Schroeder Institute + Mayo Clinic LEVERAGING TECHNOLOGY FOR SMOKING CESSATION JEFF POTERUCHA, MA, TTS AND MEGAN A. JACOBS, MPH
Overview 1. Why technology in the healthcare setting? 2. Web and mobile applications for smoking cessation developed by the Schroeder Institute 3. Integration of digital interventions: TTS-counseling context Surgical context Lung cancer screening context
The Role of Digital and Mobile Technology in Smoking Cessation
Technology and healthcare Evolution of the e-patient 72% of adults look online for health information One out of three are looking up health information on phone (52% of smart phone users are) 50% of e-patients will research health information on behalf of someone else 1 in 5 mobile users download apps to track their health Engaged Empowered Educated
Challenges facing e-patients who smoke Difficulty in connecting for ideal number of follow-up sessions Under-utilization & marginalization of cessation treatment among certain groups Online tobacco control efforts lack critical engagement (Emery et al. 2014) Emery, S., Aly, E. H., Vera, L., & Alexander, R. L. (2014). Tobacco Control in a Changing Media Landscape: How Tobacco Control Programs Use the Internet. American Journal of Preventive Medicine, 46(3), 293 296.
Synthesizing the evidence for web/mobile
Web and Mobile Smoking Cessation Interventions at the Schroeder Institute
Schroeder Institute Software Development Team 1. Develop a suite of scalable, technology-based interventions for smoking cessation 2. Conduct & disseminate research on intervention effectiveness 3. Collaborate with researchers interested in using our cessation tools 4. Partner with organizations interested in providing our cessation tools to the smokers they serve
BecomeAnEX.org
The BecomeAnEX Approach Based on Mayo Clinic s clinical protocol, EX helps smokers prepare for a comprehensive quit attempt by re-learning life without cigarettes Success in one area (e.g., having a cup of coffee without smoking) becomes a building block for success in other areas. EX breaks down the overwhelming nature of the quit into manageable/achievable pieces.
Core Features of EX Platform Cross-platform integration Rich analytics Robust research environment Partner ready
EX features 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. 6. 6. Set quit date Cigarette tracker Beat your smoking triggers Choose a quit smoking aid Build your support system Community
Interactive Quit Plan
Email + SMS sign-up on EX.org
Robust Email Campaign
Text Messaging 10 week program Multiple messages/day, tailored around quit date (mm/dd) Personalized Interactive e.g., True/False, Yes/No, MORE Customizable keywords e.g., CRAVE, MOOD, SLIP Include hyperlinks to BecomeAnEX.org Can be offered as standalone service (SMS as point of entry) Enrollment via SMS
Types of reporting Text Message User volume Enrolled Unenrolled When unenrolled? Text Message Engagement / Utilization Set/reset/cleared quit date Use of keywords (CRAVE, MOOD, SLIP) Requests for additional information (MORE) Smoking outcomes available 0, 7, 14, 30, 90, 180 days post-quit Date
Digital Interventions for Smoking Cessation: The TTS Counseling Context
Ongoing Quality Improvement Project Primary Aim Secondary Aims Evaluate feasibility of integrating text messaging into tobacco dependence treatment (in- and out-patient settings) Evaluate acceptability among patients Assess cessation outcomes associated with text message enrollment
Integration of Text Messaging into TTS Counseling At intake, a TTS informed all patients of a free text message program Patients texted QUITNOW to enroll or the TTS enrolled them via online interface Follow-up assessments conducted at 1- and 6-months Satisfaction with program Smoking outcomes
Results Enrollment and Follow-Up 313 patients referred to text message program 132 enrolled (42% uptake) 190 reached for follow-up survey at 6 months (61% response rate) Program Satisfaction 92% reported texts were somewhat or very helpful 93% would recommend the program to a friend 84% read most or all of the texts they received 70% felt the number of texts received was just right
Digital Interventions for Smoking Cessation: The Surgical Context
Tobacco and surgical patients Among the ~8,000 surgical patients seen each year at Mayo Clinic, approximately 15% are current cigarette smokers Patients who smoke are at increased risk of surgical complications Delayed/complicated wound healing Cardiovascular complications Current cigarette smoking is an independent risk factor for many postoperative complications
Tobacco and surgical outcomes Even 12 hours of abstinence prior to surgery can prevent many of these poor surgical outcomes Perioperative period is an ideal time for smoking cessation interventions Current recommendations: Maintain at least 12 hours of abstinence before surgery Maintain abstinence for as long as possible after surgery since postoperative abstinence reduces risk, even if preoperative abstinence is not achieved
Text messaging for cessation in the surgical context Use of text messaging smoking cessation interventions has not been studied in the surgical context Surgery patients are likely to be older than typical users of text message interventions Surgery patients are likely to be more motivated to quit than the general population of smokers Teachable moment Higher quit rates observed in previous studies
Tobacco Cessation in the Surgical Context: Pilot Study Primary Aim Secondary Aims Evaluate feasibility of a text message cessation intervention for surgical patients during the perioperative period (before scheduled surgery and 4 weeks postoperatively) Evaluate engagement with a text message program during the perioperative period Evaluate changes in smoking behavior of surgical patients enrolled in text messaging
Study design Prospective, observational study of 100 current smokers from Mayo Clinic preoperative evaluation clinic Brief tobacco intervention about perioperative cessation Enrolled in a text message program, with messages delivered prior to and 30 days after surgery Messages tailored to surgery date ( Your surgery is tomorrow. Just as you won't be eating after midnight, remember not to smoke either! You can do this! ) On-demand messages related to craving, relapse, and withdrawal symptoms also available Periodic assessments about smoking status ( Have you smoked at all, even a puff, in the last 24 hours? Reply YES or NO. )
Digital Interventions for Smoking Cessation: The Lung Cancer Screening Context
Smoking cessation in lung cancer screening setting Unique opportunity to deliver tobacco dependence treatment on a populationwide basis. More than 4 million current smokers age 55+ likely to be eligible for low dose computed tomography (LDCT) lung cancer screening (now covered by US Medicare) Health benefits of tobacco cessation for LDCT screening patients are far reaching Little is known about how best to integrate tobacco dependence treatment into this unique clinical context
LDCT study aims Effectiveness Implementation Reach & Adoption Usual Care vs. WEB+TXT vs. WEB+TXT+TTS Outcome = 12 mo biochemically verified abstinence Does proactive enrollment increase treatment use? Does treatment use mediate the relationship between treatment assignment and smoking outcome? Representativeness of study sample relative to all smokers screened for LDCT eligibility (reach) Potential for intervention implementation (adoption) among LDCT clinics.
Study design 3-arm randomized trial with repeated measures at 1, 3, 6, and 12 months. We will randomize N=1650 smokers who present for LDCT lung cancer screening to: 1. An Ask-Advise-Refer Usual Care control condition (UC) 2. A digital (WEB+TXT) cessation intervention (BecomeAnEX) 3. A digital cessation intervention (BecomeAnEX) combined with Tobacco Treatment Specialist counseling (WEB+TXT+TTS).
Intervention arms AAR Usual Care Brief cessation counseling(aar) WEB+TXT Brief counseling Enrollment in EX web and text messages (customized for lung cancer screening patients) WEB+TXT+TTS Brief counseling Enrollment in EX web and text messages Required session with TTS prior to LDCT screening 4 TTS sessions post-screening with real-time knowledge of EX engagement Proactive Enrollment via BOSS Registry
Questions? Megan Jacobs, MPH mjacobs@truthinitiative.org Jeff Poterucha, MA, TTS poterucha.jeffrey@mayo.edu