Use of gamification strategies and tactics in mobile applications for smoking cessation: a review of the UK mobile app market

Conducting a systematic review and evaluation of commercially available mobile applications (apps) on a health-related topic: the TECH approach and a step-by-step methodological guide

OBJECTIVES

To provide an overview of the methodological considerations for conducting commercial smartphone health app reviews (mHealth reviews), with the aim of systematising the process and supporting high-quality evaluations of mHealth apps.

DESIGN

Synthesis of our research team's experiences of conducting and publishing various reviews of mHealth apps available on app stores and hand-searching the top medical informatics journals (eg, The Lancet Digital Health, npj Digital Medicine, Journal of Biomedical Informatics and the Journal of the American Medical Informatics Association) over the last five years (2018-2022) to identify other app reviews to contribute to the discussion of this method and supporting framework for developing a research (review) question and determining the eligibility criteria.

RESULTS

We present seven steps to support rigour in conducting reviews of health apps available on the app market: (1) writing a research question or aims, (2) conducting scoping searches and developing the protocol, (3) determining the eligibility criteria using the TECH framework, (4) conducting the final search and screening of health apps, (5) data extraction, (6) quality, functionality and other assessments and (7) analysis and synthesis of findings. We introduce the novel TECH approach to developing review questions and the eligibility criteria, which considers the Target user, Evaluation focus, Connectedness and the Health domain. Patient and public involvement and engagement opportunities are acknowledged, including co-developing the protocol and undertaking quality or usability assessments.

CONCLUSION

Commercial mHealth app reviews can provide important insights into the health app market, including the availability of apps and their quality and functionality. We have outlined seven key steps for conducting rigorous health app reviews in addition to the TECH acronym, which can support researchers in writing research questions and determining the eligibility criteria. Future work will include a collaborative effort to develop reporting guidelines and a quality appraisal tool to ensure transparency and quality in systematic app reviews.

Usage of digital, social and goal-setting functionalities to support health behavior change: A mixed methods study among disadvantaged women during or after pregnancy and their healthcare professionals

OBJECTIVE

We aimed to gain insight into how and to what extent social (i.e. private/group chat) and goal-setting (e.g. rewards) functionalities in digital interventions for health behavior change were used by clients and nurses in a preventive care program for disadvantaged women during or after pregnancy, and which factors influenced usage.

METHODS

We collected quantitative and qualitative data on usage of these functionalities in 'Kindle', a mHealth intervention to prepare for health behavior change.

RESULTS

We found that nurses (n = 5) and clients (n = 20) scarcely used both functionalities. They sent 862 messages in the social functionality whose security they appreciated, but habitually used WhatsApp likewise. Moreover, nurses were hesitant to let their clients interact in the group chat. Clients formulated 59 personal goals, which they found difficult to do. Nurses rewarded 846 points for clients' progress on goal attainment, but found it hard to determine how many points to reward. Clients and nurses indicated that the functionality made it more fun and easy to discuss clients' personal goals.

CONCLUSIONS

To conclude, digital, social and goal-setting functionalities were used to a limited extent by nurses and clients, and need optimization before implementation to support disadvantaged groups to change their health behavior.

Pilot trial of QuitBet: A digital social game that pays you to stop smoking

Contingency management is an effective treatment for cigarette smoking cessation but feasibility and acceptability concerns have been barriers to implementation. We conducted a pilot test of QuitBet, a commercial, digital (smartphone) social game for smoking cessation during which participants earned financial incentives for abstinence. QuitBet included a social feed for posting messages and entirely participant-funded incentives in the form of a deposit contract (the "bet"). QuitBet had a bet of $30 and lasted for 28 days. After a week to prepare for quitting, the quit day was Day 8. Between Day 9-28 (a 20-day period), participants earned back $1 of their $30 bet for each day of carbon monoxide (CO)-verified abstinence (≤ 6 ppm). Remaining bet money was pooled into a "grand prize" pot. Participants who were abstinent on at least 19 of the 20 days (1 "lapse" day allowed) were declared "winners" and split the grand prize pot equally. A game host posted a daily message containing evidence-based education about smoking cessation or a discussion topic. Recruitment goals were met. Among the players (N = 50 U.S. adults, 78% female), 17 (34%) were winners. Thirty-seven participants (74%) responded to a post-QuitBet survey, of whom 95% said they would be interested in playing another QuitBet and would recommend QuitBet to others. Overall, feedback was positive with some suggestions for improvement. In conclusion, a digital social game for smoking cessation with a deposit contract was feasible and acceptable. Next steps include conducting a randomized trial to establish efficacy and a sustainable business model. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Identification of smoking cessation phenotypes as a basis for individualized counseling: An explorative real-world cohort study

INTRODUCTION

The rate of relapse in smokers attempting to quit is generally high. In order to maximize the chances of success, it is of interest to better understand the dynamic of lapse and relapse during smoking cessation. We hypothesized that specific behavioral patterns in tobacco consumption could predict the probability of quitting success and could open the possibility for a more targeted approach. The aim of the current study was to characterize clusters of quitting trajectories among participants involved in a smoking cessation program.

METHODS

In a retrospective real-world cohort study, data from 843 consecutive participants between March 2012 and December 2014 were collected. Data consisted of baseline information on demographics, smoking history and dependence level, as well as longitudinal data about tobacco consumption. The correlations among time series were characterized using principal coordinates analysis. Clusters were identified using k-means clustering and the average profile associated with each cluster was computed. The association between the participant’s baseline characteristics and clusters of tobacco consumption was assessed.

RESULTS

Four distinct clusters of transition phenotypes were identified based on tobacco consumption during the cessation phase: the long-term quitters (30%), the persistent smokers/reducers (44%), the short-term returners (16%) and the repeated try and failers (10%). Significant between-cluster differences were found in terms of baseline characteristics and smoking behavior during follow-up.

CONCLUSIONS

Meaningful clusters of quitting trajectories could be identified. Such specific behavioral patterns were useful for the application of personalized assistance needed to achieve successful and long-term cessation.

Exploring Users’ Experiences With a Quick-Response Chatbot Within a Popular Smoking Cessation Smartphone App: Semistructured Interview Study

Background

Engagement with smartphone apps for smoking cessation tends to be low. Chatbots (ie, software that enables conversations with users) offer a promising means of increasing engagement.

Objective

We aimed to explore smokers’ experiences with a quick-response chatbot (Quit Coach) implemented within a popular smoking cessation app and identify factors that influence users’ engagement with Quit Coach.

Methods

In-depth, one-to-one, semistructured qualitative interviews were conducted with adult, past-year smokers who had voluntarily used Quit Coach in a recent smoking cessation attempt (5/14, 36%) and current smokers who agreed to download and use Quit Coach for a minimum of 2 weeks to support a new cessation attempt (9/14, 64%). Verbal reports were audio recorded, transcribed verbatim, and analyzed within a constructivist theoretical framework using inductive thematic analysis.

Results

A total of 3 high-order themes were generated to capture users’ experiences and engagement with Quit Coach: anthropomorphism of and accountability to Quit Coach (ie, users ascribing human-like characteristics and thoughts to the chatbot, which helped foster a sense of accountability to it), Quit Coach’s interaction style and format (eg, positive and motivational tone of voice and quick and easy-to-complete check-ins), and users’ perceived need for support (ie, chatbot engagement was motivated by seeking distraction from cravings or support to maintain motivation to stay quit).

Conclusions

Anthropomorphism of a quick-response chatbot implemented within a popular smoking cessation app appeared to be enabled by its interaction style and format and users’ perceived need for support, which may have given rise to feelings of accountability and increased engagement.

MCMTC: A Pragmatic Framework for Selecting an Experimental Design to Inform the Development of Digital Interventions

Advances in digital technologies have created unprecedented opportunities to deliver effective and scalable behavior change interventions. Many digital interventions include multiple components, namely several aspects of the intervention that can be differentiated for systematic investigation. Various types of experimental approaches have been developed in recent years to enable researchers to obtain the empirical evidence necessary for the development of effective multiple-component interventions. These include factorial designs, Sequential Multiple Assignment Randomized Trials (SMARTs), and Micro-Randomized Trials (MRTs). An important challenge facing researchers concerns selecting the right type of design to match their scientific questions. Here, we propose MCMTC – a pragmatic framework that can be used to guide investigators interested in developing digital interventions in deciding which experimental approach to select. This framework includes five questions that investigators are encouraged to answer in the process of selecting the most suitable design: (1) Multiple-component intervention: Is the goal to develop an intervention that includes multiple components; (2) Component selection: Are there open scientific questions about the selection of specific components for inclusion in the intervention; (3) More than a single component: Are there open scientific questions about the inclusion of more than a single component in the intervention; (4) Timing: Are there open scientific questions about the timing of component delivery, that is when to deliver specific components; and (5) Change: Are the components in question designed to address conditions that change relatively slowly (e.g., over months or weeks) or rapidly (e.g., every day, hours, minutes). Throughout we use examples of tobacco cessation digital interventions to illustrate the process of selecting a design by answering these questions. For simplicity we focus exclusively on four experimental approaches—standard two- or multi-arm randomized trials, classic factorial designs, SMARTs, and MRTs—acknowledging that the array of possible experimental approaches for developing digital interventions is not limited to these designs.

Mobile Health for Smoking Cessation Among Disadvantaged Young Women During and After Pregnancy: User-Centered Design and Usability Study

Background

Smoking prevalence during and after pregnancy remains high among socioeconomically disadvantaged women. Mobile health (mHealth) apps with game and social support elements seem promising to support smoking cessation.

Objective

This study aims to describe the user-centered design and usability evaluation of Kindle, an mHealth app with game and social support elements, to support disadvantaged young women during and after pregnancy through the first stages of smoking cessation.

Methods

Disadvantaged women (n=9), members of their social networks (n=4), and nurses supporting these women (n=51) were informants throughout the iterative prototype development of Kindle according to the International Organization for Standardization 9241-11:2018. Specific phases included understanding the context of use through secondary analysis of qualitative interview data (phase 1), establishing the user and organizational requirements (phase 2), production of design solutions (phase 3), and usability inspection of the prototype through a heuristic evaluation (3 experts) along with user testing by a think aloud method (5 disadvantaged women and 5 nurses; phase 4). Usability problems were categorized according to the principles of the Healthcare Information and Management Systems Society.

Results

Phase 1 resulted in an understanding of the VoorZorg program and the needs of VoorZorg nurses and clients (eg, focus on early stages of change and building new supportive networks to aid clients in smoking cessation). In phase 2, we established requirements (n=22; eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring at early stages of change in smoking cessation). Phase 3 resulted in a prototype of Kindle, combining the interface for nurses and clients, including the following functionalities: personal goal setting with earning points; secured chat function between nurses and other clients; and tips, diary, and profile creation. The heuristic evaluation and thinking aloud method in phase 4 revealed 78 usability problems in the interfaces. Most usability problems concerned simplicity (eg, unclear clickable button) and naturalness (eg, unclear icon).

Conclusions

The user-centered design and usability testing of the mHealth app Kindle yielded useful insights. The involvement of end users, specifically socioeconomically disadvantaged women during and after their pregnancy, resulted in a prototype that met their needs and requirements (eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring to the early stages of change in smoking cessation) to achieve readiness for smoking cessation. Moreover, the usability evaluation by end users and experts revealed unique usability problems for this population. These insights allow for further optimization of Kindle and encourage future studies to engage disadvantaged populations in all phases of mHealth intervention design and usability testing.

Supportive Accountability and Mobile App Use in a Tobacco Control Intervention Targeting Low-Income Minority Mothers Who Smoke: Observational Study

BACKGROUND

Smartphone mobile apps are frequently used in standalone or multimodal smoking cessation interventions. However, factors that impede or improve app usage are poorly understood.

OBJECTIVE

This study used the supportive accountability model to investigate factors that influence app usage in the context of a trial designed to reduce maternal smoking in low-income and predominantly minority communities.

METHODS

We conducted a secondary analysis of data (N=181) from a randomized controlled trial that included a smoking cessation app (QuitPal-m). Supportive accountability was measured by the number of times a participant was advised by their cessation counselor to use QuitPal-m. Participants reported app use helpfulness and barriers. Investigators tracked reported phone and technical problems that impeded app use.

RESULTS

Most participants rated the app as very helpful (103/155, 66.5%), but daily use declined rapidly over time. App use was positively related to the level of perceived app helpfulness (P=.02) and education (P=.002) and inversely related to perceived barriers (P=.003), phone technical problems (P<.001), and cigarettes smoked per day at the end of treatment (P<.001). Participants used the app a greater proportion of the days following app advice than those preceding app advice (0.45 versus 0.34; P<.001). The positive relation between counselor app advice and app usage 24 hours after receiving advice was stronger among smokers with no plan to quit than in those planning to quit (P=.03), independent of education and phone or app problems.

CONCLUSIONS

Findings show the utility of supportive accountability for increasing smoking cessation app use in a predominantly low-income, minority population, particularly if quit motivation is low. Results also highlight the importance of addressing personal and phone/technical barriers in addition to adding supportive accountability.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02602288; https://clinicaltrials.gov/ct2/show/NCT02602288.

Impact of Gamification on the Self-Efficacy and Motivation to Quit of Smokers: Observational Study of Two Gamified Smoking Cessation Mobile Apps

Background

The proportion of smokers making quit attempts and the proportion of smokers successfully quitting have been decreasing over the past few years. Previous studies have shown that smokers with high self-efficacy and motivation to quit have an increased likelihood of quitting and staying quit. Consequently, further research on strategies that can improve the self-efficacy and motivation of smokers seeking to quit could lead to substantially higher cessation rates. Some studies have found that gamification can positively impact the cognitive components of behavioral change, including self-efficacy and motivation. However, the impact of gamification in the context of smoking cessation and mobile health has been sparsely investigated.

Objective

This study aims to examine the association between perceived usefulness, perceived ease of use, and frequency of use of gamification features embedded in smoking cessation apps on self-efficacy and motivation to quit smoking.

Methods

Participants were assigned to use 1 of the 2 mobile apps for a duration of 4 weeks. App-based questionnaires were provided to participants before app use and 2 weeks and 4 weeks after they started using the app. Gamification was quantitatively operationalized based on the Cugelman gamification framework and concepts from the technology acceptance model. The mean values of perceived frequency, ease of use, and usefulness of gamification features were calculated at midstudy and end-study. Two linear regression models were used to investigate the impact of gamification on self-efficacy and motivation to quit.

Results

A total of 116 participants completed the study. The mean self-efficacy increased from 37.38 (SD 13.3) to 42.47 (SD 11.5) points and motivation to quit increased from 5.94 (SD 1.4) to 6.32 (SD 1.7) points after app use. Goal setting was perceived to be the most useful gamification feature, whereas sharing was perceived to be the least useful. Participants self-reported that they used the progress dashboards the most often, whereas they used the sharing feature the least often. The average perceived frequency of gamification features was statistically significantly associated with change in self-efficacy (β=3.35; 95% CI 0.31-6.40) and change in motivation to quit (β=.54; 95% CI 0.15-0.94) between baseline and end-study.

Conclusions

Gamification embedded in mobile apps can have positive effects on self-efficacy and motivation to quit smoking. The findings of this study can provide important insights for tobacco control policy makers, mobile app developers, and smokers seeking to quit.

Efficacy of tailored recommendations to promote healthy lifestyles: a post hoc analysis of a randomized controlled trial

Prevention is the key to stopping the ravages of cardiovascular diseases, the main cause of death worldwide. The objective was to analyze the efficacy of tailored recommendations to promote healthy lifestyles. Parallel-arm randomized controlled trial with 1 year follow-up. Individuals aged 35-74 years from Girona (Spain) randomly selected from a population with no cardiovascular diseases at baseline were included. Participants in the intervention group received a brochure with tailored healthy choices according to the individual risk profile and a trained nurse explained all recommendations in detail in a 30 min consultation. One year changes in smoking, Mediterranean diet adherence, physical activity, and weight were analyzed with McNemar, Student's t, Wilcoxon, and Fisher exact tests according to an intention-to-treat strategy. Of 955 individuals (52.3% women; mean age 50 [±10] years) randomly allocated to the intervention or control group, one participant in each group presented a cardiovascular event and 768 (81%) were reexamined at 1 year follow-up. The prevalence of nonsmokers increased in both the intervention and control groups (78.1%-82.5%, p = <.001, and 76.7% to 78.8%, p = .015, respectively); however, significance persisted only in the intervention group when stratified by sex, age group, and educational level. Adherence to a Mediterranean diet increased in the intervention group (22.3%-26.5%, p = .048). In conclusion, a brief personalized intervention with science-based recommendations according to individual risk profiles appears to improve healthy lifestyles, particularly nonsmoking and adherence to a Mediterranean diet. This promising intervention system offers evidence-based recommendations to develop healthy lifestyles.

Use of mHealth Technology for Patient-Reported Outcomes in Community-Dwelling Adults with Acquired Brain Injuries: A Scoping Review

The purpose of our scoping review was to describe the current use of mHealth technology for long-term assessment of patient-reported outcomes in community-dwelling individuals with acquired brain injury (ABI). Following PRISMA guidelines, we conducted a scoping review of literature meeting these criteria: (1) civilians or military veterans, all ages; (2) self-reported or caregiver-reported outcomes assessed via mobile device in the community (not exclusively clinic/hospital); (3) published in English; (4) published in 2015-2019. We searched Ovid MEDLINE(R) < 1946 to 16 August 2019, MEDLINE InProcess, EPub, Embase, and PsycINFO databases for articles. Thirteen manuscripts representing 12 distinct studies were organized by type of ABI [traumatic brain injury (TBI) and stroke] to extract outcomes, mHealth technology used, design, and inclusion of ecological momentary assessment (EMA). Outcomes included post-concussive, depressive, and affective symptoms, fatigue, daily activities, stroke risk factors, and cognitive exertion. Overall, collecting patient-reported outcomes via mHealth was feasible and acceptable in the chronic ABI population. Studies consistently showed advantage for using EMA despite variability in EMA timing/schedules. To ensure best clinical measurement, research on post-ABI outcomes should consider EMA designs (versus single time-point assessments) that provide the best timing schedules for their respective aims and outcomes and that leverage mHealth for data collection.

Vaping-Related Mobile Apps Available in the Google Play Store After the Apple Ban: Content Review

BACKGROUND

In response to health concerns about vaping devices (eg, youth nicotine use, lung injury), Apple removed 181 previously approved vaping-related apps from the App Store in November 2019. This policy change may lessen youth exposure to content that glamorizes vaping; however, it may also block important sources of information and vaping device control for adults seeking to use vaping devices safely.

OBJECTIVE

Understanding the types of nicotine and cannabis vaping-related apps still available in the competing Google Play Store can shed light on how digital apps may reflect information available to consumers.

METHODS

In December 2019, we searched the Google Play Store for vaping-related apps using the keywords "vape" and "vaping" and reviewed the first 100 apps presented in the results. We reviewed app titles, descriptions, screenshots, and metadata to categorize the intended substance (nicotine or cannabis/tetrahydrocannabinol) and the app's purpose. The most installed apps in each purpose category were downloaded and evaluated for quality and usability with the Mobile App Rating Scale.

RESULTS

Of the first 100 apps, 79 were related to vaping. Of these 79 apps, 43 (54%) were specific to nicotine, 3 (4%) were specific to cannabis, 1 (1%) was intended for either, and for the remaining 31 (39%), the intended substance was unclear. The most common purposes of the apps were making do-it-yourself e-liquids (28/79, 35%) or coils (25/79, 32%), games/entertainment (19/79, 24%), social networking (16/79, 20%), and shopping for vaping products (15/79, 19%). Of the 79 apps, at least 4 apps (5%) paired with vaping devices to control temperature or dose settings, 8 apps (10%) claimed to help people quit smoking using vaping, and 2 apps (3%) had the goal of helping people quit vaping.

CONCLUSIONS

The majority of vaping-related apps in the Google Play Store had features either to help users continue vaping, such as information for modifying devices, or to maintain interest in vaping. Few apps were for controlling device settings or assisting with quitting smoking or vaping. Assuming that these Google Play Store apps were similar in content to the Apple App Store apps that were removed, it appears that Apple's ban would have a minimal effect on people who vape with the intention of quitting smoking or who are seeking information about safer vaping via mobile apps.

Incentivizing physical activity through activity monitoring interventions in PAD - a pilot study

Background: There is ample evidence to show that supervised exercise is efficacious and cost effective for improving claudication symptoms in patients with peripheral artery disease (PAD). Home based exercise therapy can be an effective alternative to supervised exercise however, the results of this is variable depending on the level of motivation and engagement of the patient. Patients and methods: We performed a pilot study in 41 patients to determine whether a home based exercise program with the use of an activity tracking device with personalized feedback and financial incentives can increase daily activity, improve walking and sustain engagement in the exercise regimen in patients with PAD. In this randomized pilot study, the patients in the study group were fitted with an activity monitoring device and given behavioral monitoring, motivational updates and feedback regarding their exercise program. This study group was further divided in to two groups. One half of these patients in the study group were also given financial incentives if they reached their set targets. The control group wore the device with no feedback or ability to see their number of steps walked. Results: Results showed that at the end of the 12 week period, patients in the study groups walked more compared to the controls and the financial incentive structure resulted in an additional 38-63% increase in average daily steps. Conclusions: This pilot study revealed that a home-based exercise program with activity monitoring, feedback and financial incentives resulted increased daily steps, 6-minute walking distance and overall compliance with the program in PAD patients with claudication.