Who Uses Smoking Cessation Apps? A Feasibility Study Across Three Countries via Smartphones

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

Background

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

Objective

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

Design

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

Setting

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

Participants

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

Interventions

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

Main outcome measures

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

Results

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

Limitations

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

Conclusions

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

Future work

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

Trial registration

This trial is registered as ISRCTN12326962.

Funding

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

The Impact of Digital Health on Smoking Cessation

BACKGROUND

Smartphones have become useful tools for medicine, with the use of specific apps making it possible to bring health care closer to inaccessible areas, continuously monitor a patient's pathology at any time and place, promote healthy habits, and ultimately improve patients' quality of life and the efficiency of the health care system. Since 2020, the use of smartphones has reached unprecedented levels. There are more than 350,000 health apps, according to a 2021 IQVIA Institute report, that address, among other things, the management of patient appointments; communication among different services or professionals; the promotion of lifestyle changes related to adopting healthy habits; and the monitoring of different pathologies and chronic conditions, including smoking cessation. The number of mobile apps for quitting smoking is high. As early as 2017, a total of 177 unique smoking cessation-relevant apps were identified in the iPhone App Store, 139 were identified in Google Play, 70 were identified in the BlackBerry app store, and 55 were identified in the Windows Phone Store, but very few have adequate scientific support. It seems clear that efforts are needed to assess the quality of these apps, as well as their effectiveness in different population groups, to have tools that offer added value to standard practices.

OBJECTIVE

This viewpoint aims to highlight the benefits of mobile health (mHealth) and its potential as an adjuvant tool in health care.

METHODS

A review of literature and other data sources was performed in order to show the current status of mobile apps that can offer support for smoking cessation. For this purpose, the PubMed, Embase, and Cochrane databases were explored between May and November 2022.

RESULTS

In terms of smoking cessation, mHealth has become a powerful coadjuvant tool that allows health workers to perform exhaustive follow-ups for the process of quitting tobacco and provide support anytime and anywhere. mHealth tools are effective for different groups of smokers (eg, pregnant women, patients with chronic obstructive pulmonary disease, patients with mental illness, and the general population) and are cost-effective, generating savings for the health system. However, there are some patient characteristics that can predict the success of using mobile apps in the smoking cessation process, such as the lower age of patients, dependence on tobacco, the number of quit attempts, and the previous use of mobile apps, among others. Therefore, it is preferable to offer these tools to patients with a higher probability of quitting tobacco.

CONCLUSIONS

mHealth is a promising tool for helping smokers in the smoking cessation process. There is a need for well-designed clinical studies and economic evaluations to jointly assess the effectiveness of new interventions in different population groups, as well as their impact on health care resources.

Feasibility of tobacco cessation intervention at non-communicable diseases clinics: A qualitative study from a North Indian State

BACKGROUND

One of the 'best buys' for preventing Non-Communicable Diseases (NCDs) is to reduce tobacco use. The synergy scenario of NCDs with tobacco use necessitates converging interventions under two vertical programs to address co-morbidities and other collateral benefits. The current study was undertaken with an objective to ascertain the feasibility of integrating a tobacco cessation package into NCD clinics, especially from the perspective of healthcare providers, along with potential drivers and barriers impacting its implementation.

METHODS

A disease-specific, patient-centric, and culturally-sensitive tobacco cessation intervention package was developed (published elsewhere) for the Health Care Providers (HCPs) and patients attending the NCD clinics of Punjab, India. The HCPs received training on how to deliver the package. Between January to April 2020, we conducted a total of 45 in-depth interviews [medical officers (n = 12), counselors (n = 13), program officers (n = 10), and nurses (n = 10)] within the trained cohort across various districts of Punjab until no new information emerged. The interview data wereanalyzed deductively based on six focus areas concerning feasibility studies (acceptability, demand, adaptation, practicality, implementation, and integration) using the 7- step Framework method of qualitative analysis and put under preset themes.

RESULTS

The respondent's Mean ± SD age was 39.2± 9.2 years, and years of service in the current position were 5.5 ± 3.7 years. The study participants emphasized the role of HCPs in cessation support (theme: appropriateness and suitability), use of motivational interviewing, 5A's & 5R's protocol learned during the training & tailoring the cessation advice (theme: actual use of intervention activities); preferred face-to-face counseling using regional images, metaphors, language, case vignettes in package (theme: the extent of delivery to intended participants). Besides, they also highlighted various roadblocks and facilitators during implementation at four levels, viz. HCP, facility, patient, and community (theme: barriers and favorable factors); suggested various adaptations to keep the HCPs motivated along with the development of integrated standard operating procedures (SOPs), digitalization of the intervention package, involvement of grassroots level workers (theme: modifications required); the establishment of an inter-programmatic referral system, and a strong politico-administrative commitment (theme: integrational perspectives).

CONCLUSION

The findings suggest that implementing a tobacco cessation intervention package through the existing NCD clinics is feasible, and it forges synergies to obtain mutual benefits. Therefore, an integrated approach at the primary & secondary levels needs to be adopted to strengthen the existing healthcare systems.

Intention to quit electronic cigarette smoking among university students who are e-cigarette users

OBJECTIVE

To identify factors that are significantly associated with the intention to quit electronic cigarette smoking (ECS) at multiple, ecological levels among university students.

PARTICIPANTS

365 students who were e-cigarette users from Seoul metropolitan areas, South Korea.

METHODS

A cross-sectional study through an online survey.

RESULTS

Of participants, 62.7% had the intention to quit ECS-17.2% within one month, 14.0% within six months, and 31.5% when the time is right. Factors significantly associated with the intention to quit ECS were identified: "device type," "a shorter duration of ECS," and "having started ECS for quitting traditional cigarette smoking" at the intrapersonal-level; "negative attitudes of either peers or family members toward ECS" at the interpersonal-level; and "exposure to community smoking cessation educations" at the community-level.

CONCLUSIONS

Approximately one-thirds of university e-cigarette users had no intention to quit ECS. The factors identified should be integrated into university level, behavioral smoking cessation strategies.

Methods Used in Smoking Cessation and Reduction Attempts: Findings from Help-Seeking Smokers

In addition to traditional smoking cessation methods like nicotine replacement therapy (NRT), new methods such as mobile applications and e-cigarettes have been added to the toolbox. The purpose of this study was to examine which methods smokers currently use in quit or reduction attempts and map characteristics of users of the various methods. In this study, participants were smokers who visited a website or called a quit line for smoking cessation and who were currently in quit or reduction attempts (N = 740). Data were collected in Norway in 2013-2017 through a web survey. Most smokers were currently trying to quit, and the most frequently used methods were a smoking cessation app for mobile phones, nicotine replacement therapies (NRTs), and e-cigarettes. Logistic regression analyses identified older daily smokers with high cigarette consumption as NRT users, while the users of a cessation app were younger females. The use of e-cigarettes was associated with older, low educated smokers with low cigarette consumption. The use of the mobile phone app was associated with having made several recent quit attempts. The study provides insight into help-seeking smokers' preferences for smoking cessation methods and user characteristics. This knowledge is relevant for further work in smoking cessation planning and policies.

Mining Electronic Health Records to Promote the Reach of Digital Interventions for Cancer Prevention Through Proactive Electronic Outreach: Protocol for the Mixed Methods OptiMine Study

BACKGROUND

Digital behavior change interventions have demonstrated effectiveness for smoking cessation and reducing alcohol intake, which ultimately reduce cancer risk. Leveraging electronic health records (EHR) to identify at-risk patients and increasing the reach of digital interventions through proactive electronic outreach provide a novel approach that may increase the number of individuals who engage with evidence-based treatment.

OBJECTIVE

This study aims to increase the reach of digital behavior change interventions by implementing a proactive electronic message system for smoking cessation and alcohol reduction among a large, at-risk population identified through an acute hospital EHR.

METHODS

This protocol describes a 3-phase, mixed-methods implementation study to assess the acceptability, feasibility, and reach of a proactive electronic message system to digital interventions using a hospital's EHR system to identify eligible patients. In Phase 1, we will conduct focus group discussions with patients and hospital staff to assess the overall acceptability of the electronic message system. In Phase 2, we will conduct a descriptive analysis of the patient population in the hospital EHR regarding target risk behaviors and other person-level characteristics to determine the project's feasibility and potential reach. In Phase 3, we will send proactive messages to patients identified as smokers or risky drinkers. Messages will encourage and provide access to behavior change mobile apps via an embedded link; the primary outcome will be the proportion of participants who click on the link to access information about the apps.

RESULTS

At the time of initial protocol submission, data collection was complete, but analysis had not begun. This study was funded by Cancer Research UK from April 2019 to March 2020. Health Research Authority approval was granted in June 2019.

CONCLUSIONS

Increasing the reach of digital behavior change interventions can improve population health by reducing the burden of preventable death and disease.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/23669.

Design Features for Improving Mobile Health Intervention User Engagement: Systematic Review and Thematic Analysis

Background

Well-designed mobile health (mHealth) interventions support a positive user experience; however, a high rate of disengagement has been reported as a common concern regarding mHealth interventions. To address this issue, it is necessary to summarize the design features that improve user engagement based on research over the past 10 years, during which time the popularity of mHealth interventions has rapidly increased due to the use of smartphones.

Objective

The aim of this review was to answer the question “Which design features improve user engagement with mHealth interventions?” by summarizing published literature with the purpose of guiding the design of future mHealth interventions.

Methods

This review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. Databases, namely, PubMed, Web of Science, Cochrane Library, Ovid EMBASE, and Ovid PsycINFO, were searched for English and Chinese language papers published from January 2009 to June 2019. Thematic analysis was undertaken to assess the design features in eligible studies. The Mixed Methods Appraisal Tool was used to assess study quality.

Results

A total of 35 articles were included. The investigated mHealth interventions were mainly used in unhealthy lifestyle (n=17) and chronic disease (n=10) prevention programs. Mobile phone apps (n=24) were the most common delivery method. Qualitative (n=22) and mixed methods (n=9) designs were widely represented. We identified the following 7 themes that influenced user engagement: personalization (n=29), reinforcement (n=23), communication (n=20), navigation (n=17), credibility (n=16), message presentation (n=16), and interface aesthetics (n=7). A checklist was developed that contained these 7 design features and 29 corresponding specific implementations derived from the studies.

Conclusions

This systematic review and thematic synthesis identified useful design features that make an mHealth intervention more user friendly. We generated a checklist with evidence-based items to enable developers to use our findings easily. Future evaluations should use more robust quantitative approaches to elucidate the relationships between design features and user engagement.

Craving to Quit: A Randomized Controlled Trial of Smartphone App-Based Mindfulness Training for Smoking Cessation

INTRODUCTION

Mindfulness training may reduce smoking rates and lessen the association between craving and smoking. This trial tested the efficacy of mindfulness training via smartphone app to reduce smoking. Experience sampling (ES) was used to measure real-time craving, smoking, and mindfulness.

METHODS

A researcher-blind, parallel randomized controlled trial compared the efficacy of mobile mindfulness training with experience sampling (MMT-ES; Craving to Quit) versus experience sampling only (ES) to (1) increase 1-week point-prevalence abstinence rates at 6 months, and (2) lessen the association between craving and smoking. A modified intent-to-treat approach was used for treatment starters (MMT-ES n = 143; ES n = 182; 72% female, 81% white, age 41 ± 12 year).

RESULTS

No group difference was found in smoking abstinence at 6 months (overall, 11.1%; MMT-ES, 9.8%; ES, 12.1%; χ2(1) = 0.43, p = .51). From baseline to 6 months, both groups showed a reduction in cigarettes per day (p < .0001), craving strength (p < .0001) and frequency (p < .0001), and an increase in mindfulness (p < .05). Using ES data, a craving by group interaction was observed (F(1,3785) = 3.71, p = .05) driven by a stronger positive association between craving and cigarettes per day for ES (t = 4.96, p < .0001) versus MMT-ES (t = 2.03, p = .04). Within MMT-ES, the relationship between craving and cigarettes per day decreased as treatment completion increased (F(1,104) = 4.44, p = .04).

CONCLUSIONS

Although mindfulness training via smartphone app did not lead to reduced smoking rates compared with control, our findings provide preliminary evidence that mindfulness training via smartphone app may help lessen the association between craving and smoking, an effect that may be meaningful to support quitting in the longer term.

IMPLICATIONS

This is the first reported full-scale randomized controlled trial of any smartphone app for smoking cessation. Findings provide preliminary evidence that smartphone app-based MMT-ES may lessen the association between craving and smoking.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02134509.

Perceived usefulness of receiving a potential smoking cessation intervention via mobile phones among smokers in Indonesia

Background: The use of technology to support healthcare in Indonesia holds new promise in light of decreasing costs of owning mobile devices and ease of access to internet. However, it is necessary to assess end-user perceptions regarding mobile health interventions prior to its implementation. This would throw light on the acceptability of mobile phone communication in bringing about behavioral changes among the target Indonesian population. The aim of this study was to explore the perceived usefulness of receiving a potential smoking cessation intervention via mobile phones. Methods: This is an exploratory cross-sectional study involving current and former adult tobacco smokers residing in Indonesia. Online advertisement and snowballing were used to recruit respondents. Data was collected using a web-based survey over a period of 4 weeks. Those willing to participate signed an online consent and were subsequently directed to the online questionnaire that obtained demographics, tobacco usage patterns, perceived usefulness of a mobile phone smoking cessation application and its design. Results: A total of 161 people who smoked tobacco responded to the online survey. The mean age of the participants was 29.4. Of the 123 respondents, 102 were men. Prior experience with using a mobile phone for health communication (OR 3.6, P=0.014) and those willing to quit smoking (OR 5.1, P=0.043) were likely to perceive a mobile phone smoking cessation intervention as useful. A smartphone application was preferred over text messages, media messages or interactive voice response technology. Content consisting of motivational messages highlighting the methods and benefits of quitting smoking were requested. Conclusion: People who smoke in Indonesia perceived receiving a potential smoking cessation intervention via mobile phones as useful. A multi-component, personalized smartphone application was the desired intervention technique. Such an intervention developed and implemented within a public health program could help address the tobacco epidemic in Indonesia.

Comparing a Social and Communication App, Telephone Intervention, and Usual Care for Diabetes Self-Management: 3-Arm Quasiexperimental Evaluation Study

Background

Many technology-assisted innovations have been used to manage disease. However, most of these innovations are not broadly used by older adults due to their cost. Additionally, disease management through technology-assisted innovations has not been compared with other interventions.

Objective

In this study, we tested the employment of a free and widely used social and communication app to help older adults with diabetes manage their distress and glycemic control. We also compared the effectiveness of the app with 2 other methods, namely telephone and conventional health education, and determined which subgroup experiences the most effects within each intervention.

Methods

Adults aged ≥50 years with type 2 diabetes were recruited from Southern Taiwan (N=231) and were allocated to different 3-month interventions. Informed consent was obtained at the Ministry of Science and Technology and approved by the National Cheng Kung University Hospital Institutional Review Board (No. A-ER-102-425).

Results

Participants in the mobile-based group had significant reductions in hemoglobin A1c compared with the telephone-based and usual care groups (mean changes of –0.4%, 0.1%, and 0.03%, respectively; P=.02). Diabetes-specific distress decreased to a greater extent in the mobile-based group compared to the other 2 groups (mean changes of –5.16, –3.49, and –2.44, respectively, P=.02). Subgroup analyses further revealed that the effects on reducing blood glucose levels in the social and communication app groups were especially evident in patients with lower distress scores, and diabetes-related distress was especially evident in participants who were younger than 60 years or had higher educational levels.

Conclusions

The findings of this study inform more flexible use of social and communication apps with in-person diabetes education and counselling.

Educating school students and gauging their perception about the harmful effects of smoking using a "Facial-Ageing App (mobile application):" An experience from Malaysia

INTRODUCTION

Smoking is one of the leading factors of mortality in Malaysia. Most youngsters start at adolescence, fascinated by the concept of smoking. Interventions that harness the broad availability of mobile phones, as well as adolescents' interest in their appearance, may be an innovative way to advance school-based prevention. This study aims to determine the perceptions of facial-aging apps among secondary school students.

METHODOLOGY

For this research, descriptive cross-sectional study using simple random sampling method was used. Population sampling was targeted toward three government schools. The total number of respondents is 383, with all of them aged between 13 and- 16 years of age. Legal considerations were taken to maintain the confidentiality of respondents. The specific objectives are: 1. To determine the level of change of intention on smoking, 2. To know the perceived reactions of the peer groups on the appearances of students as nonsmokers, 3. To determine whether the students learned new benefits of nonsmokingand, 4. To measure the impact of a facial-aging app among students.

RESULTS

The number of respondents who smoke was 40 (10.4%), while the number of respondents who do not smoke was 343 (89.6%). About 89% of the respondents agree that their three-dimensional selfie image motivates them not to smoke. In addition, 87.8% of respondents admit that the perceived reactions of their classmates make them think that they look better as nonsmokers. After learning the effects of smoking, about 86.4% of the respondents acknowledged that they would educate their peer groups. Furthermore, 85.9% of the respondents found this "Smokerface" app enjoyable.

CONCLUSION

The facial-aging intervention was effective in motivating Malaysian pupils to stay away from tobacco use. Thus, the analysis on the study of facial app usage in smoking prevention among youngsters concludes that most of the adolescents concur that the "Smokerface" app helps in the prevention of smoking among youths.

Perceived usefulness of receiving a potential smoking cessation intervention via mobile phones among smokers in Indonesia

Background: The use of technology to support healthcare in Indonesia holds new promise in light of decreasing costs of owning mobile devices and ease of access to internet. However, it is necessary to assess end-user perceptions regarding mobile health interventions prior to its implementation. This would throw light on the acceptability of mobile phone communication in bringing about behavioural changes among the target Indonesian population. The aim of this study was to explore the perceived usefulness of receiving a potential smoking cessation intervention via mobile phones. Methods: This is an exploratory cross-sectional study involving current and former adult tobacco smokers residing in Indonesia. Online advertisement and snowballing were used to recruit respondents. Data was collected using a web-based survey over a period of 4 weeks. Those willing to participate signed an online consent and were subsequently directed to the online questionnaire that obtained demographics, tobacco usage patterns, perceived usefulness of a mobile phone smoking cessation application and its design. Results: A total of 161 people who smoked tobacco responded to the online survey. The mean age of the participants was 29.4. Of the 123 respondents, 102 were men. Prior experience with using a mobile phone for health communication (OR 3.6, P=0.014) and those willing to quit smoking (OR 5.1, P=0.043) were likely to perceive a mobile phone smoking cessation intervention as useful. A smartphone application was preferred over text messages, media messages or interactive voice response technology. Content comprising of motivational messages highlighting the methods and benefits of quitting smoking were requested. Conclusion: People who smoke in Indonesia perceived receiving a potential smoking cessation intervention via mobile phones as useful. A multi-component, personalized smartphone application was the desired intervention technique. Such an intervention developed and implemented within a public health program could help address the tobacco epidemic in Indonesia.

Mobile Applications for the Treatment of Tobacco Use and Dependence

PURPOSE OF REVIEW

Smoking remains a leading preventable cause of premature death in the world; thus, developing effective and scalable smoking cessation interventions is crucial. This review uses the Obesity-Related Behavioral Intervention Trials (ORBIT) model for early phase development of behavioral interventions to conceptually organize the state of research of mobile applications (apps) for smoking cessation, briefly highlight their technical and theory-based components, and describe available data on efficacy and effectiveness.

RECENT FINDINGS

Our review suggests that there is a need for more programmatic efforts in the development of mobile applications for smoking cessation, though it is promising that more studies are reporting early phase research such as user-centered design. We identified and described the app features used to implement smoking cessation interventions, and found that the majority of the apps studied used a limited number of mechanisms of intervention delivery, though more effort is needed to link specific app features with clinical outcomes. Similar to earlier reviews, we found that few apps have yet been tested in large well-controlled clinical trials, although progress is being made in reporting transparency with protocol papers and clinical trial registration.

SUMMARY

ORBIT is an effective model to summarize and guide research on smartphone apps for smoking cessation. Continued improvements in early phase research and app design should accelerate the progress of research in mobile apps for smoking cessation.

Connected Health Technology for Cardiovascular Disease Prevention and Management

PURPOSE OF THE REVIEW

Advances in computing power and wireless technologies have reshaped our approach to patient monitoring. Medical grade sensors and apps that were once restricted to hospitals and specialized clinic are now widely available. Here, we review the current evidence supporting the use of connected health technologies for the prevention and management of cardiovascular disease in an effort to highlight gaps and future opportunities for innovation.

RECENT FINDINGS

Initial studies in connected health for cardiovascular disease prevention and management focused primarily on activity tracking and blood pressure monitoring but have since expanded to include a full panoply of novel sensors and pioneering smartphone apps with targeted interventions in diet, lipid management and risk assessment, smoking cessation, cardiac rehabilitation, heart failure, and arrhythmias. While outfitting patients with sensors and devices alone is infrequently a lasting solution, monitoring programs that include personalized insights based on patient-level data are more likely to lead to improved outcomes. Advances in this space have been driven by patients and researchers while healthcare systems remain slow to fully integrate and adequately adapt these new technologies into their workflows. Cardiovascular disease prevention and management continue to be key focus areas for clinicians and researchers in the connected health space. Exciting progress has been made though studies continue to suffer from small sample size and limited follow-up. Efforts that combine home patient monitoring, engagement, and personalized feedback are the most promising. Ultimately, combining patient-level ambulatory sensor data, electronic health records, and genomics using machine learning analytics will bring precision medicine closer to reality.

A content analysis of free smoking cessation mobile applications in the USA

Aims

To evaluate the quality and content of free smoking cessation apps and assess their adherence to the US Public Health Service guideline for treating tobacco use and dependence.

Methods

In total 180 apps were downloaded from the App Store and Google Play Store in January 2018; the top-ranking 30 apps were retrieved for the search terms: ‘smoking cessation’, ‘quit smoking’, ‘stop smoking’. Technical quality was rated using the Mobile Application Rating Scale (MARS) and by assessing other characteristics, behavioral change strategies and adherence to the 5As.

Results/findings

A total 67 free-to-download apps were identified for full review (n = 40 from the Apple App Store and n = 27 from the Google Play Store). The average MARS score was 16.2/19.0: Engagement (3.3/5.0), Functionality (4.4/5.0), Aesthetics (4.0/5.0), and Information (2.6/5.0). Overall, 43 apps allowed sharing, 12 allowed for an app community, and five required a password. The following features were observed: assessment (n = 51), feedback (n = 38), information/education (n = 45), monitoring (n = 52), and goal setting (n = 23). Significant differences were found among apps adhering to the 5As: Ask (n = 44), Advise (n = 54), Assess (n = 30), Assist (n = 62), and Arrange (n = 0).

Conclusions

Given the growth in smoking cessation apps, future efforts should focus on improving their technical quality and adherence to the 5As.

Comparison of Developers' and End-Users' Perspectives About Smoking Cessation Support Through the Crush the Crave App

Background

High smoking rates among end-users, combined with their high rates of app use, render this age group as a particularly captive audience for quit smoking apps. There is emerging evidence that apps are an effective way to support smoking cessation among end-users. How the expectations behind the design of apps align with the needs and preferences of end-users, and if this differs by gender, is poorly understood, limiting the ability to evaluate and scale these interventions.

Objective

The objective of this qualitative case study was to detail how the overall design approach of Crush the Crave (CTC), a quit smoking app that targets end-users, compares with young adult women’s and men’s perspectives and experiences, with consideration for the influence of gender.

Methods

Semistructured interviews were conducted with 15 developers involved in the development of CTC and 31 young adult CTC users. Data were analyzed inductively to derive thematic findings of the perceived pros and cons of CTC by both developers and end-users. Findings were grouped under 4 categories (1) technology and platforms utilized for the app, (2) foundation of app content, (3) underlying focus of the app, and (4) look, feel and functionality of the app.

Results

Under the category, technology and platforms utilized for the app, it was found that both developers and end-users agreed that apps aligned with the needs and preferences of young adult smokers. Major limitations with the technology identified by end-users were the frequent “glitches” and requirement for internet or data. For the category, foundation of app content,developers agreed that the strength of CTC was in its strong evidence-base. What mattered to end-users, however, was that the content was packaged positively, focusing on the benefits of quitting versus the consequences of smoking. It was found under the category, underlying focus of the app, that the individually-led focus of the app resonated with both developers and end-users, especially young men. Under the final category, look, feel and functionality of the app, it was found that developers were very positive about the app's aesthetics but end-users thought that the aesthetics incited a negative effect. Also, while end-users found it easy to use, they did not find the app intuitive. Finally, end-users thought that, because the app functions were largely based on a user’s quit date versus their ongoing efforts, this often lent to unmeaningful data.

Conclusions

The current study findings highlight the importance of understanding multiple perspectives of stakeholders involved in a mobile-based intervention. By gathering the viewpoints of developers and end-users, both problematic and effective approaches that underlie development goals were revealed as a means of informing the development, implementation, and evaluation of future electronic health (eHealth) interventions.

Initial Assessment of a Comprehensive Digital Smoking Cessation Program That Incorporates a Mobile App, Breath Sensor, and Coaching: Cohort Study

BACKGROUND

Cigarette smoking is the leading cause of preventable morbidity and mortality, excess health care expenditure, and lost work productivity. Otherwise effective evidence-based treatments have had limited success owing to challenges with access, engagement, and scale. Pivot is a comprehensive digital smoking cessation program that incorporates a Food and Drug Administration-cleared carbon monoxide breath sensor, smartphone app, and text-based human coaching.

OBJECTIVE

This initial evaluation of Pivot aimed to assess participant engagement, changes in attitudes toward quitting, and changes in smoking behavior.

METHODS

US cigarette smokers aged 18 to 65 years who smoked ≥5 cigarettes per day (CPD) were recruited online. Participants completed a screening call, electronic informed consent, registration, and onboarding before beginning Pivot. Pivot includes 5 sequential stages (Explore, Build, Mobilize, Quit, and Secure), taking 14.5 to 18.5 weeks to complete. Data were collected via app and online questionnaires. Outcomes included engagement and retention (ie, weeks of active engagement and Pivot stage progression); attitudes toward quitting (ie, quit readiness, quit confidence, and expected difficulty maintaining quit); and smoking behavior (ie, quit attempts, cigarette reduction, and abstinence (7- and 30-day point prevalence abstinence [PPA]).

RESULTS

A total of 319 participants completed onboarding (intention-to-treat [ITT] sample); 272/319 participants (85.3%) completed the end-of-Pivot questionnaire (study completer sample). Most (212/319, 66.5%) were not ready to quit in the next 30 days at baseline. On average, participants actively engaged in the program for a mean 12.4 (SD 7.1) weeks. Pivot stage completion rates were Explore: 88.7% (283/319), Build: 57.4% (183/319), Mobilize: 43.6% (139/319), Quit: 41.1% (131/319), and Secure: 39.5% (126/319). Repeated measures linear mixed model analyses demonstrated positive changes in attitudes from baseline to Mobilize (pre-Quit): increased confidence to quit (4.2 to 7.4, P<.001) and decreased expected difficulty maintaining quit (3.1 to 6.8, P<.001). The quit attempt rate (ie, those making ≥1 quit attempt lasting ≥1 day) was 79.4% (216/272, completer). At the end of Pivot, 7-day PPA rates were 32.0% (102/319, ITT) and 37.5% (102/272, completer); 30-day PPA rates were 27.6% (88/319, ITT) and 32.4% (88/272, completer). Moreover, 30-day PPA rates were comparable among those ready and not ready to quit in the next 30 days at baseline. Of those not achieving abstinence, 25.9% (44/170, completer) achieved ≥50% reduction in CPD by study end.

CONCLUSIONS

This study evaluated Pivot's initial performance with comparable quit rates among those ready and not ready to quit in the next 30 days at entry. The present data, considered with the program's accessibility, innovation, evidence-based foundation, and design for all smokers, suggest Pivot has the potential to address limitations of reach and scale and thereby advance smoking cessation efforts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03295643; https://clinicaltrials.gov/ct2/show/NCT03295643 (Archived by WebCite at http://www.webcitation.org/75TiNe6BE).

A Comprehensive Digital Program for Smoking Cessation: Assessing Feasibility in a Single-Group Cohort Study

Background

Cigarette smoking remains the leading cause of preventable death and disease worldwide. Evidence-based approaches are available, but few people access them. Although digital solutions offer great promise for population reach, few multicomponent programs exist. Pivot is a comprehensive digital solution combining a Food and Drug Administration–cleared carbon monoxide (CO) breath sensor; cigarette logging; a 6-phase, app-delivered smoking cessation program based on the US Clinical Practice Guidelines; and dedicated human coaching via text-based chat.

Objective

The purpose of this study was to assess program engagement, changes in attitudes toward smoking, self-reported changes in smoking behavior, and program acceptability for the initial phase of Pivot: Explore.

Methods

A total of 48 participants enrolled, and 41 completed the study. About half the participants (54%, 22/41) were men, and the mean age was 43 years. Most (85%, 35/41) were daily smokers and smoked an average of 12 cigarettes per day. Explore includes CO breath sensing, logging cigarettes in-app, learning via in-app activities, and dedicated human coaching through a text messaging interface. Participants completed surveys at baseline and exit assessing attitudes toward quitting including readiness, perceived difficulty, and confidence in quit success. At exit, participants also completed a survey of changes in smoking behavior and ratings of program acceptability.

Results

More than 80% of participants (34-39 of 41) took ≥1 CO breath sample each day, and more than 55% (23-27 of 41) took ≥5 samples each day. More than 65% of participants (27-34 of 41) logged ≥1 cigarette using the in-app logging feature each day. All 9 in-app activities had completion rates ≥80% (33-40 of 41). Response to coach-initiated outreach was also high, with all contacts receiving ≥73% (30-39 of 41) response. In matched pair analyses, significant positive changes in mean attitudes toward quitting (scale 1-10) were evident from baseline (T1) to study exit (T2), including increased readiness to quit (T1 mean=6.1, T2 mean=7.4, P=.005), lower perceived difficulty (T1 mean=3.7, T2 mean=5.6, P=.001), and greater expectations of success (T1 mean=4.5, T2 mean=6.5, P<.001). At exit, 78% (32/41) of participants reported decreasing the number of cigarettes smoked per day during the study. Participants rated program quality and satisfaction very high (mean ≥8 for all items).

Conclusions

These results support the feasibility and acceptability of the initial 9-day phase of Pivot: Explore. Participants had high levels of engagement with sensing, logging, learning, and coaching. Attitudes toward quitting improved significantly, and the majority of users indicated decreasing smoking behavior. Explore was designed to raise smoker awareness and motivation. Additional research is underway to assess how users progress through the full Pivot smoking cessation program and determine the program’s effectiveness for achieving sustained cessation.

Potential of an Interactive Drug Prevention Mobile Phone App (Once Upon a High): Questionnaire Study Among Students

BACKGROUND

In recent years, drug prevention networks and drug education programs have started using Web-based or mobile phone apps as novel prevention tools, testing their efficacy compared with face-to-face prevention.

OBJECTIVE

The aim of this study was to assess the potential of an interactive app called Once Upon a High (VoltEgySzer).

METHODS

The app approaches drug prevention from 6 different aspects, and it addresses youngsters with 6 different modules: (1) interactive comics/cartoons, telling stories of recovery; (2) quiz game; (3) roleplay game; (4) introduction of psychoactive drugs; (5) information on the somatic and psychological effects of psychoactive substances; (6) list of available treatment units, rehabs, and self-support groups in Hungary. Students of 2 vocational schools and 2 high schools filled out a questionnaire at a baseline (T0) and a 2-month follow-up (T1) data collection session. Students of 1 vocational school and 1 high school downloaded the Once Upon a High app (app group), whereas students from the other vocational school and high school did not (nonapp group). The time points of T0 and T1 questionnaires contained demographic variables, items with regard to substance use characteristics for both legal and illegal substances, including novel psychoactive substance, exercise habits, knowledge about psychoactive substances, attitudes toward substance users and validated instruments measuring the severity of tobacco (Fagerström Test for Nicotine Dependence), alcohol (Alcohol Use Disorder Identification Test), cannabis (Cannabis Abuse Screening Test), and synthetic cannabinoid consumption. Beliefs about substance use (Beliefs About Substance Abuse) and perceived self-efficacy (General Perceived Self-Efficacy) were also measured. At T1, members of the app group provided additional evaluation of the app.

RESULTS

There were 386 students who participated in the T0 session. After dropout, 246 students took part in T1 data collection procedure. Alcohol was the most frequently consumed psychoactive substance (334/364, 91.8% lifetime use), followed by tobacco (252/386, 65.3%, lifetime use) and cannabis (43/323, 13.3% lifetime use). Decreased self-efficacy (beta=-.29, P=.04) and increased daily physical exercise frequencies (beta=.04, P<.001) predicted higher frequencies of past month energy drink consumption, whereas elevated past month alcohol consumption was mainly predicted by a decrease in negative attitudes toward substance users (beta=-.13, P=.04) in the regression models. Once Upon a High was found to be effective only in reducing energy drink consumption (beta=-1.13, P=.04) after controlling for design effect, whereas perceived utility of the app showed correlation with a decreasing alcohol use (rS(44)=.32, P=.03). The roleplay module of the app was found to be the most preferred aspect of the app by the respondents.

CONCLUSIONS

The Once Upon a High app can be a useful tool to assist preventive intervention programs by increasing knowledge and self-efficacy; however, its efficacy in reducing or preventing substance use needs to be improved and further studied. Additional potential impacts of the app need further testing.

Theoretical Advancements in mHealth: A Systematic Review of Mobile Apps

There are now few hundred thousand healthcare apps, yet there is a gap in our understanding of the theoretical mechanisms for which, and how, technological features translate into improved healthcare outcomes. In particular, the technological convergence, within mobile health (mHealth) apps, of the processes of mass and interpersonal communication, and human-computer interaction requires greater parsing in the literature. This paper analyzed 85 empirical studies on mHealth apps using the Input-Mechanism-Output model. We found in the literature that, firstly, there is a greater emphasis on technological inputs (87%) of accessibility, usability, usage, and data quality, than health outputs (52%) such as system process efficiencies and individual level behavioral or health outcomes. Secondly, there is little evidence of explanatory mechanisms (19%) of how the effects of mHealth apps are achieved. While we believe that successful apps would require research that incorporates technological inputs, theoretical mechanisms and health outputs, such studies are a rarity (n = 3). There is a minor increase in rigor with randomized control trials (n = 5), and a preponderance of discussion around social influence (n = 8) and gamification (n = 7), albeit in a scattered manner. We discuss the implications of the trend towards socialization and gamification findings in terms of future research, particularly in terms of study design guided by theoretical mechanisms.

QUALITY AND USE OF FREE SMOKING CESSATION APPS FOR SMARTPHONES

OBJECTIVES

Smartphone Apps are one of the tools available to support patients who wish to quit smoking. Content analysis studies have indicated multiple deficiencies within these Apps including minimal use of evidence-based research and Nicotine Dependence Treatment Provider (NDTP) in App development. The aim of this study was to determine quality and features of smoking cessation Apps available on Android® and iOS® platforms.

METHODS

The first fifty free smoking cessation Apps available for download using the search term smoking cessation on Google Play Store and Apple App Store were chosen. Each of these Apps was analyzed and categorized based on ratings, target audience age, language, and a variety of tracking functionalities noted on the Apps. Indications and suggestions regarding either the use of NDTP or evidence-based behavior change protocols were noted.

RESULTS

There were no significant differences in the features of smoking cessation Apps on Android and iOS. Only 15 percent of all Apps analyzed on both platforms indicated some involvement of NDTP and there was no difference between the two platforms. More than 50 percent of Apps studied were downloaded over half a million times and the average user rating was 3.89/5.00 for Android and 3.72/5.00 for iOS with no significant difference.

CONCLUSIONS

Most smoking cessation Apps in both platforms offer basic tracking functionalities with limited motivational tips. Only a handful of Apps have moved beyond this role and while their development is applaudable much innovation remains.

A Face-Aging Smoking Prevention/Cessation Intervention for Nursery School Students in Germany: An Appearance-Focused Interventional Study

The Education Against Tobacco (EAT) network delivers smoking prevention advice in secondary schools, typically using the mirroring approach (i.e., a “selfie” altered with a face-aging app and shared with a class). In November 2017, however, the German assembly of EAT opted to expand its remit to include nursing students. To assess the transferability of the existing approach, we implemented it with the self-developed face-aging app “Smokerface” (=mixed − methods approach) in six nursing schools. Anonymous questionnaires were used to assess the perceptions of 197 students (age 18–40 years; 83.8% female; 26.4% smokers; 23.3% daily smokers) collecting qualitative and quantitative data for our cross-sectional study. Most students perceived the intervention to be fun (73.3%), but a minority disagreed that their own animated selfie (25.9%) or the reaction of their peers (29.5%) had motivated them to stop smoking. The impact on motivation not to smoke was considerably lower than experienced with seventh graders (63.2% vs. 42.0%; notably, more smokers also disagreed (45.1%) than agreed (23.5%) with this statement. Agreement rates on the motivation not to smoke item were higher in females than in males and in year 2–3 than in year 1 students. Potential improvements included greater focus on pathology (29%) and discussing external factors (26%). Overall, the intervention seemed to be appealing for nursing students.

Facial-Aging Mobile Apps for Smoking Prevention in Secondary Schools in Brazil: Appearance-Focused Interventional Study

Background

Most smokers start smoking during their early adolescence, often with the idea that smoking is glamorous. Interventions that harness the broad availability of mobile phones as well as adolescents' interest in their appearance may be a novel way to improve school-based prevention. A recent study conducted in Germany showed promising results. However, the transfer to other cultural contexts, effects on different genders, and implementability remains unknown.

Objective

In this observational study, we aimed to test the perception and implementability of facial-aging apps to prevent smoking in secondary schools in Brazil in accordance with the theory of planned behavior and with respect to different genders.

Methods

We used a free facial-aging mobile phone app (“Smokerface”) in three Brazilian secondary schools via a novel method called mirroring. The students’ altered three-dimensional selfies on mobile phones or tablets and images were “mirrored” via a projector in front of their whole grade. Using an anonymous questionnaire, we then measured on a 5-point Likert scale the perceptions of the intervention among 306 Brazilian secondary school students of both genders in the seventh grade (average age 12.97 years). A second questionnaire captured perceptions of medical students who conducted the intervention and its conduction per protocol.

Results

The majority of students perceived the intervention as fun (304/306, 99.3%), claimed the intervention motivated them not to smoke (289/306, 94.4%), and stated that they learned new benefits of not smoking (300/306, 98.0%). Only a minority of students disagreed or fully disagreed that they learned new benefits of nonsmoking (4/306, 1.3%) or that they themselves were motivated not to smoke (5/306, 1.6%). All of the protocol was delivered by volunteer medical students.

Conclusions

Our data indicate the potential for facial-aging interventions to reduce smoking prevalence in Brazilian secondary schools in accordance with the theory of planned behavior. Volunteer medical students enjoyed the intervention and are capable of complete implementation per protocol.

Missing the mark for patient engagement: mHealth literacy strategies and behavior change processes in smoking cessation apps

OBJECTIVE

To examine how Transtheoretical Model (TTM)'s processes of change and mHealth literacy strategies are employed in mobile smoking cessation apps.

METHODS

A purposive sample of 100 iTunes apps were coded to assess descriptive (price, type, developer, user-rating) and engagement metrics, including processes of change and mHealth literacy strategies (plain language, usability, interactivity). One-way ANOVAs and independent samples t-tests examined associations between descriptive and engagement metrics.

RESULTS

Over half of the apps included 7 (78%) processes of change. Fewer included self-liberation (36%) and reinforcement management (34%). Most apps incorporated plain language, but few integrated usability and interactivity strategies. Hypnotherapy and informational apps included more behavioral processes of change than apps incorporating a combination of features, including gaming, cigarette trackers, and motivational coaching (p<0.01).

CONCLUSION

Apps included behavior change processes but rarely incorporated usability and interactivity features to promote patient engagement. Engagement metrics did not vary by app user-ratings, price-to-download, or developer, including for-profit organizations or government and educational institutions.

PRACTICE IMPLICATIONS

Providers should acknowledge the popularity of smoking cessation apps as potential cessation aids and communicate their benefits and drawbacks to patients. Future efforts to improve smoking cessation apps should focus on enhancing the quality of tailored and interactive content.

Identification of Users for a Smoking Cessation Mobile App: Quantitative Study

BACKGROUND

The number of mobile apps that support smoking cessation is growing, indicating the potential of the mobile phone as a means to support cessation. Knowledge about the potential end users for cessation apps results in suggestions to target potential user groups in a dissemination strategy, leading to a possible increase in the satisfaction and adherence of cessation apps.

OBJECTIVE

This study aimed to characterize potential end users for a specific mobile health (mHealth) smoking cessation app.

METHODS

A quantitative study was conducted among 955 Dutch smokers and ex-smokers. The respondents were primarily recruited from addiction care facilities and hospitals through Web-based media via websites and forums. The respondents were surveyed on their demographics, smoking behavior, and personal innovativeness. The intention to use and the attitude toward a cessation app were determined on a 5-point Likert scale. To study the association between the characteristics and intention to use and attitude, univariate and multivariate ordinal logistic regression analyses were performed.

RESULTS

The multivariate ordinal logistic regression showed that the number of previous quit attempts (odds ratio [OR] 4.1, 95% CI 2.4-7.0, and OR 3.5, 95% CI 2.0-5.9) and the score on the Fagerstrom Test of Nicotine Dependence (OR 0.8, 95% CI 0.8-0.9, and OR 0.8, 95% CI 0.8-0.9) positively correlates with the intention to use a cessation app and the attitude toward cessation apps, respectively. Personal innovativeness also positively correlates with the intention to use (OR 0.3, 95% CI 0.2-0.4) and the attitude towards (OR 0.2, 95% CI 0.1-0.4) a cessation app. No associations between demographics and the intention to use or the attitude toward using a cessation app were observed.

CONCLUSIONS

This study is among the first to show that demographic characteristics such as age and level of education are not associated with the intention to use and the attitude toward using a cessation app when characteristics related specifically to the app, such as nicotine dependency and the number of quit attempts, are present in a multivariate regression model. This study shows that the use of mHealth apps depends on characteristics related to the content of the app rather than general user characteristics.

A systematic review of smartphone applications for smoking cessation

Tobacco use is the leading cause of preventable disease and death in the USA. However, limited data exists regarding smoking cessation mobile app quality and intervention effectiveness. Innovative and scalable interventions are needed to further alleviate the public health implications of tobacco addiction. The proliferation of the smartphone and the advent of mobile phone health interventions have made treatment more accessible than ever. The purpose of this review was to examine the relation between published scientific literature and available commercial smartphone health apps for smoking cessation to identify the percentage of scientifically supported apps that were commercially available to consumers and to determine how many of the top commercially available apps for smoking cessation were supported by the published scientific literature. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, apps were reviewed in four phases: (1) identified apps from the scientific literature, (2) searched app stores for apps identified in the literature, (3) identified top apps available in leading app stores, and (4) determined which top apps available in stores had scientific support. Seven articles identified six apps with some level of scientific support, three (50%) were available in at least one app store. Conversely, among the top 50 apps suggested by each of the leading app stores, only two (4%) had any scientific support. While half of the scientifically vetted apps remain available to consumers, they are difficult to find among the many apps that are identified through app store searches.

A Breastfeed-Promoting Mobile App Intervention: Usability and Usefulness Study

BACKGROUND

Breastfeeding is proven to have lasting health benefits for both mothers and infants; however, 6-month exclusive breastfeeding rate remains below 20% in Thailand. Although the number of research literature and commercial apps for breastfeeding women is significantly growing, they are country-specific and restricted to English-speaking users. There exists a major knowledge gap on how mobile health apps could support breastfeeding in Thailand. To address these gaps, MoomMae has been developed with the intention to support Thai women in breastfeeding outside of their homes and in keeping their feeding records.

OBJECTIVE

The aim of this study was to evaluate the usability and usefulness of MoomMae, a mobile phone app designed to support breastfeeding women.

METHODS

Our study was reviewed and approved by Thailand's National Science and Technology Development Agency (NSTDA) ethics committee. A total of 21 breastfeeding women with at least one Android phone or tablet were recruited via convenience and snowball sampling. The study process for each participant was as follows: the participant was requested to attend a preuse interview and given the app to use for 4 weeks. Following this period, a postuse interview was conducted to examine the usability and usefulness of the app. Both sessions were held individually and audiorecorded for qualitative analysis.

RESULTS

The mean scores of usability and usefulness from the postuse survey were 4.33 (SD 0.87; range 1-5) and 4.60 (SD 0.74; range 2-5). Our qualitative analysis revealed a total of 137 feedbacks: 71 related to usability and 66 associated with usefulness. A further sentimental analysis showed that comments on usability were generally negative (59 negative, 11 positive, and 1 neutral), and comments on usefulness were relatively positive (56 positive, 9 negative, and 1 neutral). We discovered 26 unique design issues and proposed recommendations for future improvement.

CONCLUSIONS

Our usability and usefulness assessment of MoomMae demonstrated that MoomMae has a great potential to be a useful self-management tool for breastfeeding mothers in Thailand. The qualitative analysis suggested that the app is supportive of breastfeeding on demand, but the flow and inputs of the app should be redesigned to be more intuitive. For future implementations, the most desirable feature is a pump-reminding notification system.

Smartphone Smoking Cessation Application (SSC App) trial: a multicountry double-blind automated randomised controlled trial of a smoking cessation decision-aid 'app'

OBJECTIVE

To assess the efficacy of an interactive smoking cessation decision-aid application (pp) compared with a smoking cessation static information app on continuous abstinence.

DESIGN

Automated double-blind randomised controlled trial with 6 months follow-up (2014-2015).

SETTING

Smartphone-based.

PARTICIPANTS

684 participants (daily smokers of cigarettes, 18 years old or over) recruited passively from app stores in the USA, Australia, UK and Singapore, and randomised to one of two sub-apps.

INTERVENTIONS

Behavioural, decision-aid, smartphone application.

MAIN OUTCOMES

Continuous abstinence at 10 days, 1 month, 3 months and 6 months.

RESULTS

Smokers who received the decision-aid app were more likely to be continuously abstinent at 1 month compared with the information-only app (28.5% vs 16.9%; relative risk (RR) 1.68; 95% CI 1.25 to 2.28). The effect was sustained at 3 months (23.8% vs 10.2%; RR 2.08; 95% CI 1.38 to 3.18) and 6 months (10.2% vs 4.8%; RR 2.02; 95% CI 1.08 to 3.81). Participants receiving the decision-aid app were also more likely to have made an informed choice (31.9% vs 19.6%) and have lower decisional conflict (19.5% vs 3.9%).

CONCLUSION

A smartphone decision-aid app with support features significantly increased smoking cessation and informed choice. With an increasing number of smokers attempting to quit, unassisted evidence-based decision-aid apps can provide an effective and user-friendly option to many who are making quit decisions without healthcare professionals.

TRIAL REGISTRATION NUMBER

ACTRN12613000833763.

Feasibility of e-Health Interventions on Smoking Cessation among Vietnamese Active Internet Users

Introduction: Although e-health interventions are widely implemented as a supportive measure to smoking cessation, there is a lack of evidence in the feasibility of its application among Vietnamese youths, which is considered to be one of the most frequent internet using populations. This study assessed the quitting attempts among smokers and their preference and willingness to pay for smartphone-based cessation supporting applications in a sample of active internet users approached. Methods: A total of 1082 participants were recruited for the online-based survey from August to October 2015 in Vietnam. Information on sociodemographic characteristics, health information seeking behaviors on the internet, smoking status, quitting attempts and willingness to pay for smartphone-based cessation supporting applications were collected. Multivariate logistic regression was used to determine the associated factors with current smoking and willingness to pay for the smoking cessation application. Results: About 11% of participants were current smokers while 73.4% had attempted to quit smoking. Only 26.8% of the individuals indicated that they were willing to utilize a smartphone application to assist them in quitting. Participants who were male, had partners/spouse and lived at other places were more likely to smoke cigarette. Meanwhile, people who spent 50–70% of their online time to read health information were less likely to smoke. Results also show that living with family and never sharing health information on the internet were negatively associated with a participant’s willingness to pay for the smartphone application. Meanwhile, people who highly trusted health information were more likely to be willing to pay for the application. Conclusions: This prevalence of smoking and associated factors can provide potential indicators for creating several public health interventions in the new environment with the increasing development of information technology. This study implies that in order to expand the coverage of smoking cessation interventions, we recommend the integration of e-health interventions with clinical- or telephone-based conventional models by providing smartphone applications and information on the internet from reliable sources.

Characterising smoking cessation smartphone applications in terms of behaviour change techniques, engagement and ease-of-use features

The aim of this study was to assess whether or not behaviour change techniques (BCTs) as well as engagement and ease-of-use features used in smartphone applications (apps) to aid smoking cessation can be identified reliably. Apps were coded for presence of potentially effective BCTs, and engagement and ease-of-use features. Inter-rater reliability for this coding was assessed. Inter-rater agreement for identifying presence of potentially effective BCTs ranged from 66.8 to 95.1 % with ‘prevalence and bias adjusted kappas’ (PABAK) ranging from 0.35 to 0.90 (p < 0.001). The intra-class correlation coefficients between the two coders for scores denoting the proportions of (a) a set of engagement features and (b) a set of ease-of-use features, which were included, were 0.77 and 0.75, respectively (p < 0.001). Prevalence estimates for BCTs ranged from <10 % for medication advice to >50 % for rewarding abstinence. The average proportions of specified engagement and ease-of-use features included in the apps were 69 and 83 %, respectively. The study found that it is possible to identify potentially effective BCTs, and engagement and ease-of-use features in smoking cessation apps with fair to high inter-rater reliability.

Innovative approaches to support smoking cessation for individuals with mental illness and co-occurring substance use disorders

INTRODUCTION

Tobacco remains the leading preventable cause of death in the US, accounting for over 520,000 deaths annually. While the smoking prevalence has declined over the past 50 years, those with mental illness and addictive disorders continue to smoke at high levels and with significant tobacco-related health problems. Areas covered: This review highlights the epidemiology, contributing factors, and evidence-base for intervening upon tobacco use in those with mental illness and addictive disorders. Historically underprioritized, a growing body of literature supports treating tobacco within mental health and addiction treatment settings. Critically, treating tobacco use appears to support, and not harm, mental health recovery and sobriety. This review also summarizes novel, emerging approaches to mitigate the harms of cigarette smoking. Expert commentary: People with mental illness and addictive disorders have a high prevalence of tobacco use with serious health harms. Treating tobacco use is essential. Evidence-based strategies include individual treatments that are stage-matched to readiness to quit and combine cessation medications with behavioral therapies, supported by smoke-free policies in treatment settings and residential environments. Emerging approaches, with a focus on harm reduction, are electronic nicotine delivery systems and tobacco regulatory efforts to reduce the nicotine content in cigarettes, thereby reducing their addiction potential.

Content Analysis of Smartphone Apps for Smoking Cessation in China: Empirical Study

Background

With 360 million smokers, China consumes more cigarettes than any other country in the world. Given that 620 million Chinese own smartphones, smartphone apps for smoking cessation are increasingly used in China to help smokers quit.

Objective

This study analyzed and evaluated the contents of all smoking cessation apps (iOS and Android) available in China, applying the China Clinical Smoking Cessation Guideline (CCSCG; identical to the US Clinical Practice Guideline for Treating Tobacco Use and Dependence) as a framework for analysis.

Methods

We conducted a content analysis of Chinese Android and iOS smoking cessation apps (N=64) designed to assist users in quitting smoking. Each app was independently coded by two raters for its approach to smoking cessation and adherence to the CCSCG. We also recorded the features of smoking cessation apps (eg, release date, size, frequency of downloads, user ratings, type, quality scores by raters, and designers). Linear regression was used to test predictors of popularity and user-rated quality.

Results

Chinese smoking cessation apps have low levels of adherence to guidelines, with an average score of 11.1 for Android and 14.6 for iOS apps on a scale of 0 to 46. There was no significant association between popularity, user rating, and the characteristics of apps. However, there was a positive relationship between popularity, user rating, and adherence score.

Conclusions

Chinese apps for smoking cessation have low levels of adherence to standard clinical practice guidelines. New apps need be developed and existing apps be revised following evidence-based principles in China.

Vaccinations against respiratory infections in Arabian Gulf countries: Barriers and motivators

AIM

To study the uptake, barriers and motivators of influenza, pneumococcal, meningococcal and pertussis vaccines among members of public in Arabian Gulf countries.

METHODS

A cross-sectional survey among the Gulf Cooperation Council (GCC) countries’ residents. Data collected electronically through a smartphone app. The survey variables aimed to investigate the respondents’ awareness about vaccines against influenza, pneumococcal, meningococcal and pertussis infections. Collected data concerning the respondents’ socio-demographic characteristics, their perception toward vaccine uptake and the factors that motivate or demotivate them from taking influenza vaccine. The data were analysed statistically using the SPSS v.23.0. Differences in the characteristics of users from different countries were quantified through bivariate analysis. Other important variables and controlling factors were studied using logistic regression.

RESULTS

A total of 1812 respondents participated in the study. Their mean age was 27 years, 82% were male and 24% had ≥ 1 chronic diseases. The overall uptake of influenza vaccine was 17% (21% among “at risk” people) and ranged from 15% in Saudi Arabia to 24% in Qatar. Doctor’s advice (23%) and a perception of having low body immunity (21%) were the main cited reasons for being vaccinated, whereas unawareness about the vaccine (43%) was the main barrier. The overall uptake of pneumococcal vaccine in the preceding three years was 22% (25% among “at risk” individuals) and ranged from 0% in Bahrain to 79% in Kuwait. The overall uptake of pertussis vaccine was 16% (31% among “vulnerable” people), and ranged from 7% in Saudi Arabia to 75% in Oman. The overall uptake of meningococcal vaccine was 20% (29% among the “at risk” people) and ranged from 3% in Oman to 50% in Bahrain.

CONCLUSION

The vaccination uptake across GCC countries is suboptimal and varies widely across the countries. Further research is needed to unearth the reasons and formulate action plan.

TControl: A mobile app to follow up tobacco-quitting patients

BACKGROUND AND OBJECTIVE

Tobacco smoking is a major risk factor for a wide range of respiratory and circulatory diseases in active and passive smokers. Well-designed campaigns are raising awareness to the problem and an increasing number of smokers seeks medical assistance to quit their habit. In this context, there is the need to develop mHealth Apps that assist and manage large smoke quitting programs in efficient and economic ways.

OBJECTIVES

Our main objective is to develop an efficient and free mHealth app that facilitates the management of, and assistance to, people who want to quit smoking. As secondary objectives, our research also aims at estimating the economic effect of deploying that App in the public health system.

METHODS

Using JAVA and XML we develop and deploy a new free mHealth App for Android, called TControl (Tobacco-quitting Control). We deploy the App at the Tobacco Unit of the Santa Maria Hospital in Lleida and determine its stability by following the crashes of the App. We also use a survey to test usability of the app and differences in aptitude for using the App in a sample of 31 patients. Finally, we use mathematical models to estimate the economic effect of deploying TControl in the Catalan public health system.

RESULTS

TControl keeps track of the smoke-quitting users, tracking their status, interpreting it, and offering advice and psychological support messages. The App also provides a bidirectional communication channel between patients and clinicians via mobile text messages. Additionally, registered patients have the option to interchange experiences with each other by chat. The App was found to be stable and to have high performances during startup and message sending. Our results suggest that age and gender have no statistically significant effect on patient aptitude for using TControl. Finally, we estimate that TControl could reduce costs for the Catalan public health system (CPHS) by up to € 400M in 10 years.

CONCLUSIONS

TControl is a stable and well behaved App, typically operating near optimal performance. It can be used independent of age and gender, and its wide implementation could decrease costs for the public health system.

Design Considerations for mHealth Programs Targeting Smokers Not Yet Ready to Quit: Results of a Sequential Mixed-Methods Study

Background

Mobile health (mHealth) smoking cessation programs are typically designed for smokers who are ready to quit smoking. In contrast, most smokers want to quit someday but are not yet ready to quit. If mHealth apps were designed for these smokers, they could potentially encourage and assist more people to quit smoking. No prior studies have specifically examined the design considerations of mHealth apps targeting smokers who are not yet ready to quit.

Objective

To inform the user-centered design of mHealth apps for smokers who were not yet ready to quit by assessing (1) whether these smokers were interested in using mHealth tools to change their smoking behavior; (2) their preferred features, functionality, and content of mHealth programs addressing smoking; and (3) considerations for marketing or distributing these programs to promote their uptake.

Methods

We conducted a sequential exploratory, mixed-methods study. Qualitative interviews (phase 1, n=15) were completed with a demographically diverse group of smokers who were smartphone owners and wanted to quit smoking someday, but not yet. Findings informed a Web-based survey of smokers from across the United States (phase 2, n=116). Data were collected from April to September, 2016.

Results

Findings confirmed that although smokers not yet ready to quit are not actively seeking treatment or using cessation apps, most would be interested in using these programs to help them reduce or change their smoking behavior. Among phase 2 survey respondents, the app features, functions, and content rated most highly were (1) security of personal information; (2) the ability to track smoking, spending, and savings; (3) content that adaptively changes with one’s needs; (4) the ability to request support as needed; (5) the ability to earn and redeem awards for program use; (6) guidance on how to quit smoking; and (7) content specifically addressing management of nicotine withdrawal, stress, depression, and anxiety. Results generally did not vary by stage of change for quitting smoking (precontemplation vs contemplation). The least popular feature was the ability to share progress via social media. Relevant to future marketing or distribution considerations, smokers were price-sensitive and valued empirically validated programs. Program source, expert recommendations, and user ratings were also important considerations.

Conclusions

Smokers who are not yet ready to quit represent an important target group for intervention. Study findings suggest that many of these individuals are receptive to using mHealth tools to reduce or quit smoking, despite not having made a commitment to quit yet. The preferences for specific mHealth intervention features, functionality, and content outlined in this paper can aid addiction treatment experts, design specialists, and software developers interested in creating engaging interventions for smokers who want to quit in the future but are not yet committed to this important health goal.

Public response to MERS-CoV in the Middle East: iPhone survey in six countries

Gulf Cooperation Council (GCC) countries bear the heaviest brunt of MERS-CoV. This study aims to compare public awareness and practice around MERS-CoV across GCC countries. A cross-sectional survey was conducted using the Gulf Indicators (GI) smartphone app among people in the six GCC countries, namely Saudi Arabia, Kuwait, the United Arab Emirates, Qatar, Bahrain, and Oman. A total of 1812 participants recruited. All were aware of MERS-CoV, yet the perception and practice around MERS-CoV varied widely between countries. Over two thirds were either "not concerned" or "slightly concerned" about contracting MERS-CoV; believing that they were under Allah's (God's) protection (40%) was the most cited reason. While 79% were aware that the disease can transmit through droplet from infected person, only 12% stated that MERS-CoV transmits via camels; people in Saudi Arabia were better aware of the transmission. Nevertheless, only 22% of respondents believed that camels are the zoonotic reservoir of MERS-CoV. Those who were concerned about contracting MERS-CoV (aOR: 1.6, 95% CI: 1.2-2.1, p<0.01) and those who thought MERS-CoV to be a severe disease only for those with high-risk conditions (aOR: 1.5, 95% CI: 1.1-2.1, p<0.01) were more likely to believe that camels are the zoonotic source. However, residents of KSA (aOR: 0.03, 95% CI: 0.01-0.07, p<0.01), UAE (aOR: 0.01, 95% CI: 0.004-0.02, p<0.01) and Kuwait (aOR: 0.03, 95% CI: 0.01-0.07, p<0.01) were less likely to believe that camels are the main zoonotic source compared to respondents from the other countries. Hygienic measures were more commonly adopted than avoidance of camels or their raw products, yet there was a discrepancy between the countries. This study highlights that despite being aware of the ongoing MERS-CoV epidemic; many people lack accurate understanding about MERS-CoV transmission, prevention, and are not fully compliant with preventive measures.

THE FUTURE OF MOBILE HEALTH APPLICATIONS AND DEVICES IN CARDIOVASCULAR HEALTH

Mobile health (mHealth) is the utilisation of mobile technologies in healthcare and has particular relevance in improving lifestyle behaviours which may ultimately reduce cardiovascular disease risk. Various intervention studies for example integrate self-monitoring of diet and physical activity with text messaging systems to improve intermediate outcomes. Currently the future progress of mHealth technologies in formal diagnostic and therapeutic roles is pending and includes the need to validate and standardise accelerometer and heart rate data from various devices. Data also needs to be integrated from such devices into the medical record system to facilitate communication between providers and patients. Although short-term behaviour changes have been found with technologies such as Fitbit® (Fitbit, Inc., San Francisco, California, USA), whether such technologies/interventions lead to sustained behaviour change and reduced risk of myocardial infarction and death remains to be seen.

Lessons from Practice: Designing Tools to Facilitate Individualized Support for Quitting Smoking

Many health care providers, with a variety of trainings, counsel clients on quitting smoking on a day-to-day basis. In their clinical practice, they draw from and adapt guidelines and research-based strategies to fit individual client situations and challenges. Designers of technologies to support quitting smoking can learn from these real world practices to create tools that better adapt to individual differences. We present findings from interviews with 28 providers with diverse experiences in smoking cessation counselling. Through analysis of their individualization strategies, challenges, and perceptions of technology, we find that providers: (1) individualize context appropriate coping strategies by involving clients in brainstorming, (2) emphasize the need to support nicotine withdrawal in clients, (3) mitigate social triggers and mediate social support for clients, and (4) need to navigate dependencies with other providers for managing medications and comorbid health conditions of clients. With this empirical understanding, we extend the discussion on the design of technology to support quitting smoking, highlight current barriers to individualization, and suggest future opportunities to address these barriers.

Get with the program: Adherence to a smartphone app for smoking cessation

INTRODUCTION

Although engagement is generally predictive of positive outcomes in technology-based behavioral change interventions, engagement measures remain largely atheoretical and lack treatment-specificity. This study examines the extent to which adherence measures based on the underlying behavioral change theory of an Acceptance and Commitment Therapy (ACT) app for smoking cessation predict smoking outcomes, and user characteristics associated with adherence.

METHODS

Study sample was adult daily smokers in a single arm pilot study (n=84). Using the app's log file data, we examined measures of adherence to four key components of the ACT behavior change model as predictors of smoking cessation and reduction. We also examined baseline user characteristics associated with adherence measures that predict smoking cessation.

RESULTS

Fully adherent users (24%) were over four times more likely to quit smoking (OR=4.45; 95% CI=1.13, 17.45; p=0.032). Both an increase in tracking the number of urges passed (OR=1.02; 95% CI=1.00, 1.03; p=0.043) and ACT modules completed (OR=1.27; 95% CI=1.01, 1.60; p=0.042) predicted cessation. Lower baseline acceptance of cravings was associated with over four times higher odds of full adherence (OR=4.59; 95% CI=1.35, 15.54; p=0.014).

CONCLUSIONS

Full adherence and use of specific ACT theory-based components of the app predicted quitting. Consistent with ACT theory, users with low acceptance were most likely to adhere to the app. Further research is needed on ways to promote app engagement.

Perceptions Toward a Smoking Cessation App Targeting LGBTQ+ Youth and Young Adults: A Qualitative Framework Analysis of Focus Groups

BACKGROUND

The prevalence of smoking among lesbian, gay, bisexual, trans, queer, and other sexual minority (LGBTQ+) youth and young adults (YYA) is significantly higher compared with that among non-LGBTQ+ persons. However, in the past, interventions were primarily group cessation classes that targeted LGBTQ+ persons of all ages. mHealth interventions offer an alternate and modern intervention platform for this subpopulation and may be of particular interest for young LGBTQ+ persons.

OBJECTIVE

This study explored LGBTQ+ YYA (the potential users') perceptions of a culturally tailored mobile app for smoking cessation. Specifically, we sought to understand what LGBTQ+ YYA like and dislike about this potential cessation tool, along with how such interventions could be improved.

METHODS

We conducted 24 focus groups with 204 LGBTQ+ YYA (aged 16-29 years) in Toronto and Ottawa, Canada. Participants reflected on how an app might support LGBTQ+ persons with smoking cessation. Participants indicated their feelings, likes and dislikes, concerns, and additional ideas for culturally tailored smoking cessation apps. Framework analysis was used to code transcripts and identify the overarching themes.

RESULTS

Study findings suggested that LGBTQ+ YYA were eager about using culturally tailored mobile apps for smoking cessation. Accessibility, monitoring and tracking, connecting with community members, tailoring, connecting with social networks, and personalization were key reasons that were valued for a mobile app cessation program. However, concerns were raised about individual privacy and that not all individuals had access to a mobile phone, users might lose interest quickly, an app would need to be marketed effectively, and app users might cheat and lie about progress to themselves. Participants highlighted that the addition of distractions, rewards, notifications, and Web-based and print versions of the app would be extremely useful to mitigate some of their concerns.

CONCLUSIONS

This study provided insight into the perspectives of LGBTQ+ YYA on a smoking cessation intervention delivered through a mobile app. The findings suggested a number of components of a mobile app that were valued and those that were concerning, as well as suggestions on how to make a mobile app cessation program successful. App development for this subpopulation should take into consideration the opinions of the intended users and involve them in the development and evaluation of mobile-based smoking cessation programs.

Game On? Smoking Cessation Through the Gamification of mHealth: A Longitudinal Qualitative Study

Background

Finding ways to increase and sustain engagement with mHealth interventions has become a challenge during application development. While gamification shows promise and has proven effective in many fields, critical questions remain concerning how to use gamification to modify health behavior.

Objective

The objective of this study is to investigate how the gamification of mHealth interventions leads to a change in health behavior, specifically with respect to smoking cessation.

Methods

We conducted a qualitative longitudinal study using a sample of 16 smokers divided into 2 cohorts (one used a gamified intervention and the other used a nongamified intervention). Each participant underwent 4 semistructured interviews over a period of 5 weeks. Semistructured interviews were also conducted with 4 experts in gamification, mHealth, and smoking cessation. Interviews were transcribed verbatim and thematic analysis undertaken.

Results

Results indicated perceived behavioral control and intrinsic motivation acted as positive drivers to game engagement and consequently positive health behavior. Importantly, external social influences exerted a negative effect. We identified 3 critical factors, whose presence was necessary for game engagement: purpose (explicit purpose known by the user), user alignment (congruency of game and user objectives), and functional utility (a well-designed game). We summarize these findings in a framework to guide the future development of gamified mHealth interventions.

Conclusions

Gamification holds the potential for a low-cost, highly effective mHealth solution that may replace or supplement the behavioral support component found in current smoking cessation programs. The framework reported here has been built on evidence specific to smoking cessation, however it can be adapted to health interventions in other disease categories. Future research is required to evaluate the generalizability and effectiveness of the framework, directly against current behavioral support therapy interventions in smoking cessation and beyond.

The role of interdisciplinary research team in the impact of health apps in health and computer science publications: a systematic review

BACKGROUND

Several studies have estimated the potential economic and social impact of the mHealth development. Considering the latest study by Institute for Healthcare Informatics, more than 165.000 apps of health and medicine are offered including all the stores from different platforms. Thus, the global mHealth market was an estimated $10.5 billion in 2014 and is expected to grow 33.5 percent annually between 2015 and 2020s. In fact, apps of Health have become the third-fastest growing category, only after games and utilities.

METHODS

This study aims to identify, study and evaluate the role of interdisciplinary research teams in the development of articles and applications in the field of mHealth. It also aims to evaluate the impact that the development of mHealth has had on the health and computer science field, through the study of publications in specific databases for each area which have been published until nowadays.

RESULTS

Interdisciplinary nature is strongly connected to the scientific quality of the journal in which the work is published. This way, there are significant differences in those works that are made up by an interdisciplinary research team because of they achieve to publish in journals with higher quartiles. There are already studies that warn of methodological deficits in some studies in mHealth, low accuracy and no reproducibility. Studies of low precision and poor reproducibility, coupled with the low evidence, provide low degrees of recommendation of the interventions targeted and therefore low applicability.

CONCLUSIONS

From the evidence of this study, working in interdisciplinary groups from different areas greatly enhances the quality of research work as well as the quality of the publications derived from its results.

Popular Mobile Phone Apps for Diet and Weight Loss: A Content Analysis

Background

A review of the literature has revealed that the rates of overweight and obesity have been increasing in Australia over the last two decades and that wellness mobile phone apps play a significant role in monitoring and managing individuals’ weight. Although mobile phone app markets (iTunes and Google Play) list thousands of mobile phone health apps, it is not always clear whether those apps are supported by credible sources. Likewise, despite the prevailing use of mobile phone apps to aid with weight management, the usability features of these apps are not well characterized.

Objective

The research explored how usability taxonomy could inform the popularity of downloaded, socially focused wellness mobile phone apps, in particular weight loss and diet apps. The aim of the study was to investigate the Australian mobile phone app stores (iTunes and Google Play) in order to examine the usability features of the most popular (ie, most downloaded) wellness apps.

Methods

The design of this study comprises 3 main stages: stage 1, identifying apps; stage 2, development of weight loss and diet evaluation framework; and stage 3, application of the evaluation framework. Each stage includes specific data collection, analysis tools, and techniques.

Results

The study has resulted in the development of a justified evaluation framework for weight loss and diet mobile phone apps. Applying the evaluation framework to the identified apps has shown that the most downloaded iTunes and Google Play apps are not necessarily the most usable or effective. In addition, the research found that search algorithms for iTunes and Google Play are biased toward apps’ titles and keywords that do not accurately define the real functionality of the app. Moreover, the study has also analyzed the apps’ user reviews, which served as justification for the developed evaluation framework.

Conclusions

The analysis has shown that ease of use, reminder, bar code scanning, motivation, usable for all, and synchronization are significant attributes that should be included in weight loss and diet mobile phone apps and ultimately in potential weight loss and diet evaluation frameworks.

Does a Mobile Phone Depression-Screening App Motivate Mobile Phone Users With High Depressive Symptoms to Seek a Health Care Professional's Help?

Background

The objective of disease screening is to encourage high-risk subjects to seek health care diagnosis and treatment. Mobile phone apps can effectively screen mental health conditions, including depression. However, it is not known how effective such screening methods are in motivating users to discuss the obtained results of such apps with health care professionals. Does a mobile phone depression-screening app motivate users with high depressive symptoms to seek health care professional advice? This study aimed to address this question.

Method

This was a single-cohort, prospective, observational study of a free mobile phone depression app developed in English and released on Apple’s App Store. Apple App Store users (aged 18 or above) in 5 countries, that is, Australia, Canada, New Zealand (NZ), the United Kingdom (UK), and the United States (US), were recruited directly via the app’s download page. The participants then completed the Patient Health Questionnaire (PHQ-9), and their depression screening score was displayed to them. If their score was 11 or above and they had never been diagnosed with depression before, they were advised to take their results to their health care professional. They were to follow up after 1 month.

Results

A group of 2538 participants from the 5 countries completed PHQ-9 depression screening with the app. Of them, 322 participants were found to have high depressive symptoms and had never been diagnosed with depression, and received advice to discuss their results with health care professionals. About 74% of those completed the follow-up; approximately 38% of these self-reported consulting their health care professionals about their depression score. Only positive attitude toward depression as a real disease was associated with increased follow-up response rate (odds ratio (OR) 3.2, CI 1.38-8.29).

Conclusions

A mobile phone depression-screening app motivated some users to seek a depression diagnosis. However, further study should investigate how other app users use the screening results provided by such apps.

Update on Smoking Cessation: E-Cigarettes, Emerging Tobacco Products Trends, and New Technology-Based Interventions

Tobacco use disorders (TUDs) continue to be overly represented in patients treated in mental health and addiction treatment settings. It is the most common substance use disorder (SUD) and the leading cause of health disparities and increased morbidity/mortality amongst individuals with a psychiatric disorder. There are seven Food and Drug Administration (FDA) approved medications and excellent evidence-based psychosocial treatment interventions to use in TUD treatment. In the past few years, access to and use of other tobacco or nicotine emerging products are on the rise, including the highly publicized electronic cigarette (e-cigarette). There has also been a proliferation of technology-based interventions to support standard TUD treatment, including mobile apps and web-based interventions. These tools are easily accessed 24/7 to support outpatient treatment. This update will review the emerging products and counter-measure intervention technologies, including how clinicians can integrate these tools and other community-based resources into their practice.

Evaluation of QuitNow Men: An Online, Men-Centered Smoking Cessation Intervention

BACKGROUND

Men continue to smoke cigarettes in greater numbers than women. There is growing evidence for the value of developing targeted, men-centered health promotion programs. However, few smoking cessation interventions have been designed for men. A gender-specific website, QuitNow Men, was developed based on focus group interview findings, stakeholder feedback, and evidence-based cessation strategies. The website was designed to incorporate a masculine look and feel through the use of images, direct language, and interactive content. Usability experts and end-users provided feedback on navigation and functionality of the website prior to pilot testing.

OBJECTIVES

The objectives of the pilot study were to describe (1) men's use and evaluations of the interactive resources and information on the QuitNow Men website, and (2) the potential of QuitNow Men to engage men in reducing and quitting smoking.

METHODS

A one-group, pretest-posttest study design was used. Men who were interested in quitting were recruited and invited to use the website over a 6-month period. Data were collected via online questionnaires at baseline, 3-month, and 6-month follow-up. A total of 117 men completed the baseline survey. Over half of those (67/117, 57.3%) completed both follow-up surveys.

RESULTS

At baseline, participants (N=117) had been smoking for an average of 24 years (SD 12.1) and smoked on average 15 cigarettes a day (SD 7.4). The majority had not previously used a quit smoking website (103/117, 88.0%) or websites focused on men's health (105/117, 89.7%). At the 6-month follow-up, the majority of men used the QuitNow Men website at least once (64/67, 96%). Among the 64 users, 29 (43%) reported using the website more than 6 times. The men using QuitNow Men agreed or strongly agreed that the website was easy to use (51/64, 80%), the design and images were appealing (42/64, 66%), they intended to continue to use the website (42/64, 66%), and that they would recommend QuitNow Men to others who wanted to quit (46/64, 72%). Participants reported using an average of 8.76 (SD 4.08) of the 15 resources available on the website. At 6-month follow-up, 16 of the 67 participants (24%) had quit, 27 (40%) had reduced their smoking and 24 (36%) had not changed their smoking habits. Repeated measures general linear model showed a significant decrease in the number of cigarettes smoked between the 3-month and 6-month follow-up (F1,63=6.41, P=.01, eta squared=0.09). Number of resources used on the website, quit confidence, nicotine dependence and age significantly predicted number of quit attempts by those still smoking at 6 months (F4,45=2.73, P=.04), with number of resources used being the strongest predictor (P=.02).

CONCLUSIONS

The results of this research support efforts to integrate gender-sensitive approaches in smoking cessation interventions and indicate that this novel Web-based resource has potential in supporting men's smoking cessation efforts.

Design Considerations for Smoking Cessation Apps: Feedback From Nicotine Dependence Treatment Providers and Smokers

Background

Hundreds of smoking cessation apps are commercially available, but most are not theory-based or designed to take advantage of mobile technology in ways that could make them more engaging and possibly more effective. Considering input from both clinical experts (who understand best practice nicotine dependence treatment requirements) to inform appropriate content and from smokers (the end users) to express their preferences is important in designing these programs in the future.

Objective

To assess and compare the opinions of nicotine dependence treatment providers and smokers regarding the design of future smoking cessation apps.

Methods

We surveyed providers (n=264) and smokers who own smartphones (n=40) to assess their opinions on the importance of 21 app design features. Features represented 5 domains: cost, reputation, privacy and security, content and user experience, and communication. Domains were chosen to reflect best practice treatment, leverage mobile technology to support smoking cessation, and elicit important user preferences. Data were collected between June and July 2015.

Results

Most providers agreed that mHealth apps hold promise for helping people quit smoking (203/264, 76.9%) and would recommend them to their clients/patients (201/264, 76.1%), especially if the app were empirically validated (236/264, 89.4%). Few providers believe effective cessation apps currently exist (112/264, 42.4%). Few smokers (5/40, 13%) had ever downloaded a smoking cessation app; of the ones who had not, most said they would consider doing so (29/35, 83%). Both respondent groups indicated the following features were very to extremely important to include in cessation apps: free or low cost, keeps information private, matches individual needs and interests, adapts as one’s needs and interests change, helps to manage nicotine withdrawal symptoms and medication side effects, and allows users to track their progress. Providers and smokers also indicated gaming and social media connectivity were less important than other features. Despite these similarities, the groups had significantly different opinions about the relative importance of various features. In particular, providers rated privacy as the most important feature, whereas smokers rated low cost and the ability to adaptively tailor content as the most important features.

Conclusions

Smoking cessation apps hold great promise as intervention tools but only if they engage users and appropriately treat nicotine dependence. Intervention development should take into consideration the perspectives of both treatment experts and smokers. This paper highlights important perspectives from each of these groups to be considered when designing future app-based smoking cessation programs.