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www.globalbridges.org

Erik Augustson, PhD, MPHBehavioral ScientistTobacco Control Research Branch Behavioral Research Program National Cancer Institute

Going Mobile: The Potential of mHealth for

Tobacco Dependence Treatment

Global Bridges, April 23, 2013

Smokefree Development Team

NCIErik Augustson

Ami BahdeYvonne Hunt

Heather Patrick

MMGLewellyn Belber

Jeff GoldfarbBrian Keefe

Samantha PostAmy Sanders

Shani Taylor*Alle Vargo

Additional Support

Lorien AbromsRachel Grana

Robin MermelsteinNalini Padmanabhan

Alison PilsnerAllison Rose

Mary SchwarzRobyn Whittaker

* Funded in part by NCI Contract No. HHSN261200800001E; HHSN261200544018C, NO2-PC-54418; and HHSN2612007000191

Outline• mHealth Potential for

Interventions• The Smokefree.gov Project • SmokefreeTXT• Domestic & International Case

Studies

Mobile Uptake• Mobile subscriptions

– U.S. 234 MILLION – Worldwide 6 BILLION – 90% of world pop has cell

signal access– 75% world pop has access to

mobile phone

**Source: ComScore June 2012 Report; Ericsson 2011

• Of U.S. mobile consumers:– 75% sent messages in early 2012– 51.4% used apps– 50.2% used a browser– 36.9% accessed social media sites or blogs– Motivation for health behavior change

Text Messaging

Whi

te

Afric

an A

mer

ican

Hispa

nic

79%80%

85%

American Text Messaging Preva-

lence

Send/Receive Texts

• Texting for Health– 9% of Americans

receive updates/alerts on health issues

Source: Pew Mobile Report 2012

• More likely to sign up for health text messages:– Women– 30-64 years old– African

American

U.S. Smartphone Ownership

Young adults tend to have higher-than-average levels of smartphone ownership regardless of income or educational attainment.

**Source: Pew Research Center’s Internet & American Life Project 2012

Smartphone Use for Health

2012

2010

27%

15%

35%

19%

38%

25%

Smartphone use to Find Health Infor-mation by Race

Hispanic

African American

White

Source: Pew Mobile Report 2012

• Owning a smartphone increases likelihood of accessing health information online

• More likely to look up health information on mobile phone: – Young adults– Minorities

mHealth Potential • Reach

– Large audiences– Underserved audiences

• Engagement with intervention platform– Increase access to intervention– Decrease barriers to participation (scheduling,

transportation, etc)– Decrease space/time gap between treatment &

behavior– Seamlessly integrate user interaction with treatment

within their daily life– Interactive functionality improved “dose”

• Reduces cost burden on healthcare system

Smokefree Family History

• 2003 Smokefree.gov– Focus on cessation resource– Multiple updates and iterations

• 2009 Smokefree Women– Expanded interactivity– Incorporation of social media

• 2011 Smokefree Teen– Multi-platform intervention

• 2012 Smokefree Español– Spanish

Smokefree Projects• Smokefree.gov

– Website– Mobile app (QuitGuide,

QuitPal)– Social media: Twitter

• Smokefree Women– Mobile Website (Spring

2013)– Social media: Facebook,

Twitter, Pinterest, YouTube

• Smokefree Teen– Mobile Website – Social media: Facebook,

Twitter, Tumblr– Mobile app (QuitSTART)

• Spanish Smokefree– Website– Social media

• Smokefree Pregnancy– Web content– Online video

• SmokefreeTXT– Teen– Young Adult– Spanish Language– QuitNow Library– Veteran (June 2013)– Military (coming soon)

SmokefreeTXT Program

• Text messaging smoking cessation intervention

• Features versions for teens, young adults & Spanish speaking audiences

• 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

• Bidirectional: assesses user’s mood, craving, & smokefree status– Users can text keywords (i.e. CRAVE,

MOOD, SLIP)

SmokefreeTXT Overview

SmokefreeTXT MetricsTotal Subscriptions

March 2012- March 2013

-

5,000

10,000

15,000

20,000

25,000 22,610

SmokefreeTXT MetricsSubscriber Breakdown by Sex

All Time Subscribers

Total MalesTotal FemalesTotal Unknown

34%

58%

9%

SmokefreeTXT MetricsSmoking Status Reported at Registration

for over 13,000 participants

Every dayMost daysSome daysLess than thatUnknown

81%

2%

5%

1%

11%

SmokefreeTXT MetricsAdult Subscriber Opt Outs over Course of Treatment

September 2011 – October 2012

Count

down

(2wks

)

Wee

k 1-

2

Wee

k 3-

4

Wee

k 5-

6

Post

0-1

mo

Post

1-3

mo

Post

3-6

mo

Post

Afte

r 6 m

o0

500

1000

1500

2000

2500

3000

3500

4000

4500

SmokefreeTXT Metrics ITT Adult Follow-Up Responses:

Assessment of Active Subscribers, March 2013

• 1-Month: 17%

• 3-month: 13%

• 6-month: 11%

International Opportunities

• China: 300,000,000 Smokers

• 1) US HHS-China MOH-Nokia

• 2) Emory University-Suzchou

SmokefreeTXT: China• 1) US HHS-China MOH-Nokia– Four provinces selected– Health messages developed specifically

for project– Cessation messages based on NCI library– Translated by Chinese public health

professionals– Focus Group Testing of messages with

Chinese Smokers• 8 conducted • 2 in each province• Urban & rural

SmokefreeTXT: China• 1) US HHS-China MOH-Nokia– Phase One: 250,000 Smokers• 10 days smoking health effect

messages• Started 4/15/2013

– Phase Two: 8000 Smokers • 2-arm RCT • 1 week count down to quit day• 6 week treatment• 1 & 3 month f/u• Start 4/28/2013• Finish 9/17/2013

SmokefreeTXT: China• 2) Emory University-Suzchou – Nonrandomized Demonstration Project– Part of annual Quit Contest– NCI Library translated by local health

officials– 4 week treatment w f/u at EOT– 665 Smokers received text messages– ~1000 Smokers participated w/o text

• Data available in near future

Suzchou Project: Clinical Data

• Baseline Smoking Status– Daily 60% (49% vs. 70%)

• Time to 1st cigarette– 30+ minutes 69% (72% vs. 66%)

• Cigarettes per day– 10 or less 52% (54% vs. 51%) – 11-20 CPD 36% (40% vs. 33%)

• One Month Quit Rate – 38% (57% vs. 22%)

Suzchou Project: Feedback

• Amount of text messages– Right Amount 57% (74% vs. 42%)

• Provided Helpful/Useful Information– Yes 80% (92% vs. 69%)

• Helped to Motivate Quit Attempt– Yes 78% (90% vs. 69% )

Additional International Activities

• Collaboration with Healthy Caribbean Coalition– Launch June 2013

• Technical guidance for WHO project in Costa Rica

• Collaboration in South Pacific Islands• Continued development of India

project• Exploring project in Central & South

America

Underserved Populations: Challenges

• Consistency of cell phone access• Multiple users per device• Fee structures• Populations with Low Literacy• Role of mHealth interventions

with in larger public health infrastructure

Questions?

@SmokefreeGov

augustse@mail.nih.gov