Real-World Data for Enhancement of a National Smoking Cessation Intervention SmokefreeTXT Erik Augustson, PhD, MPH Director, Smokefree.gov Initiative Tobacco Control Research Branch Behavioral Research Program National Cancer Institute
DISCLOSURES This work was supported by the National Cancer Institute. No financial relationships to disclose.
SMOKEFREE PROGRAM SmokefreeMOM HealthyYouTXT Smokefree Apps:
BACKGROUND Text message-based interventions show promise for smoking cessation Current evidence on text message-based interventions comes from RCTs NCI launched SmokefreeTXT in 2011 42-day intervention, option to start 2 weeks prior to quit date Two-way messaging for quit status, cravings, mood, and slips 35+ behavior change techniques built into the messages RCT showed quit rates of ~20% 5
RESEARCH OBJECTIVE Assess engagement and self-reported cessation rates among real-world smokers who subscribe to the SmokefreeTXT program 6
METHODS Inclusion Criteria Opted-in to the SmokefreeTXT program September 20, 2011, to May 22, 2014 Had the opportunity to complete the 42-day treatment by May 22, 2014 Exclusion Criteria Failed to set a quit date on or after enrollment date Opted out on or before their quit date 18,080 of 25,283 included in study 7
METHODS Subscribers could opt out of the program at any time by texting STOP Cessation status was self-reported as a response to a text message prompt at the following time points: 7 days post-quit End of the program 1-month post-treatment 3-months post-treatment 6-months post-treatment Sensitivity Analyses Logistic Regression 8
SAMPLE DEMOGRAPHICS Demographics Mean Age: 34.8 years; Median Age: 32 years 62% Female 88% Daily Smokers 70% had Web-Enabled Phone 9
MEASURING CESSATION Point prevalence abstinence Assessment of cessation status at the particular point in time when the question is asked End of treatment- Primary 7-days post-quit 3-months post-treatment 6-months post-treatment 10
RESULTS: ABSTINENCE RATES SmokefreeTXT Point-Prevalence Abstinence Rates All Subscribers, Nonresponders & Opt-outs = Smokers Responders Only Response Rate Treatment Completers Response Rate 7 Days Post-Quit 20.3% 64.4% 31.5% 23.7% 34.8% End of Treatment 7.2% 75.1% 9.6% 12.9% 17.0% 3 Months Post-Treatment 4.0% 52.0% 7.7% 7.3% 13.4% 6 Months Post-Treatment 2.0% 45.4% 4.4% 3.7% 7.6% 11
MEASURING ENGAGEMENT Time in Program Treatment Initiation Opt out Program Interactions Response rates
GUIDING QUESTIONS FOR ANALYSIS To what extent does SmokefreeTXT engage users in a quit attempt? To what extent does SmokefreeTXT keep users engaged? How can SmokefreeTXT more effectively re-engage users who have opted out?
POTENTIAL FAIL POINTS 2 weeks Pre- Treatment 6 Week Treatment Initiating the quit attempt Establishing an initial period of abstinence Recovering from a lapse
PURPOSE To describe baseline user characteristics associated with SmokefreeTXT user engagement Age Gender Frequency of Smoking Region Emphasis on key fail points Treatment Initiation Opt Out Re-engagement 15
METHODS Retrospective records analysis of SmokefreeTXT user data between 2011-2014 N=25,283 subscribers Logistic regression to examine differences in baseline characteristics on key engagement metrics
TREATMENT INITIATION 100.00 80.00 Treatment Initiation 71.5% 60.00 40.00 20.00 0.00 28.5% Non-initiator Treament Initiator
USER CHARACTERISTICS OF NON-INITIATORS Non-daily smokers were more likely to be non-initiators compared to daily smokers OR: 1.461; 95%CI: 1.313, 1.625 No other baseline characteristics differed significantly by treatment initiation status
Percent of Total Subscribers Remaining Number of Subscribers Who Opt Out FAIL POINT 2 Weeks Pre- Treatment 1 Week Treatment Weeks 2-6 Treatment 100.00% 1200 90.00% 80.00% 1045 1000 70.00% 800 60.00% 50.00% 40.00% 30.00% 615 630 533 440 389406 522 489 600 400 20.00% 10.00% 0.00% 0 197 182 275 227 194196 92 124 71 83 76 247 52 75 155 164 138 103 38 75 35 58 72 65 28 35 35 33 0 7 14 21 28 35 42 Quit Date Days of Treatment Percent of Total Subscribers Remaining in Treatment Number of Subscribers Who Opt Out 54 60 27 200 End of Treatment 0 19
USER CHARACTERISTICS OF TREATMENT ENGAGEMENT Odds of opting out Males OR: 0.866, 95% CI: 0.807, 0.928 Older OR: 0.987, 95% CI: 0.984, 0.990 Non-daily smokers OR: 0.866, 95% CI: 0.763, 0,984
IN-DEPTH INTERVIEWS From March 14, 2014, to April 4, 2014, the research team conducted IDIs with users of SmokefreeTXT 9 male, 9 female Qualitative data Usability & acceptability User interactions with the program, feasibility
OPPORTUNITIES: RESULTS In-depth interviews with program users suggest that opting-out was associated with relapse to smoking
CONCLUSIONS Analysis of user data provides insight to guide further research and intervention refinement Many subscribers opt out before program end Some subscribers do not respond SmokefreeTXT supports short-term cessation in a real-world implementation CONSIDERATIONS Low response rates for long-term follow up Does no response/opt-out mean relapse? 23
CONCLUSIONS CONTINUED Sub-optimal engagement is a challenge for mhealth interventions Fail points are opportunities for improvement Real world process data is needed to guide the design and implementation of mhealth interventions 24
Thank you! Smokefree.gov/SmokefreeTXT augustse@nih.mail.gov 25