A Mobile App to Aid Smoking Cessation: Preliminary Evaluation of SmokeFree28

Background Little is known about the effectiveness of mobile apps in aiding smoking cessation or their validity for automated collection of data on smoking cessation outcomes. Objective We conducted a preliminary evaluation of SF28 (SF28 is the name of the app, short for SmokeFree28)—an app aimed at helping smokers to be smoke-free for 28 days. Methods Data on sociodemographic characteristics, smoking history, number of logins, and abstinence at each login were uploaded to a server from SF28 between August 2012 and August 2013. Users were included if they were aged 16 years or over, smoked cigarettes at the time of registration, had set a quit date, and used the app at least once on or after their quit date. Their characteristics were compared with data from a representative sample of smokers trying to stop smoking in England. The percentage of users recording 28 days of abstinence was compared with a value of 15% estimated for unaided quitting. Correlations were assessed between recorded abstinence for 28 days and well-established abstinence predictors. Results A total of 1170 users met the inclusion criteria. Compared with smokers trying to quit in England, they had higher consumption, and were younger, more likely to be female, and had a non-manual rather than manual occupation. In total, 18.9% (95% CI 16.7-21.1) were recorded as being abstinent from smoking for 28 days or longer. The mean number of logins was 8.5 (SD 9.0). The proportion recording abstinence for 28 days or longer was higher in users who were older, in a non-manual occupation, and in those using a smoking cessation medication. Conclusions The recorded 28-day abstinence rates from the mobile app, SF28, suggest that it may help some smokers to stop smoking. Further evaluation by means of a randomized trial appears to be warranted.

The main drivers of smoking become significantly reduced after a month of total abstinence: particularly the nicotine hunger, cue-driven impulses to smoke and nicotine withdrawal symptoms. This means that if someone is able to stop smoking completely for one month, his or her chances of becoming a permanent ex-smoker are increased fivefold (2).
To sustain abstinence (3), resolve to achieve this must be stronger than urges to smoke at all times when the opportunity to smoke is present. Using concepts contained within the PRIME Theory of motivation (4) (5), stopping smoking involves maintaining the desire and capacity to inhibit smoking sufficiently high to override impulses to smoke that can arise at any t ime following the start of a quit attempt. b. Maximising the salience of negative emotions at the prospect of smoking, e.g. by concern over health, concern over losing the gains made thus far in the quit attempt, shame and/or embarrassment at having failed in the quit attempt c. Maximising  Because of the pharmacological actions of nicotine as delivered by cigarettes, the strongest imperative is to prevent any lapse at all. If a lapse does occur, there is a still a chance of recovery but it is small.

Pr inciples underpinning SF28
SF28 seeks to help smokers to achieve 4 weeks of total abstinence to set them on the road to life as an ex-smoker. I t focuses on behaviour change techniques (BCTs) that are expected to play the most significant role and can be delivered by means of a mobile.
The application is built around: a) providing a clear goal for the quit attempt and maintaining the salience and reward value of making progress towards that goal; b) a strong focus on development of an ex-smoker identity to make the idea of having a cigarette unthinkable; c) the use of evidencebased methods of reducing desire and impulses to smoke, such as nicotine replacement therapy and light exercise.
The core of SF28 is the target of 28 days smoke free and monitoring progress towards that target using the mobile. To help achieve that target the smokers is provided with a 'toolkit' of activit ies and aids. These include: a) advice about stop-smoking medications, which one to use and how to use it effectively; b) advice on changes to lifestyle to reduce exposure to smoking t r iggers and maintain mental energy needed to exercise self-control; c) inspirational statements from smokers who have stopped to bolster positive motivation; d) advice on specific activities to minimise or help cope with cravings when they occur.
The 'look and feel' of the application is designed to make the experience of using it enjoyable and involving minimum of effort. Attention has been paid: a) to the overall design and use of attractive imagery; b) to minimising habituation to the imagery while maintaining a reassuring continuity; c) to providing a clear structure and strong sense of forward direction to the goal.
From the Smoking Toolkit Study one would expect 15% of smokers who t ry to quit to succeed for 28 days if they use no form of evidence-based support (such as the NHS stop-smoking services). Using a conservative assumption that everyone who did not actively log in and record themselves as abstinent for at least 28 days had resumed smoking, 20% of those making a quit attempt with SF28 succeeded for that duration. While the estimated effect is small, the costeffectiveness would be high in terms of cost per life years expected to be saved.
A controlled t r ial is warranted to gain a better estimate of effect size.