Crush the Crave: Development and Formative Evaluation of a Smartphone App for Smoking Cessation

Abstract

BackgroundEmerging evidence supports the use of smartphone apps for smoking cessation, especially in young adults given their high smoking rates and high smartphone ownership rates. Although evaluative evidence is encouraging for supporting smoking cessation, there remains a paucity of research describing the design and development processes of mobile health (mHealth) interventions.ObjectiveThe aim of this paper was to describe the process of developing Crush the Crave (CTC), an evidence-informed app to support smoking cessation in young adults, and the results of a formative evaluation of app usage behavior, as part of a broader program of research that seeks to establish the effectiveness of the CTC app.MethodsThe Spiral Technology Action Research (STAR) 5-cycle model (listen, plan, do, act, and study) was employed to guide the development, implementation, and dissemination of CTC. The approach to development and formative evaluation included focus groups with young adult smokers (n=78) across 2 phases, analysis of the content of existing apps, 2 sessions with content experts, and Google Analytics to assess user behavior during a 12-month pilot.ResultsLISTEN—focus groups revealed young adult smoker preferences of (1) positive reinforcement, (2) personalization, (3) social support, (4) quit support, (5) tracking the behavior, and (6) tracking quit benefits. PLAN—informed by evidence for smoking cessation, young adult preferences and an assessment of popular cessation apps, content experts produced a mind map and a storyboard describing app content and structure. DO—focus groups with young adult smokers provided feedback on the first version of the app with opinions on content and suggestions for improvement such as providing alerts and distractions from craving. ACT—refinements were made, and app content was organized using the 4 key design components informed by principles of persuasive technology for behavior change: credibility, task support, dialogue support, and social support. CTC was launched in April 2013 and piloted from the period July 2013 to June 2014 where 1987 Android users had 18,567 sessions, resulting in 59,384 page views and 89.58% (1780/1987) of users returning within the same day to use CTC. STUDY—a pragmatic randomized controlled trial of CTC was launched in August 2014 to demonstrate that including mHealth technology as a population-based intervention can help young adult smokers to quit. The results of this phase will be presented in a subsequent publication.ConclusionsCTC is one of the first smoking cessation apps designed to meet the needs of young adult smokers. The development was informed by the inclusion of young adults in the design and the systematic application of multiple stakeholder input, scientific evidence, and theory. The STAR model approach was followed from the beginning of intervention development, which should facilitate optimization of mHealth interventions in the future.Trial RegistrationClinicalTrials.gov NCT01983150; http://clinicaltrials.gov/ct2/show/NCT01983150 (Ar...

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“…Schnall et al (2016) use a very similar method of UCD in the context of an HIV-prevention app. Baskerville et al (2018) employ the so-called 5-cycle model (listen, plan, do, act, study) which in effect results in a design process heavily involving the end user.…”

“…Collecting information on the needs of the patients via surveys and focus groups can be a central aspect of this step, often deciding the very basic direction that the development of the app takes. Valuable advice on this is to be found, for example, in Avis, van Mierlo, Fournier, & Ball (2015); Baskerville, Struik, & Dash (2018); and Harte et al (2017).…”

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“…Due to the technological era and the heavy use of smartphones, smoking cessation applications were considered a positive approach to improving cessation therapy results and a long-term abstinence period, especially in adolescents and young adults. The medical theory, the epidemiological data, the psychotherapeutic aspects, and the user's needs were involved in developing theses apps (63,64). The apps permit the patient to keep a diary of the symptoms associated with quitting, the quantification of the achievements the addict accumulates during the therapy and especially after, and the online psychotherapeutic characteristics (65).…”

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“…They also assessed CTC as having an ease of use score of 95% which was the same as the average of all apps reviewed and 82% for engagement compared to only 45% overall [30]. A more fulsome description of the development of the CTC app is available elsewhere [31].…”

“…Although automated recording of use of CTC is possible as reported elsewhere [31], it was not possible to automatically record use of the self-help guide OnRQ and consequently self-reported satisfaction and use measures were chosen to allow for comparison between conditions and there is no evidence that recall bias was different across conditions. Finally, lack of biochemical validation of smoking abstinence is a limitation that may have resulted in an overestimation of smoking abstinence [55].…”