Smoking remains a significant public health challenge, responsible for approximately 8 million deaths globally each year and a substantial burden of disease. Despite the availability of various smoking cessation aids, success rates remain suboptimal, especially among individuals experiencing depressive symptoms. These symptoms, present in 40-55% of smokers during attempts to quit, significantly predict treatment failure. Behavioral Activation (BA), a component of Cognitive Behavioral Therapy (CBT), has shown efficacy in treating depression by increasing engagement in positively reinforcing activities, which can concurrently aid in smoking cessation. A recent study published in Nicotine & Tobacco Research aimed to preliminarily evaluate the acceptability and efficacy of a BA-based mobile health application, Actify!, designed to aid smoking cessation by addressing depressive symptoms.
Dr. Jaimee Heffner, an associate professor at Fred Hutch Cancer Center, and her team recruited 242 adults who smoked daily and were interested in quitting. Participants were required to have experience using smartphone apps, be U.S. residents, and be comfortable with English as a primary language. They were stratified by depressive symptoms, sex assigned at birth, and smoking level, then randomized to either the Actify! or QuitGuide app. The National Cancer Institute's QuitGuide app provides standard cessation support based on U.S. Clinical Practice Guidelines, including tools for tracking smokefree days, cravings, mood management, and accessing relevant resources. Eligible participants completed a baseline assessment and were randomized to one of the two apps. They received reminders and follow-ups at 8 weeks and 6 months post-randomization to assess app usage, satisfaction, and smoking cessation outcomes.
The Actify! app incorporated BA principles to help users identify values, schedule meaningful activities, and track progress towards smoking cessation. It included tailored messages, daily tips, personalized feedback, user stories, and motivational badges. In contrast, the QuitGuide app provided standard cessation support, offering tools for tracking smokefree days, managing cravings, monitoring mood, and accessing comprehensive quit resources.
The authors measured acceptability by app usage (number of logins, duration of use) and user satisfaction through surveys. The primary endpoint for smoking cessation was self-reported 30-day point prevalence abstinence (PPA) at 8 weeks.
Following the intervention, Actify! users reported higher satisfaction across various metrics compared to QuitGuide users, including overall satisfaction, perceived usefulness, ease of use, and likelihood to recommend the app to others. App usage was similar between the two groups, with no significant differences in the number of logins or duration of use over 8 weeks and 6 months. At 8 weeks, 12.6% of Actify! users reported 30-day PPA compared to 7.3% of QuitGuide users. These differences persisted at 6 months, with quit rates of 18.5% for Actify! and 12.2% for QuitGuide. Biochemically verified quit rates were also higher in the Actify! group at both follow-ups.
Actify! users showed a slight increase in behavioral activation scores and a smaller increase in depressive symptoms compared to QuitGuide users, aligning with the app's theoretical framework. Dr. Jaimee Heffner emphasized the importance of this finding: "This is the first test of a behavioral activation-based mobile health app compared with a standard-care app for smoking cessation. It’s also the first demonstration that smoking cessation rates for people with depression symptoms can be boosted by integrating evidence-based depression treatment into a mobile health app."
Participants with mild to moderate depressive symptoms benefited more from Actify!, with higher quit rates and satisfaction than those without depressive symptoms, suggesting the app's particular efficacy for this subgroup. Dr. Heffner noted, "The cessation rates for people with depression who were randomized to the Actify! app were actually higher than those who had no depressive symptoms in either treatment arm, which is an important finding since people with depression tend to have consistently lower quit rates than people without depression, no matter what type of treatment they receive to help them quit smoking."
The study demonstrated that Actify!, a BA-based mHealth app, has the potential to improve smoking cessation outcomes, particularly among individuals with depressive symptoms. The app's higher user satisfaction and quit rates relative to a standard care app indicate its promise as a scalable public health intervention. Dr. Heffner highlighted the next steps: "This was a pilot trial, so the conclusions are preliminary. Our next step is to compare the effectiveness of Actify! versus the National Cancer Institute’s QuitGuide app in a fully powered trial."
This study was supported by US National Institutes of Health and National Institute on Drug Abuse.
Fred Hutch/University of Washington/Seattle Children's Cancer Consortium member Dr. Jaimee Heffner contributed to this work.
Heffner, J. L., Serfozo, E., Baker, K., Gasser, M., Watson, N., Daughters, S. B., Becoňa, E., & McClure, J. B. 2024. Behavioral Activation mHealth Application for Smoking Cessation: A Randomized Controlled Pilot Trial. Nicotine & tobacco research: official journal of the Society for Research on Nicotine and Tobacco, ntae137. Advance online publication.
| Science Spotlight writer Darya Moosavi is a postdoctoral research fellow within Johanna Lampe's research group at Fred Hutch. Darya studies the nuanced connections between diet, gut epithelium, and gut microbiome in relation to colorectal cancer using high-dimensional approaches. |