Nicotine & Tobacco Research Advance Access published April 7, 2015 Nicotine & Tobacco Research, 2015, 1–7 doi:10.1093/ntr/ntv061 Original investigation
Original investigation
Cross-Cultural Adaptation of a Text Message-Based Program for Smoking Cessation in Buenos Aires, Argentina Downloaded from http://ntr.oxfordjournals.org/ at University of Otago on October 29, 2015
Lisandro D. Colantonio MD, MSc1,2, Lorena Peña BS3, Robyn Whittaker MBChB, MPH, PhD4, Raul M. Mejia MD, PhD2,3 1 School of Public Health, University of Alabama at Birmingham, Birmingham, AL; 2School of Medicine, University of Buenos Aires, Buenos Aires, Argentina; 3Centro de Estudios de Estado y Sociedad, Buenos Aires, Argentina; 4 National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
Corresponding Author: Lisandro D. Colantonio, MD, MSc, School of Public Health, University of Alabama at Birmingham, Ryals Public Health Building, 1665 University Boulevard, Birmingham, AL 35294-0022, USA. Telephone: 205-934-6041; Fax: (205) 975-7058; E-mail:
[email protected] Abstract Introduction: Few individual-level nonpharmacological interventions are available in Argentina to support smokers who attempt to quit. Methods: We conducted a cross-cultural adaptation of Stop Smoking with Mobile Phones, an English text message-based tobacco cessation program, in Buenos Aires. The process included English–Spanish translation and back-translation, face validity checking by two local tobacco cessation experts, and a complete review using a structured questionnaire and discussion groups with potential users (current smokers who want to quit or former smokers who quit in the past 6 months). An editing group was responsible for analyzing information collected and preparing adapted messages. Readability of final messages was assessed. Results: Tobacco cessation experts found translated messages suitable for the local setting, although mention of “mate” (a local infusion which can trigger cravings) was recommended. Review of messages by two potential users confirmed most of the messages would help smokers to quit and resulted in minor edits. Potential users who participated in two discussion groups (n = 17, 64.7% female, age range: 30–73) found the content of messages was relevant for cessation and related to their own experiences, although they suggested adding information regarding the negative consequences of smoking. Participants emphasized that messages should be formatted using voseo and informal style and provided feedback on specific words and expressions. Readability of final messages was easy/very easy (Fernández Huerta Index: 79.93). Conclusion: The cross-cultural adaptation of Stop Smoking with Mobile Phones resulted in relevant revisions for the study population, including tone, wording, and pertinent information (eg, smoking consequences). Local acceptability and effectiveness should be confirmed in future studies.
Introduction In Argentina, tobacco use produces 13.6% of total deaths and accounts for 926,878 Quality-Adjusted Life Years lost every year,1,2 representing one of the most important issues for public health in the
country. As a consequence of population-level tobacco control policies implemented, national smoking prevalence has reduced from 29.7% in 2005 to 25.1% in 2013.3,4 Although motivation to quit smoking may have increased following population-level tobacco control policies, few individual-level
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Institute for Health Innovation, University of Auckland. The program has been described elsewhere.9–12 STOMP includes a text message database and a delivery system (Supplementary Figure 1). The standard program contains messages that are automatically delivered over a 26-week period (Table 1). Messages include preparation tips before the quitting day, information on symptoms expected after quitting, tips to avoid weight gain and improve nutrition, tips to cope with cravings, advice on avoiding smoking triggers, motivational support, and distraction. In addition, early and late relapse programs as well as single on-demand messages for cravings can be triggered by text messages from participants containing specific keywords. The program also contains some miscellaneous messages, including messages for the registration process, opting out, as well as scheduled smoking status assessments. The number of total messages has changed over time. The most updated version of the database at the time this study was conducted contained a total of 601 nonunique messages (some messages were repeated in different program components).
Smoking Cessation Intervention
Cross-Cultural Adaptation Process
STOMP is a text messaging smoking cessation program developed in English by the Clinical Trials Research Unit, now the National
We used a flexible and dynamic approach with a circular design in order to adapt STOMP messages. The adaptation process included four steps: (1) translation and back-translation; (2) face validity
Participants We included current smokers, smokers in the process of quitting and recent former smokers (quit in the last 6 months). Current smokers were included if they self-reported having decided to quit or having made a quit attempt in the last 6 months. We consider these individuals adequately represent the target population of STOMP and we refer to them as potential users. Additionally, participants were required to be 18 years or older, be born and living in Argentina, be a smoker for at least 1 year, owning a cell phone and using it to send/ receive text messages, and speaking Spanish. Participants were initially recruited from the smoking cessation clinic of the Hospital de Clínicas “José de San Martín,” University of Buenos Aires, and through Facebook (Facebook Inc., Menlo Park, CA). Subsequently, the sample was enhanced using a snowball method. The accessible population for this study was determined by residents of the Greater Buenos Aires area. The study protocol was approved by the Institutional Review Board of the Hospital de Clínicas “José de San Martín,” University of Buenos Aires. All participants provided written informed consent.
Table 1. Message Sequence From the STOMP Text Messaging Smoking Cessation Program Program component Standard program Pre-quitting phase Intensive phase Maintenance phase Early relapse programa Late relapse programa Craves program Miscellaneous
Timing and duration 2 weeks before the quitting day From quitting day to week 4 From week 5 to week 24 4 weeks 4 weeks On demand —
STOMP = Stop Smoking with Mobile Phones. a After quitting day.
Message rate 1–2 messages per day 3 messages per day 1 message every 3 days 3 messages per day 3 messages per day 1 message per demand, 50 messages maximum —
Total messages 21 87 60 85 85 251 12
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interventions are available to support quit attempts in Argentina. Local stakeholders and health decision makers have been reluctant to provide universal coverage of pharmacotherapy for smoking cessation.5 Smoking cessation counseling services are available in Argentina but they may not be accessible to all smokers. Other nonpharmacological interventions available to support smoking cessation include a national toll-free quitline, international Internet-based programs, and alternative therapies. Among current or former smokers who attempted to quit in the past 12 months, only 4.1%, 2.5%, and 2.9% used pharmacotherapy, counseling, or other methods, respectively.6 Mobile phones have been increasingly used for prevention and management of chronic diseases, with a focus on behavioral changes.7 Advantages of this technology include wide availability, low cost, personally tailored communication, and ability to deliver messages on demand.7,8 Stop Smoking with Mobile Phones (STOMP, HSAGlobal, Auckland) is a text message-based tobacco cessation program which has been shown to double quitting rates at 6 weeks as compared with unassisted quit attempts (28.1% vs. 12.8%, respectively, P value < .001) in a randomized controlled trial conducted in New Zealand.9 STOMP was adapted for the United Kingdom through review by smoking cessation counselors, cognitive behavioral therapists and participants in a series of focus groups.10 After adaptation, STOMP doubled biochemically verified continuous abstinence at 6 months versus unassisted attempts (9% vs. 4%, respectively, P value < .001) in a large randomized controlled trial.11 After a literature review and contact with STOMP developers, we found no evidence that a text message-based tobacco cessation program in Spanish was available. In developing/implementing a smoking cessation intervention is important to consider not only local language but also cultural aspects and users preferences. We conducted an English–Spanish translation and cross-cultural adaptation of STOMP messages in Buenos Aires, Argentina using a qualitative study design. Our main goal was to make locally available an additional nonpharmacological smoking cessation program. In preparing this study, we found very few examples of prior experiences conducting a cross-cultural adaptation of cognitive and motivational interventions for smokers. Therefore, we believe that our study could also provide valuable information for those interested in implementing smoking cessation programs in a different setting for which these interventions were originally developed.
Nicotine & Tobacco Research, 2015, Vol. 00, No. 00 checking; (3) complete review by potential users, and (4) discussion groups with potential users (Supplementary Figure 2). The adaptation process was overseen by an editing group which included two local experts in tobacco cessation (LDC and RMM) and a social scientist (LP). After each step, the editing group was responsible for reviewing all new information collected and deciding on modifications to translated messages. Decisions were achieved by consensus.
Translation and Back-Translation
Results After excluding duplicates, 327 unique messages were translated to Spanish and then back-translated to English. After contrasting original and back-translated messages, 244 (74.6%) translated messages remained without changes, 69 (21.1%) messages had minor edits (changes in wording or punctuation without changing the meaning) and 14 (4.3%) had major edits (change in the meaning).
Face Validity Checking Methods Two local experts on tobacco cessation (LDC and RMM) reviewed all translated messages, independently. Experts were aimed to provide a global assessment of translated messages and their suitability for the local setting, including relevance, appropriateness, and completeness. Final assessment was achieved by consensus between the two experts. Results Tobacco cessation experts found translated messages relevant and appropriate for being used in the local setting and no major missing topics were identified. Only minor edits were considered necessary. For example, messages were modified to include “mate” tea (Ilex paraguariensis), a popular infusion in Argentina with a high caffeine concentration,13 in the list of smoking triggers. Tips for healthy snacks were also reviewed to ensure they were in accordance to local food preferences and availability, but no changes were made.
Complete Review by Potential Users Methods A complete review of messages by potential users was conducted, which aimed to assess whether messages were easy to understand and would help local smokers to quit. Messages and topics considered potentially problematic were also identified. Potential users were invited to read all translated messages and then complete a structured questionnaire. For each message, participants were asked if they understood the meaning, if they considered the message would help them to quit smoking, if they would draft it in a different way and how. Participants were allowed to include a free comment for each message. The decision to end the
complete review of messages was made by consensus by the editing group when the amount of new information that was expected to be retrieved by including more participants was considered small. Results Two potential users reviewed all the messages and completed the structured survey in May 2012. Demographic characteristics of reviewers are shown in Table 2. Reviewers considered that most of the messages would help smokers to quit. Only 26 (8.0%) messages were found to not be helpful by at least one reviewer, including 10 (3.1%) miscellaneous messages. We also identified three (0.9%) messages that were not understood and 44 (13.5%) messages that were recommended to be drafted differently by at least one reviewer. A reviewer indicated that the expression “text… to…”, used to inform about interactive components for cravings and relapses or how to stop the program, resembled advertisements from commercial text message-based programs available in Argentina (eg, programs delivering horoscope or poems). These programs had a negative reputation and the reviewer associated these messages with a “scam.” In addition, a reviewer disliked the expression “to quit forever” used in some messages. These messages were further explored in the discussion groups. The editing group decided to end the complete review of messages after analyzing information retrieved from two potential users and the face validity checking. After this analysis, the editing group considered that the vast majority of messages were appropriate and will most likely remain unchanged after further review. Changes made on messages after this step were minor (grammar issues).
Discussion Groups With Potential Users Methods Discussion groups with local potential users were conducted to inform the final adaptation of STOMP messages. The editing group considered it unfeasible to review all translated messages during group discussions. Therefore, the editing group selected those messages considered most representative of potential issues detected in prior steps. Messages were selected for discussion if (1) they were found potentially problematic, unclear or unsuitable after reviewing all data collected in prior steps; and (2) additional information from potential users was considered relevant to inform the final adaptation. A total of 20 messages were selected for discussion with potential users. During the meetings, participants received printed copies of the messages which were read aloud separately to trigger the discussion. Participants were instructed by a coordinator to freely comment on the messages. To initiate a discussion, the coordinator asked if participants found the messages understandable and helpful for quitting. Participants were instructed to suggest changes that they considered could improve the messages and their reasons. For some messages, more than one alternative was presented and participants were asked why they would prefer one or the other. If the reasons why these messages were included in the discussion groups did not emerge after the initial talk, the coordinator asked directly about these points to participants. At the end of each discussion group, participants were asked if they would be willing to participate in the STOMP smoking cessation program. Meetings were coordinated by a social scientist (LP) with extensive experience conducting discussion groups and recorded for further analysis. Discussion groups were planned to last between 1 hour and 1 hour and a half and to include between six and 12 participants each. Two discussion groups were initially
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Methods Repeated messages were identified and excluded. Original unique messages were translated to Spanish by a native Spanish speaker translator born in Argentina, and back-translated to English by a native English speaker translator born in Australia. Original and back-translated messages were contrasted in order to identify translation discrepancies and errors. When discrepancies were detected, translated messages (in Spanish) were reviewed and modified (if needed) in order to match original messages.
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Table 2. Demographic Characteristics of Potential Users Who Participated From the Complete Review of Messages or Discussion Groups (n = 19) Participant ID
Gender
Age when started smoking
Smoking statusa
Social insurance Private insurance
Administrative Professional
14 15
Former smoker Former smoker
Secondary school (C) University (I) Tertiary school (C) Tertiary school (C) University (C) Secondary school (I) Tertiary school (C) Tertiary school (C) Secondary school (C) Tertiary school (I) Secondary school (I)
Private insurance Public health system only Private insurance Private insurance Private insurance Social insurance Private insurance Private insurance Private insurance Private insurance Private insurance
Self-employed Unemployed Administrative Supervisor Professional Retired Administrative Housewife Administrative Technician Administrative
50 18 16 12 11 50 22 24 23 17 25
Former smoker Current smoker Quitting Quitting Former smoker Current smoker Current smoker Current smoker Current smoker Former smoker Current smoker
Tertiary school (C) University (C) Tertiary school (C) University (C) University (I) Secondary school (C)
Private insurance Social insurance Private insurance Social insurance Public health system only Public health system only
Housewife Professional Student Professional Merchant Housewife
20 18 20 16 17 18
Current smoker Current smoker Former smoker Current smoker Quitting Former smoker
Highest education level
54 25
Tertiary school (C) Tertiary school (C)
62 47 31 42 63 73 34 39 47 36 39 33 37 30 42 59 44
Health insurance
C = complete; I = incomplete. a Current smoker definition include participants self-defined as current smokers who referred having decided to quit, or reported having made a quit attempt in the last 6 months prior to the recruitment. Quitting definition includes participants who reported were attempting to quit at the time of enrollment. Former smoker definition includes self-defined former smokers who referred having quit in the last 6 months prior to the recruitment.
scheduled. The editing group was responsible to decide whether obtaining more information was needed to inform the final adaptation of STOMP messages and to schedule additional discussion groups accordingly. Recordings and transcripts from discussion groups were analyzed by two researchers (LDC and LP) who used ad-hoc categories to code related information provided by participants. Categories were grouped into domains. The analysis was conducted using Atlas.ti v.7. Results A total of 17 potential users participated in two discussion groups conducted in October and November 2012. Participants were mostly female (11 participants, 64.7%), with age range 33 to 73 years, secondary school education or higher, and active workers (Table 2). Domains identified during the analysis of discussion groups included: (1) message content; (2) message style; (3) words and expressions; and (4) STOMP cessation program (Figure 1). We also identified comments or suggestions that were used to improve specific messages. The Supplementary Table contains a list of quotations from the discussion groups that illustrate the main findings described below. No major discrepancies were observed between responses from men and women nor between younger and older participants. The editing group decided to proceed with the final adaptation of STOMP messages after completing the two initially scheduled discussion groups as they provided similar and consistent results.
Message Content During meetings, the content of messages triggered the discussion about personal experiences from participants. They talked about their reasons for quitting smoking, including family, relatives with tobacco-related diseases, and concerns regarding health risks. They also talked about their personal experiences during past/current quit attempts. Participants considered that some of the elements contained in messages were very important during cessation, including preparation for cravings and identification of triggers such as drinking coffee or “mate” tea, or remaining sitting at the table after eating. Potential users also identified messages with recommendations for exercising and maintaining a healthy diet as important to avoid weight gain. Participants indicated they felt motivated by changes described in some messages, including recovery of taste and smell, lack of smoke smell on clothing, and improvements in skin and hair. Some participants noticed that messages did not contain information about negative consequences or health risks associated with smoking. They pointed out that they would like to receive this kind of message to motivate them during cessation. Messages Style Some participants considered that the tone of messages was soft or naïve and they need something more shocking to help them to quit. However, this idea was disliked by other participants who mentioned they usually avoid or overlook this kind of message. Participants also emphasized that messages should be written using voseo (Spanish variety commonly used in Argentina and in other Latin American countries) and an informal style (known as “tuteo” in Argentina).
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Complete review of messages 1 Male 2 Male Discussion group #1 1 Male 2 Female 3 Female 4 Male 5 Female 6 Female 7 Male 8 Female 9 Female 10 Male 11 Female Discussion group #2 1 Female 2 Male 3 Female 4 Female 5 Male 6 Female
Position/job
Age
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Words and Expressions We identified a few number of words and expressions that were considered inappropriate or disliked by participants from discussion groups. Participants associated the word “antojo” (translation for craving) with pregnancy cravings or having a desire for something (especially food). They considered this word does not reflect the anguish and anxiety they feel when having cravings and suggested using the word “desesperación” (desperation) instead. A few participants did not like the expression “to quit forever” contained in some messages. These participants prefer to see smoking cessation as a day-by-day process and may be reluctant to consider making a long-term effort. We also found that most participants associated the expression “text… to…” (enviá … al…) with a prank or scam from television advertisements. Finally, definitions like “deslices” (slip-ups, when someone smokes just once and then continues on cessation) and “recaida” (relapse, when someone starts to smoking regularly again) were accepted although participants were not able to spontaneously identify differences on the meaning without a prior explanation. STOMP Cessation Program Participants stated they would like to participate in the STOMP cessation program. They considered that this program could be a good option for individuals who cannot attend a smoking cessation clinic or other support interventions such as cessation groups or meetings. In addition, participants mentioned that the program could be improved by including multimedia material. They also suggested that STOMP could be used in combination with other smoking cessation tools as for example a supporting Website.
Final Messages and Readability Methods Final adapted messages were prepared by the editing group and limited to 130 characters in order to use an encoding system that includes Spanish characters as ñ and vowels with accent marks or tildes. If necessary, new messages were prepared by STOMP developers (RW) and adapted by the editing group. Some adapted messages were used to replace repeated messages from the original STOMP database. Readability of final messages in Spanish was assessed using the Flesch–Szigriszt Index, the Fernández Huerta Index, and the Inflesz scale. Readability indexes were measured using Inflesz v1.0 (Inés Mª
Table 3. Readability Statistics From Final Cross-Culturally Adapted Messages Statistics/results Syllables/word (average) Words/sentence (average) Flesch–Szigriszt Index Fernández Huerta Index Inflesz scale
1.98 7.85 75.53 79.93 Very easy
Barrio Cantalejo and Pablo Simón Lorda, Andalusian Health Service and Andalusian School of Public Health, Granada, Spain, respectively; available from: http://legibilidad.com/home/descargas.html). A Flesch–Szigriszt Index of 55–65 indicates that the text readability is adequate or normal, with higher values indicating the text is easier to read.14 A Fernández Huerta Index of 90–100 or 80–90 indicates that the text readability is very easy (suitable for children 5 years of age) or easy (suitable for children 6–8 years of age), respectively.14 Results from the Inflesz scale are provided in a nominal scale. Results Final messages were prepared taking into account all information collected through the study. Changes in messages included adding facts about negative consequences of smoking and explicit definitions for slip-ups and relapse, changing the translation for cravings and avoiding expressions like “to quit forever” or “text… to…”. No changes were made in the tone of messages to make them more shocking since the editing group considered this may negatively affect the acceptability of STOMP. Final messages were formatted using voseo and an informal style. The adapted STOMP database contains a total of 601 messages (340 unique messages, including 13 new messages about negative consequences of smoking) distributed as reported in Table 1. Readability of final messages was characterized as easy/very easy using Inflesz v1.0 (Table 3). A second set of messages, using formal style, without voseo and excluding reference to “mate” tea, was also prepared in order to facilitate future adaptations to other Spanish speaking countries.
Discussion We conducted a translation and cross-cultural adaptation of STOMP in Buenos Aires, Argentina. After translation, most of the messages
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Figure 1. Mind map of domains (dark grey) and selected categories (light grey) used during the analysis of discussion groups.
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of participants included in the study were small. This makes it difficult to evaluate if we reached saturation of the information that can be retrieved from potential users. Third, a few number of messages were selected by the editing group to be analyzed through the discussion groups. The adaptation process could have been improved by discussing all messages with potential users. Finally, generalizability of our results could be limited since we included a relatively homogeneous population. Further adaptation may be needed to implement STOMP in underrepresented subpopulations as for example Native Americans or individuals with low education. Despite these limitations, we consider that the adapted version of STOMP could provide adequate support for many smokers who want to quit in Argentina. Participants in our study were residents from the Greater Buenos Aires area and most of them had secondary school education or higher. According the last census conducted in Argentina, 89.9% of the population lives in urban areas and 55.3% of all adults 20–69 years of age have secondary school education or higher.20 In particular, the Greater Buenos Aires encompasses 37.9% of all smokers 18 to 65 years of age in Argentina21 and has a substantial cultural influence over other urban conglomerates in the country as most TV shows and important newspapers are produced in this area. Finally, readability of final messages was characterized as easy/very easy, suggesting that the adapted version of STOMP may be also suitable for smokers with lower education. Our study highlights the importance of conducting a formal cross-cultural adaptation when implementing cognitive and motivational interventions for smoking cessation that were developed in other settings. In our analysis, a simple translation of STOMP would have resulted in inappropriate messages, which may negatively affect the local acceptability of the intervention. A few number of participants were included in our study as our initial assessment of translated STOMP messages found most of them required only minor edits. Those interested in conducting a cross-cultural adaptation of STOMP in other populations may need to include a larger number of potential users if more issues are detected. Implementing the adapted version of STOMP in Argentina could provide additional information about the local acceptability of the intervention since a larger number of smokers would experience the program while quitting. This may result in further relevant revisions. Future assessment of the local effectiveness of STOMP is also warranted.
Supplementary Material Supplementary Table, Figures 1 and 2 can be found online at http:// www.ntr.oxfordjournals.org
Funding This study was funded by the Research Training Program on Tobacco Control in Argentina (CICTA). The CICTA Program was supported by Grant 103460-076 from the Teasdale-Corti Global Health Leadership Award, the International Development Research Centre, Canada.
Declaration of Interests None declared.
Acknowledgments STOMP was developed by the University of Auckland, New Zealand and licensed to HSAGlobal, New Zealand. Neither IDCR nor HSAGlobal participated in the study design, analysis, writing, or decision to publish.
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were found appropriate and suitable to support smoking cessation by two local tobacco cessation experts and two local potential users, requiring only minor edits. Further analysis of selected messages through discussion groups with potential users resulted in relevant revisions for the study population, including tone (eg, use of “voseo”), wording (eg, replacement of the word “antojo”), and pertinent information (eg, including messages about negative consequences of smoking). Although most of the messages were found appropriate to support smoking cessation, our analysis identified a few issues that could have negatively affected the acceptability of STOMP when implemented locally. This includes the use of the word “antojo” for cravings or the expression “text… to…”, which was associated with a prank or scam. In addition, discussion groups revealed a lack of information on negative consequences associated with smoking in STOMP messages. Hormes et al.15 have previously reported that many languages lack of an appropriate translation for the word “craving.” Although authors found in two separate studies that the Spanish word “antojo” can be used as a synonym for “craving,” results from our analysis indicate this is not considered appropriate by all smokers who speak Spanish, and some cultural differences may exist. Those interested in implementing STOMP or other smoking cessation program for individuals who speak Spanish should be aware of this potential limitation and revise their interventions accordingly. STOMP originally contained several messages with information about the health risks associated with smoking. These messages were removed from the version used for the present study since users from countries where the program was implemented reported being overexposed to this kind of information (Whittaker R, personal communication). However, this may not apply to other countries, particularly those where tobacco control policies have been only recently or partially implemented. In Argentina, implementation of tobacco control policies was long-delayed due to the resistance from tobacco companies.16,17 A national tobacco control bill, including a complete advertisement ban and smoke-free environments, was finally passed in 2011.18 Use of pictures as health warning labels on tobacco packaging was mandatory 1 year later, just a few months before the discussion groups were conducted. Participants from discussion groups expressed being stunned by these warnings, suggesting that potential users in Argentina may be more receptive to messages about negative consequences of smoking. Participants from discussion groups considered using STOMP alongside other interventions to support smoking cessation. Text message-based programs may increase long-term abstinence when added to routine smoking cessation support in primary care.19 A combination of text message-based and Internet-based cessation programs was also found to be effective to increase smoking cessation rates in the long-term.8 Smokers in Argentina have access to a free quitline and a Website containing booklets and other information which are supported by the Argentine Ministry of Health (www.msal.gov.ar/tabaco/). Pharmacotherapy, counseling services, international Internet-based programs, and alternative therapies are also available in Argentina to support smoking cessation, although accessibility may be limited. The implementation of STOMP may provide local smokers a valuable tool for creating the best combination of programs based on their preferences and needs. Results from our study should be considered in the context of known potential limitations. First, our study cannot be considered as evidence that the adapted version of STOMP is effective in increasing smoking cessation rates. This should be assessed in future clinical trials. Second, the number of discussion groups and the total number
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