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A gamified smoking cessation program added to nicotine replacement therapy (NRT) sampling found success with smokers who were not yet ready to quit, researchers reported.

For adults with no set quit date, those exposed to the 3-week "Take a Break" (TAB) intervention were twice as likely to have at least one 24-hour abstinence period versus a comparison group that received NRT sampling alone (OR 2.01, 95% CI 1.21-3.35), according to Rajani Sadasivam, PhD, of the University of Massachusetts Medical School in Worcester, and colleagues.

For the study's primary outcome of time to first quit attempt, the TAB group -- who were sent motivational texts, quizzes, and gift cards -- came out on top at all time points as well. At 90 days, 35% of those exposed to the intervention had a quit attempt versus 23% for the comparison group (HR 1.68, 95% CI 1.09-2.60, P=0.02), they stated in .

At 6 months follow-up, rates of carbon monoxide level-verified cessation between the two groups were 18% and 10%, respectively (OR 1.92, 95% CI 1.01-3.68, P=0.048).

"Sustaining engagement in interventions (especially health) is challenging, particularly for groups not yet ready for health behavior change," the researchers said. "TAB adopted gamification as a strategy to engage participants and was structured based on principles of designing gamified health behavior interventions."

Smoking is the leading cause of preventable death in the U.S., , but most smoking interventions engage "only those with the highest motivation," the researchers noted.

The trial took place at four sites in the Northeast U.S. from November 2016 to July 2020. Participants were randomized to receive the gamified TAB intervention along with NRT sampling (72 Nicorette lozenges) or just NRT alone. Both groups received financial compensation for completing evaluations at baseline, 3 weeks, and follow-up.

TAB had five main components:

• Motivational text messages: Participants received daily texts during the 3-week period and texts twice every week until the 6-month point
• Challenge quizzes: Participants received daily self-assessment texts and would be rewarded for completing them
• Brief goal setting with a tobacco treatment specialist: After week 1, participants were asked if they wanted to set an abstinence goal
• Coping mini-games: Participants were encouraged to use distracting apps such as Piano Tiles, Wordscapes, and Flow Free, or relaxing apps such as Take a Break, Calm, or Breathe2Relax (participants without smartphones were provided with one)
• Recognition and rewards: Participants gained points for responding to the daily assessment and bonus questions and were ranked on an anonymous leaderboard -- at 3 weeks, the top 25% of participants received a gold medal and a $15 gift card, the middle 50% received a silver medal and a $10 gift card, and the bottom 25% received a bronze medal and a $5 gift card

"All the components we used have been tested in prior studies," Sadasivam and co-author Thomas Houston, MD, of Wake Forest School of Medicine in North Carolina, told 番茄社区app. "The novel aspect was integrating them together using a novel gamification approach to engage these individuals."

Adherence to the daily quizzes varied, with 53% completing all daily quizzes in week 1 and 34% completing them all in weeks 2 and 3, the researchers wrote. Participation in the goal-setting call after week 1 was high, at 93%, and 73% of participants who completed the call set a goal to practice quitting. Three-quarters of the participants reported using coping mini-games during the intervention.

Despite the fact that the participants were not yet ready to quit at baseline, the gamified approach improved participation rates versus , the researchers said. For instance, the daily assessments were voluntary "to satisfy the game player or participant's need for autonomy," and were instead encouraged by gamification via the rewards and ranking system.

"The participation reward was provided regardless of whether individuals achieved their brief abstinence goal," Sadasivam and Houston emphasized. "We were very careful to inform the participants that the points and subsequent reward would be provided regardless of whether they abstained, or even set an abstinence goal. Thus, it was not 'contingency management' -- providing money for cessation."

The majority of participants (90%) completed the follow-up assessment, and of those, 66% in the TAB group reported using nicotine lozenges versus 56% in the comparison group (P=0.04).

Nearly 3,000 smokers were assessed for study eligibility, but over 2,000 declined to participate, the researchers noted. Participants were also excluded for not being English speakers (n=167) and for having active depression (n=69). Ultimately, 433 adults were randomized, with 213 to the intervention group and 220 to the comparison group. Both groups lost approximately 50 participants to follow-up (24% of the study population).

In the end, 160 in the intervention group and 171 in the comparison group remained for analysis (52% women; mean age 54). The authors pointed out that "the sample included participants from vulnerable socioeconomic status groups (e.g., income concerns, unemployment)," and three-fourths of randomized participants had not completed college.

At baseline, a higher proportion of the comparison group smoked less than 10 cigarettes per day versus the intervention group (44% vs 36%, respectively).

The researchers noted that the people who agreed to participate in their study may have been a "marginally more motivated subgroup of the targeted population" compared to those that did not agree, despite lack of a set quit-date. In addition, the study sites were all in urban areas.

"Our next steps are to expand implementation to include additional populations, including those in rural areas, while refining our approach to increase rates of initial recruitment," the researchers said.

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