Smoking cessation intervention for young adults using multimedia mobile phones: development and effectiveness

Abstract

Tobacco smoking is the most important single preventable cause of disease in New Zealand and a leading global health problem. Despite overall reductions, young adults and particularly young Māori (the indigenous population of New Zealand) continue to have high rates of smoking. Novel cessation support strategies that appeal to young people are required. Mobile phones have rapidly become integrated into daily life and are starting to be used for health purposes. Mobile phones offer the potential to deliver health interventions directly to people at appropriate times in a proactive manner. The aim of this thesis was to determine whether multimedia mobile phones could be effective in delivering smoking cessation support, particularly for young adults. A systematic review was conducted on studies of mobile phone-based smoking cessation interventions. Only two studies of mobile phone-delivered interventions met the inclusion criteria, one of these being a pilot study (n=200). The meta-analysis demonstrated a short-term increase in self-reported point prevalence abstinence (no smoking within past seven days) for text message-based interventions compared with control groups (RR 2.18, 95% CI 1.80-2.65). As yet there is no evidence of long-term benefits of mobile phone-only interventions. A further two studies on a mobile phone and internet programme were analysed separately demonstrating a long-term increase in repeated point prevalence abstinence (RR 2.03, 95% CI 1.40, 2.94). A major methodological issue evident in previous research was the challenge of conducting trials in young adults, both in terms of recruitment and retention during follow-up. A multimedia mobile phone cessation intervention was developed with social cognitive theory as a basis for using role models to provide observational learning. Video messages from role models included their use of effective techniques for smoking cessation, in order to enhance self-efficacy for quitting. Almost 250 young people had input into an extensive development phase and a pilot study. Some of the findings from this phase included the importance of confidentiality, flexibility, cost, and the use of peers who understand the issues. Feedback from participants endorsed the use of video role modelling messages, and included the need for a choice of role models who must be perceived by participants to be „real‟ and credible as smokers. Feedback on the content of the videos included the need for the message to be believable and not overly negative. A randomised controlled trial of the effectiveness of the intervention was undertaken. Recruitment was slower than anticipated and had to be terminated before reaching the target sample size due to funding considerations. In all, 226 participants were randomised. At six months, cessation rates were high in both groups: 26% of the intervention group (29/110) and 28% of the control group (32/116) (p=0.7) had quit (five or less cigarettes since quit date) using an intention to treat analysis. In a responders-only analysis, excluding those lost to follow-up, 39% and 36% had quit in the intervention and control groups respectively (p=0.2). These results were added to the previous meta-analysis of studies with mobile phone-only interventions, with a non-statistically significant increase in long term continuous abstinence with mobile phone interventions (RR 1.21, 95% CI 0.94-1.57, I2=65%). Feedback from the intervention group participants indicated that watching someone like them go through the quitting process was helpful (88%) and that they felt supported to quit (86%). Three-quarters stated that getting messages at the right times was helpful. In those who had relapsed at six months, their confidence in quitting next time had increased (from 58.7% to 62.0%) compared to a decrease in the control group (66.9% to 62.2%). A small qualitative sub-study (n=10) endorsed the theme of support provided by watching someone like them go through the quitting process and by feeling that they were not quitting alone. It was important to this group that they could select a role model they could relate to. Those who did not successfully quit this time reported feeling more confident to quit again in the future having learnt what would be required to be successful. Conclusions: It is difficult to draw conclusions about the effectiveness of this intervention as the trial was under-powered to detect an effect. Due to high quit rates in both groups it is possible that the control programme, of infrequent general health video messages plus the setting of a quit date, was as effective as the intensive theory-based content of the intervention. This is the first video messaging mobile phone intervention to be described in the literature. It demonstrates that it is feasible to deliver rich content via video messages directly to people. It also demonstrates the acceptability of multimedia mobile phone health interventions to at least a proportion of the population, although there are still issues with attracting young adults to smoking cessation programmes. The use of multimedia mobile phone technology has been slow to be adopted in New Zealand, which may have affected recruitment. As this technology becomes more commonplace there are likely to be future opportunities to investigate such novel interventions. Those working in this area may learn from the input of young adults into the intervention design and the feedback from participants on what was helpful.