SmokefreeTXT for Homeless Smokers: Pilot Randomized Controlled Trial

Abstract

Background Homeless smokers want to quit smoking but face numerous barriers to doing so, including pervasive smoking among peers and a lack of social support for quitting. An SMS (short message service) text messaging intervention could address these challenges by providing virtual daily support for homeless smokers who are trying to quit but coping with multiple triggers to smoke. Objective This study aimed to assess whether a free SMS text messaging program, added to evidence-based pharmacotherapy and counseling, improved smoking abstinence among homeless adult smokers. Methods From October 2015 to June 2016, we conducted an 8-week pilot randomized controlled trial (RCT) of nicotine patch therapy and weekly in-person counseling with (n=25) or without (n=25) SmokefreeTXT, a free SMS text messaging service administered by the National Cancer Institute (NCI) at Boston Health Care for the Homeless Program. All participants were provided with a mobile phone and a 2-month prepaid voice and text plan at no cost. SmokefreeTXT enrollees were sent 1 to 5 automated SMS text messages daily for up to 8 weeks and could receive on-demand tips for managing cravings, mood symptoms, and smoking lapses. The primary outcome was smoking abstinence, defined as an exhaled carbon monoxide count of <8 parts per million, assessed 14 times over 8 weeks of follow-up, and analyzed using repeated-measures logistic regression with generalized estimating equations. Other outcomes were use of SmokefreeTXT, assessed by data obtained from NCI; perceptions of SmokefreeTXT, assessed by surveys and qualitative interviews; and mobile phone retention, assessed by self-report. Results Of the SmokefreeTXT arm participants (n=25), 88% (22) enrolled in the program, but only 56% (14) had confirmed enrollment for ≥2 weeks. Among 2-week enrollees, the median response rate to interactive messages from SmokefreeTXT was 2.1% (interquartile range 0-10.5%). Across all time points, smoking abstinence did not differ significantly between SmokefreeTXT and control arm participants (odds ratio 0.92, 95% CI 0.30-2.84). Of SmokefreeTXT enrollees who completed exit surveys (n=15), two-thirds were very or extremely satisfied with the program. However, qualitative interviews (n=14) revealed that many participants preferred in-person intervention formats over phone-based, found the SMS text messages impersonal and robotic, and felt that the messages were too frequent and repetitive. Only 40% (10/25) of SmokefreeTXT arm participants retained their study-supplied mobile phone for the 8-week duration of the trial, with phone theft being common. Storing and charging phones were cited as challenges. Conclusions SmokefreeTXT, added to nicotine patch therapy and in-person counseling, did not significantly improve smoking abstinence in this 8-week pilot RCT for homeless smokers. SMS text messaging interventions for this population should be better tuned to the unique circumstances of homelessness and coupled with efforts to promote mobile phone retention over time. Trial Registration ClinicalTrials.gov NCT02565381; https://clinicaltrials.gov/ct2/show/NCT02565381 (Archived by WebCite at http://www.webcitation.org/78PLpDptZ)

The use of eHealth interventions among persons experiencing homelessness: A systematic review

“…31,33 These rates are slightly higher than those found in a prior systematic review with persons experiencing homelessness. 11 Phone retention may pose an implementation challenge as 3 studies found that some participants were not able to maintain their device throughout the study period, [31][32][33] with 1 study having to replace 11% of phones. 33 It may be beneficial for researchers of eHealth interventions for this population to include costs in their budget that allow them to provide access to devices, internet, and phone and data plans.…”

“…The RCT had the highest quality assessment rating (62%). 31 It was unclear who was blinded to treatment assignment and if reliability was assessed. The reasons for loss to follow-up were also not reported.…”

“…31,[33][34][35][36][37][38] Satisfaction was high with SMS interventions and a mental health mobile app. 31,33,34 Interventions that had 2-way interactive features, daily tips delivered through SMS or mobile apps, and virtual check-ins with case managers were also components that were valued by persons experiencing homelessness. 31,33,35,37 In two studies, homeless youth and veterans preferred to communicate by text message because it was cheaper, and more convenient and flexible.…”

“…31,34 However, participants also felt that the text messages were impersonal, repetitive, unhelpful, stigmatizing, and not applicable to the homeless population. 31 Some also expressed a preference for in-person communication, as well as more interactive and flexible SMS intervention features. 31 Two studies assessed the feasibility of using mobile apps to improve the mental health of youth experiencing homelessness and help them to access services.…”

“…31 Some also expressed a preference for in-person communication, as well as more interactive and flexible SMS intervention features. 31 Two studies assessed the feasibility of using mobile apps to improve the mental health of youth experiencing homelessness and help them to access services. 33,38 Youth reported that they were satisfied with the mobile apps, found them helpful and easy to use, and were able to learn useful skills and contact resources in their communities if needed.…”