Key learning points:
- Motivation to quit smoking is an important factor for smokers in terms of accessing support and initiating a quit attempt
- Website and text message based smoking cessation self-help have the potential to be highly accessible and effective
- There is moderate interest in digital self-help among smokers – this is likely to grow as digital device ownership increases
Every day in the UK, approximately 280 people die prematurely due to smoking. This equates to over 100,000 premature deaths every year1 – more than any other cause or risk factor. While smoking rates have been slowly reducing, one in five people still smokes in the UK. Providing effective smoking cessation support is therefore an important part of our healthcare service, in order to help smokers reduce their risk of poor health and a premature death. Increasingly, smoking cessation information and support is accessed via the internet and mobile phones. Therefore, it is important to know something about how digital smoking cessation support is used and what impact it has on smoking.
Before we look at self-help, it is important to consider the role of motivation to quit smoking, as this plays a part in accessing cessation support. Studies show that motivation to quit smoking is an important factor in attempting to quit, such as getting support and starting a quit attempt.2 However motivation does not seem to be important for successful cessation. In fact most studies undertaken in Western countries have found that motivation to quit is not associated with success in quitting.2 This suggests that if we can get smokers who are unsure about quitting or low on motivation to make use of easy-to-access support and start a quit attempt, they have about the same chance of success as smokers who are highly motivated. This is where self-help comes in.
Self-help usually refers to support that follows a set of therapeutic procedures delivered by some type of media rather than a person, such as a leaflet, website etc. The use of self-help by smokers who would otherwise not access any support increases their chances of quitting six months later by about 45%. This translates into a 2% absolute increase in quitting (from 5% of smokers who do not receive self-help to 7% who do receive self-help).3 That might not sound that promising, but in comparison very intensive support such as pharmacotherapy plus cessation counselling, increases absolute quit rates by only 6% on average (from 8% to 14%).4 Given its low cost, an effective self-help intervention will usually be highly cost-effective. Self-help is therefore recommended by the National Institute for Health and Care Excellence (NICE) for use in primary care, either alone or combined with other support.5
With rising uptake and accessibility of digital media, self-help has been experiencing a revival. Delivery via a digital interface has enabled self-help to become interactive, personalised and highly accessible, all things which can increase its effectiveness. For example, there is good evidence that tailoring self-help, ie. using the characteristics of each smoker to individualise the support provided, makes it more effective.3 So what do we know about digital self-help, and are smokers interested in it?
Digital smoking cessation self-help currently falls into three main types: websites, text message programmes and smartphone apps.
There is a large variety of cessation websites, from static sites providing quitting tips only (many of which lack therapeutic procedures and so are unlikely to be regarded as self-help) to highly interactive sites with multiple features and communication channels. Determining whether cessation websites are effective is difficult because of this variation. Researchers reviewing the trial literature to assess effectiveness have struggled with this issue. Overall, reviews have found some evidence of effectiveness of website and/or internet (such as email) programmes over non-digital self-help or no intervention.6,7 Tailored websites and internet-based programmes have been found to be the most effective type.8 Studies have found that individual usage of cessation websites tends to drop rapidly over time and that usage is associated with abstinence. So the more a smoker uses a potentially effective website, the more likely they are to report abstinence at follow up. So the effectiveness of a digital self-help intervention is likely to be in part dependent on how accessible, usable and engaging it is. This is where mobile phones may have the edge.
Text messaging programmes
These interventions vary much less in content and delivery than websites due to the limited delivery format. Most text message programmes provide regular messages of advice, encouragement and information orientated around a quit date, sent to smokers’ mobile phones. A review of randomised controlled trials of text messaging interventions found that they increased the chances of quitting by around 70% – an absolute increase of 4% (from 5% to 9%) - compared to no intervention.9 Recipients of text message support read a high proportion of the information they receive. In one study of a tailored text message intervention for pregnant smokers, 87% of participants reported reading all the text messages received.10 This study also provides insight into how this type of support might help people quit. It found that the tailored text message support plus a tailored advice leaflet increased harm beliefs, confidence in quitting, determination to quit and setting a quit date compared to control participants. Only one study has looked at the addition of text message support to usual smoking cessation advice delivered in primary care. This study, which is not yet published, found evidence of a long-term benefit for those receiving tailored text message support in addition to a tailored advice report and usual cessation advice from nurses or healthcare assistants (‘level 2’ support) compared with those only receiving usual cessation advice.11 So studies have found beneficial effects of smoking cessation text message support. One limitation of text messages, however, is that they cannot present information or advice in a particularly interactive way, unlike smartphone apps.
As with website interventions, apps vary widely in their approach and features. Most apps fall into one of five categories: calculator apps (provide feedback on number of days quit, money saved, health gained, etc), hypnosis apps (facilitate self-hypnosis), rationing apps (help smokers reduce the number of cigarettes they smoke), tracker apps (help smokers monitor when and how many cigarettes they smoke) and informational apps (tips, ‘facts’ and general advice).12 There has yet to be a published evaluation study of a cessation app, so it is difficult to assess their likely effectiveness for smoking cessation. It is reasonable to assume that an app delivering evidence-based advice, informed by clinical practice guidelines in an engaging manner, would increase abstinence in those using it. However, among those apps available in app stores, the adherence to clinical practice guidelines for smoking cessation is very low.12 For example, only 19% of apps reviewed in one study actually gave advice on how to quit or stay quit and only 5% mentioned cessation medications.12 Apps have the potential to be more effective than websites primarily due to high accessibility; they are usually viewed on phones which are carried by the smoker pretty much everywhere they go and most of the time they do not need an internet connection. But very little research into app usage and impact has been undertaken, therefore, there is much we still need to learn.
Are smokers interested in digital self-help?
A UK survey of smokers carried out in 2012 found that just under half (43%) were interested in using a website/internet cessation intervention and around one in four (24%) were interested in using a cessation app.13 Those interested in using either type of intervention are more likely to be younger, more heavily dependent on nicotine, more motivated to quit and, unsurprisingly, more likely to have a device capable of accessing such support. Interestingly, only 0.3% of responders reported using either of these intervention types to help with their most recent quit attempt in the last year. It appears, therefore, that there is currently a significant gap between interest in and access to digital self-help. There is no data published on interest in text messaging among general smokers in the UK, but a cohort survey undertaken in 2012 in Nottingham (not yet published) found that 47% of pregnant smokers were interested in a cessation app and 43% were interested in cessation text messages. It is important to note that technology-related surveys become outdated very quickly as ownership of devices increase so these rates are likely to have changed since the surveys were undertaken, most likely in an upward direction. Equally, as time goes by there are increasing numbers of young people who have grown up with digital media playing a part in their everyday life which may also make accessing digital support more popular.
What free resources are available?
There are many websites offering smoking information and advice to smokers in various forms, although the quality is very variable. A useful website for accessing multiple quitting tools is the SmokeFree NHS website. The US counterpart, smokefree.gov, provides easy-to-use self-help advice and also includes numerous quitting tools, including some smartphone apps. The www.stopsmokingcoach.eu website provides tailored self-help feedback reports and interactive tools, also including an app.
For learning more about advising patients on quitting smoking and becoming a trained stop smoking practitioner go to the UK National Centre for Smoking Cessation and Training website at www.ncsct.co.uk.
Text messaging programmes
The SmokeFree NHS website, at the time of writing, provides access to a text message programme to support smokers who have already or are willing to set a quit date. Smokers can text TXTHELP to 63818 to start receiving free text support.
There is no shortage of cessation-related apps available from app stores, but as discussed few provide evidence-based support. Some of the reputable websites listed above include links to cessation apps. Two iPhone-based apps which are evidence-based include SF-28, developed by Robert West and colleagues at University College London, and a research version of the San Francisco Stop Smoking app, developed by Ricardo Muñoz, University of California.
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