Effect of Technology-Assisted Brief Abstinence Game on Long-term Smoking Cessation in Individuals Not Yet Ready to Quit: A Randomized Clinical Trial.

IMPORTANCE: Most trials of behavioral or pharmaceutical interventions for people who smoke are limited to individuals reporting they are ready to quit smoking. Engaging individuals who initially report they are not yet ready to quit in brief, precessation, skills-building interventions (eg, practice quit attempts or nicotine replacement therapy [NRT] sampling) is challenging. OBJECTIVE: To test an integrated behavioral plus NRT-sampling intervention using a gamification approach supported by mobile health. DESIGN, SETTING, AND PARTICIPANTS: A multisite randomized clinical trial with site-level 1-to-1 allocation into 2 conditions was conducted in 4 US health care systems. A total of 433 individuals who were currently smoking and reported at enrollment that they were not ready to quit smoking were enrolled. The study was conducted from November 7, 2016, to July 31, 2020. INTERVENTIONS: Take a Break (TAB) was a 3-week game experience and included 5 behavioral components (motivational messaging, challenge quizzes, brief abstinence goal setting, mobile health apps for cravings management, and reward points for participation) integrated with NRT sampling. TAB draws on social cognitive theory and game mechanics concepts to engage participants in health behavior change. The comparison included NRT sampling only. MAIN OUTCOMES AND MEASURES: Time to first quit attempt (duration from TAB experience to primary outcome) and carbon monoxide level-verified smoking cessation at 6-month follow-up. All analyses used an intention-to-treat approach. RESULTS: Of the 433 individuals included in the trial, 223 were women (52%); mean (SD) age was 54 (13) years. More than half (53% [112 of 213]) of the TAB participants completed 100% of the daily challenge quizzes in the first week, 73% (145 of 199) of participants who completed the goal-setting call set a brief abstinence goal (most frequently 1-2 days of abstinence from cigarettes), and 75% (159 of 213) of participants used the mobile health apps to manage nicotine cravings. Time to the first quit attempt was lower for the TAB vs comparison group (hazard ratio, 1.68; 95% CI, 1.09-2.60; P = .02). At the 6-month follow-up, 18% (28 of 160) of TAB participants and 10% (17 of 171) of the comparison (χ2 test, P = .045) participants obtained carbon monoxide level-verified smoking cessation (accounting for clustering of outcomes by site; odds ratio, 1.92; 95% CI, 1.01-3.68; P = .048). CONCLUSIONS AND RELEVANCE: The findings of this randomized clinical trial demonstrate that individuals not yet ready to quit smoking could be engaged in a brief abstinence game. Six months later, the TAB group had nearly double the rate of smoking cessation vs the NRT sampling comparison group. Integrating a skills-building game experience with brief NRT sampling can enhance long-term cessation among those not yet ready to quit smoking. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02973425.

"I Felt I Was Reaching a Point with My Health": Understanding Reasons for Engagement and Acceptability of Treatment Services for Unhealthy Alcohol Use in Primary Care.

INTRODUCTION/OBJECTIVES: Despite increasing need, there are large gaps in provision of care for unhealthy alcohol use. Primary care practices have become increasingly important in providing services for unhealthy alcohol use, yet little is known about the reasons patients engage in these services and their views on acceptability of such programs. The purpose of this study was to examine primary care patients' reasons for engagement, experiences with, and acceptability of a primary care practice-based program for treating unhealthy alcohol use. METHODS: This qualitative study was conducted in a primary care practice that was developing a collaborative care model for treating unhealthy alcohol use in primary care. Semi-structured interviews were conducted with 24 primary care patients. Data were analyzed using conventional qualitative content analysis. RESULTS: Findings suggest that patients engaged for both internal (concerns about drinking and health) and external reasons (family or provider concern). Patient experiences in the program were shaped by their affective responses (enjoyable, enlightening), as well as therapeutic benefits (gaining new insights about drinking; staff/provider support). Acceptability was driven by core program elements (medication, therapy, integration) as well as positive impacts on drinking cognition and behavior and flexible, patient-centered approaches. CONCLUSIONS: Offering flexible and comprehensive programs with mutiple elements and both abstinence and moderation goals could also improve patient engagement and views on acceptability. Primary care practices will need to be thoughtful about the resources needed to implement these programs in terms of staffing, training, and program support.

The 'Take a Break' game: Randomized trial protocol for a technology-assisted brief abstinence experience designed to engage lower-motivated smokers.

BACKGROUND: While smoking continues to be the most preventable cause of mortality in the United States, most current smokers remain not ready to quit at any given time. Engaging these 'motivation phase' smokers with brief experiences to build confidence and practice skills related to cessation could lead to sooner and more successful quit attempts. Increasingly available mobile technology and gamification can be used to provide smokers with accessible and engaging support. METHODS: We describe our protocol for conducting a randomized controlled trial evaluating Take a Break, an mHealth-based smoking pre-cessation challenge designed for smokers not ready to quit. Participants in the intervention receive 1) Motivational Messages, 2) text message Challenge Quizzes, 3) Goal-setting with tobacco treatment specialist, 4) Coping Mini-Games apps, and 5) Recognition and Rewards for participation during a 3-week challenge. Access to coping mini-games and motivational messaging continues for 6-months. Both intervention and comparison group participants receive brief Nicotine Replacement Therapy (NRT) sampling and daily smoking assessment text messages for three weeks. Primary outcomes include number of days abstinent during the challenge, change in patient-reported self-efficacy after the challenge, time to first quit attempt following the challenge, and 7-day point prevalent smoking cessation at six months. CONCLUSION: Take a Break is an innovative approach to engage those not prepared for a quit attempt. Take a Break provides motivation phase smokers with tools and a brief experience to prepare them for a quit attempt, filling a gap in tobacco cessation support and current research.

Gamification to Motivate the Unmotivated Smoker: The "Take a Break" Digital Health Intervention.

Objective: Digital health technologies most often reach only those more motivated to engage, particularly when preventive health is targeted. To test whether gamification could be used to engage low-motivation smokers, we conceptualized "Take a Break"-a 3-week technology-assisted challenge for smokers to compete in setting and achieving brief abstinence goals. Materials and Methods: In the feasibility study of the multi-technology Take a Break challenge, low-motivation smokers were given (1) daily motivational messages, (2) brief "challenge quizzes" related to smoking behaviors, (3) a telehealth call to personalize their abstinence goal for the challenge, (4) "coping minigames" to help manage cravings while attempting to achieve their brief abstinence goals, and (5) a leaderboard "webApp," providing comparative feedback on smokers' participation, and allowing for competition. Heterogeneity of engagement was tracked. Results: All 41 smokers initially reported that they were not actively quitting. Over half were employed less than full time (51%), completed less than a 4-year college education (76%), and experienced financial stress (54%). No smokers opted out of the motivational messages, and mean proportion of response to the challenge quizzes was 0.88 (SD = 0.19). Half of the smokers reported using the "coping minigames." Almost all set abstinence goals (78%), with over half lasting 1-2 days (51%); median = 1 day (IQR 1-7). Leaderboard points ranged widely. Conclusions: Rates of smoking in the developed world have declined, and those who remain smokers are complex and have lower motivation to quit. Using a game-inspired challenge, we achieved high levels of engagement from low-motivation smokers.

Substance use screening and brief intervention: Evaluation of patient and implementation differences between primary care and emergency department settings.

RATIONALE, AIMS, AND OBJECTIVES: There are well-documented barriers that have limited widespread, sustained adoption of screening and brief intervention for risky substance use in health care settings. In order to better inform implementation efforts, this study evaluates whether patient characteristics, screening results, and implementation success indicators differed between two clinical setting types: primary care and emergency. METHODS: Patients presenting to an emergency or primary care setting were screened for risky substance use (n = 41 567). Patients with a positive screen were further assessed for psychosocial, health, and substance use problems (n = 1604). Differences in patient characteristics between primary care and emergency settings were examined using chi-square and t tests. Multilevel logistic regression was used to examine whether setting type predicted screening results. Site-level indicators of implementation success were calculated (percentage prescreens completed, percentage full screens completed, and percentage refused services) for all patient visits (n = 78 656). RESULTS: As compared with primary care patients, emergency patients had more severe substance use patterns and screening scores, were more likely to use a variety of illicit drugs, and reported more psychosocial issues. In logistic regression models, setting type did not predict whether patients screened positive; however, it did predict screening into a higher vs lower risk category such that emergency patients were more likely to be in a higher risk category. Emergency settings had lower indicators of implementation success (eg, 14% lower prescreen completion rate) as compared with primary care settings on some implementation measures. CONCLUSIONS: This evaluation found important differences in patient characteristics and screening and implementation results between primary care and emergency settings. Health care organizations and administrators implementing screening and brief intervention should attend to setting differences that could affect implementation and clinical care.

Usability Testing of a National Substance Use Screening Tool Embedded in Electronic Health Records.

BACKGROUND: Screening, brief intervention, and referral to treatment (SBIRT) is currently being implemented into health systems nationally via paper and electronic methods. OBJECTIVE: The purpose of this study was to evaluate the integration of an electronic SBIRT tool into an existing paper-based SBIRT clinical workflow in a patient-centered medical home. METHODS: Usability testing was conducted in an academic ambulatory clinic. Two rounds of usability testing were done with medical office assistants (MOAs) using a paper and electronic version of the SBIRT tool, with two and four participants, respectively. Qualitative and quantitative data was analyzed to determine the impact of both tools on clinical workflow. A second round of usability testing was done with the revised electronic version and compared with the first version. RESULTS: Personal workflow barriers cited in the first round of testing were that the electronic health record (EHR) tool was disruptive to patient's visits. In Round 2 of testing, MOAs reported favoring the electronic version due to improved layout and the inclusion of an alert system embedded in the EHR. For example, using the system usability scale (SUS), MOAs reported a grade "1" for the statement, "I would like to use this system frequently" during the first round of testing but a "5" during the second round of analysis. CONCLUSIONS: The importance of testing usability of various mediums of tools used in health care screening is highlighted by the findings of this study. In the first round of testing, the electronic tool was reported as less user friendly, being difficult to navigate, and time consuming. Many issues faced in the first generation of the tool were improved in the second generation after usability was evaluated. This study demonstrates how usability testing of an electronic SBRIT tool can help to identify challenges that can impact clinical workflow. However, a limitation of this study was the small sample size of MOAs that participated. The results may have been biased to Northwell Health workers' perceptions of the SBIRT tool and their specific clinical workflow.