Smartphone-delivered Automated Video-assisted Smoking Treatment for Patrons of a Food Resource Center

Smoking remains the leading cause of preventable morbidity and mortality in the United
States,1-3 with tobacco use accounting for more deaths each year than the combined deaths
attributable to alcohol, other drugs, homicide, suicide, motor vehicle accidents, and sexual
behavior.4 While smoking cessation decreases the risk of lung cancer, other cancers, heart
attack, stroke, and chronic lung disease,5 smoking quit rates are low. Approximately 40-50%
of adult daily smokers make a quit attempt each year, but less than 14% of those smokers are
able to maintain abstinence for even a single month.6 Individuals with low socioeconomic
status are far more likely to smoke and are less successful at quitting.7-9 Thus, smoking is
a critically significant behavioral risk factor that contributes to social disparities in the
incidence and mortality of disease.10-15 Data indicate that smokers with higher socioeconomic
status are more likely than those with lower socioeconomic status to use effective resources
for quitting smoking, which appears to partially explain their higher cessation rates.16
Therefore, efficiently connecting underserved smokers with limited resources to efficacious
tobacco cessation programs that are easily accessible is crucial for disease prevention and
the elimination of health disparities.

Food security is defined by the United States Department of Agriculture (USDA) as having
consistent, dependable access to enough food for all household members to lead an active,
healthy life.17 In 2014, 14% of US households were classified as food insecure,17 a condition
that describes limited or uncertain access to nutritionally adequate, personally acceptable,
and safe foods.18 National studies indicate food insecurity within low-income households is
associated with hypertension (24.6%), self-reported hyperlipidemia (43.3%), diabetes (10.2%),
and smoking (35%).19 Emerging data suggests populations accessing foods at food pantries fare
worse compared to the general low income, food insecure population, with self-reported
hypertension (65.4%) and diabetes (25.9%) being notably higher.20

Participants (n=20) will be randomized to one of two treatment conditions: 1) Standard
Treatment (ST; n=10) or Automated Treatment (AT; n=10). In the ST condition, research staff
will provide participants with in- person brief advice to quit and enroll them in a proactive
telephone counseling program for smoking cessation. This ST approach mirrors the Ask Advise
Connect (AAC) approach that our team has previously developed and implemented in numerous
clinic settings.21,22 ST will be evaluated against AT, the fully automated AVAST approach. In
the AT condition, smokers will be provided with brief in-person advice to quit and be
enrolled in a fully automated and interactive smartphone-based treatment program that
comprises interactive text messaging, images and audio/video clips. Participants in both
treatment conditions will be provided with nicotine replacement therapy (NRT) in the form of
transdermal patches. The goal of this pilot project is to establish the preliminary efficacy
and feasibility of AT. Data collected in the pilot will then be used to support the
submission of a NIH R01 application (or equivalent), and to determine if AT performs no worse
than the more resource intensive ST approach. If lack of inferiority is established in the
larger project, the AT approach will be readily scalable; easily implemented by
community-based clinics and organizations; and offer an efficient way to allocate limited
public health resources to tobacco control interventions.

Inclusion Criteria:

- >/= 18 years

- Smoked >/= 100 cigarettes in a lifetime

- English speaking

- Currently smoking 5 or more cigarettes per day

- Willing to make a quit attempt within 1 week of enrollment

- Patron of the Urban Mission Food Resource Center

Exclusion Criteria:

- History of medical condition that precludes the use of nicotine replacement therapy

- Current use of smoking cessation medications

- Pregnant or nursing

- Enrolled in another smoking cessation study