Smoking
Conditions
Keywords
Smoking Cessation, technology, developing countries
Brief summary
The purpose of this study is to develop and test a text messaging-based smoking cessation program for adults who are currently smoking and want to quit, living in Turkey.
Detailed description
Smoking has long been recognized as a significant public health concern associated with great morbidity and mortality. Although smoking rates have decreased in high income countries, these trends have not been noted for tow and middle income countries. This is especially true in Turkey, which was ranked 6th in the world in smoking consumption. Between 51-63% of Turkish men and 24-26% of Turkish women 15 years of age and older are smokers. With lung cancer the leading cancer-related cause of death for both men and women, effective and accessible smoking cessation interventions are needed. Cell phone technology represents a unique opportunity to deliver evidenced-based smoking cessation behavioral treatments through a delivery mechanism already widely adopted by adults. An estimated 35 million Turks were using cell phones, making them 1.8 times more common than land lines. Cell phone interventions are a unique delivery method because of their 'always on' capability. The rapid uptake of cell phones allows us to potentially reach those who might otherwise not utilize smoking cessation services. We designed and evaluated SMS Turkey, an evidenced-based smoking intervention that takes advantage of technologies adopted by adult smokers in Turkey. The primary outcome measure is sustained abstinence 12 weeks after quit day, confirmed with a carbon monoxide (CO) reading of 8 ppm or less. Sustained abstinence was defined as 5 or fewer cigarettes smoked since the quit date, per West et al. Secondary outcome measures included: 7-day and 30-day point prevalence of smoking behavior at 3 months; CO-verified 7-day point prevalence at 4 weeks; and reduction in cigarettes per day for those who are smoking at 3 months.
Interventions
BEHAVIORALSMS Turkey
6-week smoking cessation program delivered via daily text messages SMS Turkey: 6-week smoking cessation program delivered via text messaging. SMS Turkey content is guided by the Cognitive Behavioral Therapy (CBT) theory. Content was tailored based on participant's stage in quitting (i.e., pre-quit, quit day, early-quit, late-quit, relapse). Based on the typical relapse trajectory, content paths were created for participants based on whether or not they were smoking 2 days after quit day; and again at 7 days after quit day. Depending on the participant's content path, the total number of messages received ranged from 91 (for those assigned to the encouragement arm) to 146 (for those who relapsed and then were assigned to the late quit messages).
Sponsors
Hacettepe University
Fogarty International Center of the National Institute of Health
Center for Innovative Public Health Research
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
Yes
Inclusion criteria
* 18 years of age or older * Currently smoking every day * Owning a TXT-capable cell phone * Sent or received TXT messages at least once in the past year * Living in Ankara (to ease technology support if necessary) * Agreement to set quit day in 15 days from enrollment date * Agreement to verification of smoking cessation using a carbon monoxide breath monitor
Exclusion criteria
• No chronic disease.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Carbon Monoxide-verified Continuous Abstinence at 12 Weeks | 12-weeks post-quit day | self-reported continuous abstinence since quit day (\<=5 cigarettes) verified with carbon monoxide reading (\<=8ppm) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| CO-verified 7-day Point Prevalence Abstinence at 4 Weeks | 4 weeks | self-reported continuous abstinence in the past 7 days at 4 weeks (\<=5 cigarettes) verified with carbon monoxide reading (\<=8ppm) |
| Self-reported 7-day Point Prevalence Abstinence at 12 Weeks | 12 weeks | self-reported smoking abstinence in the past 7 days at 12 weeks (\<=5 cigarettes) |
| Self-reported 30-day Point Prevalence Abstinence at 12 Weeks | 12 weeks | self-reported smoking abstinence in the past 30 days at 12 weeks (\<=5 cigarettes) |
Countries
Turkey (Türkiye)
Participant flow
Recruitment details
Participants were recruited in Ankara, Turkey between December 2010 & June 2011, through in-person outreach at local shopping malls and local newspapers advertisements. Flyers were also posted at Hacettepe University. Smokers indicated their interest by calling the study office or speaking directly with the research assistant at the shopping mall.
Pre-assignment details
Of the 247 people who expressed interest in participating, 230 were eligible for the study. A total of 151 adults (66% of those eligible) attended the enrollment meeting, where they consented to take part in the research study and were randomly assigned to either the intervention or control group.
Participants by arm
| Arm | Count |
|---|---|
| SMS Turkey 6-week smoking cessation program delivered via daily text messages
SMS Turkey: 6-week smoking cessation program delivered via text messaging. SMS Turkey content is guided by the Cognitive Behavioral Therapy (CBT) theory.
Content was tailored based on participant's stage in quitting (i.e., pre-quit, quit day, early-quit, late-quit, relapse). Based on the typical relapse trajectory, content paths were created for participants based on whether or not they were smoking 2 days after quit day; and again at 7 days after quit day.
Depending on the participant's content path, the total number of messages received ranged from 91 (for those assigned to the encouragement arm) to 146 (for those who relapsed and then were assigned to the late quit messages). | 76 |
| Brochure Control A 7-page brochure that provided general information and tips on how to quit smoking. Participants did not receive any text messages.
The brochure encouraged smokers to follow 5 steps to quitting : (1) set a quit day and sign a contract, (2) find out about their smoking patterns-why they smoke, (3) practice quitting and change their patterns, (4) involve their family and friends, and (5) learn to be a self-supporter. | 75 |
| Total | 151 |
Baseline characteristics
| Characteristic | Total | Brochure Control | SMS Turkey |
|---|---|---|---|
| Age at first cigarette | 17.3 years STANDARD_DEVIATION 3.6 | 17.1 years STANDARD_DEVIATION 3.6 | 17.5 years STANDARD_DEVIATION 3.7 |
| Age, Continuous | 35.89 years STANDARD_DEVIATION 9.89 | 36.1 years STANDARD_DEVIATION 9.5 | 35.6 years STANDARD_DEVIATION 10.3 |
| Average Number of cigarettes smoked per day | 19.53 number of cigarettes per day STANDARD_DEVIATION 8.27 | 20.4 number of cigarettes per day STANDARD_DEVIATION 9.2 | 18.7 number of cigarettes per day STANDARD_DEVIATION 7.2 |
| Confidence in one's ability to quit | 6.0 score STANDARD_DEVIATION 2.5 | 6.0 score STANDARD_DEVIATION 2.5 | 6.0 score STANDARD_DEVIATION 2.4 |
| Educational attainment High school or less | 66 participants | 38 participants | 28 participants |
| Educational attainment Post graduate degree | 12 participants | 4 participants | 8 participants |
| Educational attainment Two-year college | 23 participants | 10 participants | 13 participants |
| Educational attainment University degree | 50 participants | 23 participants | 27 participants |
| Fagerström score | 4.8 score STANDARD_DEVIATION 2.4 | 4.9 score STANDARD_DEVIATION 2.5 | 4.8 score STANDARD_DEVIATION 2.3 |
| Importance of quitting to self | 8.9 score STANDARD_DEVIATION 1.5 | 9.0 score STANDARD_DEVIATION 1.4 | 8.9 score STANDARD_DEVIATION 1.6 |
| Income 2000 - 4000 Turkish lira per month | 62 participants | 28 participants | 34 participants |
| Income Do not want to answer | 4 participants | 1 participants | 3 participants |
| Income Less than 2000 Turkish lira per month | 60 participants | 37 participants | 23 participants |
| Income More than 4000 Turkish lira per month | 25 participants | 9 participants | 16 participants |
| Martial status Divorced | 4 participants | 0 participants | 4 participants |
| Martial status Married | 91 participants | 49 participants | 42 participants |
| Martial status Single | 55 participants | 25 participants | 30 participants |
| Martial status Widowed | 1 participants | 1 participants | 0 participants |
| Number of quit attempts in the past year | 2.4 number of quit attempts STANDARD_DEVIATION 1.5 | 2.4 number of quit attempts STANDARD_DEVIATION 1.5 | 2.4 number of quit attempts STANDARD_DEVIATION 1.5 |
| Sex: Female, Male Female | 59 Participants | 24 Participants | 35 Participants |
| Sex: Female, Male Male | 92 Participants | 51 Participants | 41 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 0 / 76 | 0 / 75 |
| serious Total, serious adverse events | 0 / 76 | 0 / 75 |
Outcome results
Primary
Carbon Monoxide-verified Continuous Abstinence at 12 Weeks
self-reported continuous abstinence since quit day (\<=5 cigarettes) verified with carbon monoxide reading (\<=8ppm)
Time frame: 12-weeks post-quit day
Population: Intention-to-treat (ITT) analysis: All participants randomized at baseline included in analyses regardless of completion of 12-week follow-up data. Missing equals failure (i.e., smoked cigarettes).
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| SMS Turkey | Carbon Monoxide-verified Continuous Abstinence at 12 Weeks | 8 participants |
| Brochure Control | Carbon Monoxide-verified Continuous Abstinence at 12 Weeks | 4 participants |
95% CI: [0.62, 6.3]
Secondary
CO-verified 7-day Point Prevalence Abstinence at 4 Weeks
self-reported continuous abstinence in the past 7 days at 4 weeks (\<=5 cigarettes) verified with carbon monoxide reading (\<=8ppm)
Time frame: 4 weeks
Population: Intention-to-treat (ITT) analysis: All participants randomized at baseline included in analyses regardless of completion of 12-week follow-up data. Missing equals failure (i.e., smoked cigarettes).
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| SMS Turkey | CO-verified 7-day Point Prevalence Abstinence at 4 Weeks | 9 participants |
| Brochure Control | CO-verified 7-day Point Prevalence Abstinence at 4 Weeks | 7 participants |
95% CI: [0.5, 3.2]
Secondary
Self-reported 30-day Point Prevalence Abstinence at 12 Weeks
self-reported smoking abstinence in the past 30 days at 12 weeks (\<=5 cigarettes)
Time frame: 12 weeks
Population: Intention-to-treat (ITT) analysis: All participants randomized at baseline included in analyses regardless of completion of 12-week follow-up data. Missing equals failure (i.e., smoked cigarettes).
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| SMS Turkey | Self-reported 30-day Point Prevalence Abstinence at 12 Weeks | 8 participants |
| Brochure Control | Self-reported 30-day Point Prevalence Abstinence at 12 Weeks | 4 participants |
95% CI: [0.62, 6.3]
Secondary
Self-reported 7-day Point Prevalence Abstinence at 12 Weeks
self-reported smoking abstinence in the past 7 days at 12 weeks (\<=5 cigarettes)
Time frame: 12 weeks
Population: Intention-to-treat (ITT) analysis: All participants randomized at baseline included in analyses regardless of completion of 12-week follow-up data. Missing equals failure (i.e., smoked cigarettes).
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| SMS Turkey | Self-reported 7-day Point Prevalence Abstinence at 12 Weeks | 10 participants |
| Brochure Control | Self-reported 7-day Point Prevalence Abstinence at 12 Weeks | 4 participants |
95% CI: [0.81, 7.5]