Text2Quit: Mobile-based Intervention for Smoking Cessation

Research and treatment on cigarette smoking has typically been separated from research on alcohol and other drugs. The findings from smoking research, however, can be applied to substance use disorder research and treatment as well.

This study investigated how an innovative text messaging program for cigarette smoking helped people. We review the study and how those findings can inform recovery research.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

There are many lessons that the field of recovery research can learn from research targeting cigarette smoking despite their focus on different types of substances. These areas have informed each other in many important ways. In one well known example, the transtheoretical stages of change model, forming the basis for understanding how people become ready to change their substance use, was first developed in cigarette smokers.

One key area where smoking cessation research can inform recovery research is technology-based interventions. While mobile text message interventions can be helpful for smoking cessation, the field knows very little about how they work – i.e., what are the mechanisms of behavior change.

Understanding the mechanisms of an intervention is important because it may or may not work the way it was designed; more information on exactly how it works can lead to modifications and thus potential improvements. In this study, Hoeppner and colleagues investigating the mechanisms of Text2Quit, an empirically-supported, easily accessible text message intervention for smoking cessation .

HOW WAS THIS STUDY CONDUCTED?

Text2Quit provides tailored text messages for 3 months intended to enhance an individual’s motivation and ability to cope effectively with difficult experiences related to quitting (e.g., craving). Participants could continue to seek help by texting certain keywords for 3 months following the initial treatment phase. It also provided access to a personalized website to learn more about other smoking cessation resources, specifically medication and quit lines.

This study analyzed how Text2Quit worked by conducting “mediation” analyses of four potential psychosocial mechanisms:

self-efficacy (“gave me confidence to quit”)
motivation to quit (“made me feel that it is worthwhile to quit”)
perceived social support for quitting (“made me feel someone cared if I quit”)
expertise/skill to quit (“made me feel I knew the right steps to take to quit”)

In addition, the authors tested whether Text2Quit worked by getting people to use one of four outside smoking cessation resources:

a quitline
medication
self-help
an online community.

Control participants were provided with online access to smoking cessation education and materials.

The study included 409 adult daily smokers (5+ cigarettes per day) who were seeking ways to help them quit online. The sample was 35 years old, on average, as well as 68% female, 79% White, 70% with less than a college degree, and 62% who had made a previous quit attempt.

The primary outcome was self-reported 7-day smoking abstinence – a common outcome in smoking cessation research – 6 months after beginning the study. The mechanisms were measured at 1 month. In each case, analyses tested just one of the four psychosocial mechanisms at a time, along with the entire set of outside resources, while controlling statistically for individual differences of participants at baseline.

See figure for a simplified illustration of one of these mediation analyses.

WHAT DID THIS STUDY FIND?

It is worth mentioning, in the initial randomized trial of Text2Quit, 38% of the intervention participants were abstinent at 6 months, compared to 22% in the control group.

For the mediation analyses, abstinence self-efficacy, skill/expertise, and perceived social support all helped explain the benefit of Text2Quit. Abstinence self-efficacy – enhanced confidence to quit – was the strongest mechanism, accounting for 35% of the benefit. Although none of the outside resources explained the benefit of Text2Quit, it is interesting to note that engagement with an online community focused on smoking cessation was associated with improved abstinence.

Receiving Text2Quit did not affect online community engagement, however, presumably because it was not directly addressed in the intervention.

WHY IS THIS STUDY IMPORTANT

This mediation analysis of Text2Quit showed that psychosocial processes like increased confidence to quit help explain how the intervention works, while linking people with outside smoking cessation resources did not explain its benefit.

Engaging with the text messages themselves, and the thinking & behavioral change that engagement promoted was the helpful piece of Text2Quit, rather than it being simply a platform to get people to use other types of resources.

This is an encouraging sign for other types of mobile technology-based interventions, in as much as they too might help change thinking, feeling, and behaving related to other health outcomes like substance use disorder recovery.

Indeed, a recent review on mechanisms of behavior change studies in all types of technology-based interventions for tobacco, alcohol, and other drug problems, also points to the central role of psychologically mediated changes, such as enhanced abstinence self-efficacy and perceived skills to help maintain quitting.

Only one study on mobile technology was included in that review, however, as most were web-based interventions. Additionally, as authors noted, given that there were unique benefits offered both by the text message intervention as well as participation in online forums on abstinence, for example, helping people change their health behaviors may be less about suggesting one type of intervention or another, and more about understanding what combination of approaches works best and for whom.

LIMITATIONS

Given that these individuals were already seeking services online, they may be a group with greater than average comfort with the use of digital resources. It is unclear whether these findings apply to individuals who are not as comfortable with technology in their day to day lives.
Also, use of outside services was measured with a simple “yes” or “no” response. Given studies showing that medications for smoking cessation, like varenicline , are helpful tools, and that Text2Quit was related to greater likelihood of obtaining medication for smoking cessation, a more in depth measurement of medication use could have produced different findings.

NEXT STEPS

This study focused on a text message smoking cessation intervention in people seeking online resources. Studies on other types of smokers are important, say if they were attending an appointment at the primary care doctor’s office, for example. Also, future work might build on the important findings of this study – that technology based intervention can effect changes in key psychological phenomena – to test whether that is also true in recovery research.

BOTTOM LINE

For Individuals & families seeking recovery: While this study was about smoking cessation, not substance use disorder recovery, it offers some insights. One important finding is that a mobile text message intervention to help curb an addictive behavior like cigarette smoking worked, in part, by improving how confident and motivated people were to stop smoking. Mobile texting for alcohol and other drug use might also work this way, though research is needed in this area that specifically targets these addictive behaviors.
For scientists: This multiple mediation analysis provides a useful model of how to examine the mechanisms of behavior change targeted by a mobile text message intervention for cigarette smoking. Though its focus was on smoking, the approach can be applied to examine proposed mechanisms of mobile technology-based approaches to treat alcohol and other drug use as well.
For policy makers: The mobile text messaging intervention for cigarette smokers reviewed here, Text2Quit, is low-cost and available online. This study built on previous research showing it is helpful, by highlighting that it works by giving people the confidence and motivation to quit rather than because it linked them to outside resources. Put another way, this application, which requires no human intervention, was helpful because it engaged people psychologically in the process of change.
For treatment professionals and treatment systems: While this study was about smoking cessation, not substance use disorder recovery, it offers some insights. One important finding is that a mobile text message intervention to help curb an addictive behavior like cigarette smoking worked, in part, by improving how confident and motivated people were to stop smoking. Mobile text message treatments for alcohol and other drug use might also work this way, though research is needed in this area that specifically targets these addictive behaviors.