Nearly one in five men and women are active smokers. For these individuals, it is estimated that their smoking will take just shy of 15 years off their life expectancy.

In 2005, the last year for which this type of data is available, nearly half a million people died due to smoking.

Unfortunately, as anyone who has tried to work with patients to help them quit knows, once someone picks up the habit it is really hard to kick.

At least in my experience, it’s usually not the chemical addiction that is the hardest part though–it’s the behavioral dependence.

For that reason, mobile health technology seems primed for the task–ready to deliver the just-in-time intervention when my patient is stressed at work and would normally get up to go have a cigarette.

A Cochrane Review of randomized controlled trials of mobile health interventions for smoking cessation would suggest that they can double a patient’s chances of long-term abstinence. However, a recent survey of apps for smoking cessation suggests the reality of what patients are using falls short of this promise.

The Promise

In the review, Whittaker et al searched for randomized controlled trials (RCTs) or “quasi” RCT’s that evaluated a principally mobile phone based intervention for smoking cessation with at least six months of follow up.

Ultimately, they identified 5 trials for inclusion including:

  • three that used personalized SMS-based interventions
  • one that used SMS with a web based quit coach (either separately or in combination)
  • one that used a video messaging intervention

In the meta-analysis of the pooled results of these trials, they found improved long term quit rates (RR 1.171, P=0.001) though with significant trial heterogeneity. Individually, only two of the five trials showed a benefit though the authors note that some of those trials face problems like inadequate enrollment.

Of the trials, the largest and most rigorous was a study by Free et al in 2011 with nearly 6,000 participants from the UK which more than doubled biochemically confirmed long-term smoking cessation with an SMS-based intervention (4% to 9% biochemically verified; 12% to 30% self-reported).

The Reality

Abroms et al started by searching for apps, both iOS and Android, using key phrases including quit smoking, stop smoking, and smoking cessation. Of the 414 apps they found, they limited themselves to ~50 of the most popular for each platform.

In addition to capturing some basic data about the app, two independent coders then assessed the apps based on an Adherence Index based on the US Clinical Practice Guideline for Treating Tobacco Use and Dependence. Overall the best Adherence Score an app could get was 42.

They found that the average Adherence Score of the 98 apps evaluated was 12.9; that the standard deviation was 6.8 suggests significant variability in the quality of the apps. Some of the most notable deficiencies include the findings that only 19% of apps offered practical counseling, 17% offered mechanisms for social support, 4.1% suggested consideration of approved medications, and none of the apps referred patients to smoking cessation support lines.

Other Takeaways

It’s hard to study this

  • One subtle fact on the first page of Abroms’ study was that the index search was on February 11th, 2012. The manuscript was published in December, 2013. It took two years! That’s clearly not going to work in this space.

iOS wins in a small way

  • Looking at their supplementary files, iOS has 6 apps above or tied with the highest rated Android app which came in at an Adherence Score of 25.5. Android is certainly winning in quantity but perhaps this raises some questions about quality.

Maybe App Store ratings are not so bad

  • Abroms et al found that the higher rated apps tended to have better adherence scores. The r value was around 0.3 however, so take that with a grain of salt.

A 2012 meta-analysis with all SMS-based trials

  • Clearly more research is needed to help inform the best strategies to use mobile tools to promote smoking cessation. A quick review of ClinicalTrials.gov shows at least half a dozen trials listed as either active or recruiting that involve using mobile health tools like smartphone apps or social media to promote smoking cessation.

Conclusion

While the mean was disappointing, an important takeaway from Abroms’ study is that there are outliers near the top and it is up to healthcare professionals to guide our patients to them. Just as we suggest–based on their history–that maybe a nicotine gum is the way to go and to replace the stress-induced cigarette with some sugar free candy, we need to get familiar with apps that do follow guidelines so that we can recommend them to appropriate patients. No, we don’t have data to say that apps work to help improve cessation rates, but if we believe Whittaker’s analysis, the principle of mobile phone based intervention is promising. Additionally, the top-rated app, UCSF/SFGH Stop Smoking for iOS, is $0.99.

References:

Go, a. S., Mozaffarian, D., Roger, V. L., Benjamin, E. J., Berry, J. D., Blaha, M. J., … Turner, M. B. (2013). Heart Disease and Stroke Statistics–2014 Update: A Report From the American Heart Association. Circulation. doi:10.1161/01.cir.0000441139.02102.80
Abroms, L., & Westmaas, J. L. (2013). A Content Analysis of Popular Smartphone Apps for Smoking Cessation. American journal of …, 45(6), 732–736. doi:10.1016/j.amepre.2013.07.008
Whittaker, R., Borland, R., & Bullen, C. (2009). Mobile phone-based interventions for smoking cessation. … Database Syst Rev, (11).