Effect of Technology-Assisted Brief Abstinence Game on Long-term Smoking Cessation in Individuals Not Yet Ready to Quit: A Randomized Clinical Trial

Abstract

Importance: Most trials of behavioral or pharmaceutical interventions for people who smoke are limited to individuals reporting they are ready to quit smoking. Engaging individuals who initially report they are not yet ready to quit in brief, precessation, skills-building interventions (eg, practice quit attempts or nicotine replacement therapy [NRT] sampling) is challenging.

Objective: To test an integrated behavioral plus NRT-sampling intervention using a gamification approach supported by mobile health.

Design, setting, and participants: A multisite randomized clinical trial with site-level 1-to-1 allocation into 2 conditions was conducted in 4 US health care systems. A total of 433 individuals who were currently smoking and reported at enrollment that they were not ready to quit smoking were enrolled. The study was conducted from November 7, 2016, to July 31, 2020.

Interventions: Take a Break (TAB) was a 3-week game experience and included 5 behavioral components (motivational messaging, challenge quizzes, brief abstinence goal setting, mobile health apps for cravings management, and reward points for participation) integrated with NRT sampling. TAB draws on social cognitive theory and game mechanics concepts to engage participants in health behavior change. The comparison included NRT sampling only.

Main outcomes and measures: Time to first quit attempt (duration from TAB experience to primary outcome) and carbon monoxide level-verified smoking cessation at 6-month follow-up. All analyses used an intention-to-treat approach.

Results: Of the 433 individuals included in the trial, 223 were women (52%); mean (SD) age was 54 (13) years. More than half (53% [112 of 213]) of the TAB participants completed 100% of the daily challenge quizzes in the first week, 73% (145 of 199) of participants who completed the goal-setting call set a brief abstinence goal (most frequently 1-2 days of abstinence from cigarettes), and 75% (159 of 213) of participants used the mobile health apps to manage nicotine cravings. Time to the first quit attempt was lower for the TAB vs comparison group (hazard ratio, 1.68; 95% CI, 1.09-2.60; P = .02). At the 6-month follow-up, 18% (28 of 160) of TAB participants and 10% (17 of 171) of the comparison (χ2 test, P = .045) participants obtained carbon monoxide level-verified smoking cessation (accounting for clustering of outcomes by site; odds ratio, 1.92; 95% CI, 1.01-3.68; P = .048).

Conclusions and relevance: The findings of this randomized clinical trial demonstrate that individuals not yet ready to quit smoking could be engaged in a brief abstinence game. Six months later, the TAB group had nearly double the rate of smoking cessation vs the NRT sampling comparison group. Integrating a skills-building game experience with brief NRT sampling can enhance long-term cessation among those not yet ready to quit smoking.

Trial registration: ClinicalTrials.gov Identifier: NCT02973425.

Figure 1.. Flow Diagram of the Process of Enrollment, Allocation, Follow-up, and Data Analysis

Figure 2.. Abstinence in the First 3 Weeks and Time to First Quit Attempt

A, Daily abstinence: for each day, proportion of smokers who reported 24-hour abstinence (ie, 0 cigarettes for the past 24 hours) by texting, with trend predicted by generalized estimating equations. B, Kaplan-Meier function, with proportions of participants with Take a Break (TAB) vs nicotine replacement therapy (NRT) achieving quit attempt at 7 days (TAB + NRT, 0.063; NRT only, 0.027; difference, 0.036), 21 days (TAB + NRT, 0.125; NRT only, 0.061; difference, 0.064), 30 days (TAB + NRT, 0.160; NRT only, 0.075; difference, 0.085), 60 days (TAB + NRT, 0.236; NRT only, 0.143; difference, 0.093), and 90 days (TAB + NRT, 0.354; NRT only, 0.231; difference, 0.123).