Effectiveness of ecological momentary assessment guided telephone counseling and instant messaging support for smoking cessation : a randomized controlled trial

Abstract

Background: Even though evidence-based pharmacotherapy and behavioral therapy have been shown to increase tobacco abstinence, the use of smoking cessation aids remains low. Ecological momentary assessment (EMA) can repeatedly collect real-time data in naturalistic settings, making it a feasible profiling tool for studying smoking behaviors. This study aimed to assess the effectiveness of a novel mobile health (mHealth) profiling approach using EMA to personalize smoking cessation intervention for smokers with no intention of using smoking cessation services and medications. Methods: This thesis has two phases. In phase one, a two-arm, assessor-blinded, individual-randomized controlled trial (RCT) was conducted with 459 adult daily smokers recruited from the community in Hong Kong. Participants had not used smoking cessation services or medications in the past 7 days and had no intention to use these aids in the next 30 days were allocated 1:1 to the intervention (n=231) or control (n=228) groups. Both groups completed 5 EMAs daily for 7 consecutive days with a smartphone application to report personal smoking behaviors, including smoking, nicotine craving, tobacco products purchased, and corresponding triggers. Additionally, the intervention group received a nurse-led telephone counseling session (about 20 minutes) and 10 weeks of instant messaging support guided by mHealth profiling from EMA. Primary outcomes were biochemically validated tobacco abstinence and Incremental Behavior Change toward Smoking Cessation (IBC-S) (score range 0–24; higher scores indicating more readiness and preparation in quitting) at 3 months after EMA initiation. Secondary outcomes were biochemically validated tobacco abstinence and IBC-S at 6 months after EMA initiation, self-reported 7-day point prevalence of abstinence (PPA), smoking cessation services used, and smoking cessation medication used at 3 and 6 months after EMA initiation. Analysis was done using intention-to-treat. In phase two, I conducted semi-structured interviews with 20 participants from the intervention group to explore their experiences and perceptions of EMA and personalized mHealth intervention. Results: In phase one, the biochemically validated tobacco abstinence rate was 8.2% in the intervention group and 3.5% in the control group (odd ratio (OR)=2.46, 95% CI 1.06 to 5.75) at 3-month follow-up. The corresponding rates at 6-month follow-up were 9.5% and 4.0% (OR=2.56, 95% CI 1.15 to 5.70). The intervention group showed greater IBC-S at 3 (B=0.73, 95% CI 0.20 to 1.27) and 6 months (B=0.81, 95% CI 0.27 to 1.34) than the control group. Self-reported 7-day PPA, smoking cessation services use, and smoking cessation medications use were also higher in the intervention group at 3 and 6-month follow-ups than in the control group (all Ps<0.05). In phase two, participants perceived completing EMAs and receiving EMA summarization increased their awareness of smoking behaviors and triggers. This could help them proactively avoid triggers and reduce cigarette consumption. Conclusions: This study showed that telephone counseling and instant messaging support, guided by mHealth profiling, increased tobacco abstinence versus EMA alone. This intervention also increased the use of smoking cessation services and medications. Therefore, it can be used to supplement conventional smoking cessation promotion for smokers unwilling to use smoking cessation aids.