Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
10/6/2015
1
Dr. Lorien Abroms/GWU has licensed Text2Quit & Quit4Baby to Voxiva Inc.
This research was supported by NIH grants to Dr. Lorien Abroms, 5K07 CA124579-02 and 1R15CA167586
Funding Source:
Disclosure:
Topics I’ll cover
I. Pregnancy Smoking Cessation
II. Potential role of mHealth
III. Current Programs & Evidence
• Text Messaging Programs
• Smartphone apps
IV. Future opportunities
10/6/2015
2
Smoking in Pregnancy • Many women are motivated to quit during
pregnancy; 46% of smokers quit directly
before or during pregnancy (Colman, 2003)
• In 2008, 10.7% of women smoked in last 3
months of pregnancy (Prams 2013)
• Up to 40-60% of those who quit during
pregnancy will relapse within 6 months
postpartum, and 80-90% by 12 months
postpartum (Floyd, 1993, Fingerhut, 1990;
CDC 2014)
• Tobacco use is the most important modifiable cause of adverse pregnancy outcomes in the U.S. (Fang, 2004)
• Effects on pregnancy & baby:
• miscarriage • placental bleeding • premature delivery • Low birth weight • Born with a cleft
lip/cleft palate, • Higher risks of
SIDS
• Dose response relationship
Health effects of smoking during
pregnancy (cont.)
Smoking accounts for 20% of low birth weight
deliveries (<2500 grams), 8% of preterm births
and 5% of all perinatal deaths (Orleans, 2001)
6
10/6/2015
3
Figure 1. Prevalence of smoking during the last 3 months of pregnancy by
demographic characteristics, 24 PRAMS states, 2011.
Figure 2. Prevalence of smoking during the last 3 months of
pregnancy (Prams 2011).
Pregnancy Smoking Cessation
Pregnancy-specific in-person counseling** at first visit and throughout pregnancy
Ask the patient about smoking status at first prenatal visit with multiple choice
Advise the patient to quit. Assess the patient’s willingness to quit. Assist the patient in quitting. Arrange follow-up visits to track quit progress.
Quitlines : 10 call program
NRT: NRT evidence is mixed
not FDA-approved not recommended in the CTP, Cochrane 2012 ACOG recommends, if unable to stop, with
close supervision of a provider.
10/6/2015
4
Pregnancy smoking cessation counseling is covered by the ACA
Some state Medicaid systems offer extensive programs
10-call phone counseling
Free in-person counseling/home visits & Follow up
Self-help materials, videos
Some successes
SCRIPT (Windsor et al. 2000)
The Core SCRIPT Procedures
---------------------------------------------------------------
Component #1: Commit to Quit Smoking During &
After Pregnancy Video (10 Min.)
Component #2: A Pregnant Women’s Guide to Quit
Smoking (5th-6th grade literacy)
Component #3: Patient-centered counseling session
(10-15 Minutes)
Low Reach
Even across trials, only 20-40% of pregnant smokers will receive free counseling
Very few preg. smokers call quitlines
Because:
Prefer self-help (Ussher,West & Hibbs 20004)
Low uptake of prenatal care, esp in first trimester
Once in care,
Providers lack training or appropriate systems for offering them in-person counseling
Patient reluctant to disclose their smoking (stigma)
Patient refuse free counseling services
Challenges
10/6/2015
5
Topics I’ll cover
I. Pregnancy and Smoking
II. Potential role of mHealth
III. Current Programs & Evidence
• Text Messaging Programs
• Smartphone apps
IV. Future opportunities
High Reach of Mobile Phones
90% of US adults
88% text message, top activity
64%+ have smartphones,
75% have used phone to look up health information
(Pew 2014; CTIA 2014)
10/6/2015
6
“We Marry Them!” 82 % of mobile phone owners never leave
home without their phones
68 % sleep with device by bedside
Invite them to interrupt us (at family
gatherings, at restaurant, at meetings)
Increasingly rate as something “not willing to
live without”
Smoking Cessation related services delivered via mobile communications devices
mCessation can be defined as:
Advantages of mobile
1. Help anywhere and anytime
2. Proactive messages interrupt you
3. Interactive help
4. Personalized help
5. Increase contact time
6. Unobtrusive and confidential
7. (Goes with smoking) Source: Abroms, Padmanabhan, and Evans 2011
10/6/2015
7
Evidence: Cessation programs should:
Ask for tobacco use status
Advise every user to quit
Assess willingness to quit
Assist with a quit plan
Practical counseling
Intra-treatment social support
Connect to a quitline
Arrange for follow-up
mCessation Services 1. SMS Programs 3. Mobile Web
2. Smartphone Apps 4. Mobile Devices: CO Monitor
Topics I’ll cover
I. Pregnancy and Smoking
II. Potential role of mHealth
III. Current Programs & Evidence
• Text Messaging Programs
• Smartphone apps
IV. Future opportunities
10/6/2015
8
To call these programs a success, need ….
Reach Availability,
Enrollment machine,
Subscribers/ Downloads, sustained users
Efficacy Quit attempts,
days without smoking,
cigs smoked/day,
Quit rates
Text messaging
SmokefreeMOM (800+, July 2015)
Quit4baby (300+, Sept. 2015)
MiQuit (UK)
SMAT (Canada)
Smartphone Apps
Quit for You; Quit for Two (40,000-50,000)
Smokefree Baby
Reach-Available Programs
Source: Heminger et al. 2015
Text Messaging
10/6/2015
9
Quit4baby (Quit4baby.com)
300+ users since Summer 2015
Integrated with text4baby in some States
SmokefreeMOM
Text MOM to 222888
800+ users since May 2014
Promoted on Smokefree.gov & women.smokefree.gov
US Cessation Text Messaging Services
Both program provide 24/7 encouragement, advice, and tips to help pregnant women and mothers quit smoking and stay quit
Overview of Smokefree Moms Automated, interactive text messages for quitting smoking Derived from SmokefreeTXT
• Messages are timed around quit date
• Proactive: Advice on quitting, interactive peer ex-smoker messages, games, and relapse messages.
• On-Demand: need additional motivation, having a craving, relapse.
Program runs for 9 months, with post-partum relapse protocol Frequency increase pre- & post-quit date;
8 messages on quit date; 3 or more messages/day during the immediate post-quit period.
Cost: Standard message and data rates may apply.
10/6/2015
10
SmokefreeMOM General advice
baby
development
info
Interaction:
Pre-Quit Lea/Quit Pal
Quit & Post-Quit “Did you Quit?” survey
Daily, weekly, monthly
SFM/Lea: Ugh, my
friend just tried to
smoke in my car. Guess
what I did? Text 1 if I
said "don't smoke in my
car it's bad for baby."
Text 2 if I said "it's
super gross!" Text 3 if I
grabbed her cig and
threw it out the window.
Quit Pal
24-7 Help
CRAVE (TIP or GAME)
FACT
DATE
SMOKED
SFM: Use our 3 step
plan to help! At
anytime get motivated
by texting FACT,
manage cravings by
texting CRAVE, or set
a new date by texting
DATE.
10/6/2015
11
{ { Smokefree
MOM
Reminders about quitting and healthy
pregnancy
Info on how to quit (follows 5A’s)
Tracking & feedback/check-ins
Quitpal
Tools if craving or derailed
Intermediate Outcomes
(theory)
Priority to cessation &
healthy pregnancy
Benefits to mom and baby/Barriers
Social Support
Increase Self-Regulation
Self-Efficacy (Ability)
Proximal Outcomes/
Processes of Changes
Quit Attempt
Get back on track if slip during
pregnancy and post-partum
Call quitline/talk to doctor/ seek out
info
Health Outcome
Quit smoking & healthy pregnancy
Logic Model for mHealth & Pregnant Smoking Cessation
Quit4Baby
10/6/2015
12
Overview of Quit4Baby
Derived from Text2Quit
At enrollment, set a quit date within 2 weeks/coming Monday OR enter program with no date
Frequency is high; integrated with Text4Baby
Cost: All texts are free to user
Future: App will be available in 2016
Text4Baby Core Partners:
Outreach Partners:
Telecoms industry support:
35
N=900,000+ subscribers
since launch (2011)
CMS pays for Quit4baby
as add on service in 4
states
300+ enrolled in
Quit4baby
text4baby: Ask your
baby’s doctor how
vaccines protect
your newborn right
from the start. Learn
more at
text4baby.org
Quit4baby: If your
friends light up around
you remind them that
you’re pregnant and
that you do not smoke.
They should get the
hint. Reply TIP for
more tips.
Text4baby+ Quit4baby
10/6/2015
13
Whittaker et al. Meta-Analysis. Cochrane. 2012
RR 1.7; 70% increase over control
Evidence : Text messaging
Abroms et al. 2014 (N=503)
Abroms et al. Am J Prev Medicine. 2014
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
1 month 3 months 6 months
Text2Quit
Control
No
Sm
ok
ing
in
th
e P
ast
7 d
ays
30.5%
14.5%
33.2%
19.9%
31.7%
20.7%
US Preventive Services
10/6/2015
14
3 month follow-up; salvia sample
3 month follow-up; salvia sample
Weekly data from OB
& GYN Center on
pregnant smokers
GW Research staff call potentially eligible
participants (n=726) We enroll approximately 19% we contact (n=88)
Some are ineligible (n=182); Some refuse (n=115)
Intervention Group (SFM texts)
Control Group-1 text (Pamphlets and Quitline)
1 month follow-up 1 month follow-up
(6 month follow-up) (6 month follow-up)
SmokefreeMOM
Randomized Trial
“Liked how they stick with you, they don't give up on you even though I failed a number of times”
“To a certain extent, it made me accountable to not smoking more. Helped me stay on track.”
“Liked that they were informative, liked the facts, liked there was somebody that quit effectively.”
“Other people were telling me how they quit smoking; so when they had [SFM Lea] - they said how they controlled their smoking during the day - their quotes and their opinions.”
What, if anything, did you like about the messages?
“Some days, it was a lot of messages. A lot of them do repeat-it's the same stories. Stories about quitting are the same.
“I didn't like how they increased before the day before my quit date and it got annoying after awhile.”
“I don't think it helps; too frequent- reminded me of smoking.”
“Not sure as to whether it was human who really cared or whether it was an automated system - not knowing”
What, if anything, didn’t you like about the messages?
10/6/2015
15
Intervention Control 1-month 1-month
Measure Abstained from smoking in past 7 daysa,b,c
24% 21%
Abstained from smoking in past 30 daysa,b,c
12% 0%
Number of continuous days quitb
13.0 9.4
Banned smoking from their homeb
66% 58%
Banned smoking from their carb,c
63% 35%
Smoking-Related
Outcomes
Program Data: Days Enrolled
0102030405060708090
100
Fre
qu
ency
Days
~30% unsubscribe in first week
N=480 Abroms LC, Leavitt LE, Schindler-Ruwisch JM, Augustson, EM. 2015
Text4Baby Core Partners:
Outreach Partners:
Telecoms industry support:
45
N=900,000+ subscribers
since launch (2011)
CMS pays for Quit4baby
as add on service in 4
states
300+ enrolled in
Quit4baby
10/6/2015
16
Three messages tested for study recruitment:
Quitting smoking is tough but it's easier with help
Want FREE messages to help you quit smoking?
If you smoke, it's important to quit. You'll be proud you did!
4,593 text4baby subscribers were sent a message
301 (6.6%) replied to the recruitment message expressing interest,
44% (133) were reached by phone for follow-up
47% (63) were enrolled.
enrollment was ~1.6% of those sent a message
Quit4baby Enrollment
Abroms, Turner, Schindler-Ruwisch, Leavitt, Johnson,
Obi, Cleary 2015
Evidence for efficacy is solid in adult smokers
Evidence emerging in pregnant smokers
Program data suggests
Need further develop enrollment machine (reach is still low)
Text4baby is promising
UK is developing method for integrating into NHS
High unsubscribe rates suggest additional adjustments needed for existing subscribers
Text Messaging Conclusions
Smartphone Apps
10/6/2015
17
Overview of Programs
Text
Quit4baby (Abroms et al.)
SmokefreeMom (Abroms et al.)
MiQuit (Naughton et al. )
SMAT (Van Mierlo et al.)
SGR (Pollack et al.)
App
Quit for You; Quit for Two (10,000-50,000 downloads)
Smokefree Baby (100-500 downloads)
Sampling Process
100,000+
Apps in
iTunes Store
71
Apps
52
Apps
47 Apps in
Sample
Power Search for “quit smoking”, “stop smoking”, and “smoking
cessation”
Assess
relevance
from app
description
Download available apps
Smartphone apps: Emerging Evidence
CBT 28-day program:
Ubhi HK1, Michie S, Kotz D, Wong
WC, West R. 2015
Acceptance & Commitment Theory:
Bricker JB, Mull KE, Kientz JA,
Vilardaga R, Mercer LD, Akioka KJ,
Heffner JL 2014
10/6/2015
18
Overview of Programs
Text
Quit4baby (Abroms et al.)
SmokefreeMom (Abroms et al.)
MiQuit (Naughton et al. )
SMAT (
SGR (Pollack et al.)
App
Quit for You; Quit for Two
Smokefree Baby
Fun craving tool:
•Bouncing Baby game
(Doodle Jump)
•Baby Boogie game
•Baby Bubble game
•Baby name selector
•Breathing yoga exerciser
Set up: pick your baby avatar and name
•Week-by-week facts about your baby's
development
•Daily savings announcements based on money
not spent on smoking
(n=10,000-50,000 downloads)
10/6/2015
19
Baby Bubble game
•Baby name selector
Daily savings announcements based on
money not spent on smoking
10/6/2015
20
Cessation programs should:
Ask for tobacco use status
Advise every user to quit
Assess willingness to quit
Assist with a quit plan
Recommend approved meds
Practical counseling
Intra-treatment social support
Connect to a quitline
Enhance motivation
Arrange for follow-up
Popular Smoking Cessation Apps
Overall Low Adherence: 12/42
Present in Apps (>50%)
Specific to smoking
Interactive
Personalized Advice to Quit
Ask for tobacco status
Lacking in Apps (<20%)
Practical counseling on how to quit (19.4%)
Social support (17.3%)
Text alerts (12.2%)
Recommend meds (4.1%)
Connecting to a quitline (0.0 %)
Abroms et al. 2013
N=98
N=10,000-50,000
downloads
10/6/2015
21
Evidence for efficacy is emerging in adult smokers, tho most apps have low adherence to USPHS-CPG
No evidence in pregnant smokers
Program data suggests
Some promising enrollment models
Australia’s Quit for you; Quit for two
Further study to see how app used once downloaded
App Conclusions
Conclusions
To call these programs a success, need ….
Reach Availability,
Enrollment machine,
Subscribers/ Downloads, sustained users
Efficacy Quit attempts, days without smoking, cigs smoked/day, quitting
10/6/2015
22
Integration with health systems supplement in-person clinician, phone counseling and other
traditional models EHR Medicaid integration
Outside health system: Packs of cigarettes with mCessation on the warning label Text4baby
Next Generation of Programs Smartphone apps integrated with texting Sensors—track opening a pack of cigs; lighter Games Social Media iWatch apps
The future… To quit, text “Quit” to 47848
One Resource
Thank-you!
Contact [email protected]
10/6/2015
23
Enrollment through a registry model Identify patients from EHR
Send invitation SMS
Patient opts-in
GW MFA: Get SMS to
improve your
health. Reply
1 for info on quit smoking
program, 2 for weight loss
and 3 for physical
activity.
Design Considerations
+Spohr et al. 2015; ^Head et al. 2014
Effect
•Message tailoring and
personalization ^
•Decreasing vs. fixed
message frequency ^
No Effect
•Text plus other
modality. +^
•Extra protocols of
messages
•On Demand messages
•Social/peer to peer
messages