The leading cause of cancer-related mortality and preventable death in the United States is cigarette smoking. Currently, it’s reported that cigarette smoking explains 32% of all cancer-related deaths. Smoking cessation interventions which tackle mental health issues are needed to identify psychosocial factors that aids in the continuation of smoking. Recent studies have reported that depression or anxiety could reduce the likelihood of quitting smoking by 50%. Therefore, it’s important to address depression symptoms as a barrier to smoking cessation.
Behavioral Activation Treatment for Depression, also known as BAT-D, has been added to cessation counseling to improve smoking cessation outcomes among those who reported depressive symptoms. BAT-D provided an integrative, behavioral-theory based approach focused on depressive symptoms during smoking cessation interventions. BAT-D’s goal is to enhance valuable experiences and rewards in daily activities – the participants of the program plan and schedule activities to aid in increasing the recurrence of the activities. Previous studies have motivated the application of BAT-D to smoking cessation. One in particular - a pilot, randomized controlled trial with two arms: a group delivered Behavioral Activation Treatment for Smoking -BATS (n=35) and standard cessation treatment (n=33). BATS participants were 2.1 times more likely to abstain from smoking than the control/ standard treatment program (p=.02). Also, during the 26 week-follow-up period of the study, BATS participants were more likely to remain abstinent (14.3% vs 0%; p=.02).
With the promising results of the BATS and the Behavioral Activation Treatment for Cardiac Smokers – BAT-CS, Dr. Jaimee Heffner’s group from the Division of Public Health Sciences developed a BAT-D mobile health app to extend the reach of this intervention to smokers in the US who own smartphones. Dr. Heffner explains, “This project was the first effort to create a broadly accessible, self-guided mobile health program that brings together an evidence-based brief treatment for depression called behavioral activation with smoking cessation content to improve quit rates.” Because of the development of the BAT-D mobile app, this treatment modality has the potential to reach an estimated 13 to 16 million smokers with depression. After the creation of the app, Dr. Heffner’s aim was to determine the app’s feasibility, acceptability, and preliminary effects on theory-based behavioral processes of behavioral activation, depressive symptomatology reduction, and the primary outcome of smoking cessation. The design process and results were published in JMIR Formative Research.
The app was created following a user-centered design process including competitive analysis, focus groups, prototype testing, and a single arm pilot trial. A 6-week evaluation was conducted to assess the participants’ commitment and short-term efficacy outcomes; user feedback was also obtained through a 6-week in-person, follow-up. The participants were recruited from the greater Seattle area via Craigslist ads and Facebook advertisements. After a 2-stage process which included a web-based screening form to access eligibility and a call to the participants to explain the purpose and procedures of the study, 17 eligible participants were enrolled in the single-arm trial. Eligibility criteria for the study include: participants 18 years or older, current smoker – averaging at least 5 cigarettes per day, interested in quitting within the next 30 days, own an iPhone version 5 or higher, and screened positive for mild to moderate current depressive symptoms.
Dr. Heffner’s group used a semi-structured guide during the 6-week follow-up visit and collected qualitative data on the participants’ experiences. The participants opened the app an average of 16.6 times over the 6-week period. Based on the results, they viewed their calendar an average of 13.9 times and scheduled activities with the app an average of 18 times. Sixty-three percent of participants reported overall satisfaction and 75% thought accompanying text messages through SmokefreeTXT were helpful. According to the Patient Health Questionnaire, completed at baseline and during the follow-up period, there was a 5-point decrease from baseline after using the app (p=0.02), which represented a clinically significant improvement in depressive symptoms.
The results from the pilot trial indicate engagement with the app and a potential signal for impact on theory-based change processes, depression symptoms, and cessation outcomes. This was the first study to examine the efficacy of smoking cessation apps for depressed smokers. Based on the qualitative data, Dr. Heffner’s group learned valuable lessons that may be helpful to others developing digital interventions based on BAT-D. Dr. Heffner describes the future of the BAT-D App, “We saw a promising signal that this approach could help people quit smoking and reduce depressive symptoms. We’re currently doing some redesign work to improve the app based on the feedback we got from users and have applied for a new grant, which we just learned got a promising score. New funding will allow us to continue improving the program and test its effectiveness compared with a smoking cessation app that isn’t targeted for people with depression.
This research was supported by PHS Bid and Proposal Funding.
Fred Hutch/UW Cancer Consortium members Drs. Jaimee Heffner, Jonathan Bricker, Noreen Watson carried out this research.
Heffner JL, Watson NL, Serfozo E, Mull KE, MacPherson L, Gasser M, Bricker JB. A Behavioral Activation Mobile Health App for Smokers With Depression: Development and Pilot Evaluation in a Single-Arm Trial. JMIR formative research. 2019;3(4):e13728.