by: Perry Payne, MD/JD/MPP
Recently, the Community Preventive Services Task Force made a positive recommendation for using mobile phone-based tobacco cessation interventions. This recommendation is significant because it was based on existing research, as opposed to some other approaches used to recommend apps (such as crowdsourcing).
The committee indicated that there was sufficient evidence for effectiveness of these interventions in increasing tobacco abstinence among people interested in quitting smoking. It made its determination based on findings from “six studies in which mobile phone-based interventions were implemented alone or in combination with Internet-based interventions.”
What is the Community Preventive Services Task Force?
The Community Preventive Services Task Force is an “independent, non-federal, uncompensated body of public health and prevention experts.” All of the members are appointed by the Director of the Center for Disease Control and Prevention (CDC). It is not the same as the United States Preventive Services Task Force, which conducts reviews of existing literature to make recommendations for preventive health services in primary health care.
The goals of the Task Force include the following:
- Oversee the prioritization process for which systematic reviews to conduct
- Participate in development and refinement of review methods
- Consider the findings of all reviews and issue recommendations and findings to help inform decision making about policy, practice, research, and research funding in a wide range of U.S. settings
The Task Force produces summaries of evidence for different public health interventions. These are placed on a website called The Community Guide which is a resource for anyone interested in using an evidence-based approach to improve community health.
The services reviewed by the US Preventive Services Task Force are usually prescribed by a physician or other health care professional. The Affordable Care Act gives this Task Force a great deal of power by stating that none of the services receiving a high level recommendation are subject to cost sharing by insurers, essentially making these services free.
The recommendation of the Community Preventive Services Task Force was based on a systematic review approach. This procedure consisted of three major steps: identifying all relevant studies, assessing their quality, and summarizing the evidence. For mobile phone based smoking cessation interventions, the Task Force reviewed an existing systematic review conducted in December of 2008 along with subsequent studies up until August of 2011. The evidence for the recommendation came from six studies which evaluated the effectiveness of interventions that used automated text messaging for previously recruited participants who were willing to make an attempt to quit smoking.
All the studies were randomized controlled trials and assessed either self-reported or biochemically verified cessation outcomes at 6 or 12 months. Among these studies, three used mobile phone text interventions as the primary cessation support and three used mobile phone text interventions as a complement to an Internet based approach. At 6 months, both approaches demonstrated cessation rates better than control groups with more improvement in the studies with an Internet based approach and mobile phone texting as a complement.
Problems with the recommendation
One problem with the recommendation is that it is not specific to a particular age group. This intervention may work best for younger people because recruitment rates for older tobacco users were low in the studies. In addition, the studies were all conducted in other countries (Norway, New Zealand, and the United Kingdom), so their applicability to the US, especially populations experiencing smoking health disparities (mainly poorer Americans), is not clear and requires more research. None of the studies provide any information on the economic costs and benefits of mobile phone based interventions for tobacco cessation. Such information will be useful in the future as clinicians seek reimbursement from insurers for prescribing these kind of programs.
In addition, companies administering these cessation support programs will likely seek reimbursement for this procedure. Another problem the Task Force points out is that although mobile phone based interventions can be tailored to specific populations, they require on-going advertising and service promotion to ensure that people use them.
Thus, they require evidence based approaches to disseminate and/or implement them. For some populations, the evidence for health promotion may not be that strong which provides weaker infrastructure for implementing mobile interventions. There may be a role for the private sector here because of their ongoing efforts to advertise a variety of products to different populations (such as certain ethnic or gender populations). There are also concerns about the technological complications that arise for some users of these interventions as well as confidential and privacy concerns.
Future Research Needed
As with any recommendations of this nature, the recommendations are only as good as the existing evidence. Some of the key research questions raised by the Task Force are:
- What are the economic costs and benefits of mobile phone based texting interventions for smoking cessation? In particular, what are the costs and benefits of interventions that are sustained over one year
- Can these interventions work in US populations suffering from smoking disparities?
- Are there certain age groups that are more receptive to these interventions? If so, which ones and why?
- How do these interventions work in combination with other types of smoking cessation interventions?