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www.globalbridges.org
Erik Augustson, PhD, MPHBehavioral ScientistTobacco Control Research Branch Behavioral Research Program National Cancer Institute
Going Mobile: The Potential of mHealth for
Tobacco Dependence Treatment
Global Bridges, April 23, 2013
Smokefree Development Team
NCIErik Augustson
Ami BahdeYvonne Hunt
Heather Patrick
MMGLewellyn Belber
Jeff GoldfarbBrian Keefe
Samantha PostAmy Sanders
Shani Taylor*Alle Vargo
Additional Support
Lorien AbromsRachel Grana
Robin MermelsteinNalini Padmanabhan
Alison PilsnerAllison Rose
Mary SchwarzRobyn Whittaker
* Funded in part by NCI Contract No. HHSN261200800001E; HHSN261200544018C, NO2-PC-54418; and HHSN2612007000191
Outline• mHealth Potential for
Interventions• The Smokefree.gov Project • SmokefreeTXT• Domestic & International Case
Studies
Mobile Uptake• Mobile subscriptions
– U.S. 234 MILLION – Worldwide 6 BILLION – 90% of world pop has cell
signal access– 75% world pop has access to
mobile phone
**Source: ComScore June 2012 Report; Ericsson 2011
• Of U.S. mobile consumers:– 75% sent messages in early 2012– 51.4% used apps– 50.2% used a browser– 36.9% accessed social media sites or blogs– Motivation for health behavior change
Text Messaging
Whi
te
Afric
an A
mer
ican
Hispa
nic
79%80%
85%
American Text Messaging Preva-
lence
Send/Receive Texts
• Texting for Health– 9% of Americans
receive updates/alerts on health issues
Source: Pew Mobile Report 2012
• More likely to sign up for health text messages:– Women– 30-64 years old– African
American
U.S. Smartphone Ownership
Young adults tend to have higher-than-average levels of smartphone ownership regardless of income or educational attainment.
**Source: Pew Research Center’s Internet & American Life Project 2012
Smartphone Use for Health
2012
2010
27%
15%
35%
19%
38%
25%
Smartphone use to Find Health Infor-mation by Race
Hispanic
African American
White
Source: Pew Mobile Report 2012
• Owning a smartphone increases likelihood of accessing health information online
• More likely to look up health information on mobile phone: – Young adults– Minorities
mHealth Potential • Reach
– Large audiences– Underserved audiences
• Engagement with intervention platform– Increase access to intervention– Decrease barriers to participation (scheduling,
transportation, etc)– Decrease space/time gap between treatment &
behavior– Seamlessly integrate user interaction with treatment
within their daily life– Interactive functionality improved “dose”
• Reduces cost burden on healthcare system
Smokefree Family History
• 2003 Smokefree.gov– Focus on cessation resource– Multiple updates and iterations
• 2009 Smokefree Women– Expanded interactivity– Incorporation of social media
• 2011 Smokefree Teen– Multi-platform intervention
• 2012 Smokefree Español– Spanish
Smokefree Projects• Smokefree.gov
– Website– Mobile app (QuitGuide,
QuitPal)– Social media: Twitter
• Smokefree Women– Mobile Website (Spring
2013)– Social media: Facebook,
Twitter, Pinterest, YouTube
• Smokefree Teen– Mobile Website – Social media: Facebook,
Twitter, Tumblr– Mobile app (QuitSTART)
• Spanish Smokefree– Website– Social media
• Smokefree Pregnancy– Web content– Online video
• SmokefreeTXT– Teen– Young Adult– Spanish Language– QuitNow Library– Veteran (June 2013)– Military (coming soon)
SmokefreeTXT Program
• Text messaging smoking cessation intervention
• Features versions for teens, young adults & Spanish speaking audiences
• Users can opt-in and select a quit date up to 30 days into the future– Free with unlimited texting plan – Receive messages 2 weeks before and up
to 6 weeks after quit date– Increased number of messages close to
quit date
• Bidirectional: assesses user’s mood, craving, & smokefree status– Users can text keywords (i.e. CRAVE,
MOOD, SLIP)
SmokefreeTXT Overview
SmokefreeTXT MetricsTotal Subscriptions
March 2012- March 2013
-
5,000
10,000
15,000
20,000
25,000 22,610
SmokefreeTXT MetricsSubscriber Breakdown by Sex
All Time Subscribers
Total MalesTotal FemalesTotal Unknown
34%
58%
9%
SmokefreeTXT MetricsSmoking Status Reported at Registration
for over 13,000 participants
Every dayMost daysSome daysLess than thatUnknown
81%
2%
5%
1%
11%
SmokefreeTXT MetricsAdult Subscriber Opt Outs over Course of Treatment
September 2011 – October 2012
Count
down
(2wks
)
Wee
k 1-
2
Wee
k 3-
4
Wee
k 5-
6
Post
0-1
mo
Post
1-3
mo
Post
3-6
mo
Post
Afte
r 6 m
o0
500
1000
1500
2000
2500
3000
3500
4000
4500
SmokefreeTXT Metrics ITT Adult Follow-Up Responses:
Assessment of Active Subscribers, March 2013
• 1-Month: 17%
• 3-month: 13%
• 6-month: 11%
International Opportunities
• China: 300,000,000 Smokers
• 1) US HHS-China MOH-Nokia
• 2) Emory University-Suzchou
SmokefreeTXT: China• 1) US HHS-China MOH-Nokia– Four provinces selected– Health messages developed specifically
for project– Cessation messages based on NCI library– Translated by Chinese public health
professionals– Focus Group Testing of messages with
Chinese Smokers• 8 conducted • 2 in each province• Urban & rural
SmokefreeTXT: China• 1) US HHS-China MOH-Nokia– Phase One: 250,000 Smokers• 10 days smoking health effect
messages• Started 4/15/2013
– Phase Two: 8000 Smokers • 2-arm RCT • 1 week count down to quit day• 6 week treatment• 1 & 3 month f/u• Start 4/28/2013• Finish 9/17/2013
SmokefreeTXT: China• 2) Emory University-Suzchou – Nonrandomized Demonstration Project– Part of annual Quit Contest– NCI Library translated by local health
officials– 4 week treatment w f/u at EOT– 665 Smokers received text messages– ~1000 Smokers participated w/o text
• Data available in near future
Suzchou Project: Clinical Data
• Baseline Smoking Status– Daily 60% (49% vs. 70%)
• Time to 1st cigarette– 30+ minutes 69% (72% vs. 66%)
• Cigarettes per day– 10 or less 52% (54% vs. 51%) – 11-20 CPD 36% (40% vs. 33%)
• One Month Quit Rate – 38% (57% vs. 22%)
Suzchou Project: Feedback
• Amount of text messages– Right Amount 57% (74% vs. 42%)
• Provided Helpful/Useful Information– Yes 80% (92% vs. 69%)
• Helped to Motivate Quit Attempt– Yes 78% (90% vs. 69% )
Additional International Activities
• Collaboration with Healthy Caribbean Coalition– Launch June 2013
• Technical guidance for WHO project in Costa Rica
• Collaboration in South Pacific Islands• Continued development of India
project• Exploring project in Central & South
America
Underserved Populations: Challenges
• Consistency of cell phone access• Multiple users per device• Fee structures• Populations with Low Literacy• Role of mHealth interventions
with in larger public health infrastructure
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