THE BARRIERS AND FACILITATORS TO EFFECTIVE USE OF A SMARTPHONE APPLICATION FOR SMOKING CESSATION BY HEALTH PROFESSIONALS AND SMOKERSJOSEPH VAN AGTEREN 1 , 2 , KRISTIN CARSON 1 , 2 , 3 , HARSHANI JAYASINGHE 1 , 2 , 3 , BRIAN J SMITH 1 , 2 , 3

Respiratory Medicine, The Queen Elizabeth Hospital, Adelaide; The Clinical Practice Unit, Basil Hetzel Institute for Translational Health Research, Adelaide; School of Medicine, The University of Adelaide, Adelaide

THE SMOKING EPIDEMICSmoking is a modern-day epidemic with no clear end in sight1,2

While a large proportion of smokers want to quit, most of them fail to do so during their first attempts3

Successful aids for quitting are available to boost success rate4

• Pharmacotherapy5

• Behavioural support/counselling6,7

However, most quit attempts are unassisted!8

WHY SMOKERS QUIT UNAIDED9-11

• Smoker related• Smoking status (e.g. low perceived nicotine dependence)• Demographics (e.g. age, gender, ethnicity)

• Treatment related• Barriers (e.g. costs)

• Prioritisation of Lay knowledge• Misperceptions about safety and efficacy based on own narrative

• Own responsibility: use of support is sign of weakness• Quitting unassisted is “better choice”

• Perceived value of quitting unassisted versus assisted

• Deep-rooted societal values such as independence and self-control influence choice for unaided quitting

SHIFT IN FOCUS IS NEEDED• Disproportionate focus on use of pharmacotherapy &

behavioral support in research and practice8

• “Research follows the money”

• Despite:• Underutilization of both methods by smokers8-11

• Conventional treatments being less effective in real world setting• E.g. problems in NRT treatment adherence12,13

• Augment current treatment• Pharmacotherapy: Education, reminders• Counselling: Tracking of behaviour

• Reach new subset of patients• Boost chances of quitting cold turkey• Can act as standalone treatment• Persuasive system design

TECHNOLOGY OFFERS A SOLUTION

• mHealth apps are booming!14

• 165,000+ mhealth apps in Apple Store alone & 400+ quit smoking apps

• Interventions show promising results, but results are heterogeneous15

• Increased chance of 47-99% for abstinence at 6 months16

• However, smoking cessation apps show major flaws17,18:• Not in line with current clinical care• Not based on behavioural change theories or evidence-based intervention

development frameworks• Underutilization of technological capabilities

PROMISING RESULTS OF MHEALTH APPS

OUR SOLUTION: KICK.IT• Evidence-based smoking cessation platform

built like a social network, centred around:• Ecological momentary assessment

• Tracking of behaviour• Tailored intervention delivery

• Distractions to combat cravings• Social support• Specialized behavioural support course• Normalizing relapse

AIM OF STUDY• Involvement of major stakeholders in design of the application is an essential

part of the design process.

• Aim: to determine the facilitators and barriers for the use of a smartphone app as a smoking cessation method by smokers and health professionals (HP’s).

• Focus on• Determinants for behavioural uptake• Specific smoking cessation content• Specific technological elements of the app

METHODS• Focus group with current & ex-smokers • Semi-structured interviews with:

• Current & ex-smokers• Health professional

• Hospital Personnel• General Practitioners • Smoking cessation counsellors

PARTICIPANT SELECTION• Sampling techniques

• Main strategy: purposive sampling • Snowball & convenience were used to find additional participants

• Approach: recruitment took place face-to-face, via email, via newsletters and via social media posts

• Expected sample size:• Smokers: focus-group and 10 interviews• HP’s: 10 interviews per category (n=30 total)

• Only audio was recorded. Coding performed by 2 researchers• Data analysis was conducted via QSR Nvivo 11

TRIANDIS MODEL OF INTERPERSONAL BEHAVIOUR 19

Beliefs about outcomes

Evaluation of outcomes

Norms

Roles

Self concept

Emotions

Frequency of past behaviours

Triandis 1st LevelPersonal characteristics

Triandis 2nd LevelFormation of intention

Perceived consequences

Social Factors

Affect

Triandis 3rd LevelExplain intention relating to behaviour

Facilitating conditions

Habits

Behaviour: using Kick.it

to quit smoking

Intentions

PERSUASIVE SYSTEM DESIGN (PSD) FRAMEWORK 20

• Technology designed to change behaviour is called persuasive technology

• The PSD framework gives 28 design principles organized in 4 categories• Primary task support: features to improve target behaviour • Dialogue support: features to improve engagement with app/treatment• System Credibility support: features to improve credibility of app/treatment• Social Support: using social influence to improve persuasiveness

RESULTS• Smokers

• Focus-group: 4 current and 1 ex-smoker (n=2 male, age 27-55)

• Interviews 2 current smokers and 1 ex-smoker (n=1 male, age 24-57)

• HP • 8 hospital staff (n=3 male, age 28-61)• 2 smoking cessation counsellors (age 27-40)

RESULTS: TRIANDIS 1ST LEVELBeliefs about

outcomes

Evaluation of outcomes

Norms

Roles

Self concept

Emotions

Frequency of past behaviours

Triandis 1st Level

Personal characteristics

• Overall lack of experience with quit smoking apps in all but 1 smoker• Influence of past therefore of limited value

• Positive attitudes towards health apps in general• App is not considered to be a “treatment”• App is not considered to be crucial for quit attempt, but can rather aid

and support

• Less positive attitudes towards use of conventional treatments by smokers

Smoker 1: “I would never [use Quitline or pharmacotherapy], that would never cross my mind.” I feel that if i wanted to quit smoking i can do it myself. I purposefully wouldn't seek out a professional counsellor or something

RESULTS: TRIANDIS 1ST LEVELBeliefs about

outcomes

Evaluation of outcomes

Norms

Roles

Self concept

Emotions

Frequency of past behaviours

Triandis 1st Level

Personal characteristics

• Quitting seen as personal responsibility• Large focus on own motivation and self-controlSmoker 3: “I tried too many things. I Think its something in my mind. if I made the decision to give up smokes, I will give up. But I have not made up my mind”

• Importance of social support is recognised by both groups• Bad influence of other smokers does not influence

everyone

RESULTS: TRIANDIS 2ND LEVELPerceived efficacy of an app differs per group• Smokers: overall positive attitude, less appropriate for older age

group

• HP’s: solid evidence-base is needed before adoption

Social surrounding• Role of social surrounding can break attempt for some, but wouldn’t

hurt another. Support is universally treasured.

• Having friends or support on platform can increase their intention to use the app.

Smoker 5: “for me, what might work is for example if there is a notification that ‘two of your friends didnt smoke today’ or ‘two of your friends only smoked this amount today.. they have decreased their smoking’.

Perceived consequences

Social Factors

Affect

Triandis 2nd LevelFormation of intention

RESULTS: TRIANDIS 3RD LEVELTriandis 3rd LevelExplain intention

relating to behaviour

Facilitating conditions

Habits

Intentions

• Facilitating conditions differ per group• Smokers: app needs to get good ratings in reviews and needs to have

face validity• HP’s: evidence-base and to lesser extend endorsement by colleagues• Cost is less important if its proven to be effective

• HP: Intention to use boosted by sense of ownership

• Habit of HP’s: • Personal smartphone (app) use is often high, but does not result in

recommendation to patients• Default recommendation of pharmacotherapy + QuitlineHP 8:“I simply never heard of apps for smoking cessation”

RESULTS• Lack of familiarity with smoking cessation apps prompted

researchers to ask participants to:1. Think about their own smartphone use

a) What apps do they useb) Which elements do they likec) Which elements do they not like

2. Brainstorm about hypothetical apps the participants could design themselves

RESULTS: PRIMARY TASK SUPPORTReduction

Tunneling

Tailoring

Personalization

Self monitoring

Simulation

Rehearsal

PSD FrameworkPrimary task

support

• High need for tailored solutions• Health- versus money-oriented approach

• Personalization improved liking towards other apps• Use ‘real-world examples’

“You know how much a packet of cigarettes has been over a certain amount of time [..] and you say that its equivalent to [..] things you like to do, like travelling, going to shows or buying clothes or whatever. [Without smoking] you could have gone to Bali. you know that could be an incentive for people to quit.

• Self-monitoring of behaviour especially relevant for health-oriented smokers

• HP’s: use of Fletcher-Peto curves. Can aid in own education

RESULTS: DIALOGUE SUPPORTPraise

Rewards

Reminders

Suggestion

Similarity

Liking

Social role

PSD Framework

Dialogue Support

• Push notification were often mentioned• HP’s: reminders were linked to treatment adherence• Smokers: to give them praise

• “Gamification” of quit attempt was seen as motivating

• Good usability with low learning curve will boost use of app

• App should not just focus on 1 quit attempt, but keep approaching quitters.

RESULTS: CREDIBILITY SUPPORTTrustworthiness

Expertise

Surface credibility

Real world feel

Authority

Third party endorsement

Verifiability

PSD Framework

Credibility support

• Credibility support is mostly important for HP’s• Evidence base is crucial

• Credibility from peers rather than from doctors for smokers

• Reviews from other users in app store

• App needs to look good and be fast (no lag)

RESULTS: SOCIAL SUPPORTSocial Learning

Social comparison

Normative influence

Social facilitation

Cooperation

Competition

Recognition

PSD Framework

Social Support

• Social support is valued by both groups• Often considered to be more important than other methods

• Social networks can offer empowerment

• Privacy is not considered to be important for most • New insight: circular social network rather than wall-feed

based

• Gamification and competition can boost their engagement

CONCLUSION- Adoption by HP’s and smokers will require marketing strategy similar to

conventional treatments to promote awareness of app and its efficacy- Ownership is required from HP perspective- Overall positive view on ability of app to make a difference

- High need for individualized approach: each smoker is different

- Features planned for Kick.it were in line with desires of the participants- Tracking of progress- Social network & support- Positive approach & empowerment

NEXT STEPS• Complete interviews with GP’s and with smoking cessation experts

• Incorporate changes into design• Relate results to already existing quantitative work

• Release MVP on app store (expected date: August 2016)• User testing: July-August

• Staged release of extra functionality afterwards

• More input needed!• Research side: collaborators sought to test different approaches• Development side: interested in hearing your thoughts• Roll-out to other addictions: interviews with addiction experts

ACKNOWLEDGEMENTS

THE BARRIERS AND FACILITATORS TO EFFECTIVE USE OF A SMARTPHONE APPLICATION FOR SMOKING CESSATION BY HEALTH PROFESSIONALS AND SMOKERSJOSEPH VAN AGTEREN 1 , 2 , KRISTIN CARSON 1 , 2 , 3 , HARSHANI JAYASINGHE 1 , 2 , 3 , BRIAN J SMITH 1 , 2 , 3

Respiratory Medicine, The Queen Elizabeth Hospital, Adelaide; The Clinical Practice Unit, Basil Hetzel Institute for Translational Health Research, Adelaide; School of Medicine, The University of Adelaide, Adelaide

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