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Real-World Data for Enhancement of a National Smoking Cessation Intervention –SmokefreeTXT
Erik Augustson, PhD, MPH Director, Smokefree.gov Initiative Tobacco Control Research Branch Behavioral Research Program National Cancer Institute
DISCLOSURES
This work was supported by the National Cancer Institute.
No financial relationships to disclose.
Smokefree
Apps:
SmokefreeMOM
HealthyYouTXT
SMOKEFREE PROGRAM
BACKGROUND
Text message-based interventions show promise for smoking
cessation
Current evidence on text message-based interventions comes
from RCTs
NCI launched SmokefreeTXT in 2011
42-day intervention, option to start 2 weeks prior to quit date
Two-way messaging for quit status, cravings, mood, and slips
35+ behavior change techniques built into the messages
RCT showed quit rates of ~20%
5
RESEARCH OBJECTIVE
Assess engagement and self-reported
cessation rates among real-world
smokers who subscribe to the
SmokefreeTXT program
6
Inclusion Criteria
Opted-in to the SmokefreeTXT
program September 20, 2011, to May
22, 2014
Had the opportunity to complete the
42-day treatment by May 22, 2014
Exclusion Criteria
Failed to set a quit date on or after
enrollment date
Opted out on or before their quit date
18,080 of 25,283 included in study
7
METHODS
METHODS
Subscribers could opt out of the
program at any time by texting
STOP
Cessation status was self-reported
as a response to a text message
prompt at the following time points:
7 days post-quit
End of the program
1-month post-treatment
3-months post-treatment
6-months post-treatment
Sensitivity Analyses
Logistic Regression
8
SAMPLE DEMOGRAPHICS
9
Demographics
Mean Age: 34.8 years; Median Age: 32 years
62% Female
88% Daily Smokers
70% had Web-Enabled Phone
MEASURING CESSATION
Point prevalence abstinence Assessment of cessation status at the
particular point in time when the question is
asked
End of treatment- Primary
7-days post-quit
3-months post-treatment
6-months post-treatment
10
RESULTS: ABSTINENCE RATES
All Subscribers, Non-
responders & Opt-outs = Smokers
Responders Only
Response Rate
Treatment Completers
Response Rate
7 Days Post-Quit 20.3% 64.4% 31.5% 23.7% 34.8%
End of Treatment 7.2% 75.1% 9.6% 12.9% 17.0%
3 Months Post-Treatment 4.0% 52.0% 7.7% 7.3% 13.4%
6 Months Post-Treatment 2.0% 45.4% 4.4% 3.7% 7.6%
11
SmokefreeTXT Point-Prevalence Abstinence Rates
MEASURING ENGAGEMENT
Time in Program
Treatment Initiation
Opt out
Program Interactions
Response rates
GUIDING QUESTIONS FOR ANALYSIS To what extent does SmokefreeTXT engage
users in a quit attempt?
To what extent does SmokefreeTXT keep users
engaged?
How can SmokefreeTXT more effectively
re-engage users who have opted out?
POTENTIAL FAIL POINTS
Initiating the quit attempt
Establishing an initial period of abstinence
Recovering from a lapse
2 weeks Pre-Treatment
6 Week Treatment
PURPOSE
15
To describe baseline user characteristics associated with SmokefreeTXT user engagement Age
Gender
Frequency of Smoking
Region
Emphasis on key “fail points” Treatment Initiation
Opt Out
Re-engagement
METHODS
Retrospective records analysis of
SmokefreeTXT user data between 2011-2014
N=25,283 subscribers
Logistic regression to examine differences in
baseline characteristics on key engagement
metrics
TREATMENT INITIATION
28.5%
71.5%
0.00
20.00
40.00
60.00
80.00
100.00
Non-initiator Treament Initiator
Treatment Initiation
USER CHARACTERISTICS OF NON-INITIATORS
Non-daily smokers were more likely to be
non-initiators compared to daily smokers
OR: 1.461; 95%CI: 1.313, 1.625
No other baseline characteristics differed
significantly by treatment initiation status
FAIL POINT
19
1 Week Treatment
0
1045
615
630
533
440 389 406
197 182
522
275 227
194 196
92
489
124 71 83 76
247
52 75
155 103
38 75
138
35 58
28 72
35 35 65
33
164
27
60
54
0
200
400
600
800
1000
1200
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
0 7 14 21 28 35 42
Nu
mb
er o
f Su
bsc
rib
ers
Wh
o O
pt
Ou
t
Per
cen
t o
f To
tal S
ub
scri
ber
s R
emai
nin
g
Days of Treatment Percent of Total Subscribers Remaining in Treatment
Quit Date End of Treatment
Number of Subscribers Who Opt Out
2 Weeks Pre-
Treatment Weeks 2-6 Treatment
USER CHARACTERISTICS OF TREATMENT ENGAGEMENT
Odds of opting out
Males
OR: 0.866, 95% CI: 0.807, 0.928
Older
OR: 0.987, 95% CI: 0.984, 0.990
Non-daily smokers
OR: 0.866, 95% CI: 0.763, 0,984
IN-DEPTH INTERVIEWS
From March 14, 2014, to April 4, 2014, the
research team conducted IDIs with users of
SmokefreeTXT
9 male, 9 female
Qualitative data
Usability & acceptability
User interactions with the program, feasibility
OPPORTUNITIES: RESULTS
In-depth interviews with program users suggest that
opting-out was associated with relapse to smoking
CONCLUSIONS
23
Analysis of user data provides insight to guide
further research and intervention refinement
Many subscribers opt out before program end
Some subscribers do not respond
SmokefreeTXT supports short-term cessation
in a real-world implementation
CONSIDERATIONS
Low response rates for long-term follow up
Does no response/opt-out mean relapse?
CONCLUSIONS CONTINUED
24
Sub-optimal engagement is a challenge for
mHealth interventions
“Fail points” are opportunities for improvement
Real world process data is needed to guide the
design and implementation of mHealth
interventions
