Let me first say that smoking is the number one preventable cause of premature death. A billion people in the world smoke. And 6 million die every year from a smoking-related illness. Nearly half of the cigarettes consumed in the US are by people with a mental disorder. Yet, therapists rarely offer assistance in how to help their clients quit smoking---and many don't even ask if they smoke or want to quit. We are just not trained to take this on. The truth is the that smoking will kill our clients before their depression or anxiety will. Its the elephant in the room. And I still hear resistance on this point. We need to get over that.
I will be talking more about smoking and ACT in an upcoming TED talk. (See the talk here)
How did this app come about?
One of my Tobacco and Health Behavior Science Research Group's core research missions is to improve the success rates of quit smoking programs. Our ten-year goal is to help 1 million people quit smoking as a result of our research. So that app is one way we are trying to fulfill this mission and goal.
Specifically, along with my group, I have been very fortunate to get the needed research funding to do some really fun, innovative, rigorous, and groundbreaking work with the potential to impact millions of lives. We received a $140,000 grant (total costs) from the Fred Hutchinson Cancer Research Center's ("Fred Hutch") Hartwell Innovation Fund to develop and test SmartQuit in a pilot randomized trial. The key innovations were behavior and technology: ACT and the first test of an app to quit smoking. We are on the cutting edge of technology-delivered interventions for smoking cessation and for ACT.
How have you integrated ACT process into the app? Have you included other processes of change?
Integrating the core intervention processes into the app was guided by several overall questions. First, what does our prior research tell us are the critical ACT processes that predict smoking cessation? Second, what does our prior research tell us are critical best practices that predict smoking cessation? Third, and this was the most challenging, how can those processes be distilled into a 30-60 second interaction with a user on a smartphone? Following these questions, we developed sample material in text, audio, and video form. We did multiple rounds of focus groups and user testing studies to see how people reacted. Six rounds of testing yielded 150 changes! So usability testing is absolutely critical for human interaction software development. The best ideas fail if your users don't understand them, don't connect with them.
What are some key functions of the app that the CBS community would be interested to know about?
The key functions of the app are (1) developing a behavior change plan (in this case, a quit plan), (2) tracking their urges to smoke (as opposed to how much they smoked, which can induce self-judgment, guilt, and shame), (3) specific ACT acceptance exercises tailored to smoking cessation, and (4) motivational exercises that tap values. They also receive push notifications and text messages. Naturally, the best way for people to understand those functions is to download the free version of SmartQuit onto their phone. Nothing I can really say that their own experience of it wont say ten times better.
Is there in-app data collection/monitoring and would this be of use for ongoing therapy?
Absolutely. They monitor and can see progress results on two metrics our research has shown is important: (1) number of urges passed (accepting a craving AND not smoking) and (2) number of smokefree days.
In your pilot testing how did this app fare as compared with other smoking cessation interventions?
The ACT app had about 60% higher quit rates than the comparison app, which was based on the NCI's smokefree.gov--the most accessed website in the world for quitting smoking. As a pilot trial, the study was not powered so these differences are not statistically significant. Thus, the promise of the ACT app is leading us to pursue its testing in a large randomized trial.
What was your most surprising challenge in developing this research/app and how did you overcome it?
As I mentioned above, it was the distillation. A lot of people told me I was crazy to think we could put ACT in an app format. We are so used to the 50-minute face-to-face therapy hour that it seemed far-fetched or naive. People told me the same thing in 2008 when I was developing our telephone counselor delivered protocol which has one 30-min session and four 15-minute sessions. Yes, it is hard to do. But it was certainly feasible. It required completely rethinking what is a therapeutic interaction and how that interaction made sense in the particular delivery format. We had to ask the hard question of what works in a few sentences. Metrics we used to evaluate our distillations: vividness, concreteness, relevance to the behavioral target, immediately actionable.
There is a "full version" of the app available for a fee. Who receives the fee and how will it be used? (if it's used to support research I would think this question would help all involved)
The fee is part of a licensing agreement the Fred Hutch made with 2Morrow, Inc. The agreement is part of a larger effort in which the Washington State Life Sciences Discovery Fund awarded a $250,000 grant to commercialize the app. The mission of the Fund is stimulate job growth in Washington State in the field of life sciences. The coolest thing is that this the first time the Fund ever gave a grant for a behavioral intervention!
The fee goes to 2Morrow, and proceeds then go the Fred Hutch to support research. So if someone does purchase the full version of the app, they will be helping support scientific research.
What is the next step in your research (either with this app or other lines of research)?
We have a number of next steps all going on in parallel. In our app research, we are planning to test an ACT app for smoking cessation in a large randomized trial with longer term follow-up, and to learn its cost-effectiveness. In our web-based research, we have a large randomized trial now ongoing for testing web-based ACT for smoking cessation. And we are about to start a large trial of telephone counselor-delivered ACT for smoking cessation. Each of these platforms of delivery are critical because they are the major platforms for reaching smokers. Finally, we are also starting to branch out to developing and testing interventions for ACT for weight loss. Stay tuned!
Finally, my colleague Dr. Jaimee Heffner is leading efforts to test ACT for smoking cessation among high-risk smokers--especially the mentally ill. For example, people with bipolar disorder have up to 70% smoking rates but quit at half the rate of people without bipolar. Because of their high smoking rate, they die about 25 years earlier. When you see her publication come out of her recently completed NIDA-K award, you will be fascinated by the quit success rates her study of ACT for bipolar smokers achieved. Combined with our great promise in helping smokers with depression quit smoking (see Bricker et al., 2014 in Nicotine & Tobacco Research), so she is now working on a protocol for smokers with mood disorders in general. She is the next shining star in ACT for smoking cessation.