Cell Phone-Based Expert Systems for Smoking Cessation

Objective: This project examined the effectiveness of tailored text messages as an
enhancement to a computerized tailored intervention (CTI) for smoking cessation with
Veterans. It was theorized that the ubiquity and sophistication of today's wireless mobile
technologies would represent new modes of delivery for empirically based smoking cessation
and other behavioral health interventions. CTIs have shown increasing promise as useful
behavior change programs for improved health behaviors; however, the ubiquity and
sophistication of today's wireless mobile technologies represent new modes of delivery for
evidence-based smoking cessation and other behavioral health interventions. The CTI was
based on the Transtheoretical Model of Behavior Change (TTM) and developed by Pro-Change
Behavior Systems, Inc.

Research Design: This randomized, prospective pilot employed a 2 (group) x 3 (timepoint)
research design. Veteran smokers were recruited nationally from direct mailings, Facebook
ads, community newsletters, posters, and flyers. In addition to the randomized control trial
(RCT), a focus group (n=9) and individual usability tests (n=5) were conducted in order to
assess the acceptability of the graphic user interface, questions, tailoring and program
content to Veteran smokers. The pilot study tested the effectiveness of the CTI alone and
CTI plus individualized text messaging enhancements in reducing smoking behavior in
Veterans. In addition to smoking cessation, readiness to change other negative health
behaviors � such as alcohol use, healthy eating, and exercise � was also assessed.

Summary of Research Methodology and Procedures: Usability Testing: Five separate usability
tests were conducted for the CTI smoking cessation program using a combination of the Think
Aloud protocol and Wizard of Oz approach. Usability testing software was used to take notes
and record participant interactions with the program. Participants provided qualitative and
quantitative feedback on overall presentation and usability of the program. All interview
data were coded, categorized, and summarized in a feedback report so that revisions to the
system could be adapted. Pilot Study: At all three timepoints, participants completed a
brief Health Risk Intervention (HRI), two additional smoking assessments, and the smoking
cessation (SC) intervention. The HRI assessment determined baseline readiness to change for
smoking and several other related health behaviors, and the smoking cessation intervention
provided assessment and feedback about participants' confidence to quit smoking, decisional
balance, and use of various change strategies. Following the baseline HRI and SC
intervention, the CTI system randomized participants into either the treatment group (Tx),
who also received the CTI only, or the treatment-plus group (Tx-plus), who received the CTI
and tailored text messages. The study was conducted as entirely anonymous. All participants
were given three months' access to the web-based CTI system. The Tx participants received
only the online feedback narratives/report that all participants received upon completion of
the online Smoking Cessation intervention. Tx-plus participants also received individualized
text messages on their cell phones 2-5 times per week (the number of messages correlated
with the participant's stage of change) that provide expert guidance, encouragement, and
reminders that support their smoking cessation efforts.

Findings: Four-hundred and forty-six Veterans were recruited at baseline. All participants
were active smokers, distributed across the stages of change as 11.9% in Precontemplation
(n=53; not intending to change in the next 6 months); 63% in Contemplation (n=281; intending
to change in the next 6 months), and 25.1% in Preparation (n=112; intending to change in the
next 30 days). Two-hundred and thirty-five individuals (52.7%) completed the one-month and
three-month follow-ups: n=116 in the treatment group (CTI only; Tx) and n=119 in the
treatment-plus group (CTI plus text messages; Tx-plus). Results indicated that the
CTI-plus-text-messaging intervention outperformed the CTI-only intervention at an
unprecedented quit rate. For those participants in the Tx group 32.8% had quit smoking at
three-month follow-up; however, those in the Tx-plus group had quit rates of 43.2%. These
findings are highly encouraging, and exceed those quit rates found for other CTI
interventions for both groups by almost 15% (Krebs, Prochaska & Rossi, 2010).

Summary of Participant Experiences: While data are available only for those participants who
completed the study, indications from the User Satisfaction Scale, as well as the open-ended
questions, were that Veterans found the CTI and tailored text messages to be both
appropriate and relevant. In addition, participants in the Tx-plus group also indicated that
the text messages were helpful, timely and useful. There were no adverse events to report.

Summary of Current Risk - Potential Benefit Assessment based on Study Results: This study
was able to demonstrate that the TTM is an appropriate model to promote multiple behavior
change in Veterans. Furthermore, the addition of tailored text messages increased the effect
of the smoking cessation intervention (CTI) and improved quit rates in the Tx-plus group to
levels that are unprecedented in the literature. Additionally, individuals who were at risk
for other health behaviors progressed to A or M without intervention. For Veterans who are
not ready for in-person psychotherapy, have practical issues attending therapy sessions, or
fear stigma associated with seeking mental health care, this Veteran-tailored, motivational
enhancement CTI may provide unique benefits. In addition, Veterans who smoke and have
comorbid behavioral risk factors may find this CTI sufficient to resolve their problems. In
this sense, the adapted CTI will make evidence-based mental health care more accessible to
Veterans in need without adding concerns about stigma and costs.

Impact/Significance: This is the Final Abstract for this research project. This study was
the first to adapt a smoking cessation Internet-based CTI to provide personalized feedback
on a cell phone to reduce smoking behaviors in military Veterans. The findings suggest that
behavior change interventions can be successfully delivered to Veterans via the Internet,
and that tailored text messaging can significantly enhance the intervention effects.

Inclusion Criteria:

Male and female veterans, OIF/OEF service preferred 18 years or older Current cigarette
smoker Own cell phone with text messaging capabilities Ability to read and comprehend
English Beginner level computer literacy Access to a computer with Internet connectivity

Exclusion Criteria:

Lack of basic computer literacy Non-smoker (includes smokeless tobacco use) Unable to read
and comprehend English No access to computer with Internet connectivity (applicable if no
project computer with Internet access can be arranged) Non-owner of cell phone with text
messaging capabilities