mtb Tobacco and mhealth interventions for smoking cessation Mark Parascandola, PhD, MPH Epidemiologist Tobacco Control Research Branch Behavioral Research Program Division of Cancer Control and Population Sciences
Promise of mhealth Interventions International Telecommunications Union (ITU) estimates over 7 billion mobile phone subscriptions in 2015 Access to mobile broadband growing fast -- estimated 47% of the world's population subscribe to mobile broadband cf 29% with landline subscriptions Increasing use of mobile phones in health information and delivery worldwide. appointment reminders, preventive activities and medication adherence. monitoring and the self management of chronic disorders such as diabetes smartphone applications for health and wellness are proliferating, although there is little published research in this area 2
Potential benefits of mobile phone-based smoking cessation interventions Ease of use anywhere at anytime Cost-effective delivery and scalability to large populations, regardless of location Ability to tailor messages to key user characteristics (such as age, sex, ethnicity, or even specific tobacco use behaviors) Ability to send time-sensitive messages with an 'always on' device Provision of content that can distract the user from cravings Ability to link the user with others for social support Ability to collect data on use and interaction with the program for evaluation 3
Mobile phone-based interventions for smoking cessation Robyn Whittaker, Hayden McRobbie, Chris Bullen, Anthony Rodgers, Yulong Gu 10 April 2016 http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd006611.pub4/full 4
SmokefreeTXT Home Page
Quitting: on your phone, on your terms Text messaging smoking cessation intervention for teens and young adults ready to quit 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 Program assesses user s mood, craving, & smokefree status User can text keywords (i.e. WANT, BOOST, UHOH) User can opt-out any time by texting STOP to iquit
Dynamic, Tailored Message Structure TEEN LOTS KINDA NOPE Think you can have just one puff? It will only feed your cravings and make them stronger. Still having cravings? Text back: LOTS, KINDA, or NOPE Wait it out-even the strongest cravings will go away after a few mins. Focus on something else & remind yourself why you are smokefree. We know the feeling - but think about what you are gaining & why you wanna leave cigs behind. Stay focused - it will get easier for sure. Cool! Glad youre not missing those nasty cigs. Keep staying strong & smokefree. Youre on your way to a healthy new you! :) ADULT GOOD OK BAD How you feel can be a smoking trigger. Feeling cranky or grouchy? Its only temporary, so stay strong! What is your mood? Reply: GOOD, OK, or BAD Glad to hear you are feeling good! Keep up that positive attitude and keep staying strong. Hang in there! It could be worse, right? No one said it would be easy but they do say its worth it! We know quitting is tough but hang in there! We all have bad days, and you will get through this. Do whatever to boost your mood-just dont smoke.
WHO and The Union Recommendations: Incorporate brief advice on smoking cessation in TB treatment programs
Social Determinants of TB and smoking are similar 95% of TB deaths in LMIC 80% of smoking deaths in LMIC High-income countries: Decline in TB and smoking Tobacco use estimated to account for 25% of global TB mortality
Opportunities and Challenges TB treatment context provides opportunity to intervene around tobacco use Existing infrastructure for community interventions Diagnosis of TB provides teachable moment However, smoking cessation interventions for TB patients present additional challenges Lower cessation rates Complications with other comorbidities Bulk of the evidence base for tobacco cessation comes from HICs LMICs may have limited access to pharmacologic treatments, fewer trained health professionals, weaker tobacco control policies Need for tailored interventions in LMIC context
mtb-tobacco Program
mtb-tobacco Program Development Global Workshop for mhealth for TB and Tobacco at the American University in Cairo, New Cairo Campus, Cairo, Egypt, February 24-25, 2016. TB and tobacco cessation experts, country representatives, WHO staff and partners for preliminary discussions and planning to develop mobile technologies to address tobacco use in the context of TB prevention and management using a human-centered design approach Build on mcessation experience in Tunisia and Costa Rica and mdiabetes in Egypt Developed manual on how to plan and implement an mtb-tobacco program, building on existing mcessation handbook 12
Designing a Text Messaging Program Step 1: Choose the behavior change goal E.g. smoking cessation for working-age Indian men Step 2: Step 3 Choose the communication objectives (e.g. beliefs, attitudes, knowledge) and behavioral techniques (e.g. actions) Based on theory and research Design the framework for the program Timing and frequency of messages, surveys, keywords, one-way vs. two-way Step 4 Write the message library For each case supported by the program, 160 characters or less
Components of message content Information based Motivational messages and behavior change for tobacco cessation Emotional support Stigma and discrimination Adherence to treatment Prevention during or after treatment Sharing my TB story with others Signs and symptoms of TB (for those at risk)
mtb-tobacco Message Algorithm TB germs spread in the air when TB patient coughs, sneezes or spits. TB is curable! You must take the medicine regularly for full [xx] months as your doctor tells. Deciding to quit tobacco for good is a great step [name].you should feel proud of yourself. We ll send you tips to help you get ready!
mtb-tobacco Message Algorithm First, can you tell us about your use of tobacco? There are 3 options, reply: 1. if you smoke tobacco; 2. if you chew tobacco; 3. if you use both Within 1 month, your cough and sputum production will decrease and you will be able to breathe easily. If you don t quit, your recovery will be delayed!
mtb-tobacco Pilot Study Design Prior to enrolment Initial assessment & seek consent All TB patients in the 11 facilities TB Patients who are tobacco users N= 200: Participants recruited 100 Intervention 100 control Receive Messages on tobacco cessation and TB adherence Reminder messages on tobacco cessation and TB adherence Receive Health education on TB adherence Reminder messages on TB adherence Assessment of quitting tobacco use and TB adherence
Conclusions Mobile health interventions show great promise for addressing tobacco use in LMICs, but more research is needed around use of interventions in different settings and more advanced apps Tobacco control and cessation should go beyond NCDs and seek opportunities to build on existing global health programs Implementation of mtb-tobacco requires education of TB program managers and staff about tobacco use Need to develop message content for waterpipe use and study mhealth interventions in waterpipe users. Existing evidence limited to cigarette smokers
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