mhealth tools for smoking cessation · motivation i over last two decades, widespread efforts to...
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mHealth tools for smoking cessationJacobs Center - CCWD 2018 Workshop
Séverine Toussaert (U. of Oxford)
November 5, 2018
Acknowledgments
Study Team:I Justin S. White, PhD, University of California, San FranciscoI Johannes Thrul, PhD, Johns Hopkins UniversityI Lee Westmaas, PhD, American Cancer SocietyI Jeuneviette Bontemps-Jones, MPH, American Cancer SocietyI Lorien Abroms, ScD, George Washington University
(Some) Study Partners:I Erik Augustson, National Cancer InstituteI Sydney Sattell, Wellpass (previously Sense Health), Inc
Funding: American Cancer Society
Motivation
I Over last two decades, widespread efforts to expand access tosmoking cessation aids.
I Yet, 2/3 of quit attempts still occur without treatment.
I Barriers: restricted assess, high costs, inconvenience.
I mHealth technologies can reach large population at low cost.
I Smokers are increasingly using their smartphone for cessationsupport:
I 1.2 million Android app downloads per month (Abroms 2013)
MotivationI Typical app (Smoke Free):
I Rarely evaluated, poor concordance with medical guidelines.I Support often less targeted and less personal.
What we propose
Our long-term goal is to design a custom smartphone app with 2innovative features:
1. Peer mentoring
I Users supported through messages by peer mentor.I Peer mentor = former smoker who quit successfully.
Status: Results from first RCT presented today.
2. Game-based environment
I Users enroll in 7-day quit challenges.I Mentor and users accumulate points for engaging with the app.I Points translate into non-monetary rewards.
Status: Ongoing (design stage)
What we propose
Our long-term goal is to design a custom smartphone app with 2innovative features:
1. Peer mentoring
I Users supported through messages by peer mentor.I Peer mentor = former smoker who quit successfully.
Status: Results from first RCT presented today.
2. Game-based environment
I Users enroll in 7-day quit challenges.I Mentor and users accumulate points for engaging with the app.I Points translate into non-monetary rewards.
Status: Ongoing (design stage)
Why interesting? (1)
I Widespread adoption of peer mentoring for health promotion.I AA, Weight Watchers
I Lack of rigorous evaluation and existing evidence is mixed(Webel et al. 2010)
I Westmaas (2010) points to ceiling effects, different definitionsof social support, mechanisms not examined
I Yet, reasons to believe in efficacy (Gale 2018):1. Informational channel2. Emotional pathway3. Social pressure and accountability
I More so if strong connection between mentor and mentee:
) study how similarity affects engagement and likelihood of quitting.
Why interesting? (2)
I Incentive-based behavioral interventions can promote cessation.I Volpp et al. (2009), White et al. (2013), Halpern et al. (2015)I Leverage behavioral science concepts such as loss aversion or
present bias.
I Gamification for health behavior change still fairly uncommon.I SuperBetter (.5M users), KwitI But lack of rigorous evaluation.
I Two distinguishing features of our incentive scheme:1. Incentives with surprise elements: keeping novelty up2. Focus on identity and image concerns: keeping esteem high
Outline
1. Results from RCT focused on peer mentoring
2. Discussion of next steps involving gamification
Peer mentoring via text messages
I We conducted an RCT to test the effectiveness of peermentoring for smoking cessation delivered via text messages.
I We study (i) preferences for peer mentors; (ii) whether successdepends on the similarity between mentor and mentee.
1. Preference for similarity:I Do smokers have a preference for a mentor more similar to
themselves? If so, what dimensions of similarity matter?
2. Importance of similarity for success:I How does similarity impact engagement and likelihood of
quitting?
Sample and design
I Recruit 200 U.S. adult smokers whoI want to quit within 30 daysI do not use NRT or e-cigsI agree to take a salivary cotinine test
IControl group: receives automated text messages used inSmokefreeTXT (developed by National Cancer Institute)
I 1-5 messages per day for up to 8 weeksI Messages include encouragement, advice, and tips for quitting
ITreatment group: receives similar automated messages +personalized messages from a peer mentor.
I Follow-up at 3 months (self-report + saliva test)
Text messaging intervention
Our peer mentors
I Peer mentor: former smoker who quit successfully at least 6months ago.
I Good diversity in terms of socio-demographic characteristics.
I 36 mentors assigned 3 smokers each. Assignment is random.
I Had to complete a 2-hour online training and create a profilepage.
I Incentives: $50 for training, $150 for mentoring + entry in$1,000 lottery drawing (additional entries if mentees quit)
Preferences for peer mentors
I Before assignment to treatment, smokers complete a baselinesurvey gathering data on their preferences for a peer mentor.
I 7 characteristics considered:
1. Demographic variables: gender, age, race/ethnicity2. Smoking-related variables: heavy/light smoker, reason for
smoking, reason for quitting, method used to quit
I Smokers asked to rank 7 dimensions in order of importance.
I For each dimension, also asked to express a preference.I choice from a list of categoriesI option “no preference” available
Baseline characteristics
Intervention effects on abstinence
10.6 points *
13.1
23.8
0
10
20
30
Perc
ent a
bstin
ent
ControlGroup
MentorGroup
A. Self-report(unadjusted)
12.7 points **
12.8
25.5
ControlGroup
MentorGroup
B. Self-report(adjusted)
4.9 points
3.0
7.9
ControlGroup
MentorGroup
C. Verified(unadjusted)
6.5 points **
2.5
9.0
ControlGroup
MentorGroup
D. Verified(adjusted)
Abstinence over time
0.00.10.20.30.40.5
Prop
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Panel A. Any Response to Abstinence Questions
0.000.050.100.150.20
Prop
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0 20 40 60 80
Panel B. Abstinence (Intent-to-Treat)
0.00.20.40.6
Prop
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0 20 40 60 80Day
Panel C. Abstinence (Responses Only)
Control Mentor
Mood over time
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Panel A. Any Response to Mood Questions
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Panel B. Good Mood (Intent-to-Treat)
0.00.20.40.6
Prop
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Panel C. Good Mood (Responses Only)
Control Mentor
Cravings over time
0.00.10.20.30.40.5
Prop
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Panel A. Any Response to Craving Questions
0.000.050.100.150.20
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0 10 20 30 40
Panel B. Low Craving (Intent-to-Treat)
0.00.20.40.6
Prop
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0 10 20 30 40Day
Panel C. Low Craving (Responses Only)
Control Mentor
Engagement
Preference for similarity with peer mentor
54 ***
35
21 **
49 ***
50 ***
52 ***
36 ***
17
28
12
32
23
25
17
Age
Gender
Race/ethnicity
Smoking intensity
Reason for smoking
Reason for quitting
Quit method
0 10 20 30 40 50 60 70 80 90 100Percent preferring similarity
Observed Random shuffle
Heterogeneity in preferences: age
Heterogeneity in preferences: gender
Summary (1)
1. It is feasible to train former smokers to act as peer mentors
2. Peer mentoring improves smoking abstinence at 3 monthsrelative to automated texting
I Verified abstinence: ↑ 5-7 points over 3% baseI Self-reported abstinence: ↑ 10-13 points over 13% base.
3. Smokers display a strong preference for mentors who aresimilar to themselves.
I Though we find heterogeneity in preferences, e.g., by gender.I “Smart” matching algorithms may help attract and retain users
of dyadic programs.
Summary (2)
I Similarity of own vs. mentor attributes did not strongly predictabstinence or engagement.
I However, the study findings need to be replicated in a larger,more diverse sample.
I The social interactions may not have been intense enough foreffects to appear.
I Mentees did not remember their mentor’s attributes very wellwhen quizzed in endline survey.
I A wider range of attributes also merit attention.
I Currently analyzing content of conversations to gain moreinsights.
Next steps
I Develop a prototype for a gamified app
I Game based on “quit challenges”I Commitment for short duration of 7 daysI Focus on early stage, small steps: “foot in the door”
I Engaging with the app unlocks rewards:I Points for completing various “missions”I Missions emphasize both processes and outcomes
I Integration with a carbon monoxide sensor connected to phoneallowing for personal monitoring.
CO sensor
Virtual rewards
Points from missions completed allow to:
1. Unlock new territories and play new “mystery” gamesI Curiosity, preference for non-instrumental information
2. Make digital pet grow:I Identity: symbol of transformationI Increases sense of accountability (good for teenagers?)
Virtual rewards
Points from missions completed allow to:
1. Unlock new territories and play new “mystery” gamesI Curiosity, preference for non-instrumental information
2. Make digital pet grow:I Identity: symbol of transformationI Increases sense of accountability (good for teenagers?)
Surprise and curiosity
Combining peer mentoring and gamificationI Importance of building self-esteem capital both for users and
mentors.
I For mentors:I Of course, social preferences - stronger for mentees who feel
“closer”I Commitment value of being a role model: “keep being
awesome”I Status concerns: leaderboard with list of top mentors
Discussion
I Game play as substitute for smoking?I “Temptation bundling”I Substituting one addiction for another?
I Building confidence through game playI Transfer from virtual to real world?
I MonitoringI Necessary? Detrimental?I Importance of feedback, but danger of reminders