10/6/2015

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Dr. Lorien Abroms/GWU has licensed Text2Quit & Quit4Baby to Voxiva Inc.

This research was supported by NIH grants to Dr. Lorien Abroms, 5K07 CA124579-02 and 1R15CA167586

Funding Source:

Disclosure:

Topics I’ll cover

I. Pregnancy Smoking Cessation

II. Potential role of mHealth

III. Current Programs & Evidence

• Text Messaging Programs

• Smartphone apps

IV. Future opportunities

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Smoking in Pregnancy • Many women are motivated to quit during

pregnancy; 46% of smokers quit directly

before or during pregnancy (Colman, 2003)

• In 2008, 10.7% of women smoked in last 3

months of pregnancy (Prams 2013)

• Up to 40-60% of those who quit during

pregnancy will relapse within 6 months

postpartum, and 80-90% by 12 months

postpartum (Floyd, 1993, Fingerhut, 1990;

CDC 2014)

• Tobacco use is the most important modifiable cause of adverse pregnancy outcomes in the U.S. (Fang, 2004)

• Effects on pregnancy & baby:

• miscarriage • placental bleeding • premature delivery • Low birth weight • Born with a cleft

lip/cleft palate, • Higher risks of

SIDS

• Dose response relationship

Health effects of smoking during

pregnancy (cont.)

Smoking accounts for 20% of low birth weight

deliveries (<2500 grams), 8% of preterm births

and 5% of all perinatal deaths (Orleans, 2001)

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Figure 1. Prevalence of smoking during the last 3 months of pregnancy by

demographic characteristics, 24 PRAMS states, 2011.

Figure 2. Prevalence of smoking during the last 3 months of

pregnancy (Prams 2011).

Pregnancy Smoking Cessation

Pregnancy-specific in-person counseling** at first visit and throughout pregnancy

Ask the patient about smoking status at first prenatal visit with multiple choice

Advise the patient to quit. Assess the patient’s willingness to quit. Assist the patient in quitting. Arrange follow-up visits to track quit progress.

Quitlines : 10 call program

NRT: NRT evidence is mixed

not FDA-approved not recommended in the CTP, Cochrane 2012 ACOG recommends, if unable to stop, with

close supervision of a provider.

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Pregnancy smoking cessation counseling is covered by the ACA

Some state Medicaid systems offer extensive programs

10-call phone counseling

Free in-person counseling/home visits & Follow up

Self-help materials, videos

Some successes

SCRIPT (Windsor et al. 2000)

The Core SCRIPT Procedures

---------------------------------------------------------------

Component #1: Commit to Quit Smoking During &

After Pregnancy Video (10 Min.)

Component #2: A Pregnant Women’s Guide to Quit

Smoking (5th-6th grade literacy)

Component #3: Patient-centered counseling session

(10-15 Minutes)

Low Reach

Even across trials, only 20-40% of pregnant smokers will receive free counseling

Very few preg. smokers call quitlines

Because:

Prefer self-help (Ussher,West & Hibbs 20004)

Low uptake of prenatal care, esp in first trimester

Once in care,

Providers lack training or appropriate systems for offering them in-person counseling

Patient reluctant to disclose their smoking (stigma)

Patient refuse free counseling services

Challenges

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Topics I’ll cover

I. Pregnancy and Smoking

II. Potential role of mHealth

III. Current Programs & Evidence

• Text Messaging Programs

• Smartphone apps

IV. Future opportunities

High Reach of Mobile Phones

90% of US adults

88% text message, top activity

64%+ have smartphones,

75% have used phone to look up health information

(Pew 2014; CTIA 2014)

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“We Marry Them!” 82 % of mobile phone owners never leave

home without their phones

68 % sleep with device by bedside

Invite them to interrupt us (at family

gatherings, at restaurant, at meetings)

Increasingly rate as something “not willing to

live without”

Smoking Cessation related services delivered via mobile communications devices

mCessation can be defined as:

Advantages of mobile

1. Help anywhere and anytime

2. Proactive messages interrupt you

3. Interactive help

4. Personalized help

5. Increase contact time

6. Unobtrusive and confidential

7. (Goes with smoking) Source: Abroms, Padmanabhan, and Evans 2011

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Evidence: Cessation programs should:

Ask for tobacco use status

Advise every user to quit

Assess willingness to quit

Assist with a quit plan

Practical counseling

Intra-treatment social support

Connect to a quitline

Arrange for follow-up

mCessation Services 1. SMS Programs 3. Mobile Web

2. Smartphone Apps 4. Mobile Devices: CO Monitor

Topics I’ll cover

I. Pregnancy and Smoking

II. Potential role of mHealth

III. Current Programs & Evidence

• Text Messaging Programs

• Smartphone apps

IV. Future opportunities

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To call these programs a success, need ….

Reach Availability,

Enrollment machine,

Subscribers/ Downloads, sustained users

Efficacy Quit attempts,

days without smoking,

cigs smoked/day,

Quit rates

Text messaging

SmokefreeMOM (800+, July 2015)

Quit4baby (300+, Sept. 2015)

MiQuit (UK)

SMAT (Canada)

Smartphone Apps

Quit for You; Quit for Two (40,000-50,000)

Smokefree Baby

Reach-Available Programs

Source: Heminger et al. 2015

Text Messaging

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Quit4baby (Quit4baby.com)

300+ users since Summer 2015

Integrated with text4baby in some States

SmokefreeMOM

Text MOM to 222888

800+ users since May 2014

Promoted on Smokefree.gov & women.smokefree.gov

US Cessation Text Messaging Services

Both program provide 24/7 encouragement, advice, and tips to help pregnant women and mothers quit smoking and stay quit

Overview of Smokefree Moms Automated, interactive text messages for quitting smoking Derived from SmokefreeTXT

• Messages are timed around quit date

• Proactive: Advice on quitting, interactive peer ex-smoker messages, games, and relapse messages.

• On-Demand: need additional motivation, having a craving, relapse.

Program runs for 9 months, with post-partum relapse protocol Frequency increase pre- & post-quit date;

8 messages on quit date; 3 or more messages/day during the immediate post-quit period.

Cost: Standard message and data rates may apply.

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SmokefreeMOM General advice

baby

development

info

Interaction:

Pre-Quit Lea/Quit Pal

Quit & Post-Quit “Did you Quit?” survey

Daily, weekly, monthly

SFM/Lea: Ugh, my

friend just tried to

smoke in my car. Guess

what I did? Text 1 if I

said "don't smoke in my

car it's bad for baby."

Text 2 if I said "it's

super gross!" Text 3 if I

grabbed her cig and

threw it out the window.

Quit Pal

24-7 Help

CRAVE (TIP or GAME)

FACT

DATE

SMOKED

SFM: Use our 3 step

plan to help! At

anytime get motivated

by texting FACT,

manage cravings by

texting CRAVE, or set

a new date by texting

DATE.

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{ { Smokefree

MOM

Reminders about quitting and healthy

pregnancy

Info on how to quit (follows 5A’s)

Tracking & feedback/check-ins

Quitpal

Tools if craving or derailed

Intermediate Outcomes

(theory)

Priority to cessation &

healthy pregnancy

Benefits to mom and baby/Barriers

Social Support

Increase Self-Regulation

Self-Efficacy (Ability)

Proximal Outcomes/

Processes of Changes

Quit Attempt

Get back on track if slip during

pregnancy and post-partum

Call quitline/talk to doctor/ seek out

info

Health Outcome

Quit smoking & healthy pregnancy

Logic Model for mHealth & Pregnant Smoking Cessation

Quit4Baby

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Overview of Quit4Baby

Derived from Text2Quit

At enrollment, set a quit date within 2 weeks/coming Monday OR enter program with no date

Frequency is high; integrated with Text4Baby

Cost: All texts are free to user

Future: App will be available in 2016

Text4Baby Core Partners:

Outreach Partners:

Telecoms industry support:

35

N=900,000+ subscribers

since launch (2011)

CMS pays for Quit4baby

as add on service in 4

states

300+ enrolled in

Quit4baby

text4baby: Ask your

baby’s doctor how

vaccines protect

your newborn right

from the start. Learn

more at

text4baby.org

Quit4baby: If your

friends light up around

you remind them that

you’re pregnant and

that you do not smoke.

They should get the

hint. Reply TIP for

more tips.

Text4baby+ Quit4baby

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Whittaker et al. Meta-Analysis. Cochrane. 2012

RR 1.7; 70% increase over control

Evidence : Text messaging

Abroms et al. 2014 (N=503)

Abroms et al. Am J Prev Medicine. 2014

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 month 3 months 6 months

Text2Quit

Control

No

Sm

ok

ing

in

th

e P

ast

7 d

ays

30.5%

14.5%

33.2%

19.9%

31.7%

20.7%

US Preventive Services

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3 month follow-up; salvia sample

3 month follow-up; salvia sample

Weekly data from OB

& GYN Center on

pregnant smokers

GW Research staff call potentially eligible

participants (n=726) We enroll approximately 19% we contact (n=88)

Some are ineligible (n=182); Some refuse (n=115)

Intervention Group (SFM texts)

Control Group-1 text (Pamphlets and Quitline)

1 month follow-up 1 month follow-up

(6 month follow-up) (6 month follow-up)

SmokefreeMOM

Randomized Trial

“Liked how they stick with you, they don't give up on you even though I failed a number of times”

“To a certain extent, it made me accountable to not smoking more. Helped me stay on track.”

“Liked that they were informative, liked the facts, liked there was somebody that quit effectively.”

“Other people were telling me how they quit smoking; so when they had [SFM Lea] - they said how they controlled their smoking during the day - their quotes and their opinions.”

What, if anything, did you like about the messages?

“Some days, it was a lot of messages. A lot of them do repeat-it's the same stories. Stories about quitting are the same.

“I didn't like how they increased before the day before my quit date and it got annoying after awhile.”

“I don't think it helps; too frequent- reminded me of smoking.”

“Not sure as to whether it was human who really cared or whether it was an automated system - not knowing”

What, if anything, didn’t you like about the messages?

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Intervention Control 1-month 1-month

Measure Abstained from smoking in past 7 daysa,b,c

24% 21%

Abstained from smoking in past 30 daysa,b,c

12% 0%

Number of continuous days quitb

13.0 9.4

Banned smoking from their homeb

66% 58%

Banned smoking from their carb,c

63% 35%

Smoking-Related

Outcomes

Program Data: Days Enrolled

0102030405060708090

100

Fre

qu

ency

Days

~30% unsubscribe in first week

N=480 Abroms LC, Leavitt LE, Schindler-Ruwisch JM, Augustson, EM. 2015

Text4Baby Core Partners:

Outreach Partners:

Telecoms industry support:

45

N=900,000+ subscribers

since launch (2011)

CMS pays for Quit4baby

as add on service in 4

states

300+ enrolled in

Quit4baby

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Three messages tested for study recruitment:

Quitting smoking is tough but it's easier with help

Want FREE messages to help you quit smoking?

If you smoke, it's important to quit. You'll be proud you did!

4,593 text4baby subscribers were sent a message

301 (6.6%) replied to the recruitment message expressing interest,

44% (133) were reached by phone for follow-up

47% (63) were enrolled.

enrollment was ~1.6% of those sent a message

Quit4baby Enrollment

Abroms, Turner, Schindler-Ruwisch, Leavitt, Johnson,

Obi, Cleary 2015

Evidence for efficacy is solid in adult smokers

Evidence emerging in pregnant smokers

Program data suggests

Need further develop enrollment machine (reach is still low)

Text4baby is promising

UK is developing method for integrating into NHS

High unsubscribe rates suggest additional adjustments needed for existing subscribers

Text Messaging Conclusions

Smartphone Apps

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Overview of Programs

Text

Quit4baby (Abroms et al.)

SmokefreeMom (Abroms et al.)

MiQuit (Naughton et al. )

SMAT (Van Mierlo et al.)

SGR (Pollack et al.)

App

Quit for You; Quit for Two (10,000-50,000 downloads)

Smokefree Baby (100-500 downloads)

Sampling Process

100,000+

Apps in

iTunes Store

71

Apps

52

Apps

47 Apps in

Sample

Power Search for “quit smoking”, “stop smoking”, and “smoking

cessation”

Assess

relevance

from app

description

Download available apps

Smartphone apps: Emerging Evidence

CBT 28-day program:

Ubhi HK1, Michie S, Kotz D, Wong

WC, West R. 2015

Acceptance & Commitment Theory:

Bricker JB, Mull KE, Kientz JA,

Vilardaga R, Mercer LD, Akioka KJ,

Heffner JL 2014

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Overview of Programs

Text

Quit4baby (Abroms et al.)

SmokefreeMom (Abroms et al.)

MiQuit (Naughton et al. )

SMAT (

SGR (Pollack et al.)

App

Quit for You; Quit for Two

Smokefree Baby

Fun craving tool:

•Bouncing Baby game

(Doodle Jump)

•Baby Boogie game

•Baby Bubble game

•Baby name selector

•Breathing yoga exerciser

Set up: pick your baby avatar and name

•Week-by-week facts about your baby's

development

•Daily savings announcements based on money

not spent on smoking

(n=10,000-50,000 downloads)

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Baby Bubble game

•Baby name selector

Daily savings announcements based on

money not spent on smoking

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Cessation programs should:

Ask for tobacco use status

Advise every user to quit

Assess willingness to quit

Assist with a quit plan

Recommend approved meds

Practical counseling

Intra-treatment social support

Connect to a quitline

Enhance motivation

Arrange for follow-up

Popular Smoking Cessation Apps

Overall Low Adherence: 12/42

Present in Apps (>50%)

Specific to smoking

Interactive

Personalized Advice to Quit

Ask for tobacco status

Lacking in Apps (<20%)

Practical counseling on how to quit (19.4%)

Social support (17.3%)

Text alerts (12.2%)

Recommend meds (4.1%)

Connecting to a quitline (0.0 %)

Abroms et al. 2013

N=98

N=10,000-50,000

downloads

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Evidence for efficacy is emerging in adult smokers, tho most apps have low adherence to USPHS-CPG

No evidence in pregnant smokers

Program data suggests

Some promising enrollment models

Australia’s Quit for you; Quit for two

Further study to see how app used once downloaded

App Conclusions

Conclusions

To call these programs a success, need ….

Reach Availability,

Enrollment machine,

Subscribers/ Downloads, sustained users

Efficacy Quit attempts, days without smoking, cigs smoked/day, quitting

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Integration with health systems supplement in-person clinician, phone counseling and other

traditional models EHR Medicaid integration

Outside health system: Packs of cigarettes with mCessation on the warning label Text4baby

Next Generation of Programs Smartphone apps integrated with texting Sensors—track opening a pack of cigs; lighter Games Social Media iWatch apps

The future… To quit, text “Quit” to 47848

One Resource

Thank-you!

Contact Lorien@gwu.edu

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Enrollment through a registry model Identify patients from EHR

Send invitation SMS

Patient opts-in

GW MFA: Get SMS to

improve your

health. Reply

1 for info on quit smoking

program, 2 for weight loss

and 3 for physical

activity.

Design Considerations

+Spohr et al. 2015; ^Head et al. 2014

Effect

•Message tailoring and

personalization ^

•Decreasing vs. fixed

message frequency ^

No Effect

•Text plus other

modality. +^

•Extra protocols of

messages

•On Demand messages

•Social/peer to peer

messages