 30 days after the electronic outreach. Secondary outcomes included physician perceptions of the electronic outreach intervention, using a 5-point scale to assess perceptions of workload, comfort with providing medication from survey information, and further interest in the program 6 months after the intervention.

RESULTS

A total of 188 participants (99 women [52.4%] and 89 men [47.3%]) with mean (SD) age of 55.2 (13.9) years were randomized to 1 of 4 conditions. Group 1 (n = 46) received a message from the PCP without a link to the survey; group 2 (n = 48) received a message from the PCP with a link to asynchronous care in the form of the survey. Group 3 (n = 47) received a message from the health system without a link to the survey; group 4 (n = 47) received a message from the health system with a link to the survey. No statistically significant difference in documented quite attempts was found among the 4 study groups. There was also no statistically significant difference in quit attempts between the group that received the asynchronous care survey link and the group that did not (odds ratio, 2.50 [95% CI, 0.72-8.72]). However, the quit attempt rate for those with asynchronous care offered (9 of 95 [9.5%]) was more than double the quit attempt rate for those with in-person care offered (4 of 93 [4.3%]).

CONCLUSIONS AND RELEVANCE

This quality improvement randomized clinical trial did not find a statistically significant difference in physician-assisted quit attempts among patients who received electronic with asynchronous care vs those who received outreach alone, regardless of whether the message source was a PCP or a health system. However, the program engaged patients in difficult-to-reach rural areas as well as younger patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05172219.

Expert-Moderated Peer-to-Peer Online Support Group for People With Knee Osteoarthritis: Mixed Methods Randomized Controlled Pilot and Feasibility Study

Background

Osteoarthritis (OA) is a major problem globally. First-line management comprises education and self-management strategies. Online support groups may be a low-cost method of facilitating self-management.

Objective

The aim of this randomized controlled pilot study is to evaluate the feasibility of the study design and implementation of an evidence-informed, expert-moderated, peer-to-peer online support group (My Knee Community) for people with knee OA. The impacts on psychological determinants of self-management, selected self-management behaviors, and health outcomes were secondary investigations.

Methods

This mixed methods study evaluated study feasibility (participant recruitment, retention, and costs), experimental intervention feasibility (acceptability and fidelity to the proposed design, including perceived benefit, satisfaction, and member engagement), psychological determinants (eg, self-efficacy and social support), behavioral measures, health outcomes, and harms. Of a total of 186, 63 (33.9%) participants (41/63, 65% experimental and 22/63, 35% control) with self-reported knee OA were recruited from 186 volunteers. Experimental group participants were provided membership to My Knee Community, which already had existing nonstudy members, and were recommended a web-based education resource (My Joint Pain). The control group received the My Joint Pain website recommendation only. Participants were not blinded to their group allocation or the study interventions. Participant-reported data were collected remotely using web-based questionnaires. A total of 10 experimental group participants also participated in semistructured interviews. The transcribed interview data and all forum posts by the study participants were thematically analyzed.

Results

Study feasibility was supported by acceptable levels of retention; however, there were low levels of engagement with the support group by participants: 15% (6/41) of participants did not log in at all; the median number of times visited was 4 times per participant; only 29% (12/41) of participants posted, and there were relatively low levels of activity overall on the forum. This affected the results for satisfaction (overall mean 5.9/10, SD 2.7) and perceived benefit (17/31, 55%: yes). There were no differences among groups for quantitative outcomes. The themes discussed in the interviews were connections and support, information and advice, and barriers and facilitators. Qualitative data suggest that there is potential for people to derive benefit from connecting with others with knee OA by receiving support and assisting with unmet informational needs.

Conclusions

Although a large-scale study is feasible, the intervention implementation was considered unsatisfactory because of low levels of activity and engagement by members. We recommend that expectations about the support group need to be made clear from the outset. Additionally, the platform design needs to be more engaging and rewarding, and membership should only be offered to people willing to share their personal stories and who are interested in learning from the experiences of others.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12619001230145; http://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377958

Conversational Agent for Healthy Lifestyle Behavior Change: Web-Based Feasibility Study

BACKGROUND

The rising incidence of chronic diseases is a growing concern, especially in Singapore, which is one of the high-income countries with the highest prevalence of diabetes. Interventions that promote healthy lifestyle behavior changes have been proven to be effective in reducing the progression of prediabetes to diabetes, but their in-person delivery may not be feasible on a large scale. Novel technologies such as conversational agents are a potential alternative for delivering behavioral interventions that promote healthy lifestyle behavior changes to the public.

OBJECTIVE

The aim of this study is to assess the feasibility and acceptability of using a conversational agent promoting healthy lifestyle behavior changes in the general population in Singapore.

METHODS

We performed a web-based, single-arm feasibility study. The participants were recruited through Facebook over 4 weeks. The Facebook Messenger conversational agent was used to deliver the intervention. The conversations focused on diet, exercise, sleep, and stress and aimed to promote healthy lifestyle behavior changes and improve the participants' knowledge of diabetes. Messages were sent to the participants four times a week (once for each of the 4 topics of focus) for 4 weeks. We assessed the feasibility of recruitment, defined as at least 75% (150/200) of our target sample of 200 participants in 4 weeks, as well as retention, defined as 33% (66/200) of the recruited sample completing the study. We also assessed the participants' satisfaction with, and usability of, the conversational agent. In addition, we performed baseline and follow-up assessments of quality of life, diabetes knowledge and risk perception, diet, exercise, sleep, and stress.

RESULTS

We recruited 37.5% (75/200) of the target sample size in 1 month. Of the 75 eligible participants, 60 (80%) provided digital informed consent and completed baseline assessments. Of these 60 participants, 56 (93%) followed the study through till completion. Retention was high at 93% (56/60), along with engagement, denoted by 50% (30/60) of the participants communicating with the conversational agent at each interaction. Acceptability, usability, and satisfaction were generally high. Preliminary efficacy of the intervention showed no definitive improvements in health-related behavior.

CONCLUSIONS

The delivery of a conversational agent for healthy lifestyle behavior change through Facebook Messenger was feasible and acceptable. We were unable to recruit our planned sample solely using the free options in Facebook. However, participant retention and conversational agent engagement rates were high. Our findings provide important insights to inform the design of a future randomized controlled trial.

Public Perceptions of Diabetes, Healthy Living, and Conversational Agents in Singapore: Needs Assessment

Background

The incidence of chronic diseases such as type 2 diabetes is increasing in countries worldwide, including Singapore. Health professional–delivered healthy lifestyle interventions have been shown to prevent type 2 diabetes. However, ongoing personalized guidance from health professionals is not feasible or affordable at the population level. Novel digital interventions delivered using mobile technology, such as conversational agents, are a potential alternative for the delivery of healthy lifestyle change behavioral interventions to the public.

Objective

We explored perceptions and experiences of Singaporeans on healthy living, diabetes, and mobile health (mHealth) interventions (apps and conversational agents). This study was conducted to help inform the design and development of a conversational agent focusing on healthy lifestyle changes.

Methods

This qualitative study was conducted in August and September 2019. A total of 20 participants were recruited from relevant healthy living Facebook pages and groups. Semistructured interviews were conducted in person or over the telephone using an interview guide. Interviews were transcribed and analyzed in parallel by 2 researchers using Burnard’s method, a structured approach for thematic content analysis.

Results

The collected data were organized into 4 main themes: use of conversational agents, ubiquity of smartphone apps, understanding of diabetes, and barriers and facilitators to a healthy living in Singapore. Most participants used health-related mobile apps as well as conversational agents unrelated to health care. They provided diverse suggestions for future conversational agent-delivered interventions. Participants also highlighted several knowledge gaps in relation to diabetes and healthy living. Regarding barriers to healthy living, participants mentioned frequent dining out, high stress levels, lack of work-life balance, and lack of free time to engage in physical activity. In contrast, discipline, preplanning, and sticking to a routine were important for enabling a healthy lifestyle.

Conclusions

Participants in this study commonly used mHealth interventions and provided important insights into their knowledge gaps and needs in relation to changes in healthy lifestyle behaviors. Future digital interventions such as conversational agents focusing on healthy lifestyle and diabetes prevention should aim to address the barriers highlighted in our study and motivate individuals to adopt healthy lifestyle behavior.

A digital solution to streamline access to smoking cessation interventions in England; findings from a primary care pilot (STOPNOW study)

Objectives

Despite the proven efficacy of several smoking cessation medications that have been shown to improve long-term abstinence rates, approximately two-thirds of smokers report not having used medication in their most recent quit attempt. A main barrier could be delayed access to pharmacological interventions. This study investigated the utility of a primary care linked online portal to streamline timely access to pharmacological support to patients who want to quit smoking by making an asynchronous request for treatment to their general practitioner.

Study design

Prospective cohort study.

Methods

An online portal with added functionality was developed, which allowed patients with a unique link to make an asynchronous request for treatment. Two GP practices identified a total of 4337 eligible patients who received an SMS or email invite to engage with an online portal including an electronic survey to capture information about smoking behaviours and to request treatment. Portal informatics and patient level data were analysed to measure the efficacy of the online system in reducing the time between making a formal request to treatment and access to pharmacological support. The primary outcome measure was the time between making a formal request for treatment and access to pharmacological support from a designated community pharmacy.

Results

323 patients (7.4%) initiated the survey, but only 56 patients completed the survey and made a formal request for treatment. 94% of participants did not return to use the portal to make a second or follow-up request for treatment. Only 3 participants completed the 12-week pathway. A total of 75 medication items were prescribed and collected by 56 patients. The time difference between the formal request to treatment and GP review ranged between 20 h and 1 week. The time difference between approval of prescription by the GP and access to medication was 5 days ± 2.1 days (range = 1.9–7.0 days).

Conclusion

The widespread adoption and diffusion of an IT enabled and asynchronous primary care led remote consultation pathway can streamline timely access to smoking cessation support without the need for the patient to see a GP or an independent prescriber in the first instance.

•

Traditional face-to-face smoking cessation interventions may result in significant delays between the patient's decision to quit and access to effective pharmacological support or behavioural therapies.

•

This was the first attempt in the UK where a GP-led online portal with added functionality was used to streamline timely access to pharmacotherapy for smoking cessation using an asynchronous formal request for treatment.

•

We evaluated the findings of a primary care pilot from two general practices in West London where 4337 patients who are registered as smokers were contacted with unique link to access the portal.

•

The pervasive use of a primary care-led online portal could enablie patients to make an asynchronous request for treatment without the need to visit the general practice.

Reach versus effectiveness: The design and protocol of randomized clinical trial testing a smartphone application versus in-person mindfulness-based smoking cessation intervention among young cancer survivors

Approximately 45% of young cancer survivors (18-40 years) are cigarette smokers. Continued smoking after cancer diagnosis leads to lower survival rates. A major logistical problem with smoking cessation efforts in this group is their geographic dispersion which makes them hard to reach. In addition, depression is a major predictor of smoking relapse and its rates are roughly twice as high in cancer survivors as the general population. Smartphone applications (apps) show promise in terms of efficacy, dissemination, and improving access to treatment. Mindfulness training (defined as maintaining attention on one's immediate experience and cultivating an attitude of acceptance toward this experience) is effective in improving smoking cessation outcomes by reducing psychological stress and controlling craving. Given that smartphone apps can address the issues of mobility and remote access, and mindfulness can address the high depression rate among cancer survivors, validating the feasibility and efficacy of a mindfulness-based smoking cessation intervention app in young cancer survivors is a high priority. Thus, the aims of the current study are: (1) test the feasibility, acceptability, and potential efficacy of the mindfulness-based smoking cessation app versus in-person mindfulness or usual care in a 3-arm pilot randomized clinical trial among young cancer survivors (n = 60; 18-40 years); and 2) conduct semi-structured exit interviews with participants in the two mindfulness groups to fine-tune the two active interventions based on feedback from participants. Findings will have implications for the development and dissemination of innovative and highly scalable tobacco cessation interventions designed for young cancer survivors.

A referral aid for smoking cessation interventions in primary care: study protocol for a randomized controlled trial

BACKGROUND

To expedite the use of evidence-based smoking cessation interventions (EBSCIs) in primary care and to thereby increase the number of successful quit attempts, a referral aid was developed. This aid aims to optimize the referral to and use of EBSCIs in primary care and to increase adherence to Dutch guidelines for smoking cessation.

METHODS

Practice nurses (PNs) will be randomly allocated to an experimental condition or control condition, and will then recruit smoking patients who show a willingness to quit smoking within six months. PNs allocated to the experimental condition will provide smoking cessation guidance in accordance with the referral aid. Patients from both conditions will receive questionnaires at baseline and after six months. Cessation effectiveness will be tested via multilevel logistic regression analyses. Multiple imputations as well as intention to treat analysis will be performed. Intervention appreciation and level of informed decision-making will be compared using analysis of (co)variance. Predictors for appreciation and informed decision-making will be assessed using multiple linear regression analysis and/or structural equation modeling. Finally, a cost-effectiveness study will be conducted.

DISCUSSION

This paper describes the study design for the development and evaluation of an information and decision tool to support PNs in their guidance of smoking patients and their referral to EBSCIs. The study aims to provide insight into the (cost) effectiveness of an intervention aimed at expediting the use of EBSCIs in primary care.

Effectiveness of Digital Interventions for Reducing Behavioral Risks of Cardiovascular Disease in Nonclinical Adult Populations: Systematic Review of Reviews

BACKGROUND

Digital health interventions are increasingly being used as a supplement or replacement for face-to-face services as a part of predictive prevention. They may be offered to those who are at high risk of cardiovascular disease and need to improve their diet, increase physical activity, stop smoking, or reduce alcohol consumption. Despite the popularity of these interventions, there is no overall summary and comparison of the effectiveness of different modes of delivery of a digital intervention to inform policy.

OBJECTIVE

This review aims to summarize the effectiveness of digital interventions in improving behavioral and health outcomes related to physical activity, smoking, alcohol consumption, or diet in nonclinical adult populations and to identify the effectiveness of different modes of delivery of digital interventions.

METHODS

We reviewed articles published in the English language between January 1, 2009, and February 25, 2019, that presented a systematic review with a narrative synthesis or meta-analysis of any study design examining digital intervention effectiveness; data related to adults (≥18 years) in high-income countries; and data on behavioral or health outcomes related to diet, physical activity, smoking, or alcohol, alone or in any combination. Any time frame or comparator was considered eligible. We searched MEDLINE, Embase, PsycINFO, Cochrane Reviews, and gray literature. The AMSTAR-2 tool was used to assess review confidence ratings.

RESULTS

We found 92 reviews from the academic literature (47 with meta-analyses) and 2 gray literature items (1 with a meta-analysis). Digital interventions were typically more effective than no intervention, but the effect sizes were small. Evidence on the effectiveness of digital interventions compared with face-to-face interventions was mixed. Most trials reported that intent-to-treat analysis and attrition rates were often high. Studies with long follow-up periods were scarce. However, we found that digital interventions may be effective for up to 6 months after the end of the intervention but that the effects dissipated by 12 months. There were small positive effects of digital interventions on smoking cessation and alcohol reduction; possible effectiveness in combined diet and physical activity interventions; no effectiveness for interventions targeting physical activity alone, except for when interventions were delivered by mobile phone, which had medium-sized effects; and no effectiveness observed for interventions targeting diet alone. Mobile interventions were particularly effective. Internet-based interventions were generally effective.

CONCLUSIONS

Digital interventions have small positive effects on smoking, alcohol consumption, and in interventions that target a combination of diet and physical activity. Small effects may have been due to the low efficacy of treatment or due to nonadherence. In addition, our ability to make inferences from the literature we reviewed was limited as those interventions were heterogeneous, many reviews had critically low AMSTAR-2 ratings, analysis was typically intent-to-treat, and follow-up times were relatively short.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42019126074; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=126074.

An Analysis of Consumer Protection for Gamblers Across Different Online Gambling Operators in Ireland: A Descriptive Study

The aim of the present study was to evaluate the responsible gambling tools which are available to online gamblers at Irish online gambling websites. The present study used a similar methodology to a recent study carried out on the world’s most popular websites (Bonello and Griffiths Gaming Law Review and Economics, 21, 278–285, 2017), where 50 of the most advertised online gambling websites were evaluated in relation to their responsible gambling (RG) practices. The present study evaluated 39 gambling websites with either a “.ie” or “.com/ie” domain. Each website was evaluated by checking for a number of RG practices, including presence of a dedicated RG page; age verification; access to gambling account history; the availability of RG tools, such as limit setting facilities and exclusion settings; and links to limit-setting options on the deposit page. Descriptive statistics were then performed on the results from each website. Of the 39 online gambling operators identified, 22 redirected gamblers to a “.com” domain, while 17 operators remained as a “.ie” domain. Thirty-five websites (89.7%) visited had a dedicated RG page. Responsible gambling features were evaluated and demonstrated to be available in an inconsistent manner across online gambling websites. Irish websites were shown to perform poorly in comparison with non-Irish counterparts in the provision of RG tools. The researchers of the present study are not aware of any similar studies conducted to date in Ireland.

Does addition of craving management tools in a stop smoking app improve quit rates among adult smokers? Results from BupaQuit pragmatic pilot randomised controlled trial

OBJECTIVES

Delivery of craving management tools via smartphone applications (apps) may improve smoking cessation rates, but research on such programmes remains limited, especially in real-world settings. This study evaluated the effectiveness of adding craving management tools in a cessation app (BupaQuit).

METHODS

The study was a two-arm pragmatic pilot parallel randomised controlled trial, comparing a fully-automated BupaQuit app with craving management tool with a control app version without craving management tool. A total of 425 adult UK-based daily smokers were enrolled through open online recruitment (February 2015-March 2016), with no researcher involvement, and individually randomised within the app to the intervention (n = 208) or control (n = 217). The primary outcome was self-reported 14-day continuous abstinence assessed at 4-week follow-up. Secondary outcomes included 6-month point-prevalence and sustained abstinence, and app usage. The primary outcome was assessed with Fisher's exact test using intent to treat with those lost to follow-up counted as smoking. Participants were not reimbursed.

RESULTS

Re-contact rates were 50.4% at 4 weeks and 40.2% at 6 months. There was no significant difference between intervention and control arms on the primary outcome (13.5% vs 15.7%; p = 0.58; relative risk = 0.86, 95% confidence interval = 0.54-1.36) or secondary cessation outcomes (6-month point prevalence: 14.4% vs 17.1%, p = 0.51; relative risk = 0.85, 95% confidence interval = 0.54-1.32; 6-month sustained: 11.1% vs 13.4%, p = 0.55; relative risk = 0.83, 95% confidence interval = 0.50-1.38). Bayes factors supported the null hypothesis (B[0, 0, 1.0986] = 0.20). Usage was similar across the conditions (mean/median logins: 9.6/4 vs 10.5/5; time spent: 401.8/202 s vs 325.8/209 s).

CONCLUSIONS

The addition of craving management tools did not affect cessation, and the limited engagement with the app may have contributed to this.

Tailored Web-Based Smoking Interventions and Reduced Attrition: Systematic Review and Meta-Analysis

Background

The increasing number of internet users presents an opportunity to deliver health interventions to large populations. Despite their potential, many web-based interventions, including those for smoking cessation, face high rates of attrition. Further consideration of how intervention features impact attrition is needed.

Objective

The aim of this systematic review is to investigate whether tailored web-based smoking cessation interventions for smokers are associated with reduced rates of attrition compared with active or passive untailored web-based interventions. The outcomes of interest were dropout attrition at 1-, 3-, 6-, and 12-month follow-ups.

Methods

Literature searches were conducted in May 2018 and updated in May 2020 on MEDLINE (Medical Literature Analysis and Retrieval System Online), PsycINFO (Psychological Information), EMBASE (Excerpta Medica dataBASE), CINAHL (Cumulated Index to Nursing and Allied Health Literature), Scopus, and the Cochrane Tobacco Addiction Group Specialized Register with the following search terms: smoking cessation, tailored, or web- or internet-based. Included studies were published in English before or in May 2020 using a randomized controlled trial design. Studies were restricted to those with web-based delivery, a tailored intervention group, an untailored control group, and a reported outcome of smoking cessation. Studies were assessed for methodological quality using the Cochrane Risk of Bias tool. Two reviewers independently extracted the study characteristics and the number of participants lost to follow-up for each treatment group.

Results

A total of 13 studies were included in the systematic review, of which 11 (85%) were included in the meta-analysis. Tailoring had no statistically significant effect on dropout attrition at 1-month (risk ratio [RR]=1.02, 95% CI 0.95-1.09; P=.58; I²=78%), 3-month (RR=0.99, 95% CI 0.95-1.04; P=.80; I²=73%), 6-month (RR=1.00, 95% CI 0.95-1.05; P=.90; I²=43%), or 12-month (RR=0.97, 95% CI 0.92-1.02; P=.26; I²=28%) follow-ups. Subgroup analyses suggested that there was a statistically significant effect of tailoring between the active and passive subgroups at 1-month (P=.03), 3-month (P<.001), and 6-month (P=.02) follow-ups but not at 12-month follow-up (P=.25).

Conclusions

The results suggest that tailoring of web-based smoking cessation interventions may not be associated with reduced rates of dropout attrition at 1-, 3-, 6-, or 12-month follow-ups. Significant differences between studies that include untailored active and passive control groups suggest that the role of tailoring may be more prominent when studies include a passive control group. These findings may be because of variability in the presence of additional features, the definition of smokers used, and the duration of smoking abstinence measured. Future studies should incorporate active web-based controls, compare the impact of different tailoring strategies, and include populations outside of the Western countries.

The Stop-Tabac smartphone application for smoking cessation: study protocol for a randomized controlled trial in the general population

Background

Smartphone-based support can reach thousands of smokers and help those who would otherwise try to quit smoking by themselves with little chance of success. Nicotine medications double the chances of quitting smoking, but few smokers use them, and they often use them for too short a time and at an insufficient dose. It is therefore important to increase access to support for smoking cessation and compliance with nicotine therapy. The objectives of this study are to assess whether the Stop-Tabac application (app) is effective for smoking cessation and to examine whether the outcome is influenced by the personal characteristics of participants.

Methods

Trial design: this is a two-arm, parallel-group, superiority, individually randomized, “placebo” controlled trial in 5200 smokers, with follow up after 1 week, 1 month and 6 months. The participants are adult daily smokers (N = 5200) enrolled on the Internet, living in France or Switzerland. The intervention is the Stop-tabac fully-automated app for smartphones, which was launched in 2012 and continuously improved thereafter. It includes fact sheets; calculators of cigarettes not smoked, money saved, and years of life gained; an interactive “coach” that provides automated, individually tailored counseling messages based on the user’s personal profile, sent regularly for 6 months; immediate feedback during episodes of craving and tobacco withdrawal symptoms; a discussion forum (“The Tribe”) where participants provide and receive social support; a quiz that informs users in a playful way; and a module on nicotine therapy that includes personalized feedback and follow up. The outcome is self-reported smoking cessation after 6 months (no puff of tobacco in the past 4 weeks), and after 1 week and 1 month (no puff in the past 7 days). Participants will be randomized automatically based on a list of random numbers. Participants, assistants in charge of collecting follow-up data and data analysts will be blinded to allocation. Funding is provided by the Swiss National Science Foundation, CHF 194,942 (EUR 182,200, USD 200,700), grant 32003_179369. JFE’s salary is paid by the University of Geneva, YK’s salary is paid by the Lausanne University Hospitals.

Discussion

There is little evidence from randomized trials of the impact of health apps in general and of smoking cessation apps in particular. This study will fill this gap.

Trial registration

ISRCTN Registry: ISRCTN11318024. Registered on 17 May 2018.

Efficacy of the Ascure Smoking Cessation Program: Retrospective Study

BACKGROUND

Smoking cessation helps extend a healthy life span and reduces medical expenses. However, the standard 12-week smoking cessation program in Japan has several notable problems. First, only 30% of participants complete this program. Second, participants may choose not to participate unless they have a strong motivation to quit smoking, such as health problems. Third, the program does not provide enough support during the period between clinical visits and after 12 weeks.

OBJECTIVE

This study examined the efficacy of the 24-week ascure program to address the problems of accessibility and continuous support. The program combines online mentoring, over-the-counter pharmacotherapy, and a smartphone app.

METHODS

Using a retrospective study design, we investigated data for 177 adult smokers who were enrolled in the ascure smoking cessation program between August 2017 and August 2018. The primary outcomes were continuous abstinence rates (CARs) during weeks 9-12 and weeks 21-24. To confirm smoking status, we performed salivary cotinine testing at weeks 12 and 24. We also evaluated the program adherence rate. Finally, we performed exploratory analysis to determine the factors associated with continuous abstinence at weeks 21-24 to provide insights for assisting with long-term continuous abstinence.

RESULTS

The CARs of all participants for weeks 9-12 and weeks 21-24 were 48.6% (95% CI 41.2-56.0) and 47.5% (95% CI 40.0-54.8), respectively. Program adherence rates were relatively high throughout (72% at week 12 and 60% at week 24). In the analysis of the factors related to the CAR at weeks 21-24, the number of entries in the app's digital diary and number of educational videos watched during the first 12 weeks were significant factors.

CONCLUSIONS

The ascure program achieved favorable CARs, and participants showed high adherence. Proactive usage of the smartphone app may help contribute to smoking cessation success in the long-term.

Concussion Symptom Underreporting Among Incoming National Collegiate Athletic Association Division I College Athletes

OBJECTIVE

Accurate diagnosis of sport-related concussions relies heavily on truthful self-reporting of symptom severity. Previous studies have emphasized lack of knowledge as a factor in symptom nondisclosure. This study sought to examine concussion knowledge and the relationship of knowledge to reasons for symptom nondisclosure.

DESIGN

Cross-sectional study.

SETTING

Data were collected during preparticipation athletic evaluations via electronic survey.

PARTICIPANTS

One hundred fifty-six incoming National Collegiate Athletic Association Division I student-athletes.

MAIN OUTCOME MEASURES

Survey items included previous concussion diagnosis, concussion fact and symptom knowledge, reasons and situational contexts for nondisclosure, and stakeholder attitudes.

RESULTS

Participants, on average, had substantial concussion symptom and fact knowledge. Unexpectedly, participants with higher concussion fact knowledge endorsed more reasons that athletes may hide symptoms. Concussion symptom knowledge was unrelated to reasons for nondisclosure. Athletes believed that symptom reporting was less likely in high-stakes versus low-stakes situations and consistently identified their teammates as holding attitudes that support underreporting and athletic trainers as engaging in behaviors that support player safety.

CONCLUSIONS

Greater concussion knowledge did not reduce the number of reasons that participants viewed as drivers for concussion nondisclosure. In other words, participants understood why athletes choose to hide symptoms even when they also understood the symptoms, risks, sequelae, and consequences of concussion (and potential harm of nondisclosure). Situational contexts and important stakeholder attitudes also appeared to importantly influence symptom disclosure decisions. A multifaceted approach that goes beyond current educational strategies to addresses situational, social, and athletic pressures may be needed to initiate a widespread cultural shift away from concussion nondisclosure.

Making Come-Alive and Keeping Un-Alive: How People Relate to Self-Guided Web-Based Health Interventions

Health interventions delivered online (self-guided web-based interventions) may become more helpful through a person-to-program "working alliance." In psychotherapy, the working alliance signifies a therapeutically useful client-therapist relationship and includes an emotional bond. However, there exist no theories of how program users relate to online programs, or that explain a person-to-program bond theoretically. Addressing this gap, we conducted qualitative interviews with and collected program data from users of a self-guided web-based intervention. Taking a grounded theory approach, the analysis arrived at a model of relating based on two relational modes-making come-alive and keeping un-alive. Different combinations of these modes could describe a range of ways of relating to the program, including a nonsocial interaction, a semi-social interaction, and a semi-social relationship. A person-to-program bond is explained by the model as an experienced supportive social presence, enabled by making come-alive and a positive program interaction.

Evidence-based policy making for health promotion to reduce the burden of non-communicable diseases in Moldova

The Republic of Moldova faces several concurrent health challenges most notably an increase in chronic non-communicable diseases, spiralling health care costs and widening health inequalities. To accelerate progress in their resolution there is a need for new and innovative health promotion and behaviour change communication interventions. The Ministry of Health, Labour and Social Protection in collaboration with the newly created National Agency for Public Health held a conference on the occasion of the Moldovan National Day of Health Promotion on 14th March 2018 in which national and invited international experts exchanged their views on (1) best practice examples of behaviour change interventions, health promotion activities and lessons learned from the UK and elsewhere; and (2) possible ways forward for Moldova to implement cost-effective and evidence-based intersectoral health promotion programmes. The experts provided recommendations on implementing behaviour change interventions to reduce and prevent obesity; on the creation of a favourable tobacco control environment to reduce smoking prevalence; and on how physical activity programme design can benefit from health psychology research. All these strategies could foster health promotion activities and ultimately contribute to improving the health outcomes of the Moldovan population.

The Use of Web-Based Support Groups Versus Usual Quit-Smoking Care for Men and Women Aged 21-59 Years: Protocol for a Randomized Controlled Trial

Background

Existing smoking cessation treatments are challenged by low engagement and high relapse rates, suggesting the need for more innovative, accessible, and interactive treatment strategies. Twitter is a Web-based platform that allows people to communicate with each other throughout the day using their phone.

Objective

This study aims to leverage the social media platform of Twitter for fostering peer-to-peer support to decrease relapse with quitting smoking. Furthermore, the study will compare the effects of coed versus women-only groups on women’s success with quitting smoking.

Methods

The study design is a Web-based, three-arm randomized controlled trial with two treatment arms (a coed or women-only Twitter support group) and a control arm. Participants are recruited online and are randomized to one of the conditions. All participants will receive 8 weeks of combination nicotine replacement therapy (patches plus their choice of gum or lozenges), serial emails with links to Smokefree.gov quit guides, and instructions to record their quit date online (and to quit smoking on that date) on a date falling within a week of initiation of the study. Participants randomized to a treatment arm are placed in a fully automated Twitter support group (coed or women-only), paired with a buddy (matched on age, gender, location, and education), and encouraged to communicate with the group and buddy via daily tweeted discussion topics and daily automated feedback texts (a positive tweet if they tweet and an encouraging tweet if they miss tweeting). Recruited online from across the continental United States, the sample consists of 215 male and 745 female current cigarette smokers wanting to quit, aged between 21 and 59 years. Self-assessed follow-up surveys are completed online at 1, 3, and 6 months after the date they selected to quit smoking, with salivary cotinine validation at 3 and 6 months. The primary outcome is sustained biochemically confirmed abstinence at the 6-month follow-up.

Results

From November 2016 to September 2018, 960 participants in 36 groups were recruited for the randomized controlled trial, in addition to 20 participants in an initial pilot group. Data analysis will commence soon for the randomized controlled trial based on data from 896 of the 960 participants (93.3%), with 56 participants lost to follow-up and 8 dropouts.

Conclusions

This study combines the mobile platform of Twitter with a support group for quitting smoking. Findings will inform the efficacy of virtual peer-to-peer support groups for quitting smoking and potentially elucidate gender differences in quit rates found in prior research.

Trial Registration

ClinicalTrials.gov NCT02823028; https://clinicaltrials.gov/ct2/show/NCT02823028

International Registered Report Identifier (IRRID)

DERR1-10.2196/16417

Design, development and randomised controlled trial of a smartphone application, 'QinTB', for smoking cessation in tuberculosis patients: study protocol

INTRODUCTION

Providing smoking cessation treatment is an important intervention for tuberculosis (TB) patients. Mobile technologies, such as smartphone applications, have shown promising potential. However, there are few effective applications that could support TB patients in their efforts to quit smoking. To address this problem, we will develop a smartphone application 'QinTB' to help TB patients quit smoking, and we will evaluate the clinical efficacy of this application by using a randomised controlled trial (RCT).

METHODS AND ANALYSIS

This is a two-step study. In the first step, we will develop a smartphone application based on an interactive application of the transtheoretical model and protection motivation theory. Then, we will perform an RCT using a two-arm design; a total of 400 patients will be randomly assigned to the application group or the doctors' advice group; both treatments will be 6 months and follow-up will be 12 months; the primary outcome is the biochemically verified 6 month sustained abstinence rate; data will be analysed on an intention-to-treat basis.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of Beijing Research Institute for Tuberculosis Control and Prevention. We will disseminate the findings of this study through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

This study was registered in the Chinese Clinical Trial Registry (ChiCTR1900022008) and the stage is Pre-results.

Individual-level behavioural smoking cessation interventions tailored for disadvantaged socioeconomic position: a systematic review and meta-regression

BACKGROUND

Socioeconomic inequalities in smoking cessation have led to development of interventions that are specifically tailored for smokers from disadvantaged groups. We aimed to assess whether the effectiveness of interventions for disadvantaged groups is moderated by tailoring for socioeconomic position.

METHODS

For this systematic review and meta-regression, we searched MEDLINE, PsycINFO, Embase, Cochrane Central Register, and Tobacco Addiction Register of Clinical Trials and the IC-SMOKE database from their inception until Aug 18, 2019, for randomised controlled trials of socioeconomic-position-tailored or non-socioeconomic-position-tailored individual-level behavioural interventions for smoking cessation at 6 months or longer of follow-up in disadvantaged groups. Studies measured socioeconomic position via income, eligibility for government financial assistance, occupation, and housing. Studies were excluded if they were delivered at the community or population level, did not report differential effects by socioeconomic position, did not report smoking cessation outcomes from 6 months or longer after the start of the intervention, were delivered at a group level, or provided pharmacotherapy with standard behavioural support compared with behavioural support alone. Individual patient-level data were extracted from published reports and from contacting study authors. Random-effects meta-analyses and mixed-effects meta-regression analyses were done to assess associations between tailoring of the intervention and effectiveness. Meta-analysis outcomes were summarised as risk ratios (RR). Certainty of evidence was assessed within each study using the Cochrane risk-of-bias tool version 2 and the grading of recommendations assessment, development, and evaluation approach. The study is registered with PROSPERO, CRD42018103008.

FINDINGS

Of 2376 studies identified by our literature search, 348 full-text articles were retrieved and screened for eligibility. Of these, 42 studies (26 168 participants) were included in the systematic review. 30 (71%) of 42 studies were done in the USA, three (7%) were done in the UK, two (5%) each in the Netherlands and Australia, and one (2%) each in Switzerland, Sweden, Turkey, India, and China. 26 (62%) of 42 studies were trials of socioeconomic-position-tailored interventions and 16 (38%) were non-socioeconomic-position-tailored interventions. 17 (65%) of 26 socioeconomic-position-tailored interventions were in-person or telephone-delivered behavioural interventions, four (15%) were digital interventions, three (12%) involved financial incentives, and two (8%) were brief interventions. Individuals who participated in an intervention, irrespective of tailoring, were significantly more likely to quit smoking than were control participants (RR 1·56, 95% CI 1·39-1·75; I2=54·5%). Socioeconomic-position-tailored interventions did not yield better outcomes compared with non-socioeconomic-position-tailored interventions for disadvantaged groups (adjusted RR 1·01, 95% CI 0·81-1·27; β=0·011, SE=0·11; p=0·93). We observed similar effect sizes in separate meta-analyses of non-socioeconomic-position-tailored interventions using trial data from participants with high socioeconomic position (RR 2·00, 95% CI 1·36-2·93; I2=82·7%) and participants with low socioeconomic position (1·94, 1·31-2·86; I2=76·6%), although certainty of evidence from these studies was graded as low.

INTERPRETATION

We found evidence that individual-level interventions can assist disadvantaged smokers with quitting, but there were no large moderating effects of tailoring for disadvantaged smokers. Improvements in tailored intervention development might be necessary to achieve equity-positive smoking cessation outcomes.

FUNDING

Cancer Research UK.

Pilot study of a mobile smoking cessation intervention for low-income smokers with serious mental illness

Introduction

People with serious mental illness (SMI) have high rates of smoking and need better access to cessation treatment. Mobile behavioral interventions for cessation have been effective for the general population, but are not usable by many with SMI due to cognitive impairments or severe symptoms. We developed a tailored mobile cessation treatment intervention with features to reduce cognitive load.

Method

We enrolled 20 smokers with SMI and showed them how to use the program on a device of their choice. They were assessed at 8 weeks for intervention use, usability, satisfaction, smoking characteristics, and biologically verified abstinence.

Results

Participants accessed an average of 23.6 intervention sessions (SD = 17.05; range 1–48; median = 17.5) for an average total of 231.64 minutes (SD = 227.13; range 4.89–955.21; median = 158.18). For 87% of the sessions, average satisfaction scores were 3 or greater on a scale of 1–4. Regarding smoking, 25% of participants had reduced their smoking and 10% had biologically verified abstinence from smoking at 8 weeks.

Conclusion

Home and community use of this mobile cessation intervention was feasible among smokers with SMI. Further research is needed to evaluate such scalable approaches to increase access to behavioral treatment for this group.

"Like you are fooling yourself": how the "Stoptober" temporary abstinence campaign supports Dutch smokers attempting to quit

Background

The Stoptober temporary abstinence campaign challenges smokers to engage in a collective quit attempt for 28 days. The campaign is based on social contagion theory, SMART (i.e., Specific, Measurable, Attainable, Realistic and Time-sensitive) goal setting and PRIME (i.e., Plans, Responses, Impulses, Motives and Evaluations) theory. Although Stoptober was found to yield impressive 28-day quit rates, relapse rates remained substantial. Therefore, we examined how Stoptober supported smokers in their attempt to quit and how the campaign’s effectiveness could be strengthened.

Methods

In 2016, we conducted semi-structured interviews with 23 Stoptober participants in the Netherlands. Data were analyzed thematically.

Results

Respondents explained how social contagion-based components had familiarized them with Stoptober, motivated them to participate, and created a pro-smoking cessation social norm. Setting SMART goals was reported as “fooling yourself”, since it distracted respondents from their goal of quitting for good and helped them perceive that temporary abstinence was achievable. Respondents also illustrated the usefulness of PRIME theory. They typically used an individual selection of available supports that varied over time. To achieve long-term abstinence, respondents expressed the need for additional social network support and interactive, personalized and professional support during and after the campaign.

Conclusions

Stoptober supports smokers in their attempts to quit and generally according to the campaign’s theoretical principles. Added to available evidence, this finding supports the continuation and wider implementation of Stoptober, while connecting the campaign to social networks and regular smoking-cessation services to help improve long-term abstinence rates.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6833-y) contains supplementary material, which is available to authorized users.

Potential sources of cessation support for high smoking prevalence groups: a qualitative study

Objective This study aimed to: i) explore potential sources of cessation support as nominated by disadvantaged smokers; and ii) identify factors influencing decisions to use these sources. Methods Semi-structured interviews were conducted with 84 smokers accessing community service organisations from the alcohol and other drugs, homeless, and mental health sectors. Transcripts were coded and thematically analysed. Results Doctors emerged as the most commonly recognised source of cessation support, followed by Quitline, community service organisation staff; and online resources. The main factors contributing to the possible use of these sources of support were identified as awareness, perceived usefulness and anticipated emotional support. Conclusions The results suggest that doctors are an important group to consider when developing cessation interventions for disadvantaged smokers due to their recognised ability to provide practical and emotional support. However, efforts are needed to ensure doctors are aware of the benefits of cessation for these groups. Community service organisations appear to be another potentially effective source of cessation support for disadvantaged smokers. Implications for public health The results indicate that cessation interventions among high-priority groups should endeavour to provide personalised emotional and practical support. Doctors and community service organisation staff appear to be well-placed to deliver this support.

Results from e-KISS: electronic-KIOSK Intervention for Safer Sex: A pilot randomized controlled trial of an interactive computer-based intervention for sexual health in adolescents and young adults

INTRODUCTION

Interactive computer-based interventions (ICBI) are potentially scalable tools for use in real-world settings to promote sexual health and prevent sexually transmitted infections (STIs) and unintended pregnancies. We developed and assessed the feasibility and acceptability of an ICBI for promoting adolescent and young adult sexual health, and the effectiveness of the intervention in reducing unprotected sex, STIs, and unintended pregnancy.

METHODS

This pilot randomized controlled trial enrolled STI Clinic patients, in Seattle, Washington, who were 14-24 years old and reported unprotected vaginal sex during the last 2 months. Both the control and intervention group used a computerized survey to enter their sexual health and only the intervention group received the ICBI. The ICBI included personalized sexual health feedback from a physician avatar; instructive video modules advocating sexual health; and identification of one behavior to change. At 3-month follow-up, participants reported on interim sexual and pregnancy histories and underwent repeat STI testing. We assessed intervention impact on unprotected vaginal sex, number of sexual partners, incident STIs, and unintended pregnancy.

RESULTS

Of 272 participants, 242 (89%) completed the study, of whom 65% were female. While these findings did not reach statistical significance, at 3-month follow-up, the intervention group reported a 33% lower rate of unprotected vaginal sex (no condom use) [IRR = 0.67, 95% CI: 0.44-1.02]; 29% fewer sex partners [IRR = 0.71, 95% CI: 0.50-1.03]; and 48% fewer STIs [IRR = 0.52, 95% CI: 0.25-1.08] when compared to the control group. Similarly, as compared to the control group, intervention females reported a lower rate of unprotected vaginal sex (no birth control) [IRR = 0.80, 95% CI: 0.47-1.35] and half as many unintended pregnancies (n = 5) versus control females (n = 10) [IRR = 0.51, 95% CI: 0.17-1.58]. In exploratory analyses, intervention females reported fewer partners [IRR = 0.71, 95% CI: 0.50-1.00] and a significantly lower rate of vaginal sex without condoms [IRR = 0.50, 95% CI: 0.30-0.85].

CONCLUSION

The intervention was acceptable to both males and females, and at 3-month follow-up, there were non-significant reductions in risk behavior for all outcomes. Among females, exploratory analysis showed a significant reduction in vaginal sex without condoms.

Inferring Smoking Status from User Generated Content in an Online Cessation Community

Introduction

User generated content (UGC) is a valuable but underutilized source of information about individuals who participate in online cessation interventions. This study represents a first effort to passively detect smoking status among members of an online cessation program using UGC.

Methods

Secondary data analysis was performed on data from 826 participants in a web-based smoking cessation randomized trial that included an online community. Domain experts from the online community reviewed each post and comment written by participants and attempted to infer the author's smoking status at the time it was written. Inferences from UGC were validated by comparison with self-reported 30-day point prevalence abstinence (PPA). Following validation, the impact of this method was evaluated across all individuals and time points in the study period.

Results

Of the 826 participants in the analytic sample, 719 had written at least one post from which content inference was possible. Among participants for whom unambiguous smoking status was inferred during the 30 days preceding their 3-month follow-up survey, concordance with self-report was almost perfect (kappa = 0.94). Posts indicating abstinence tended to be written shortly after enrollment (median = 14 days).

Conclusions

Passive inference of smoking status from UGC in online cessation communities is possible and highly reliable for smokers who actively produce content. These results lay the groundwork for further development of observational research tools and intervention innovations.

Implications

A proof-of-concept methodology for inferring smoking status from user generated content in online cessation communities is presented and validated. Content inference of smoking status makes a key cessation variable available for use in observational designs. This method provides a powerful tool for researchers interested in online cessation interventions and establishes a foundation for larger scale application via machine learning.

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.

Conversation Within a Facebook Smoking Cessation Intervention Trial For Young Adults (Tobacco Status Project): Qualitative Analysis

Background

Smoking cessation interventions delivered through social media have the potential to engage young people in behavior change.

Objective

The aim of this study was to describe participant-posted messages in a Facebook smoking cessation intervention for young adults to discern support for behavior change.

Methods

We qualitatively analyzed data from the treatment arm of a randomized trial testing the efficacy of the Tobacco Status Project Facebook intervention. Young adults (N=138) aged 18-25 years (female: 81/138, 58.7%; white: 101/138, 73.2%; mean age 21 years) were recruited using Facebook and placed into one of the 15 secret Facebook groups based on readiness-to-quit smoking. Messages posted to groups for 90 consecutive days were tailored to readiness-to-quit: Not Ready (46/138, 33.3%), Thinking (66/138, 47.8%), and Getting Ready (26/138, 18.8%). Groups were randomized to receive up to US $90 for posting or no incentive. Two independent coders conducted open coding of user posts. We considered content by readiness-to-quit group and incentive condition.

Results

There were 4 dominant themes across all groups: coping skills, friends and family, motivation to quit, and benefits of quitting. The dominant themes in Not Ready groups were friends and family (incentive) and motivation to quit (no incentive), whereas coping skills was the dominant theme in Thinking and Getting Ready groups. The expression of themes varied by readiness-to-quit group but not by incentive condition.

Conclusions

Intervention messages tailored to readiness-to-quit appear useful in eliciting the desired responses from young adult smokers, with limited influence by monetary incentive.

Trial Registration

ClinicalTrials.gov NCT02207036; https://clinicaltrials.gov/ct2/show/NCT02207036 (Archived by WebCite at http://www.webcitation.org/722XAEAAz)

Exploring Online Asynchronous Counseling With Tobacco Treatment Specialists in the QUIT-PRIMO and National Dental PBRN HI-QUIT Studies: Who Uses It and What Do They Say?

PURPOSE

To describe the content of messages sent by smokers through asynchronous counseling within a Web-based smoking cessation intervention.

DESIGN

Qualitative.

SETTING

National community-based setting of patients who had been engaged by the medical or dental practices at which they attended or via Google advertisements.

PARTICIPANTS

Adults older than 19 years who were current smokers and interested in quitting. Participants throughout the United States referred to a Web-based cessation intervention by their medical or dental provider or by clicking on a Google advertisement.

METHODS

We conducted a qualitative review of 742 asynchronous counseling messages sent by 270 Web site users. Messages were reviewed, analyzed, and organized into qualitative themes by the investigative team.

RESULTS

The asynchronous counseling feature of the intervention was used most frequently by smokers who were white (87%), female (67%), aged 45 to 54 (32%), and who had at least some college-level education (70%). Qualitative analysis yielded 7 basic themes-Talk about the Process of Quitting, Barriers to Quitting, Reasons to Quit, Quit History, Support and Strategies for Quitting, Quitting with Medication, and Quit Progress. The most common theme was Support and Strategies for Quitting with 255 references among all messages.

CONCLUSION

We found rich communication across the spectrum of the quit process, from persons preparing to quit to those who had successfully quit. Asynchronous smoking cessation counseling provides a promising means of social support for smokers during the quit process.

Crush the Crave: Development and Formative Evaluation of a Smartphone App for Smoking Cessation

Background

Emerging evidence supports the use of smartphone apps for smoking cessation, especially in young adults given their high smoking rates and high smartphone ownership rates. Although evaluative evidence is encouraging for supporting smoking cessation, there remains a paucity of research describing the design and development processes of mobile health (mHealth) interventions.

Objective

The aim of this paper was to describe the process of developing Crush the Crave (CTC), an evidence-informed app to support smoking cessation in young adults, and the results of a formative evaluation of app usage behavior, as part of a broader program of research that seeks to establish the effectiveness of the CTC app.

Methods

The Spiral Technology Action Research (STAR) 5-cycle model (listen, plan, do, act, and study) was employed to guide the development, implementation, and dissemination of CTC. The approach to development and formative evaluation included focus groups with young adult smokers (n=78) across 2 phases, analysis of the content of existing apps, 2 sessions with content experts, and Google Analytics to assess user behavior during a 12-month pilot.

Results

LISTEN—focus groups revealed young adult smoker preferences of (1) positive reinforcement, (2) personalization, (3) social support, (4) quit support, (5) tracking the behavior, and (6) tracking quit benefits. PLAN—informed by evidence for smoking cessation, young adult preferences and an assessment of popular cessation apps, content experts produced a mind map and a storyboard describing app content and structure. DO—focus groups with young adult smokers provided feedback on the first version of the app with opinions on content and suggestions for improvement such as providing alerts and distractions from craving. ACT—refinements were made, and app content was organized using the 4 key design components informed by principles of persuasive technology for behavior change: credibility, task support, dialogue support, and social support. CTC was launched in April 2013 and piloted from the period July 2013 to June 2014 where 1987 Android users had 18,567 sessions, resulting in 59,384 page views and 89.58% (1780/1987) of users returning within the same day to use CTC. STUDY—a pragmatic randomized controlled trial of CTC was launched in August 2014 to demonstrate that including mHealth technology as a population-based intervention can help young adult smokers to quit. The results of this phase will be presented in a subsequent publication.

Conclusions

CTC is one of the first smoking cessation apps designed to meet the needs of young adult smokers. The development was informed by the inclusion of young adults in the design and the systematic application of multiple stakeholder input, scientific evidence, and theory. The STAR model approach was followed from the beginning of intervention development, which should facilitate optimization of mHealth interventions in the future.

Trial Registration

ClinicalTrials.gov NCT01983150; http://clinicaltrials.gov/ct2/show/NCT01983150 (Archived by WebCite at http://www.webcitation.org/6VGyc0W0i)

Subgroups Among Smokers in Preparation: A Cluster Analysis Using the I-Change Model

BACKGROUND

Investigating potential sub-stages of change could provide important information that could be used to improve the tailoring of smoking cessation interventions to individual smokers' profiles. Smokers in the preparation stage may be most interesting, as they are most likely to participate in smoking cessation interventions.

OBJECTIVE

To examine whether Dutch adult smokers in the preparation stage of change, i.e. motivated to quit smoking within one month, can be organized into subgroups.

METHODS

Data from 753 smokers who participated in an effectiveness trial of a web-based, computer-tailored smoking cessation programme were subjected to secondary analysis. Cluster analyses were based on respondents' baseline responses to items on pros and cons of quitting and quitting self-efficacy. Chi-squared tests and ANOVA were used to compare the baseline characteristics of the resulting clusters. Logistic and multinomial regression were used for longitudinal comparisons of clusters with respect to smoking abstinence and stage transition at six-week and six-month follow-ups.

RESULTS

Four clusters were identified; Classic, Unprepared, Progressing and Disengaged Preparers. Cross-sectional and longitudinal analyses validated these clusters: they differed with respect to the clustering variables, gender, cigarette dependence and educational level. Disengaged Preparers were less likely than Progressing Preparers to report smoking abstinence at six months (OR = 0.28; p < .05).

CONCLUSIONS

These results suggest that smoking cessation interventions tailored to the preparation stage of change, i.e. the set of cognitions usually present in preparers, are only appropriate for the subgroup we defined as Classic Preparers. The other clusters might need different interventions as they display different cognition sets.

The Methodological Quality and Effectiveness of Technology-Based Smoking Cessation Interventions for Disadvantaged Groups: A Systematic Review and Meta-analysis

Aims

To assess the methodological quality and effectiveness of technology-based smoking cessation interventions in disadvantaged groups.

Method

Four databases (EMBASE, Cochrane, Medline, and PsycInfo) were searched for studies conducted from 1980 to May 2016. Randomized controlled trials that compared a behavioral smoking cessation intervention delivered primarily through a technology-based platform (eg, mobile phone) with a no-intervention comparison group among disadvantaged smokers were included. Three reviewers assessed all relevant studies for inclusion, and one reviewer extracted study, participant and intervention-level data, with a subset crosschecked by a second reviewer.

Results

Thirteen studies targeting disadvantaged smokers (n =4820) were included. Only one study scored highly in terms of methodological rigor on EPOC criteria for judging risk of bias. Of the 13 studies using a technology-based platform, most utilized websites (n = 5) or computer programs (n = 5), and seven additionally offered nicotine replacement therapy. Technology-based interventions increased the odds of smoking cessation for disadvantaged groups at 1 month (odds ratio [OR] 1.70, 95% confidence interval [CI] 1.10, 2.63), 3 months (OR 1.30, 95% CI 1.07, 1.59), 6 months (OR 1.29, 95% CI 1.03, 1.62), and 18 months post-intervention (OR 1.83, 95% CI 1.11, 3.01).

Conclusion

Few methodologically rigorous studies were identified. Mobile phone text-messaging, computer- and website-delivered quit support showed promise at increasing quit rates among Indigenous, psychiatric and inpatient substance use disorder patients. Further research is needed to address the role technology-based interventions have on overcoming health inequalities to meet the needs of disadvantaged groups.

Implications

This review provides the first quantitative evidence of the effectiveness of a range of technology-based smoking cessation interventions among disadvantaged smokers, with separate estimates on the basis of intervention type, and cessation outcome measure. Providing cost-effective, easily accessible and real-time smoking cessation treatment is needed, and innovative technology-based platforms will help reach this endpoint. These interventions need to be tested in larger scale randomized controlled trial designs and target broader disadvantaged groups. Data collection beyond 6 months is also needed in order to establish the efficacy of these intervention approaches on long-term cessation rates among disadvantaged population groups.

Brief intervention in substance use disorders

Unhealthy substance use lies on a wide range that extends from occasional mild risky/harmful/hazardous use to severe substance use disorder. Brief intervention (BI) is a technique, used to initiate change for an unhealthy or risky substance use. It can be delivered by a vast array of trained professionals, in opportunistic settings (i.e. in people seeking help not for their substance use, but either its consequences or for completely unrelated physical or psychiatric disorders), and across substances, age and ethno-cultural groups. The six common elements of BIs are summarized by the acronym FRAMES, consisting of Feedback, Responsibility, Advise, Menu for change, Empathy, and enhancing Self-efficacy. BI has also been strategically combined with referral to appropriate treatment services. BI has shown efficacy for reducing substance use and its harmful consequences. The evidence for post-BI improved functionality and quality of life are also emerging.

Use of digital technology in addiction disorders

The expanding use of digital technology in mental health has widened the scope of emerging addiction interventions. This review focus on the use of technological advances in the field of addiction and mental health. We discuss about how these advances has been implemented in addiction treatment and research. Further, we also mention about the utilisation of these services in India.

Baseline Characteristics and Generalizability of Participants in an Internet Smoking Cessation Randomized Trial

BACKGROUND

The potential for sampling bias in Internet smoking cessation studies is widely recognized. However, few studies have explicitly addressed the issue of sample representativeness in the context of an Internet smoking cessation treatment trial.

PURPOSE

The purpose of the present study is to examine the generalizability of participants enrolled in a randomized controlled trial of an Internet smoking cessation intervention using weighted data from the National Health Interview Survey (NHIS).

METHODS

A total of 5290 new users on a smoking cessation website enrolled in the trial between March 2012 and January 2015. Descriptive statistics summarized baseline characteristics of screened and enrolled participants, and multivariate analysis examined predictors of enrollment. Generalizability analyses compared demographic and smoking characteristics of trial participants to current smokers in the 2012-2014 waves of NHIS (n = 19,043) and to an NHIS subgroup based on Internet use and cessation behavior (n = 3664). Effect sizes were obtained to evaluate the magnitude of differences across variables.

RESULTS

Predictors of study enrollment were age, gender, race, education, and motivation to quit. Compared to NHIS smokers, trial participants were more likely to be female, college educated, and daily smokers and to have made a quit attempt in the past year (all effect sizes 0.25-0.60). In comparisons with the NHIS subgroup, differences in gender and education were attenuated, while differences in daily smoking and smoking rate were amplified.

CONCLUSIONS

Few differences emerged between Internet trial participants and nationally representative samples of smokers, and all were in expected directions. This study highlights the importance of assessing generalizability in a focused and specific manner. CLINICALTRIALS.GOV: #NCT01544153.