Changes over time in reasons for quitting vaping among treatment-seeking young people from 2019 to 2022.

Objectives: The landscape of availability, policies, and norms around e-cigarette use and cessation has changed rapidly in the last few years. There is also high interest in quitting vaping among teens and young adults. Understanding the motivation of those who want to quit vaping is important for effective intervention development. This analysis compares user-submitted reasons for quitting (RFQ) vaping from 2022 to a previous analysis from 2019 to determine whether motivations have shifted among young people. Methods: We reviewed 2000 RFQ submissions from users who enrolled in a vaping cessation text message program in 2022. Each response was coded by ≥ 2 researchers and categorized into one of 16 themes. Findings were compared to the 2019 analysis using item-wise comparisons. Results: The most frequent RFQ in 2022 were health (56.1%), social influence (15.8%), and other (11.7%). In comparison to 2019, health remained the top reason, but the rank order of all other reasons shifted. Theme prevalence changed significantly, with cost decreasing and health increasing. Among health-related sub-categories, current and mental health increased compared to 2019 submissions. Discussion: RFQ among young people shifted between 2019 and 2022. We observed greater concern about current and mental health, possibly from experiencing negative health impacts from vaping or from increased awareness of these impacts. The lower prevalence of cost may reflect the widespread availability of cheaper e-cigarettes. RFQ likely change rapidly with the fluctuating e-cigarette landscape and should be considered in cessation interventions, promotional campaigns, and policy.

E-cigarette and combusted tobacco abstinence among young adults: Secondary analyses from a U.S.-based randomized controlled trial of vaping cessation.

OBJECTIVE: To examine patterns of abstinence from e-cigarettes, combusted tobacco products (CTPs), both, or neither among young adults enrolled in a U.S.-based randomized trial of a text message vaping cessation intervention. METHODS: At baseline, 1829 young adult e-cigarette users were categorized as Exclusive E-cigarette Users (no past 30-day CTP use; n = 1036, 56.6%) or Dual Users (past 30-day CTP use; n = 793, 43.4%). Four groups were defined at 7-months: 1) Dual Abstinent, 2) Exclusive Vaping, 3) Exclusive CTP Use, and 4) Dual Users. The proportion of participants who were Dual Abstinent was the outcome of interest. RESULTS: At follow-up, 22.1% (95% CI: 20.3, 24.1) of participants were Dual Abstinent, 44.8% (95% CI: 42.5, 47.1) reported Exclusive Vaping, 6.3% (95% CI: 5.2, 7.5) reported Exclusive CTP Use, and 26.8% (95% CI: 24.8, 28.9) were Dual Users. A higher proportion of participants randomized to Intervention were Dual Abstinent (25.9%, 95% CI 23.1, 28.9) compared to Control (18.5%, 95% CI 16.0, 21.1; p = .0002). Analyses of treatment effects on dual abstinence by baseline tobacco product use favored Intervention over Control among both Exclusive E-cigarette Users (p = .019) and Dual Users (p = .0014). CONCLUSION: A text message vaping cessation intervention was effective in promoting dual abstinence from e-cigarettes and CTPs among young adults. The advantage of treatment over control was equivalent for Exclusive E-cigarette Users and Dual Users. Rates of dual abstinence were higher among exclusive vapers than dual users, signaling the need for more research to optimize cessation programs for poly-tobacco users.

Effectiveness of an optimized text message and Internet intervention for smoking cessation: A randomized controlled trial.

AIMS: To evaluate the effectiveness of a combined internet and text message intervention for smoking cessation compared with an internet intervention alone. The text message intervention was optimized for engagement in an earlier multiphase optimization (MOST) screening phase. DESIGN: A parallel, two-group, individually randomized clinical trial (RCT) was conducted in a MOST confirming phase. Recruitment spanned December 2018 to March 2019. Follow-up was conducted at 3 and 9 months, beginning March 2019 and ending January 2020. SETTING: United States: a digital study conducted among new registrants on a free tobacco cessation website. PARTICIPANTS: Eligible individuals were 618 adult current smokers in the United States, age 18 years or older who signed up for text messages during website registration (67.2% female, 70.4% white). INTERVENTIONS: The treatment arm (WEB+TXT; n = 311) received access to the website and text messaging. The control arm (WEB; n = 307) received access to the website alone. MEASUREMENTS: The primary outcome was self-reported 30-day point prevalence abstinence (ppa) at 9 months post-randomization analyzed under intent to treat (ITT), counting non-responders as smoking. Secondary outcomes included 3-month measures of 30-day ppa, intervention engagement and intervention satisfaction. FINDINGS: Abstinence rates at 9 months were 23.1% among WEB+TXT and 23.2% among WEB (OR = 1.00, 95% CI = 0.69-1.45; P = 0.99). WEB+TXT increased engagement with 5 of 6 interactive features (standardized mean difference (SMD) = 0.26-0.47, all P < 0.001) and repeat website visits (48.7% vs 38.9%, SMD = 0.14, P = 0.02). Satisfaction metrics favored WEB+TXT (satisfied: 96.3% vs 90.5%, SMD = 0.17, P = 0.008; recommend to friend: 95.9% vs 90.1%, SMD = 0.16, P = 0.028). CONCLUSIONS: A randomized controlled trial found no evidence that a combined internet and text message intervention for smoking cessation compared with an internet intervention alone increased 9-month abstinence rates among adult current smokers in the United States, despite evidence of higher levels of intervention engagement and satisfaction at 3 months.

Effectiveness of a Vaping Cessation Text Message Program Among Young Adult e-Cigarette Users: A Randomized Clinical Trial.

Importance: e-Cigarettes are the most commonly used tobacco product among young adults (YAs). Despite the harms of nicotine exposure among YAs, there are few, if any, empirically tested vaping cessation interventions available. Objective: To determine the effectiveness of a text message program for vaping cessation among YAs vs assessment-only control. Design, Setting, and Participants: A parallel, 2-group, double-blind, individually randomized clinical trial was conducted from December 2019 to November 2020 among YA e-cigarette users. Eligible individuals were US residents aged 18 to 24 years who owned a mobile phone with an active text message plan, reported past 30-day e-cigarette use, and were interested in quitting in the next 30 days. Participants were recruited via social media ads, the intervention was delivered via text message, and assessments were completed via website or mobile phone. Follow-up was conducted at 1 and 7 months postrandomization; follow-up data collection began January 2020 and ended in November 2020. The study was prespecified in the trial protocol. Interventions: All participants received monthly assessments via text message about e-cigarette use. The assessment-only control arm (n = 1284) received no additional intervention. The active intervention arm (n = 1304) also received This is Quitting, a fully automated text message program for vaping cessation that delivers social support and cognitive and behavioral coping skills training. Main Outcomes and Measures: The primary outcome was self-reported 30-day point prevalence abstinence (ppa) at 7 months analyzed under intention-to-treat analysis, which counted nonresponders as vaping. Secondary outcomes were 7-day ppa under intention-to-treat analysis and retention weighted complete case analysis of 30-day and 7-day ppa. Results: Of the 2588 YA e-cigarette users included in the trial, the mean (SD) age was 20.4 (1.7) years, 1253 (48.4%) were male, 2159 (83.4%) were White, 275 (10.6%) were Hispanic, and 493 (19.0%) were a sexual minority. Most participants (n = 2129; 82.3%) vaped within 30 minutes of waking. The 7-month follow-up rate was 76.0% (n = 1967), with no differential attrition. Abstinence rates were 24.1% (95% CI, 21.8%-26.5%) among intervention participants and 18.6% (95% CI, 16.7%-20.8%) among control participants (odds ratio, 1.39; 95% CI, 1.15-1.68; P < .001). No baseline variables moderated the treatment-outcome relationship, including nicotine dependence. Conclusions and Relevance: Results of this randomized clinical trial demonstrated that a tailored and interactive text message intervention was effective in promoting vaping cessation among YAs. These results establish a benchmark of intervention effectiveness. Trial Registration: ClinicalTrials.gov Identifier: NCT04251273.

"It's really addictive and I'm trapped:" A qualitative analysis of the reasons for quitting vaping among treatment-seeking young people.

BACKGROUND: Debate continues over how e-cigarettes have impacted the health of young people, and what regulatory policies should be enacted. The debate has appropriately been informed by quantitative studies, often focused on initiation, prevalence, and product transition among the general population and demographic segments. Factors driving cessation and subjective experiences that motivate young users to quit have been largely absent from the debate. This qualitative study highlights the range of motivating experiences among a population of treatment-seeking young e-cigarette users. METHODS: Three researchers coded reasons for quitting provided by a sample of n = 1000 youth (13-17) and n = 1000 young adults (18-24) enrolled in a text message cessation program. Data spanned January 18 - February 22, 2019. Codes were adapted from previous literature. RESULTS: The most common reasons were health (50.9%; "I want my lungs back"), financial cost (21.7%; "I don't have enough money to feed my addiction"), freedom from addiction (16.0%; "i hate juuling. it's taking over my life"), and social influence (10.1%; "it's affecting my friendships"). Selected quotes highlight a broad range of additional ways in which e-cigarette use negatively impacted young people, including decreased academic performance and mental health. CONCLUSIONS: Young people trying to quit e-cigarettes are motivated by a diversity of reasons including health, financial, social, and academic. The range of impacts should be considered in discussions of policies intended to protect young people, and incorporated into cessation programs designed to serve them.

Vaping in the Workplace: Implications for Employer-Sponsored Tobacco Cessation Programs.

OBJECTIVE: Assess workplace vaping as a trigger for tobacco use; examine interest in and prevalence of vaping cessation programs; determine needs of parents whose children vape. METHODS: Employees of companies with more than 150 employees, drawn from an opt-in national online panel (N = 1607), ages 18 to 65, completed an online survey in November 2019. RESULTS: Among tobacco users, 46% to 48% reported workplace vaping was a trigger for smoking and vaping, respectively; 7% of former users reported it as a trigger. Quit vaping support is important to 85% of employees; 1/3 of workplaces have such programs, with industry variation. Child vaping results in presenteeism and absenteeism among roughly 1/3 of parents. CONCLUSIONS: Workplace vaping is a trigger for smoking and vaping among current and former tobacco users. A gap exists between desired support for vaping cessation and current employer-sponsored cessation programs.

Correction: Optimizing Text Messages to Promote Engagement With Internet Smoking Cessation Treatment: Results From a Factorial Screening Experiment.

[This corrects the article DOI: 10.2196/17734.].

Effectiveness of a Quit Vaping Text Message Program in Promoting Abstinence Among Young Adult E-Cigarette Users: Protocol for a Randomized Controlled Trial.

BACKGROUND: Millions of young adults currently vape electronic cigarettes (e-cigarettes), yet little research on vaping cessation interventions exists. Text messaging is a promising, scalable intervention strategy for delivering vaping cessation treatment. OBJECTIVE: This study evaluates the effectiveness of a text message quit vaping program (This is Quitting) in promoting abstinence from e-cigarettes among young adults; examines changes in self-efficacy, perceived social norms, and social support for quitting as hypothesized mediators of effectiveness; and examines if treatment effectiveness is moderated by gender, race, ethnicity, or sexual minority status. METHODS: Overall, 2600 young adult (aged 18-24 years) e-cigarette users in the United States will be recruited via web advertisements to participate in the study. Participants will be randomized to This is Quitting or an assessment-only control condition. The primary outcome measure is 30-day vaping abstinence at 7 months post enrollment. RESULTS: Study recruitment began on December 18, 2019, and is projected to be completed by spring 2020. The final 7-month follow-up is anticipated to be completed by fall/winter 2020. Because this is the first-ever evaluation of a quit vaping program, we were unable to draw on existing literature to determine the appropriate sample size. Therefore, we examined abstinence rates among an initial pilot sample of 269 participants (This is Quitting: n=148 and control: n=121) who completed the 1-month follow-up to determine the final sample size. The 1-month response rate was 79.2% (213/269), with no difference between arms. Using intention-to-treat analyses that counted nonresponders as still vaping, 30-day abstinence rates were 16.2% (24/148) among those randomized to This is Quitting and 8.3% (10/121) among those randomized to control. A treatment difference of 16% vs 8% is detectable with 80% power at 2-sided alpha=.05 with 260/group (520 total). To detect treatment differences of this magnitude in a 20% subsample (eg, Hispanic or sexual minority young adult e-cigarette users), we will enroll 1300/group (2600 total). CONCLUSIONS: The scientific, clinical, and public health communities are desperate for cessation resources to address vaping among young people. This study is the first-ever comparative effectiveness trial of an intervention to help young people quit vaping. It focuses on evaluating the effectiveness of a theory-grounded, empirically informed text message intervention among young adults. The study is fully powered to examine potentially important subgroup differences among young people who are more vulnerable to e-cigarette use. Although potentially more challenging from a research ethics and pragmatic standpoint, evaluating quit vaping intervention approaches in teens is an important area for future research. Data from this trial will establish a benchmark of effectiveness for other vaping cessation programs and begin to create a body of evidence focused on how best to help young people break free from e-cigarettes. TRIAL REGISTRATION: ClinicalTrials.gov NCT04251273; https://clinicaltrials.gov/ct2/show/NCT04251273. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/18327.

Optimizing Text Messages to Promote Engagement With Internet Smoking Cessation Treatment: Results From a Factorial Screening Experiment.

BACKGROUND: Smoking remains a leading cause of preventable death and illness. Internet interventions for smoking cessation have the potential to significantly impact public health, given their broad reach and proven effectiveness. Given the dose-response association between engagement and behavior change, identifying strategies to promote engagement is a priority across digital health interventions. Text messaging is a proven smoking cessation treatment modality and a powerful strategy to increase intervention engagement in other areas of health, but it has not been tested as an engagement strategy for a digital cessation intervention. OBJECTIVE: This study examined the impact of 4 experimental text message design factors on adult smokers' engagement with an internet smoking cessation program. METHODS: We conducted a 2×2×2×2 full factorial screening experiment wherein 864 participants were randomized to 1 of 16 experimental conditions after registering with a free internet smoking cessation program and enrolling in its automated text message program. Experimental factors were personalization (on/off), integration between the web and text message platforms (on/off), dynamic tailoring of intervention content based on user engagement (on/off), and message intensity (tapered vs abrupt drop-off). Primary outcomes were 3-month measures of engagement (ie, page views, time on site, and return visits to the website) as well as use of 6 interactive features of the internet program. All metrics were automatically tracked; there were no missing data. RESULTS: Main effects were detected for integration and dynamic tailoring. Integration significantly increased interactive feature use by participants, whereas dynamic tailoring increased the number of features used and page views. No main effects were found for message intensity or personalization alone, although several synergistic interactions with other experimental features were observed. Synergistic effects, when all experimental factors were active, resulted in the highest rates of interactive feature use and the greatest proportion of participants at high levels of engagement. Measured in terms of standardized mean differences (SMDs), effects on interactive feature use were highest for Build Support System (SMD 0.56; 95% CI 0.27 to 0.81), Choose Quit Smoking Aid (SMD 0.38; 95% CI 0.10 to 0.66), and Track Smoking Triggers (SMD 0.33; 95% CI 0.05 to 0.61). Among the engagement metrics, the largest effects were on overall feature utilization (SMD 0.33; 95% CI 0.06 to 0.59) and time on site (SMD 0.29; 95% CI 0.01 to 0.57). As no SMD >0.30 was observed for main effects on any outcome, results suggest that for some outcomes, the combined intervention was stronger than individual factors alone. CONCLUSIONS: This factorial experiment demonstrates the effectiveness of text messaging as a strategy to increase engagement with an internet smoking cessation intervention, resulting in greater overall intervention dose and greater exposure to the core components of tobacco dependence treatment that can promote abstinence. TRIAL REGISTRATION: ClinicalTrials.gov NCT02585206; https://clinicaltrials.gov/ct2/show/NCT02585206. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2015-010687.

Feasibility of a Perioperative Text Messaging Smoking Cessation Program for Surgical Patients.

Although surgical patients who smoke could benefit from perioperative abstinence, few currently receive support. This pilot study determined the feasibility and acceptability of a perioperative text messaging smoking cessation program. One hundred patients (73% of eligible patients approached) enrolled in a surgery-specific messaging service, receiving 1-3 daily messages about smoking and surgical recovery for 30 days. Only 17 patients unenrolled, the majority responded to prompting messages, and satisfaction with the program was high. Surgical patients are amenable to text message-based interventions; a future efficacy trial of text messaging smoking cessation support in surgical patients is warranted.

An integrated digital/clinical approach to smoking cessation in lung cancer screening: study protocol for a randomized controlled trial.

BACKGROUND: Delivering effective tobacco dependence treatment that is feasible within lung cancer screening (LCS) programs is crucial for realizing the health benefits and cost savings of screening. Large-scale trials and systematic reviews have demonstrated that digital cessation interventions (i.e. web-based and text message) are effective, sustainable over the long-term, scalable, and cost-efficient. Use of digital technologies is commonplace among older adults, making this a feasible approach within LCS programs. Use of cessation treatment has been improved with models that proactively connect smokers to treatment rather than passive referrals. Proactive referral to cessation treatment has been advanced through healthcare systems changes such as modifying the electronic health record to automatically link smokers to treatment. METHODS: This study evaluates the impact of a proactive enrollment strategy that links LCS-eligible smokers with an evidence-based intervention comprised of a web-based (WEB) program and integrated text messaging (TXT) in a three-arm randomized trial with repeated measures at one, three, six, and 12 months post randomization. The primary outcome is biochemically confirmed abstinence at 12 months post randomization. We will randomize 1650 smokers who present for a clinical LCS to: (1) a usual care control condition (UC) which consists of Ask-Advise-Refer; (2) a digital (WEB + TXT) cessation intervention; or (3) a digital cessation intervention combined with tobacco treatment specialist (TTS) counseling (WEB + TXT + TTS). DISCUSSION: The scalability and sustainability of a digital intervention may represent the most cost-effective and feasible approach for LCS programs to proactively engage large numbers of smokers in effective cessation treatment. We will also evaluate the impact and cost-effectiveness of adding proven clinical intervention provided by a TTS. We expect that a combined digital/clinical intervention will yield higher quit rates than digital alone, but that it may not be as cost-effective or feasible for LCS programs to implement. This study is innovative in its use of interoperable, digital technologies to deliver a sustainable, scalable, high-impact cessation intervention and to facilitate its integration within clinical practice. It will add to the growing knowledge base about the overall effectiveness of digital interventions and their role in the healthcare delivery system. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03084835 . Registered on 9 March 2017.

An exploration of the Facebook social networks of smokers and non-smokers.

BACKGROUND: Social networks influence health behavior, including tobacco use and cessation. To date, little is known about whether and how the networks of online smokers and non-smokers may differ, or the potential implications of such differences with regards to intervention efforts. Understanding how social networks vary by smoking status could inform public health efforts to accelerate cessation or slow the adoption of tobacco use. OBJECTIVES: These secondary analyses explore the structure of ego networks of both smokers and non-smokers collected as part of a randomized control trial conducted within Facebook. METHODS: During the trial, a total of 14,010 individuals installed a Facebook smoking cessation app: 9,042 smokers who were randomized in the trial, an additional 2,881 smokers who did not meet full eligibility criteria, and 2,087 non-smokers. The ego network for all individuals was constructed out to second-degree connections. Four kinds of networks were constructed: friendship, family, photo, and group networks. From these networks we measured edges, isolates, density, mean betweenness, transitivity, and mean closeness. We also measured diameter, clustering, and modularity without ego and isolates. Logistic regressions were performed with smoking status as the response and network metrics as the primary independent variables and demographics and Facebook utilization metrics as covariates. RESULTS: The four networks had different characteristics, indicated by different multicollinearity issues and by logistic regression output. Among Friendship networks, the odds of smoking were higher in networks with lower betweenness (p = 0.00), lower transitivity (p = 0.00), and larger diameter (p = 0.00). Among Family networks, the odds of smoking were higher in networks with more vertices (p = .01), less transitivity (p = .04), and fewer isolates (p = .01). Among Photo networks, none of the network metrics were predictive of smoking status. Among Group networks, the odds of smoking were higher when diameter was smaller (p = .04). Together, these findings suggested that compared to non-smokers, smokers in this sample had less connected, more dispersed Facebook Friendship networks; larger but more fractured Family networks with fewer isolates; more compact Group networks; and Photo networks that were similar in network structure to those of non-smokers. CONCLUSIONS: This study illustrates the importance of examining structural differences in online social networks as a critical component for network-based interventions and lays the foundation for future research that examines the ways that social networks differ based on individual health behavior. Interventions that seek to target the behavior of individuals in the context of their social environment would be well served to understand social network structures of participants.

Social Media Use and Access to Digital Technology in US Young Adults in 2016.

BACKGROUND: In 2015, 90% of US young adults with Internet access used social media. Digital and social media are highly prevalent modalities through which young adults explore identity formation, and by extension, learn and transmit norms about health and risk behaviors during this developmental life stage. OBJECTIVE: The purpose of this study was to provide updated estimates of social media use from 2014 to 2016 and correlates of social media use and access to digital technology in data collected from a national sample of US young adults in 2016. METHODS: Young adult participants aged 18-24 years in Wave 7 (October 2014, N=1259) and Wave 9 (February 2016, N=989) of the Truth Initiative Young Adult Cohort Study were asked about use frequency for 11 social media sites and access to digital devices, in addition to sociodemographic characteristics. Regular use was defined as using a given social media site at least weekly. Weighted analyses estimated the prevalence of use of each social media site, overlap between regular use of specific sites, and correlates of using a greater number of social media sites regularly. Bivariate analyses identified sociodemographic correlates of access to specific digital devices. RESULTS: In 2014, 89.42% (weighted n, 1126/1298) of young adults reported regular use of at least one social media site. This increased to 97.5% (weighted n, 965/989) of young adults in 2016. Among regular users of social media sites in 2016, the top five sites were Tumblr (85.5%), Vine (84.7%), Snapchat (81.7%), Instagram (80.7%), and LinkedIn (78.9%). Respondents reported regularly using an average of 7.6 social media sites, with 85% using 6 or more sites regularly. Overall, 87% of young adults reported access or use of a smartphone with Internet access, 74% a desktop or laptop computer with Internet access, 41% a tablet with Internet access, 29% a smart TV or video game console with Internet access, 11% a cell phone without Internet access, and 3% none of these. Access to all digital devices with Internet was lower in those reporting a lower subjective financial situation; there were also significant differences in access to specific digital devices with Internet by race, ethnicity, and education. CONCLUSIONS: The high mean number of social media sites used regularly and the substantial overlap in use of multiple social media sites reflect the rapidly changing social media environment. Mobile devices are a primary channel for social media, and our study highlights disparities in access to digital technologies with Internet access among US young adults by race/ethnicity, education, and subjective financial status. Findings from this study may guide the development and implementation of future health interventions for young adults delivered via the Internet or social media sites.

Systematic review and meta-analysis of Internet interventions for smoking cessation among adults.

BACKGROUND: The aim of this systematic review was to determine the effectiveness of Internet interventions in promoting smoking cessation among adult tobacco users relative to other forms of intervention recommended in treatment guidelines. METHODS: This review followed Cochrane Collaboration guidelines for systematic reviews. Combinations of "Internet," "web-based," and "smoking cessation intervention" and related keywords were used in both automated and manual searches. We included randomized trials published from January 1990 through to April 2015. A modified version of the Cochrane risk of bias assessment tool was used. We calculated risk ratios (RRs) for each study. Meta-analysis was conducted using random-effects method to pool RRs. Presentation of results follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS: Forty randomized trials involving 98,530 participants were included. Most trials had a low risk of bias in most domains. Pooled results comparing Internet interventions to assessment-only/waitlist control were significant (RR 1.60, 95% confidence interval [CI] 1.15-2.21, I (2)=51.7%; four studies). Pooled results of largely static Internet interventions compared to print materials were not significant (RR 0.83, 95% CI 0.63-1.10, I (2)=0%; two studies), whereas comparisons of interactive Internet interventions to print materials were significant (RR 2.10, 95% CI 1.25-3.52, I (2)=41.6%; two studies). No significant effects were observed in pooled results of Internet interventions compared to face-to-face counseling (RR 1.35, 95% CI 0.97-1.87, I (2)=0%; four studies) or to telephone counseling (RR 0.95, 95% CI 0.79-1.13, I (2)=0%; two studies). The majority of trials compared different Internet interventions; pooled results from 15 such trials (24 comparisons) found a significant effect in favor of experimental Internet interventions (RR 1.16, 95% CI 1.03-1.31, I (2)=76.7%). CONCLUSION: Internet interventions are superior to other broad reach cessation interventions (ie, print materials), equivalent to other currently recommended treatment modes (telephone and in-person counseling), and they have an important role to play in the arsenal of tobacco-dependence treatments.

Diffusion of an Evidence-Based Smoking Cessation Intervention Through Facebook: A Randomized Controlled Trial.

OBJECTIVES: To examine the diffusion of an evidence-based smoking cessation application ("app") through Facebook social networks and identify specific intervention components that accelerate diffusion. METHODS: Between December 2012 and October 2013, we recruited adult US smokers ("seeds") via Facebook advertising and randomized them to 1 of 12 app variants using a factorial design. App variants targeted components of diffusion: duration of use (t), "contagiousness" (ß), and number of contacts (Z). The primary outcome was the reproductive ratio (R), defined as the number of individuals installing the app ("descendants") divided by the number of a seed participant's Facebook friends. RESULTS: We randomized 9042 smokers. App utilization metrics demonstrated between-variant differences in expected directions. The highest level of diffusion (R = 0.087) occurred when we combined active contagion strategies with strategies to increase duration of use (incidence rate ratio = 9.99; 95% confidence interval = 5.58, 17.91; P < .001). Involving nonsmokers did not affect diffusion. CONCLUSIONS: The maximal R value (0.087) is sufficient to increase the numbers of individuals receiving treatment if applied on a large scale. Online interventions can be designed a priori to spread through social networks.

Optimising text messaging to improve adherence to web-based smoking cessation treatment: a randomised control trial protocol.

INTRODUCTION: Millions of smokers use the Internet for smoking cessation assistance each year; however, most smokers engage minimally with even the best designed websites. The ubiquity of mobile devices and their effectiveness in promoting adherence in other areas of health behaviour change make them a promising tool to address adherence in Internet smoking cessation interventions. Text messaging is used by most adults, and messages can proactively encourage use of a web-based intervention. Text messaging can also be integrated with an Internet intervention to facilitate the use of core Internet intervention components. METHODS AND ANALYSIS: We identified four aspects of a text message intervention that may enhance its effectiveness in promoting adherence to a web-based smoking cessation programme: personalisation, integration, dynamic tailoring and message intensity. Phase I will use a two-level full factorial design to test the impact of these four experimental features on adherence to a web-based intervention. The primary outcome is a composite metric of adherence that incorporates general utilisation metrics (eg, logins, page views) and specific feature utilisation shown to predict abstinence. Participants will be N=860 adult smokers who register on an established Internet cessation programme and enrol in its text message programme. Phase II will be a two-arm randomised trial to compare the efficacy of the web-based cessation programme alone and in conjunction with the optimised text messaging intervention on 30-day point prevalence abstinence at 9 months. Phase II participants will be N=600 adult smokers who register to use an established Internet cessation programme and enrol in text messaging. Secondary analyses will explore whether adherence mediates the effect of treatment condition on outcome. ETHICS AND DISSEMINATION: This protocol was approved by Chesapeake IRB. We will disseminate study results through peer-reviewed manuscripts and conference presentations related to the methods and design, outcomes and exploratory analyses. TRIAL REGISTRATION NUMBER: NCT02585206.

Using Tumblr to Reach and Engage Young Adult Smokers: A Proof of Concept in Context.

OBJECTIVES: To describe a proof of concept social media strategy to reach and engage young adult smokers on the social media site Tumblr. METHODS: This strategy includes creating novel, branded content, conducting proactive outreach to current and former smokers, and fostering user engagement and support within Tumblr. This social media strategy is reviewed in the context of other young adult social media-based cessation interventions and other Tumblr-based health interventions. RESULTS: Steady community growth and positive qualitative feedback constitute early indicators of impact. CONCLUSIONS: Unique challenges and limitations of data extraction from Tumblr may complicate formal evaluation efforts. Future research should consider offline or hybrid methods to mitigate these challenges.

Impact of Baseline Assessment Modality on Enrollment and Retention in a Facebook Smoking Cessation Study.

BACKGROUND: Few studies have addressed enrollment and retention methods in online smoking cessation interventions. Fully automated Web-based trials can yield large numbers of participants rapidly but suffer from high rates of attrition. Personal contact with participants can increase recruitment of smokers into cessation trials and improve participant retention. OBJECTIVE: To compare the impact of Web-based (WEB) and phone (PH) baseline assessments on enrollment and retention metrics in the context of a Facebook smoking cessation study. METHODS: Participants were recruited via Facebook and Google ads which were randomly displayed to adult smokers in the United States over 27 days from August to September 2013. On each platform, two identical ads were randomly displayed to users who fit the advertising parameters. Clicking on one of the ads resulted in randomization to WEB, and clicking on the other ad resulted in randomization to PH. Following online eligibility screening and informed consent, participants in the WEB arm completed the baseline survey online whereas PH participants completed the baseline survey by phone with a research assistant. All participants were contacted at 30 days to complete a follow-up survey that assessed use of the cessation intervention and smoking outcomes. Participants were paid $15 for follow-up survey completion. RESULTS: A total of 4445 people clicked on the WEB ad and 4001 clicked on the PH ad: 12.04% (n=535) of WEB participants and 8.30% (n=332) of PH participants accepted the online study invitation (P<.001). Among the 726 participants who completed online eligibility screening, an equivalent proportion in both arms was eligible and an equivalent proportion of the eligible participants in both arms provided informed consent. There was significant drop-off between consent and completion of the baseline survey in the PH arm, resulting in enrollment rates of 32.7% (35/107) for the PH arm and 67.9% (114/168) for the WEB arm (P<.001). The overall enrollment rate among everyone who clicked on a study ad was 2%. There were no between group differences in the proportion that installed the Facebook app (66/114, 57.9% WEB vs 17/35, 49% PH) or that completed the 30-day follow-up survey (49/114, 43.0% WEB vs 16/35, 46% PH). A total of $6074 was spent on ads, generating 3,834,289 impressions and resulting in 8446 clicks (average cost $0.72 per click). Per participant enrollment costs for advertising alone were $27 WEB and $87 PH. CONCLUSIONS: A more intensive phone baseline assessment protocol yielded a lower rate of enrollment, equivalent follow-up rates, and higher enrollment costs compared to a Web-based assessment protocol. Future research should focus on honing mixed-mode assessment protocols to further optimize enrollment and retention.

Facebook apps for smoking cessation: a review of content and adherence to evidence-based guidelines.

BACKGROUND: Facebook is the most popular social network site, with over 1 billion users globally. There are millions of apps available within Facebook, many of which address health and health behavior change. Facebook may represent a promising channel to reach smokers with cessation interventions via apps. To date, there have been no published reports about Facebook apps for smoking cessation. OBJECTIVE: The purpose of this study was to review the features and functionality of Facebook apps for smoking cessation and to determine the extent to which they adhere to evidence-based guidelines for tobacco dependence treatment. METHODS: In August 2013, we searched Facebook and three top Internet search engines using smoking cessation keywords to identify relevant Facebook apps. Resultant apps were screened for eligibility (smoking cessation-related, English language, and functioning). Eligible apps were reviewed by 2 independent coders using a standardized coding scheme. Coding included content features (interactive, informational, and social) and adherence to an established 20-item index (possible score 0-40) derived from the US Public Health Service's Clinical Practice Guidelines for Treating Tobacco Use and Dependence. RESULTS: We screened 22 apps for eligibility; of these, 12 underwent full coding. Only 9 apps were available on Facebook. Facebook apps fell into three broad categories: public pledge to quit (n=3), quit-date-based calculator/tracker (n=4), or a multicomponent quit smoking program (n=2). All apps incorporated interactive, informational, and social features except for two quit-date-based calculator/trackers apps (lacked informational component). All apps allowed app-related posting within Facebook (ie, on self/other Facebook profile), and four had a within-app "community" feature to enable app users to communicate with each other. Adherence index summary scores among Facebook apps were low overall (mean 15.1, SD 7.8, range 7-30), with multicomponent apps scoring the highest. CONCLUSIONS: There are few smoking cessation apps available within Facebook. Among those available, adherence to cessation treatment guidelines was low. Smoking cessation interventions provided via the Facebook platform are a unique and as yet untapped treatment strategy that can harness existing social support and social networks for quitting. Research is needed to examine whether apps that adhere to clinical practice guidelines for tobacco dependence treatment are more effective in promoting cessation than those that do not.