Interactive Skills-Building Game Linked to Long-Term Smoking Cessation

Thomas K. Houston, MD

A recent investigation suggested that the implementation of nicotine replacement therapy in the lives of adult smokers through a skills-building game experience could enhance long-term cessation among individuals not yet ready to quit smoking.

Investigators led by Thomas K. Houston, MD, General Internal Medicine at Wake Forest School of Medicine, Winston-Salem, North Carolina, noted that most behavioral or pharmaceutical interventions have been limited to individuals who reported they are ready to quit smoking.

Likewise, the process of engaging with smokers with brief, precessation, skills-building interventions has also been a challenge.

The team hypothesized that patients who experienced “Take a Break”, a novel game experience with mobile tools, would have a greater mean number of days abstinent during the first 3 weeks, a faster time to the first quit attempt, a greater increase in self-efficacy, and a higher likelihood for 6-month smoking cessation than those who experienced nicotine replacement therapy (NRT).

The Methods

The Take A Break (TAB) randomized clinical trial was conducted across 4 sites with site-level 1-to-1 allocation into 2 conditions including TAB (and NRT) sampling or a comparison group receiving only active NRT sampling.

The trial was conducted November 7, 2016 to July 31, 2020, and participants were followed up for 6 months after the study.

Individuals who had at least 1 visit in the preceding 12 months at participating clinical site were eligible for inclusion. Screening for eligibility also included a readiness to quit assessment, and participants responded in 3 categories: I am not thinking about quitting, I am thinking about quitting, or I have set a quit date.

Take a Break, which drew on social cognitive theory, was a 3-week experience.

Week 1 helped participants consider their smoking behaviors and engage in “taking a break". Following week 1, a coach trained in tobacco treatment prepared the participant for the core game experience, which was a 2-week abstinence challenge.

A total of 5 TAB components and integrated NRT sampling components were included in the study.

Components included motivational text messages, challenge quizzes, brief goal setting with a tobacco treatment specialist, coping mini games intended to provide relaxation or distraction, and recognition and rewards.

Change in self-efficacy was measured using the Smoking Self-Efficacy Questionnaire (SEQ-12), and the dates of all quit attempts were assessed using the Timeline Follow-Back Method at the 6-month follow-up visit.

The Findings

Of the 433 individuals included in the trial, 223 were women (52%) with a mean (SD) age of 54 (13) years.

Investigators observed that more than half (53%) of the TAB participants completed 100% of the daily challenge quizzes in the first week, while 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.

Additionally, 75% (159 of 213) of participants used the mobile health apps to manage nicotine cravings.

Regarding time to the first quit attempt, participants were more inclined to quit faster than the comparison group (hazard ratio, 1.68; 95% CI, 1.09-2.60; P = .02). A

Lastly, at the 6-month follow-up, 18% (28 of 160) of participants in the TAB group and 10% (17 of 171) of the comparison (χ2 test, P = .045) participants obtained carbon monoxide level–verified smoking cessation (P = .048).

The team noted that clinic-based interventions had recently moved toward an opt-out approach for smoking cessation counseling and away from the traditional opt-in consent. They were hopeful that the TAB experience would be incorporated across more diverse patient populations.

“Our next steps are to expand implementation to include additional populations, including those in rural areas, while refining our approach to increase rates of initial recruitment.”

The study, "Effect of Technology-Assisted Brief Abstinence Game on Long-term Smoking Cessation in Individuals Not Yet Ready to QuitA Randomized Clinical Trial," was published online in JAMA Internal Medicine.