Smart Devices and a Future of Hybrid Tobacco Cessation Programs
Rachel Pulverman, BS, and Peter M. Yellowlees, MBBS, MD
Are Online and Mobile Applications Effective Tools for Tobacco Cessation?
Department of Psychiatry, University of California, Davis, Sacramento, California.
Given the importance of tobacco cessation, from a public health perspective, and the number of Web sites and smartphone ‘‘apps’’ now focused on this issue, it is remarkable that there is so little research published on the topic. The small amount of research available comparing tobacco cessation methods has found that online tobacco cessation programs are more likely to be successful than other methods of tobacco cessation, such as telephone programs, advice from general practitioners, and unassisted quit attempts, and may be more helpful if combined with them.3,5,6 In 2007, Saul et al.6 studied the effectiveness of their Web-based online cessation program compared with previous research on cessation methods. They found comparable quit results among participants in online programs and those using behavioralbased telephone quitlines, but concluded that the online programs would likely be more successful overall because of their accessibility. In 2008, Zbikowski et al.3 found that the number of Web log-ins for cessation programs was positively correlated with quit outcomes. In 2011, Hung et al.5 surveyed over 1,000 recent tobacco quitters and found online programs to have ‘‘high helpfulness,’’ albeit low use; they reported that online programs were more helpful than advice from a general practitioner. This study also found that online programs were used most commonly by those 31–50 years of age and least by smokers over the age of 51 years.5 The use of online methodologies in general is reportedly greater by women than by men,4 and Zbikowski et al.3 have attributed this to the social support that women wish to obtain online, such as from discussion forums. These findings overall suggest that the Internet and online applications may well be a good resource for tobacco cessation. Despite these findings, critics have argued that online information and information within mobile applications may be invalid and potentially harmful.7 In 2004, Bock et al. determined that 80% of currently available smoking cessation Web sites ‘‘did not cover one or more of the key components of cessation treatment as recommended by national guidelines’’; however, in their later 2008 study, Bock et al.7 found that the majority of the reviewed Web sites did now cover these guidelines. The latter study asked PhD-level specialists in tobacco cessation treatments to review the content of common smoking cessation Web sites and found that the majority of commonly used smoking cessation Web sites contained no inaccurate information.7 This research suggests that, although not all Internet content was reviewed and validated, the most commonly searched tobacco cessation Web sites did in 2008 provide sufficient information for the needs of tobacco users trying to quit. In 2009, Abroms et al.8 examined the content of 47 iPhone (Apple, Cupertino, CA) applications for smoking cessation and concluded that few adhered to proven strategies for smoking
Abstract The Internet and mobile ‘‘apps’’ on smart devices are increasingly being seen as primary tools to combat tobacco abuse with the development of several online tobacco cessation programs. This article reviews the small and recent body of research into the functionality and effectiveness of these Web-based programs, most of which are now being designed for mobile devices rather than for fixed computers. Based on current research findings, it is apparent that successful future tobacco cessation programs will utilize a wide variety of features available through smart devices and mobile applications, but will also incorporate the capacity to easily access live healthcare professionals as necessary, either online or in-person. These hybrid models of behavioral intervention for tobacco cessation appear likely to be more successful than previous approaches, but require more evaluation than has occurred in the past. Key words: tobacco cessation, smoking cessation, smartphones
Introduction
T
obacco is directly linked to the deaths of more than 5 million people per year worldwide and is the leading cause of preventable death in the United States.1 According to the Centers for Disease Control and Protection (CDC),2 over 45 million adults in the United States smoke cigarettes containing tobacco at an annual cost for smoking-related illness in the country of $96 billion.1 In response, healthcare providers have developed several innovative smoking prevention and cessation strategies, including the use of the Internet and smartphones. As early as 2006, approximately 9% of Internet users searched for online information about quitting smoking.3 Today, 85% of U.S. adults own a cell phone, and 53% of those cell phone owners use a smartphone, which can access the Internet and other applications.4 Recent findings suggest that 19% of smartphone owners have at least one health application on their phone.4 Although we do not currently know how many smartphone users attempt to search for online tobacco cessation programs, it is self-evident that smart devices have the potential to be used to provide cessation tools to tobacco users as well as educate the public on the risks of tobacco use.
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cessation. These investigators noted that very few of the applications recommended treatment or endorsed medications or counseling. In addition, the applications examined ‘‘did not connect users to anything outside of the app, like a quitline or clinic, or provide opportunities to reach out to friends and family for social support.’’8 This study suggested possible benefits through using mobile applications for tobacco cessation, but noted that at that time the available iPhone apps contained a lack of evidence-based strategies and connections with outside sources (such as other smokers, online communities, or healthcare professionals) known to be helpful. Civljak et al.9 undertook a Cochrane style review in 2010 to attempt to determine the effectiveness of Internet-based interventions for smoking cessation. Twenty trials met inclusion criteria, but these trials were heterogeneous for populations, interventions, and outcomes and allowed for very little pooling of results.9 The authors concluded that some Internet-based interventions can assist smoking cessation, especially if the information is appropriately tailored to the users and frequent automated contacts with the users are ensured; however, they noted that the trials did not show consistent effects.9 This first major review of the area confirmed the need for more methodologically sound research that has a strong conceptual and theoretical base and identified a general lack of quality and strength of the current published trials. In 2012, Whittaker et al.10 studied the effectiveness of multiple tobacco cessation programs that utilized combinations of mobile phone features. The group studied a text messaging intervention, an online QuitCoach, a combination of text messaging and online QuitCoach, and a video messaging intervention delivered via mobile phone.10 All of these interventions proved to be more effective than those smokers attempting to quit without utilizing their mobile phone’s features to do so.10 This study suggested that utilizing mobile technology, regardless of the specific features, is effective and supports the use of text messaging, video messaging, and Web-based applications.10 Because text messaging requires limited effort and is affordable, it may be the most effective feature of mobile phones for smokers to use when trying to quit with their healthcare providers.
link to many social networking sites so that patients may read and view motivational stories from former smokers and even interact with them, as well as with patients currently attempting to quit smoking. The U.S. Government has launched two free text messaging programs that contain some of the aforementioned features: SmokeFreeTXT14 and QuitNowTxt.15 SmokeFreeTXT (Fig. 1) provides ‘‘24/7 encouragement, advice, and tips to help smokers stop smoking.’’14 SmokeFreeTXT also allows individuals to respond to texts using key words to receive additional support.14 QuitNowTxt is a text messaging library for health departments, academic institutions, and government agencies to use when developing smoking cessation programs.15 The library includes day-specific messages and key word responses.15 For example, the keyword ‘‘BOOST’’ will prompt additional texts with positive messages for more difficult days.15 In 2012, the National Cancer Institute launched Quitpal,16 a free smartphone app that incorporates multiple tools to help change behavior and assist smokers with not giving up on their smoking cessation goal (Fig. 2). Quitpal includes an interactive calendar, reminders, graphs that track money saved and cigarette packages not smoked, text alerts, connections to social networking sites, the ability to create and view video diaries, and contact information for live health professionals.16 This impressive combination of multiple integrated smart device technologies and person-to-person counseling and assistance promises to be an effective method of tobacco cessation.
What Are the Most Promising Features of Online Programs and Mobile Applications for Tobacco Cessation? Mobile phone-based tobacco cessation programs have changed as the phones themselves have increased their capabilities and are now very creative, although seldom scientifically evaluated. A decade ago they relied on text messaging, but smartphones today have the capacity for applications with a variety of interactive features. Newer models of iPhones, for example, include forward-facing cameras and ‘‘FaceTime’’ videoconferencing software, which allows patients to see and interact with their healthcare provider from a remote location. Other mobile applications, such as QuitSTART,11 allow individuals to upload personalized ‘‘pick me ups,’’ such as family photos, to encourage patients to stay smoke free. Mobile applications such as Since iQuit12 and SmokeTrack13 simply track the amount of time since a patient has stopped smoking. Smartphone applications can
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Fig. 1. SmokeFreeTXT screenshot. Example of an iPhone text message from the SmokeFreeTXT program.15
HYBRID TOBACCO CESSATION PROGRAMS
because the concept is new and the accessibility and prevalence of smart devices are recent.
What Are the Disadvantages of Online and Mobile Tobacco Cessation Programs?
Fig. 2. QuitPal home screen. Example of a tobacco cessation mobile application that incorporates multiple uses of smart device technology, including goal setting, progress tracking, text alerts, access to social networking sites, and quick access to live health professionals.14
What Are the Benefits of Using Smart Devices and the Internet for Tobacco Cessation? The effectiveness of smart devices and the Internet results from their accessibility, ease of use, low cost, and time-saving opportunities.8 The Internet is available anywhere in the world, especially in isolated and remote locations where a person-to-person tobacco cessation program may not be available or an option. The Internet is inexpensive and is available for no cost in certain locations, such as public libraries, community centers, and schools. It requires limited travel time and may be accessed from one’s own home or via smartphone. The Internet is appealing because of its ‘‘24/7 ‘‘aroundthe-clock’’ availability.’’7 Internet programs and smartphone applications are generally simple and involve few keystrokes. Potential shortfalls from person-to-person tobacco cessation programs may be reduced in an online and mobile setting. Internet programs and smartphone applications allow for the confidentiality and anonymity, which studies have shown are especially important to young smokers who wish to quit.17 We also know from the work of Mohr et al.18 that ‘‘people tend to be more willing to engage in socioemotional communication in text-based media than in face-to-face communication.’’ Such programs also allow easy incorporation of known effective cessation techniques ‘‘such as individuals setting their own quit date, goal setting, reminders and motivational messages, advice, and information on what has been shown to be effective.’’17 Although there are many benefits to online and mobile cessation programs, proof of their effectiveness is still to be evaluated
There are some disadvantages to using the Internet and mobile applications for tobacco cessation, such as lack of personal contact and the learning curve associated with these programs. In 2008, Bock et al.7 found ‘‘a notable lack in using the capacity of the Internet for personalization of treatment.’’ They also found that the interactive capabilities were underutilized and follow-up contacts were not provided.7 Research by Smit et al.19 found their online smoking cessation program ineffective when they measured user’s abstinence after 6 months. The program was seen to be effective when measured after only 6 weeks, so they attributed the failure after 6 months to users who did not finish the program and lack of follow-up on users’ prescribed medications.19 Many individuals, especially those over the age of 50 years, are less likely to use the Internet or smartphones, partly because of the learning curve associated with them.4,5 It is important to note, however, that elderly patients interested in quitting smoking may still be easier to train to access the programs on their computer or smartphone compared with arranging for transportation to an in-person program.
Should Smart Devices Be the Primary Source for Tobacco Cessation? Research suggests that the most effective method of tobacco cessation is to leverage technology in conjunction with person-toperson cessation programs. In 2008, Zbikowski et al.3 found that quit rates were higher in an integrated telephone and Web program than in programs that used the Internet alone. An effective integrated program would include an online component, available to patients at all times for the purpose of setting goals, tracking progress, seeking motivation and support from peers, and obtaining tips and information. Counselors and other staff would be available to address technology and other concerns, ensure participation and reduce dropout rates, and remedy other shortfalls of the online program, as well as to see patients in person for tobacco cessation counseling as required. Similar integrative approaches were seen during the March–June 2012 National Tobacco Education Campaign, where the CDC aired stories from former smokers and encouraged tobacco users to call a quitline.20 This method of utilizing the mass media in conjunction with other education methods was seen to be effective in increasing quitline calls and traffic to smoking cessation Web sites.20 In 2011, Mohr et al.18 argued that human support enhances adherence to e-health interventions through ‘‘accountability to a coach who is seen as trustworthy, benevolent, and having expertise.’’ Furthermore, methods may be used in different sequences depending on the situation.18 E-mail may be used prior to a person-to-person meeting in order to prepare all parties involved.18 Mohr et al.18 concluded that ‘‘a choice of medium that is suboptimal by itself may make sense as part of a larger strategy.’’
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The way that we deliver education and behavioral intervention programs matters. Students only remember about 10% of the content of the average conventional lecture 1 week later. Students can now stay home with online learning, which can be accessed from mobile devices. The millennial generations sees Wikipedia, Facebook, and Youtube as core educational delivery services. Mohr et al.18 have commented that ‘‘American teenagers now spend almost as much time in text-based communication (text/chat) as they do in face-toface and telephone communication, suggesting that these media can provide valued forms of communication. Adults learn best if resources are provided ‘‘just in time’’—when and where they are needed—and are problem or case based, interactive, and visual.21 When implementing software to support a business process—such as a behavioral intervention for tobacco cessation—the key informatics principles to recognize are complementarity and workflow redesign. This means recognizing that humans and computers have different strengths that are synergistic. Humans are creative, are analytic, and interact well, whereas computers are excellent at remembering, organizing, searching, and presenting data. A poorly organized in-person behavioral intervention will not improve by being presented online unless it is reengineered first. The implementation of tobacco cessation programs is an ideal environment for the development of hybrid behavioral interventions that follow these approaches.
Conclusions Tobacco cessation programs should utilize online and mobile technologies in order to maintain success in the future. Based on current research, successful programs will utilize a wide variety of features available through smart devices and mobile applications, as well as including the capacity to easily access live healthcare professionals. This model is congruent with the model of supportive accountability of Mohr et al.18 and is in line with the discussion by Yellowlees and Marks21 of the conceptual and practical similarities between adult learning theories and the implementation of educational technologies of the future. Mobile applications and text messaging should also be leveraged for tobacco cessation in a more meaningful way in the future. Although 84% of smartphone owners have downloaded one or more applications, only 20% have downloaded an application to track or manage their health.4,22 Similarly, although text messaging is common among cell phone owners, especially younger owners, it has not yet had a significant impact on the health field,4 and although 80% of cell phone owners admit to sending and receiving text messages, only 9% use them for updates and alerts about health or medical issues.4 Quitlines have been used as the primary source for tobacco cessation support, but access to healthcare professionals may be more efficient via text message or smartphone application. The future holds great opportunities for tobacco cessation programs and current users of them. The U.S. Government is dedicated to resolving the negative health impacts of widespread tobacco use and is ‘‘committed to using technology to help Americans lead longer healthier lives.’’23 In 2010, President Obama signed into law the
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Patient Protection and Affordable Care Act, which established a fund ‘‘to promote effective public health and preventive measures.’’24 Current research suggests that mobile and Web-based cessation programs and education are likely to be effective and less expensive than efforts that require facilities, transportation, counselors, and other resources. Furthermore, funding from the Affordable Care Act and other government-sponsored efforts could be put toward implementing statewide or even nationwide hybrid cessation programs. Currently, the National Network of Tobacco Cessation provides free telephone cessation counseling throughout the United States.24 The CDC has provided funds from the Affordable Care Act to enhance and expand these services, which could include adding a Web-based component.24 In November 2012, the U.S. Department of Health and Human Services launched BeTobaccoFree.gov, which includes upto-date information on tobacco, including ‘‘federal and state laws and policies, health statistics, and evidence-based methods on how to quit.’’23 BeTobaccoFree.gov is available on any platform (such as smartphone, tablet, or desktop computer) and links to Facebook, Twitter, YouTube, Infographics, Podcasts, and Tumblr.23 This is an excellent example of educational leadership supporting tobacco cessation. Continuing collaborative efforts between private industries and local, state, and federal government agencies using a variety of modalities should continue to ensure that tobacco users are receiving validated information that will ultimately save lives. The development of hybrid models of behavioral intervention for tobacco cessation appears likely to be more successful than previous approaches, but does require much more evaluation than has occurred in the past.
Acknowledgments This research used information and screenshots from Smokefree.gov and QuitPal. These are federal government–managed resources from the National Cancer Institute; therefore, they are considered in the public domain.
Disclosure Statement No competing financial interests exist. REFERENCES 1. Centers for Disease Control and Prevention. Smoking-attributable mortality, years of potential life lost, and productivity losses—United States, 2000–2004. MMWR Morb Mortal Wkly Rep 2008;57:1226–1228. 2. Centers for Disease Control and Prevention. Vital signs: Current cigarette smoking among adults aged ‡18 years—United States, 2005–2010. MMWR Morb Mortal Wkly Rep 2011;60:1207–12. 3. Zbikowski SM, Hapgood J, Barnwell SS, McAfee T. Phone and Web-based tobacco cessation treatment: Real-world utilization patterns and outcomes for 11,000 tobacco users. J Med Internet Res 2008;10:e41. 4. Fox S, Duggan M. Mobile health 2012. Pew Research Center’s Internet & American Life Project. 2012. Available at www.pewInternet.org/Reports/2012/ Mobile-Health.aspx (last accessed July 1, 2013). 5. Hung WT, Dunlop SM, Perez D, Cotter T. Use and perceived helpfulness of smoking cessation methods: Results from a population survey of recent quitters. BMC Public Health 2011;11:592.
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6. Saul JE, Schillo BA, Evered S, Luxenberg MG, Kavanaugh A, Cobb N, An LC. Impact of a statewide Internet-based tobacco cessation intervention. J Med Internet Res 2007;9:e28.
19. Smit ES, Vries H, Hoving C. Effectiveness of a Web-based multiple tailored smoking cessation program: A randomized control trial among Dutch adult smokers. J Med Internet Res 2012;14:e82.
7. Bock BC, Graham AL, Whiteley JA, Stoddard JL. A review of web-assisted tobacco interventions (WATIs). J Med Internet Res 2008;10:e39.
20. Centers for Disease Control and Prevention. Increases in quitline calls and smoking cessation website visitors during a national tobacco education campaign—March 19–June 10, 2012. MMWR Morb Mortal Wkly Rep 2012;61:667–670.
8. Abroms LC, Padmanabhan N, Thaweethai L, Phillips T. iPhone apps for smoking cessation: A content analysis. Am J Prev Med 2011;40: 279–285. 9. Civljak M, Sheikh A, Stead LF, Car J. Internet-based interventions for smoking cessation. Cochrane Database Syst Rev 2010;(9):CD007078. 10. Whittaker R, McRobbie H, Bullen C, Borland R, Rodgers A, Gu Y. Mobile phonebased interventions for smoking cessation. Cochrane Database Syst Rev 2012;11:CD006611. 11. National Cancer Institute. QuitSTART app. Available at http:// teen.smokefree.gov/QuitSTARTApp.aspx (last accessed July 1, 2013). 12. DUNK Ltd. Since iQuit. 2009–2012. Available at http://dunkdigital.com/iphone/ sinceiquit/ (last accessed July 1, 2013). 13. Davoli F. SmokeTrack. Available at www.appato.com/frank-davoli/smoketrack/ (last accessed July 1, 2013).
21. Yellowlees PM, Marks S. Pedagogy and educational technologies of the future. Acad Psychiatry 2006;30:439–441. 22. Fox S, Duggan M. Tracking for health. Pew Research Center’s Internet & American Life Project. 2013. Available at www.pewInternet.org/Reports/2013/Tracking-forHealth/Main-Report/Seven-in-ten-US-adults-track-a-health-indicator-forthemselves-or-for-a-loved-one.aspx (last accessed July 1, 2013). 23. U.S. Department of Health and Human Services. HHS Launches BeTobaccoFree.gov. 2012. Available at www.hhs.gov/news/press/2012pres/11/ 20121115b.html (last accessed July 1, 2013). 24. Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services. Progress toward a healthier nation. 2012. Available at www.hhs.gov/ash/initiatives/tobacco (last accessed November 30, 2012).
14. National Cancer Institute. Smokefree TXT. Available at http://teen.smokefree .gov/smokefreeTXT.aspx (last accessed July 1, 2013).
Address correspondence to: Peter M. Yellowlees, MBBS, MD Department of Psychiatry University of California, Davis 2450 48th Street, Suite 2856 Sacramento, CA 95817
15. National Cancer Institute. QuitNowTXT. Available at www.smokefree.gov/pubs/ 55026-1_QuitNowTXT_description_for_Health_Professionals_Page_v4_09-0711.pdf (last accessed July 1, 2013). 16. National Cancer Institute. Smokefree smartphone applications. Available at www.smokefree.gov/apps/nciquitpal/ (last accessed July 1, 2013). 17. Whittaker R, Maddison R, McRobbie H, Bullen C, Denny S, Dorey E, Ellis-Pegler M, Rooyen JV, Rodgers A. A multimedia mobile phone-based youth smoking cessation intervention: Findings from content development and piloting studies. J Med Internet Res 2008;10:e49.
E-mail: [email protected] Received: April 1, 2013 Revised: July 2, 2013 Accepted: July 3, 2013
18. Mohr DC, Cuijpers P, Lehman K. Supportive accountability: A model for providing human support to enhance adherence to eHealth interventions. J Med Internet Res 2011;13:e30.
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Rachel Pulverman, BS, and Peter M. Yellowlees, MBBS, MD
Are Online and Mobile Applications Effective Tools for Tobacco Cessation?
Department of Psychiatry, University of California, Davis, Sacramento, California.
Given the importance of tobacco cessation, from a public health perspective, and the number of Web sites and smartphone ‘‘apps’’ now focused on this issue, it is remarkable that there is so little research published on the topic. The small amount of research available comparing tobacco cessation methods has found that online tobacco cessation programs are more likely to be successful than other methods of tobacco cessation, such as telephone programs, advice from general practitioners, and unassisted quit attempts, and may be more helpful if combined with them.3,5,6 In 2007, Saul et al.6 studied the effectiveness of their Web-based online cessation program compared with previous research on cessation methods. They found comparable quit results among participants in online programs and those using behavioralbased telephone quitlines, but concluded that the online programs would likely be more successful overall because of their accessibility. In 2008, Zbikowski et al.3 found that the number of Web log-ins for cessation programs was positively correlated with quit outcomes. In 2011, Hung et al.5 surveyed over 1,000 recent tobacco quitters and found online programs to have ‘‘high helpfulness,’’ albeit low use; they reported that online programs were more helpful than advice from a general practitioner. This study also found that online programs were used most commonly by those 31–50 years of age and least by smokers over the age of 51 years.5 The use of online methodologies in general is reportedly greater by women than by men,4 and Zbikowski et al.3 have attributed this to the social support that women wish to obtain online, such as from discussion forums. These findings overall suggest that the Internet and online applications may well be a good resource for tobacco cessation. Despite these findings, critics have argued that online information and information within mobile applications may be invalid and potentially harmful.7 In 2004, Bock et al. determined that 80% of currently available smoking cessation Web sites ‘‘did not cover one or more of the key components of cessation treatment as recommended by national guidelines’’; however, in their later 2008 study, Bock et al.7 found that the majority of the reviewed Web sites did now cover these guidelines. The latter study asked PhD-level specialists in tobacco cessation treatments to review the content of common smoking cessation Web sites and found that the majority of commonly used smoking cessation Web sites contained no inaccurate information.7 This research suggests that, although not all Internet content was reviewed and validated, the most commonly searched tobacco cessation Web sites did in 2008 provide sufficient information for the needs of tobacco users trying to quit. In 2009, Abroms et al.8 examined the content of 47 iPhone (Apple, Cupertino, CA) applications for smoking cessation and concluded that few adhered to proven strategies for smoking
Abstract The Internet and mobile ‘‘apps’’ on smart devices are increasingly being seen as primary tools to combat tobacco abuse with the development of several online tobacco cessation programs. This article reviews the small and recent body of research into the functionality and effectiveness of these Web-based programs, most of which are now being designed for mobile devices rather than for fixed computers. Based on current research findings, it is apparent that successful future tobacco cessation programs will utilize a wide variety of features available through smart devices and mobile applications, but will also incorporate the capacity to easily access live healthcare professionals as necessary, either online or in-person. These hybrid models of behavioral intervention for tobacco cessation appear likely to be more successful than previous approaches, but require more evaluation than has occurred in the past. Key words: tobacco cessation, smoking cessation, smartphones
Introduction
T
obacco is directly linked to the deaths of more than 5 million people per year worldwide and is the leading cause of preventable death in the United States.1 According to the Centers for Disease Control and Protection (CDC),2 over 45 million adults in the United States smoke cigarettes containing tobacco at an annual cost for smoking-related illness in the country of $96 billion.1 In response, healthcare providers have developed several innovative smoking prevention and cessation strategies, including the use of the Internet and smartphones. As early as 2006, approximately 9% of Internet users searched for online information about quitting smoking.3 Today, 85% of U.S. adults own a cell phone, and 53% of those cell phone owners use a smartphone, which can access the Internet and other applications.4 Recent findings suggest that 19% of smartphone owners have at least one health application on their phone.4 Although we do not currently know how many smartphone users attempt to search for online tobacco cessation programs, it is self-evident that smart devices have the potential to be used to provide cessation tools to tobacco users as well as educate the public on the risks of tobacco use.
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cessation. These investigators noted that very few of the applications recommended treatment or endorsed medications or counseling. In addition, the applications examined ‘‘did not connect users to anything outside of the app, like a quitline or clinic, or provide opportunities to reach out to friends and family for social support.’’8 This study suggested possible benefits through using mobile applications for tobacco cessation, but noted that at that time the available iPhone apps contained a lack of evidence-based strategies and connections with outside sources (such as other smokers, online communities, or healthcare professionals) known to be helpful. Civljak et al.9 undertook a Cochrane style review in 2010 to attempt to determine the effectiveness of Internet-based interventions for smoking cessation. Twenty trials met inclusion criteria, but these trials were heterogeneous for populations, interventions, and outcomes and allowed for very little pooling of results.9 The authors concluded that some Internet-based interventions can assist smoking cessation, especially if the information is appropriately tailored to the users and frequent automated contacts with the users are ensured; however, they noted that the trials did not show consistent effects.9 This first major review of the area confirmed the need for more methodologically sound research that has a strong conceptual and theoretical base and identified a general lack of quality and strength of the current published trials. In 2012, Whittaker et al.10 studied the effectiveness of multiple tobacco cessation programs that utilized combinations of mobile phone features. The group studied a text messaging intervention, an online QuitCoach, a combination of text messaging and online QuitCoach, and a video messaging intervention delivered via mobile phone.10 All of these interventions proved to be more effective than those smokers attempting to quit without utilizing their mobile phone’s features to do so.10 This study suggested that utilizing mobile technology, regardless of the specific features, is effective and supports the use of text messaging, video messaging, and Web-based applications.10 Because text messaging requires limited effort and is affordable, it may be the most effective feature of mobile phones for smokers to use when trying to quit with their healthcare providers.
link to many social networking sites so that patients may read and view motivational stories from former smokers and even interact with them, as well as with patients currently attempting to quit smoking. The U.S. Government has launched two free text messaging programs that contain some of the aforementioned features: SmokeFreeTXT14 and QuitNowTxt.15 SmokeFreeTXT (Fig. 1) provides ‘‘24/7 encouragement, advice, and tips to help smokers stop smoking.’’14 SmokeFreeTXT also allows individuals to respond to texts using key words to receive additional support.14 QuitNowTxt is a text messaging library for health departments, academic institutions, and government agencies to use when developing smoking cessation programs.15 The library includes day-specific messages and key word responses.15 For example, the keyword ‘‘BOOST’’ will prompt additional texts with positive messages for more difficult days.15 In 2012, the National Cancer Institute launched Quitpal,16 a free smartphone app that incorporates multiple tools to help change behavior and assist smokers with not giving up on their smoking cessation goal (Fig. 2). Quitpal includes an interactive calendar, reminders, graphs that track money saved and cigarette packages not smoked, text alerts, connections to social networking sites, the ability to create and view video diaries, and contact information for live health professionals.16 This impressive combination of multiple integrated smart device technologies and person-to-person counseling and assistance promises to be an effective method of tobacco cessation.
What Are the Most Promising Features of Online Programs and Mobile Applications for Tobacco Cessation? Mobile phone-based tobacco cessation programs have changed as the phones themselves have increased their capabilities and are now very creative, although seldom scientifically evaluated. A decade ago they relied on text messaging, but smartphones today have the capacity for applications with a variety of interactive features. Newer models of iPhones, for example, include forward-facing cameras and ‘‘FaceTime’’ videoconferencing software, which allows patients to see and interact with their healthcare provider from a remote location. Other mobile applications, such as QuitSTART,11 allow individuals to upload personalized ‘‘pick me ups,’’ such as family photos, to encourage patients to stay smoke free. Mobile applications such as Since iQuit12 and SmokeTrack13 simply track the amount of time since a patient has stopped smoking. Smartphone applications can
242 TELEMEDICINE and e-HEALTH M A R C H 2 0 1 4
Fig. 1. SmokeFreeTXT screenshot. Example of an iPhone text message from the SmokeFreeTXT program.15
HYBRID TOBACCO CESSATION PROGRAMS
because the concept is new and the accessibility and prevalence of smart devices are recent.
What Are the Disadvantages of Online and Mobile Tobacco Cessation Programs?
Fig. 2. QuitPal home screen. Example of a tobacco cessation mobile application that incorporates multiple uses of smart device technology, including goal setting, progress tracking, text alerts, access to social networking sites, and quick access to live health professionals.14
What Are the Benefits of Using Smart Devices and the Internet for Tobacco Cessation? The effectiveness of smart devices and the Internet results from their accessibility, ease of use, low cost, and time-saving opportunities.8 The Internet is available anywhere in the world, especially in isolated and remote locations where a person-to-person tobacco cessation program may not be available or an option. The Internet is inexpensive and is available for no cost in certain locations, such as public libraries, community centers, and schools. It requires limited travel time and may be accessed from one’s own home or via smartphone. The Internet is appealing because of its ‘‘24/7 ‘‘aroundthe-clock’’ availability.’’7 Internet programs and smartphone applications are generally simple and involve few keystrokes. Potential shortfalls from person-to-person tobacco cessation programs may be reduced in an online and mobile setting. Internet programs and smartphone applications allow for the confidentiality and anonymity, which studies have shown are especially important to young smokers who wish to quit.17 We also know from the work of Mohr et al.18 that ‘‘people tend to be more willing to engage in socioemotional communication in text-based media than in face-to-face communication.’’ Such programs also allow easy incorporation of known effective cessation techniques ‘‘such as individuals setting their own quit date, goal setting, reminders and motivational messages, advice, and information on what has been shown to be effective.’’17 Although there are many benefits to online and mobile cessation programs, proof of their effectiveness is still to be evaluated
There are some disadvantages to using the Internet and mobile applications for tobacco cessation, such as lack of personal contact and the learning curve associated with these programs. In 2008, Bock et al.7 found ‘‘a notable lack in using the capacity of the Internet for personalization of treatment.’’ They also found that the interactive capabilities were underutilized and follow-up contacts were not provided.7 Research by Smit et al.19 found their online smoking cessation program ineffective when they measured user’s abstinence after 6 months. The program was seen to be effective when measured after only 6 weeks, so they attributed the failure after 6 months to users who did not finish the program and lack of follow-up on users’ prescribed medications.19 Many individuals, especially those over the age of 50 years, are less likely to use the Internet or smartphones, partly because of the learning curve associated with them.4,5 It is important to note, however, that elderly patients interested in quitting smoking may still be easier to train to access the programs on their computer or smartphone compared with arranging for transportation to an in-person program.
Should Smart Devices Be the Primary Source for Tobacco Cessation? Research suggests that the most effective method of tobacco cessation is to leverage technology in conjunction with person-toperson cessation programs. In 2008, Zbikowski et al.3 found that quit rates were higher in an integrated telephone and Web program than in programs that used the Internet alone. An effective integrated program would include an online component, available to patients at all times for the purpose of setting goals, tracking progress, seeking motivation and support from peers, and obtaining tips and information. Counselors and other staff would be available to address technology and other concerns, ensure participation and reduce dropout rates, and remedy other shortfalls of the online program, as well as to see patients in person for tobacco cessation counseling as required. Similar integrative approaches were seen during the March–June 2012 National Tobacco Education Campaign, where the CDC aired stories from former smokers and encouraged tobacco users to call a quitline.20 This method of utilizing the mass media in conjunction with other education methods was seen to be effective in increasing quitline calls and traffic to smoking cessation Web sites.20 In 2011, Mohr et al.18 argued that human support enhances adherence to e-health interventions through ‘‘accountability to a coach who is seen as trustworthy, benevolent, and having expertise.’’ Furthermore, methods may be used in different sequences depending on the situation.18 E-mail may be used prior to a person-to-person meeting in order to prepare all parties involved.18 Mohr et al.18 concluded that ‘‘a choice of medium that is suboptimal by itself may make sense as part of a larger strategy.’’
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The way that we deliver education and behavioral intervention programs matters. Students only remember about 10% of the content of the average conventional lecture 1 week later. Students can now stay home with online learning, which can be accessed from mobile devices. The millennial generations sees Wikipedia, Facebook, and Youtube as core educational delivery services. Mohr et al.18 have commented that ‘‘American teenagers now spend almost as much time in text-based communication (text/chat) as they do in face-toface and telephone communication, suggesting that these media can provide valued forms of communication. Adults learn best if resources are provided ‘‘just in time’’—when and where they are needed—and are problem or case based, interactive, and visual.21 When implementing software to support a business process—such as a behavioral intervention for tobacco cessation—the key informatics principles to recognize are complementarity and workflow redesign. This means recognizing that humans and computers have different strengths that are synergistic. Humans are creative, are analytic, and interact well, whereas computers are excellent at remembering, organizing, searching, and presenting data. A poorly organized in-person behavioral intervention will not improve by being presented online unless it is reengineered first. The implementation of tobacco cessation programs is an ideal environment for the development of hybrid behavioral interventions that follow these approaches.
Conclusions Tobacco cessation programs should utilize online and mobile technologies in order to maintain success in the future. Based on current research, successful programs will utilize a wide variety of features available through smart devices and mobile applications, as well as including the capacity to easily access live healthcare professionals. This model is congruent with the model of supportive accountability of Mohr et al.18 and is in line with the discussion by Yellowlees and Marks21 of the conceptual and practical similarities between adult learning theories and the implementation of educational technologies of the future. Mobile applications and text messaging should also be leveraged for tobacco cessation in a more meaningful way in the future. Although 84% of smartphone owners have downloaded one or more applications, only 20% have downloaded an application to track or manage their health.4,22 Similarly, although text messaging is common among cell phone owners, especially younger owners, it has not yet had a significant impact on the health field,4 and although 80% of cell phone owners admit to sending and receiving text messages, only 9% use them for updates and alerts about health or medical issues.4 Quitlines have been used as the primary source for tobacco cessation support, but access to healthcare professionals may be more efficient via text message or smartphone application. The future holds great opportunities for tobacco cessation programs and current users of them. The U.S. Government is dedicated to resolving the negative health impacts of widespread tobacco use and is ‘‘committed to using technology to help Americans lead longer healthier lives.’’23 In 2010, President Obama signed into law the
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Patient Protection and Affordable Care Act, which established a fund ‘‘to promote effective public health and preventive measures.’’24 Current research suggests that mobile and Web-based cessation programs and education are likely to be effective and less expensive than efforts that require facilities, transportation, counselors, and other resources. Furthermore, funding from the Affordable Care Act and other government-sponsored efforts could be put toward implementing statewide or even nationwide hybrid cessation programs. Currently, the National Network of Tobacco Cessation provides free telephone cessation counseling throughout the United States.24 The CDC has provided funds from the Affordable Care Act to enhance and expand these services, which could include adding a Web-based component.24 In November 2012, the U.S. Department of Health and Human Services launched BeTobaccoFree.gov, which includes upto-date information on tobacco, including ‘‘federal and state laws and policies, health statistics, and evidence-based methods on how to quit.’’23 BeTobaccoFree.gov is available on any platform (such as smartphone, tablet, or desktop computer) and links to Facebook, Twitter, YouTube, Infographics, Podcasts, and Tumblr.23 This is an excellent example of educational leadership supporting tobacco cessation. Continuing collaborative efforts between private industries and local, state, and federal government agencies using a variety of modalities should continue to ensure that tobacco users are receiving validated information that will ultimately save lives. The development of hybrid models of behavioral intervention for tobacco cessation appears likely to be more successful than previous approaches, but does require much more evaluation than has occurred in the past.
Acknowledgments This research used information and screenshots from Smokefree.gov and QuitPal. These are federal government–managed resources from the National Cancer Institute; therefore, they are considered in the public domain.
Disclosure Statement No competing financial interests exist. REFERENCES 1. Centers for Disease Control and Prevention. Smoking-attributable mortality, years of potential life lost, and productivity losses—United States, 2000–2004. MMWR Morb Mortal Wkly Rep 2008;57:1226–1228. 2. Centers for Disease Control and Prevention. Vital signs: Current cigarette smoking among adults aged ‡18 years—United States, 2005–2010. MMWR Morb Mortal Wkly Rep 2011;60:1207–12. 3. Zbikowski SM, Hapgood J, Barnwell SS, McAfee T. Phone and Web-based tobacco cessation treatment: Real-world utilization patterns and outcomes for 11,000 tobacco users. J Med Internet Res 2008;10:e41. 4. Fox S, Duggan M. Mobile health 2012. Pew Research Center’s Internet & American Life Project. 2012. Available at www.pewInternet.org/Reports/2012/ Mobile-Health.aspx (last accessed July 1, 2013). 5. Hung WT, Dunlop SM, Perez D, Cotter T. Use and perceived helpfulness of smoking cessation methods: Results from a population survey of recent quitters. BMC Public Health 2011;11:592.
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Address correspondence to: Peter M. Yellowlees, MBBS, MD Department of Psychiatry University of California, Davis 2450 48th Street, Suite 2856 Sacramento, CA 95817
15. National Cancer Institute. QuitNowTXT. Available at www.smokefree.gov/pubs/ 55026-1_QuitNowTXT_description_for_Health_Professionals_Page_v4_09-0711.pdf (last accessed July 1, 2013). 16. National Cancer Institute. Smokefree smartphone applications. Available at www.smokefree.gov/apps/nciquitpal/ (last accessed July 1, 2013). 17. Whittaker R, Maddison R, McRobbie H, Bullen C, Denny S, Dorey E, Ellis-Pegler M, Rooyen JV, Rodgers A. A multimedia mobile phone-based youth smoking cessation intervention: Findings from content development and piloting studies. J Med Internet Res 2008;10:e49.
E-mail: [email protected] Received: April 1, 2013 Revised: July 2, 2013 Accepted: July 3, 2013
18. Mohr DC, Cuijpers P, Lehman K. Supportive accountability: A model for providing human support to enhance adherence to eHealth interventions. J Med Internet Res 2011;13:e30.
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