Running Head: SMARTPHONE VIDEOGAME SMOKING CESSATION

Transcription

1 Running Head: SMARTPHONE VIDEOGAME SMOKING CESSATION Prototype Testing of BreatheFree: A Videogame-based Smoking Cessation Smartphone Application Bethany R. Raiff 1, Nicholas Fortugno 3, Daniel R. Scherlis 2, Darion Rapoza 2 1 Department of Psychology, Rowan University 2 Entertainment Science, Inc. 3 Playmatics LLC

2 SMARTPHONE VIDEOGAME SMOKING CESSATION 2

3 SMARTPHONE VIDEOGAME SMOKING CESSATION 3 Abstract Background Cigarette smoking is the leading preventable cause of death in the United States, causing an estimated 438, deaths each year. Researchers have developed many efficacious smokingcessation interventions, yet ample room remains for improvement upon not only their efficacy, but also their effectiveness. One of the most effective smoking cessation interventions is contingency management (CM). Objective There are two barriers to CM, which involves delivering monetary incentives for objective evidence of health behavior, including the cost of incentives and sustainability of treatment outcomes. The goal of the present study was to evaluate the feasibility of a videogamebased smartphone application, BreathFree, to replace monetary incentives used in CM with videogame-based incentives. Methods Twenty-one smokers participated in this study. Participants were given an overview of the goals of the BreathFree game and were trained to submit a carbon monoxide (CO) sample via an Android tablet. After playing several levels of the game participants were told that they could continue and play one extra level, or they could stop and complete an outcome survey, receive payment, and be dismissed. Results When asked with a multiple choice question whether the game was fun, 52% said "Yes," 29%" said "Maybe, it has the potential to be fun," and 19% said "No." Fifty-eight percent of

4 SMARTPHONE VIDEOGAME SMOKING CESSATION 4 participants, given the option to play an extra level of the game, chose to do so, and 86% signed up to be notified when the full version of the game was released. Conclusions This was the first study to evaluate a smartphone-delivered, videogame-based CM application for smoking cessation. The prototype of BreathFree was highly endorsed on multiple dimensions from a group of treatment-seeking smokers. More than half of participants decided to play the extra level, which meant they delayed smoking their next cigarette, as well as getting paid, by at least a few minutes. These results are promising and we are now fully developing the game to test in the context of a clinical trial. Keywords Smoking; Smoking Cessation; Contingency Management; Video Games; Carbon Monoxide; Incentives

5 SMARTPHONE VIDEOGAME SMOKING CESSATION 5 Introduction Cigarette smoking is the leading preventable cause of death in the United States, causing an estimated 48, deaths or about 1 out of every 5 deaths each year [1]. Approximately 15.1% of US adults are current smokers, comprising approximately 36.5 million smokers [1]. Smoking cessation is therefore a critical national health issue [2]. Researchers have developed many efficacious smoking-cessation interventions, yet ample room remains for improvement upon not only their efficacy, but also their effectiveness. Each year, one-third to one-half of all smokers attempt to quit at least once [3], but the annual incidence of successful quitting is less than 6% [4]. Media campaigns and cessation programs can increase quit attempts and successful cessation rates, respectively, by a margin of nearly 5% (i.e., 1.5 x baseline, or a ~3% improvement) [3, 5]. Based on solid evidence, smoking-cessation rates that are better than those obtained with placebo are achieved with: physician advice; counseling by health professionals; a variety of cognitive-behavioral, social-influence, and motivation-enhancement cessation programs; and drug treatments, including nicotine replacement therapies (gum, patch, spray, lozenge, and inhaler), selected antidepressant therapies (e.g., bupropion), and nicotinic receptor agonist therapy (varenicline) [1, 5, 6]. Nevertheless, nearly 8% of smokers who attempt to quit do so without the assistance of any of these approaches [7], half or more consider counseling and cessation programs ineffective, and over a third consider pharmacotherapy ineffective [8]. The majority of young smokers report they would never use any of these methods, other than the nicotine patch (which only 5% would use) [9]. Thus, the three major weaknesses of current approaches are underutilization, lack of appeal to smokers who wish to quit, and, in general, modest efficacy in supporting smoking cessation.

6 SMARTPHONE VIDEOGAME SMOKING CESSATION 6 Clearly, more-appealing and more-efficacious smoking cessation interventions are needed. One of the most efficacious aids for initiating smoking abstinence is contingency management (CM) [1-12]. CM for smoking cessation consists of delivering rewards (typically money) contingent on objective evidence of smoking abstinence (e.g., low levels of the combustion product carbon monoxide (CO) in the exhaled breath). Unfortunately, CM s effectiveness on a population level has been limited by a number of constraints leading to low adoption rates and shorter than optimal treatment durations. These factors include the cost of providing the cash or cash-equivalent rewards [13-16], and the distance that must be traveled, as well as the time required, to participate in supervised monitoring procedures at a clinic [13, 15]. Monetary reward payments for smoking cessation can range from $1-5 per person for approximately 2-12 week interventions [11, 17, 18]. The cost of these payments limits the feasibility of widespread CM adoption. Furthermore, the ongoing nature of these costs curtails the acceptability of longer-term treatment and/or booster sessions that could otherwise extend program effects (by reducing relapse), not only due to the added expense, but also because many find it philosophically objectionable to continue to pay people for continuing to not do what they already aren t doing, and which was self-harmful for them to have been doing in the first place. CM procedures require biochemical verification of abstinence, because participants are much more likely to falsify self-reports when incentives are delivered contingent on their abstinence [19]. Carbon monoxide (CO) is one method to biochemically verify abstinence; however, the half-life of CO is short (~3-6 hours), requiring at least twice daily check-ins to verify abstinence [2]. To address this barrier, Dallery and colleagues developed an efficacious CM intervention that is delivered over the Internet [11, 17, 21, 22], in which participants are provided with a breath CO monitor, and remotely record and submit video clips of themselves

7 SMARTPHONE VIDEOGAME SMOKING CESSATION 7 providing their breath CO samples twice daily. More recently, mobile CM for smoking cessation (where participants use the camera on their smartphone to record and submit the video clips) has been shown to be feasible, acceptable, and show promise in promoting smoking abstinence [23-25]. Mobile CM further overcomes barriers to using the intervention. However, even these Internet and mobile CM interventions rely on monetary incentives for abstinence, therefore cost remains a barrier to widespread dissemination. To directly address the remaining barriers for widely disseminating CM (i.e., cost and sustainability), we proposed to develop a mobile, social, videogame-based CM intervention for smoking cessation. In this mobile application, the monetary incentives typically used to reward abstinence will be replaced with in-game virtual rewards that can immediately be used to help players meet game objectives. The rewards will be automatically delivered for meeting individual smoking abstinence goals, and players will also play in the context of a group setting where they will be able to give and receive social rewards from other players who are also trying to quit. "Virtual rewards" can be instantiated by software at essentially no cost and they can have demonstrably significant economic/monetary value (the US market for videogame content was an estimated $24.5 billion in 216) [26]. This suggests that "virtual rewards" in the form of videogame content may readily substitute for monetary incentives in a CM procedure, drastically reducing cost while maintaining efficacy. The game will have the added benefit of minimizing delays to the receipt of rewards for abstinence once they are earned, as participants can immediately "consume" the rewards in the game. In addition to the more traditional individual contingencies, BreathFree will also include group contingencies for smoking abstinence [27], leveraging the naturally occurring contingencies that arise in the context of groups to further support smoking cessation.

8 SMARTPHONE VIDEOGAME SMOKING CESSATION 8 To assess the social validity of a videogame-based CM intervention we conducted a survey with smokers to assess their views of using an online social game with contingent access to virtual rewards, in place of monetary incentives, in the context of a CM intervention for smoking cessation [28]. From a sample of 235 smokers (ranging in age from 18-64), 75% reported playing video games. The vast majority of smokers, 78%, reported playing social games (i.e., played casual games online, usually with friends and family on social networks such as Facebook). This rate is slightly higher than the population at large. Approximately 73% of all smokers, and 7% of all videogame players, surveyed said they thought contingent access to virtual rewards, in place of money, would motivate smokers to abstain. Additionally, 75% of those surveyed would recommend or use a treatment such as this if they knew someone who wanted to quit, or if they were trying to quit themselves [28]. With the support of these promising outcomes, we developed and evaluated a prototype of BreathFree, our mobile, smartphone-delivered, videogame-based CM intervention to promote smoking cessation. Below are the outcomes of that development and evaluation effort. Methods Participants Participants were recruited online via Craigslist, a free classified advertisement service, and Facebook, a social networking website (N = 28; see Table 1 for participant characteristics). The advertisement specified that Rowan University researchers were seeking cigarette smokers to test a prototype of a game to help people quit smoking, and that they would be compensated $4. for their participation. Participants were eligible if they reported smoking cigarettes, expressed a desire to quit smoking, and were available during the testing session times. All study

9 SMARTPHONE VIDEOGAME SMOKING CESSATION 9 procedures were approved by the Rowan University Institutional Review Board. All participants provided informed consent before beginning the session. Table 1. Participant demographics (N = 28) Demographic n (%) Gender Female 1 (35.7) Race White 1 (35.7) Black 11 (39.3) Asian 1 (3.5) Unknown 6 (21.4) Ethnicity Hispanic 5 (17.9) Not Hispanic 19 (67.9) Unknown 4 (14.2) Cigarettes per day 1 or less 16 (57.1) (35.7) (7.2) FTND ALL (N = 28; M±SD) 3.39 ± 2.6 FTND Smokers (n = 21, M±SD) 4.48 ± 2. Note. FTND = Fagerstro m Test for Nicotine Dependence. Materials and Procedure The prototype testing was completed over the course of three days, consisted of seven total group sessions, and the duration of each session was approximately one hour. Groups were

10 SMARTPHONE VIDEOGAME SMOKING CESSATION 1 comprised of approximately 2-7 participants. After completing the consent process, participants were given a presentation of the game, carbon monoxide as it relates to cigarette smoking, and an explanation of the researchers' purpose in developing the game. Each participant was loaned an Android tablet (Nexus 7 213; Google, Asus) and a pico+ CO meter (Bedfont; Kent, United Kingdom) and were asked to submit a video sample of their CO using the camera on the tablet. The video samples showed them exhaling into the CO meter and showing their CO value to the camera. All prototype game testing sessions were video recorded using a Samsung HMX-F9 camcorder. One of the authors and game developers (NF) then provided an overview of the game objectives to players, after which they were asked to begin playing the first level of the game on the Android tablet. The game consisted of having the participant hold the tablet with both hands in landscape view and swipe different colored gems into specific locations on a lotus flower (see Figure 1). At the end of each level a window appeared explaining what resources had been earned for completing that level (see Figure 2), and the author (NF) explained how the game would advance over time. Figure 1 Figure 2

11 SMARTPHONE VIDEOGAME SMOKING CESSATION 11 Before each new level the player saw a screen explaining that a CO sample would be required before completing the level (although they only actually submitted one CO sample at the very beginning of the session). Additionally, mock-up screens were shown to illustrate how the social and group incentives would be arranged for continuous abstinence (see Figures 3 and 4). Figure 3 Figure 4 Participants could also see how their home screen would change over time, as they progressed through the game (see Figure 5 and 6), and they played a "gifting" level where their earnings from the level were awarded to another, hypothetical, player who had been abstinent for some period of time. Participants could ask questions about the game at any time. At the end of the last level, they were told that there was one extra level that they had the choice to play. They could either end the game at that point and finish the last few steps of the study (i.e., complete an exit survey and receive payment), or they could stay a few more minutes longer and play one Figure 5 Figure 6 extra level before completing the final steps. It was made clear that the choice was entirely theirs and that there would be no penalty for skipping the extra level.

12 SMARTPHONE VIDEOGAME SMOKING CESSATION 12 At the end of prototype testing, participants completed a brief outcome evaluation survey, which consisted of four parts. The first part asked participants to classify how well they agreed with each item using a 1-mm visual analog scale (VAS; anchors, starting at zero, were "Definitely Not," "Maybe, " and "Yes, Absolutely"). The second part consisted of multiplechoice and free-response questions (e.g., how much would they be willing to pay to use the BreathFree program, what did they like most and least about the BreathFree game, etc). The third part of the survey consisted of multiple-choice demographic questions to collect information about race, ethnicity, and gender. The fourth and final part of the survey was comprised of the 6-item Fagerstro m Test for Nicotine Dependence (FTND) [29]. Before leaving, participants were given the option of providing research staff with their contact information if they were interested in being contacted when the full version of the BreathFree game was released. Data Analysis The median and interquartile range (-1mm), as well as the percentage of participants who "endorsed" each statement, defined in the following two ways, were evaluated: (1) ratings of 51 or higher on the VAS translate as an endorsement on a binary scale (e.g. anchors Disagree, Agree ), whereas (2) ratings of 67 or higher translate as an endorsement on a 3-choice scale

13 SMARTPHONE VIDEOGAME SMOKING CESSATION 13 (e.g., anchors Definitely Not, Maybe, and Yes, Absolutely ). To further analyze the VAS scores, percentiles were calculated (similar to the calculation of percentile rank scores common on standardized college entrance exams) to permit a fine-grained assessment of the data while minimizing the influence of outliers. To find the percentiles, the raw data values were arranged in rank order and were then divided into 1 equal-sized data subsets, making the value at the 5 th percentile the median. Additionally, to determine whether there were any differences in the likelihood of endorsing items on the VAS based on nicotine dependence, participants were divided into two approximately equal groups (FTND 2-5; n = 12 versus FTND 6-1; n = 9) and the differences in the two groups responses to the outcome evaluation questions (part one) were qualitatively compared. Results Twenty-eight individuals participated in the BreathFree prototype testing study (see Table 1 for demographic information). Of those, 21 met the criteria for "current smokers" based on FTND scores of two or greater. Therefore, the seven participants who were not current smokers were excluded from the primary analyses, unless otherwise noted. To further analyze the VAS scores, outcome evaluations and their median [IQR] scores are presented (see Table 2). Percentiles were also calculated as described above to permit a finegrained assessment of the data, while minimizing the influence of outliers.

14 SMARTPHONE VIDEOGAME SMOKING CESSATION 14 Table 2. Outcome evaluation median (IQR) of VAS ratings and percent of endorsements at rankings of >51 (binary) and >67 (trinary).

15 SMARTPHONE VIDEOGAME SMOKING CESSATION 15 Item # Median (IQR) VAS Endorsed (>51) Endorsed (>67) Item Q1 84 (7-99) 9% 81% Would you use the proposed full version of BreathFree to help you quit smoking and stay smoke-free? Q2 96 (82-99) 95% 95% Would you recommend BreathFree to a friend that wants to quit smoking? Q3 66 (51-93) 76% 48% Do you think using the BreathFree program would help you to quit smoking? Q4 94 (79-98) 9% 81% Do you think the BreathFree program could help some smokers quit smoking? Q5 88 (67-97) 1% 76% Do you think using the BreathFree program as a whole (including breath monitoring, playing the game, and giving and receiving rewards for not smoking) will be FUN? Q6 85 (69-96) 1% 76% Do you think the BreathFree game will be FUN to play? Q7 64 (53-81) 81% 38% In terms of FUN, where do you think you would rank the BreathFree game compared to all other games you have ever played on a smartphone (including games you played only once)? Q8 73 (51-95) 76% 52% Do you think incorporating information about the health benefits of not smoking directly into the game would make the Breath Free program more effective in helping people quit smoking? Q9 81 (72-99) 1% 81% Do you think incorporating tips about how to quit smoking such as ways to deal with cravings directly into the game would make the Breath Free program

16 SMARTPHONE VIDEOGAME SMOKING CESSATION 16 more effective in helping people quit smoking? Q1 If the full version of BreathFree were currently available, and you were selecting a smoking cessation aid to use in your next attempt to quit smoking, do you think you would be more likely to use BreathFree than... Q1a 81 (51-96) 76% 57% any other smoking aid? Q1b 95 (71-98) 86% 76% the nicotine patch? Q1c 97 (54-99) 81% 62% a drug designed to help reduce your cravings? Q1d 92 (75-99) 95% 86% a program that involves you attending multiple training sessions or support group meetings? Q1e 86 (59-1) 9% 67% than hypnosis? The percentiles for the VAS scores on the outcome evaluation are shown below (see Table 3). Using Question 1 as an example, a rating of 51 at the 9 th percentile indicates that 9% of participants assigned a rating of 51 or higher to that item.

17 SMARTPHONE VIDEOGAME SMOKING CESSATION 17 Table 3. Percentile of rankings of VAS scores for each item on the outcome evaluation survey (light gray indicates scores >51 (binary) and dark gray indicates scores > 67 (trinary). Percentil e Q1 Q2 Q 3 Q4 Q5 Q6 Q 7 Q8 Q9 Q1 a Q1 b Q1 c Q1 d Q1 e When an endorsement was defined by a ranking of 51 or higher (binary), at least 75% of participants provided an endorsement on every single item (range 75-1%, depending on the item; see Tables 2 & 3). The items with the lowest percentiles of endorsement were Q3, 8, and 1a (at least 75%), and the highest percentiles of endorsement were Q5, 6, and 9 (1%). Alternatively, if endorsement was defined as a ranking of 67 or higher (trinary), at least 25% of participants endorsed every item, at least 5% endorsed all but two items (Q3 & 7), and at least 75% endorsed all but 6 items (Q3, 7, 8, 1a, 1c, & 1e), with a range of at least 25-95% across

18 SMARTPHONE VIDEOGAME SMOKING CESSATION 18 all of the items. The item that received the lowest percentile of endorsements was Q7 (25%), whereas the item that received the highest percentile of endorsements was Q2 (95%). The percentage of highly dependent smokers who endorsed Q3 (would BreathFree help you quit smoking), Q5, Q6, and Q7 (is BreathFree fun in itself and compared to other games), as well as Q1c (more likely to use BreathFree than a drug designed to reduce cravings) was higher than the percentage of low dependent smokers who endorsed the same items (Q3 High = 67-89% vs Low = %, Q5 High = % vs Low = %; Q6 High = 1% vs Low = %, Q7 High = % vs Low = 25-75%, Q1c High = 88.9% vs Low = %). When asked the question, "If the BreathFree program had been demonstrated to be just as effective as other smoking cessation aids (such as the nicotine patch), and included ongoing access to the game, the monitoring program, and a CO monitor that was yours to keep, how much would you be willing to pay for the program?" the mean (±SD) responses were $14.4 per month (±$16.2) OR $133. for a one-time purchase (±$186.). Smokers with higher dependence reported that they would pay more than 2.5 times as much per month than lower dependence smokers (High = $21.3 vs Low = $6.7). When asked with a multiple choice question whether the game was fun, 52% said "Yes," 29%" said "Maybe, it has the potential to be fun," and 19% said "No." There were no notable differences based on nicotine dependence. In the free-response portion of the survey, when participants were asked what they liked best about the BreathFree game, the most frequent response was that they liked the game itself, either because it was fun, creative, challenging, or because they liked the puzzle style of the game (43%). Participants also reported that they liked the rewards delivered for abstinence (29%), the community and social support aspects of the game (24%), the simple instructions

19 SMARTPHONE VIDEOGAME SMOKING CESSATION 19 (19%), the graphics (14%), and the ability of the game to serve as a distraction from smoking (14%). A couple of participants also mentioned that they liked the CO monitor (1%). When asked what they liked least, the most frequent response was that they thought the game lacked variety (29%). Participants also noted that glitches with the game needed to be resolved (e.g., swiping gems to the correct location, screen loading, etc; 14%), the graphics could be improved (14%), and that the game was too easy (1%). Other comments were that the CO meter was too bulky, there were too many screens, the game was too challenging, they did not like the idea of social support, and that the game felt disconnected from the rewards. Two participants did not indicate any weaknesses with the proposed intervention (1%). Participants were also asked to give suggestions about how to move forward with the game, and the only response that appeared more than once was to improve variety in the game (33%). Other suggestions were to provide real rewards for abstinence, resolve glitches, improve graphics, and to explore having insurance companies cover the cost of the game. Fifty-eight percent of participants given the option to play an extra level of the game chose to do so (15 of 26 participants), and 86% signed up to be notified when the full version of the game was released (23 of 28). Because participant responses to the outcome evaluation were anonymous, it was not possible to determine which of the participants who stayed to play the extra level, and which participants who chose to sign up for the full version of the game, were later classified as nonsmokers based on their FTND scores. Thus, those results are based on the full sample.

20 SMARTPHONE VIDEOGAME SMOKING CESSATION 2 Discussion This was the first evaluation of a smartphone-delivered, videogame-based CM intervention for smoking cessation. The prototype of BreathFree was highly endorsed on multiple dimensions from a group of treatment-seeking smokers. In order for BreathFree to be effective at motivating smokers to quit, using videogame-based rewards as incentives for abstinence, it is critically important that the game be fun. Simply put, if the game is not fun, the virtual rewards will not be effective at reinforcing abstinence. In the current study, the extent to which the prototype of BreathFree was fun was evaluated in a number ways. To begin, responses on VAS items Q5 and Q6 of the outcome evaluation survey (shown in Tables 2 & 3), addressed whether participants thought the game as a whole was fun, of which 76-1% of participants agreed, depending on how an "endorsement" was defined. Additionally, more than half of participants also responded "Yes" to the multiple-choice question asking whether the game was fun, and an additional 29% said they thought it had potential to become fun with further development. Finally, probably one of the strongest indicators that the game has great potential to be both fun and effective at promoting smoking cessation was when participants were given the option to play an extra level. More than half of participants (58%) decided to play the extra level, which meant they delayed smoking their next cigarette, as well as getting paid, by at least a few minutes. This is the ultimate objective of the game. Between 8-9% of participants said they would be interested in trying BreathFree to help them quit, 95% would recommend it to someone they know who was trying to quit, and 4-9% of participants thought it was likely to help them, or someone else, quit (depending on how endorsement is defined). Between 76-86% said they were more likely to use BreathFree than the nicotine patch, 62-81% said they were more likely to use BreathFree than a drug designed to

21 SMARTPHONE VIDEOGAME SMOKING CESSATION 21 reduce cravings to smoke (e.g., Chantix), 86-95% said they were more likely to use BreathFree than a program that involves attending training sessions or support group meetings, and 57-76% of participants said they were more likely to use BreathFree than any other smoking cessation aid. The question asking how much participants would be willing to pay for the intervention confirmed the commercial viability of the proposed game, ranging from $1.99-$6 per month, or $9.99-$7 as a one-time fee. Participants with greater levels of nicotine dependence tended to show higher endorsements regarding how much fun and how helpful they thought the game could be, and subsequently tended to report a willingness to pay a higher per-month premium to get access to the game. Finally, 82% of study participants signed up to be notified when BreathFree becomes available so they can use it if they have not yet successfully quit smoking by that time, further supporting the ultimate commercial viability of the game. Item Q7 on the outcome evaluation survey was included to help inform the game design team of how they were doing so far, at this early stage of development. Participants were asked to rank the intervention game relative to every other game they had ever played on their smartphone. Because the participants were asked to compare this prototype of the game, which was less than 1% developed at the time of testing, and had yet to be completed and polished for commercial release, a median VAS of 64 was a very promising outcome. Participants provided useful feedback for moving forward with game development, probably the most consistent of which involved adding variation to the game to keep it interesting and engaging. Overall, feedback about the type of game, the game graphics, as well as the social elements and CO monitoring in the game, were viewed favorably. Outcome

22 SMARTPHONE VIDEOGAME SMOKING CESSATION 22 evaluation survey items Q8 and Q9 were also included to inform future work beyond the scope of the currently planned BreathFree game. Participants were more likely to endorse the idea of incorporating tips and advice about how to quit smoking (e.g., how to deal with cravings) than they were to endorse incorporating the health effects of smoking in to the game (Q9 = 81-1% vs Q8 = 52-76%, respectively). These findings should be considered when future iterations of BreathFree, or other games, are designed and developed. The current study has a few limitations worth noting. First, because of the small sample size it was not possible to determine whether there were statistically significant differences between endorsements, or other measures, between high and low nicotine dependent participants. A number of items seemed to suggest differences, but it was not possible to further evaluate the potential differences using inferential statistics. Second, information about the participants' individual histories with playing games, particularly smartphone games, was not collected. Anecdotally, it was made clear that there was a range of past experiences. However, because the game is being designed as a smoking cessation aid, a level of heterogeneity of past experiences with videogames is expected among the target population of treatment-seeking smokers as well. A third limitation is the possibility that participants may have rated the game favorably to avoid offending the experimenters and game designers (i.e., demand characteristics). At the beginning of the group sessions, it was made clear to participants that they were being asked to give an honest evaluation of a very early version of the game, and that their feedback could help shape the future development of the game. Although it is impossible to rule out potential bias, it is clear that participants felt comfortable enough rating the game lower in terms of how it compared to other, commercially available games (Q7 received the lowest scores), as well as other available smoking cessation aids. Additionally, there were several participants who used

23 SMARTPHONE VIDEOGAME SMOKING CESSATION 23 the lower half of the rating scale on a number of items, building confidence in the honesty of their evaluations. Finally, the fact that over half of the participants voluntarily played extra, unrequired, levels of the game supports the conclusion that the subsequent endorsements for the game were genuine. Although there are other videogames that have been evaluated for smoking cessation, none are based on the empirically supported procedures and theoretical foundations of contingency management and behavior analysis [3-32]. This study is the first to show that a videogame-based CM intervention has great potential to be both helpful and fun to smokers who wish to quit. If successful, the game could overcome a number of barriers to using CM for smoking cessation, such as the high costs associated with abstinence-based incentives, the longterm sustainability of successful treatment outcomes, and perhaps most importantly, the increased accessibility to a fun and engaging smoking cessation intervention. Acknowledgements This grant was funded by a National Institutes of Health, National Institute of Drug Abuse Small Business Innovations Research Grant (SBIR R44DA36252). We thank Margaret Wallace and Noelle Hoffman for their assistance with recruitment and data entry. Conflicts of Interest Author BR does not have any conflicts of interest. Authors DR, DS, and NF are in conflict because they have the potential to benefit from sales of the final BreathFree game. Abbreviations CM = contingency management

24 SMARTPHONE VIDEOGAME SMOKING CESSATION 24 CO = carbon monoxide FTND = Fagerstro m test for nicotine dependence M = mean SBIR = Small Business Innovations Research SD = standard deviation VAS = visual analog scale

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