The Mexico SimSmoke tobacco control policy model: Development of a simulation model of daily and nondaily cigarette smoking

Background Nondaily smoking has been on the rise, especially in Mexico. While Mexico has strengthened its tobacco control policies, their effects on nondaily smokers have gone largely unexamined. We developed a simulation model to estimate the impact of tobacco control policies on daily and nondaily smoking in Mexico. Methods A previously validated Mexico SimSmoke model that estimated overall trends in smoking prevalence from 2002 through 2013 was extended to 2018 and adapted to distinguish daily and nondaily smoking prevalence. The model was then validated using data from Mexican surveys through 2016. To gauge the potential effects of policies, we compared the trends in smoking under current policies with trends from policies kept at their 2002 levels. Results Between 2002 and 2016, Mexico SimSmoke underestimated the reduction in male and female daily smoking rates. For nondaily smoking, SimSmoke predicted a decline among both males and females, while survey rates showed increasing rates in both genders, primarily among ages 15–44. Of the total reduction in smoking rates predicted by the model by 2018, tax policies account for more than 55%, followed by health warnings, cessation treatment, smoke-free air laws, and tobacco control spending. Conclusions Although Mexico SimSmoke did not successfully explain trends in daily and nondaily smoking, it helps to identify gaps in surveillance and policy evaluation for nondaily smokers. Future research should consider appropriate measures of nondaily smoking prevalence, trajectories between daily and nondaily smoking, and the separate impact of tobacco control policies on each group.

Feasibility and Acceptability of Version 2 of the “Smiling Instead of Smoking” (SiS) Smartphone App for Nondaily Smokers (Preprint)

BACKGROUND Recent evidence highlights the significant detrimental impact of nondaily smoking on health and its disproportionate prevalence in underserved populations, yet little work has been done to develop treatments specifically geared toward quitting nondaily smoking. OBJECTIVE To test the feasibility, acceptability, and conceptual underpinnings of Version 2 of the “Smiling Instead of Smoking” (SiS2) smartphone app, which was developed specifically for nondaily smokers and uses a positive psychology approach. METHODS Prospective, single-group study of nondaily smokers (n=100) who were prescribed SiS2 app use for seven weeks while undergoing a quit attempt (1 week pre-, 6 weeks post-quit). The app assigned daily positive psychology exercises and behavioral tasks every 2-3 days, which guided smokers through using the smoking cessation tools offered in the app. Participants answered surveys at baseline and 2, 6, 12 and 24 weeks post-quit. Feasibility was evaluated based on app usage and acceptability by survey responses. The underlying conceptual framework was tested by examing if theorized within-person changes occurred from baseline to end-of-treatment on survey scales measuring self-efficacy, desire to smoke, and processing of self-relevant health information (i.e., pros and cons of smoking, importance of pros and cons of quitting, motivation). RESULTS Participants used the SiS2 app on average on 24.7±13.8 days out of the 49 prescribed days. In end-of-treatment surveys, participants indicated that the various functions of the app were “easy” to “very easy” to use. The average score on the System Usability Scale was a 79.8±17.3 (“A” grade; “A+”≥84.1, “B+”<78.8; Sauro, 2011). Most participants indicated that the app helped them in their quit attempt (87%); the app reminded them of why they wanted to quit (92%), helped them prepare for the quit attempt (84%), stay positive while quitting (82%), and deal with risky smoking times (68%). Large effects were found for within-person decreases in desire to smoke (b=-1.5[-1.9,-1.1],p<0.0001,gav=1.01), importance of pros of smoking (b=-20.7[-27.2,-14.3],p<0.0001,gav=0.83), and perceived psychoactive benefits of smoking (b=-0.8[-1.0,-0.5],p<0.0001,gav=0.80). Medium effects were found for increases in self-efficacy for remaining abstinent when encountering internal (b=13.1[7.6,18.7],p<0.0001,gav=0.53) and external (b=11.2[6.1,16.1],p<0.0001,gav=0.49) smoking cues. Smaller effects, and contrary to expectation, were found for decreases in motivation to quit smoking and perceived importance of pros of quitting (ps<0.01). Post-hoc analyses showed that motivation decreased for those who did not succeed in quitting while increasing for those who did (p<0.0001). No such interaction effect existed for the perceived importance of pros of quitting (p=0.94). Self-reported 30-day point prevalence abstinence rates were 40%, 56%, and 56% 6, 12 and 24 weeks after the quit day, respectively. CONCLUSIONS The SiS2 app was feasible and acceptable, showed promising changes on constructs relevant to smoking cessation, and had high self-reported quit rates by nondaily smokers. The SiS2 app warrants testing in a randomized controlled trial. CLINICALTRIAL Trial Registry: Clinicaltrials.gov Registration Number: NCT03951766 URL of Registry: https://clinicaltrials.gov/ct2/show/NCT03951766

Leveraging Positive Psychology to Support Smoking Cessation in Nondaily Smokers Using a Smartphone App: Feasibility and Acceptability Study (Preprint)

BACKGROUND Nondaily smoking is an increasingly prevalent smoking pattern that poses substantial health risks. OBJECTIVE We tested the feasibility of using a smartphone app with positive psychology exercises to support smoking cessation in nondaily smokers. METHODS In this prospective, single-group pilot study, nondaily smokers (n=30) used version 1 of the Smiling Instead of Smoking (SiS) app for 3 weeks while undergoing a quit attempt. The app assigned daily happiness exercises, provided smoking cessation tools, and made smoking cessation information available. Participants answered surveys at baseline and 2, 6, 12, and 24 weeks after their chosen quit day and participated in structured user feedback sessions 2 weeks after their chosen quit day. RESULTS App usage during the prescribed 3 weeks of use was high, with an average 84% (25.2/30) of participants using the app on any given day. App use was largely driven by completing happiness exercises (73%, 22/30) of participants per day), which participants continued to complete even after the end of the prescribed period. At the end of prescribed use, 90% (27/30) of participants reported that the app had helped them during their quit attempt, primarily by reminding them to stay on track (83%, 25/30) and boosting their confidence to quit (80%, 24/30) and belief that quitting was worthwhile (80%, 24/30). Happiness exercises were rated more favorably than user-initiated smoking cessation tools, and 80% (24/30) of participants proactively expressed in interviews that they liked them. App functionality to engage social support was not well received. Functionality to deal with risky times was rated useful but was rarely used. Within-person changes from baseline to the end of prescribed use were observed for several theorized mechanisms of behavior change, all in the expected direction: confidence increased (on a 0-100 scale, internal cues: b=16.7, 95% CI 7.2 to 26.3, P=.001; external cues: b=15.8, 95% CI 5.4 to 26.1, P=.004), urge to smoke decreased (on a 1-7 scale, b=−0.8, 95% CI −1.3 to −0.3, P=.002), and perceptions of smoking became less positive (on a 1-5 scale, psychoactive benefits: b=−0.5, 95% CI −0.9 to −0.2, P=.006; pleasure: b=−0.4, 95% CI −0.7 to −0.01, P=.03; on a 0-100 scale, importance of pros of smoking: b=−11.3, 95% CI −18.9 to −3.8, P=.004). Self-reported abstinence rates were 40% (12/30) and 53% (16/30) of participants 2 and 24 weeks post quit, respectively, with 30% (9/30) biochemically validated as abstinent 2 weeks post quit. CONCLUSIONS A smartphone app using happiness exercises to aid smoking cessation was well received by nondaily smokers. Given the high nonadherence and dropout rates for technology-delivered interventions reported in the literature, the high engagement with positive psychology exercises is noteworthy. Observed within-person changes and abstinence rates are promising and warrant further development of this app.

A Smartphone App to Leverage Positive Psychology to Support Smoking Cessation in Nondaily Smokers: Results of SiS Study 1 (Preprint)

BACKGROUND The population of nondaily smokers is large (ie, 24.3% of adult smokers) and increasing (ie, 27% increase over the past decade). The cancer risk of nondaily smoking is substantial (40%-50% of that seen in daily smokers). Existing treatments are ill-suited for nondaily smoking, because the treatments are based on nicotine dependence, and traditional treatments and treatment modalities (eg, in-person counseling, medication) do not appeal to non-dependent nondaily smokers. OBJECTIVE We sought to develop a smartphone app that acts as a behavioral, in-the-pocket coach and uses positive psychology exercises to enhance quitting success. METHODS Nondaily smokers (n=30) used Version 1 of the “Smiling Instead of Smoking” (SiS) app while undergoing a quit attempt (1 week pre-, 2 weeks post-quit). The app assigned daily positive psychology exercises, provided smoking cessation tools (ie, scheduling quit day, logging personal reasons for quitting, planning for challenging times, enlisting social support), and made information about smoking cessation available (ie, benefits of quitting, strategies for cravings). Participants answered surveys at baseline and 2, 6, and 12 weeks post-quit and participated in structured user feedback sessions 2 weeks after their chosen quit day. RESULTS During the 3 weeks of ‘prescribed’ use, 50% of participants completed every daily positive psychology exercise, and the remaining 50% completed on average 85% of the daily exercises. Use of the user-initiated tools was limited: 20% did not use the “Challenging Times” tool at all; those who did only used it twice (median); 27% used the “Social Support” tool on multiple days. Self-reported smoking abstinence rates were 43.3% (7-day abstinence) 2 weeks post-quit, and 40.0% and 43.3% (30-day abstinence) at 6 and 12 weeks post-quit, respectively. Most participants (90%) felt the app helped them during their quit attempt, especially in terms of staying on track, giving them confidence, and reinforcing the idea that quitting was worthwhile. Usefulness ratings were particularly high for functionality that allowed participants to (re-)schedule their quit day and log their personal reasons for quitting smoking. In line with putative mechanisms underlying smoking cessation, compared to baseline, participants reported a lower urge to smoke (F(1,29)=20.55, P<.001), increased self-efficacy to abstain from smoking, both in response to internal (F[,29]=12.69, P<.01) and external stimuli (F[1,29]=18.95, P<.001), decreased endorsement of the psychoactive benefits (F[1,29]=16.24, P<.001) and pleasure (F[1,29]=5.44, P=.03) of smoking, and lower perceived importance of the pros of smoking (F[1,29]=18.26, P<.001). Qualitative feedback indicated a desire for more variety in the positive psychology exercises, more recommended strategies for dealing with cravings, less wordy but more frequent behavioral counseling check-ins, a reward systems, and the removal of the “social support” tool. CONCLUSIONS A positive psychology approach to support smoking cessation resonated well with nondaily smokers. App usage of these exercises was high over a 3-week period, suggesting that this treatment approach is sustainable during the critical phase of smoking cessation. Abstinence rates were substantially higher than natural quit rates in this population, and thus offer some promise, which will need to be evaluated in a randomized trial.

Daily and Nondaily Smoking Varies by Acculturation among English-Speaking, US Latino Men and Women

<p><strong>Background: </strong>Higher smoking prevalence and quantity (cigarettes per day) has been linked to acculturation in the United States among Latinas, but not Latino men. Our study examines variation between a dif­ferent and increasingly important target behavior, smoking level (nondaily vs daily) and acculturation by sex.</p><p><strong>Methods: </strong>An online English-language sur­vey was administered to 786 Latino smokers during July through August 2012. The Brief Acculturation Rating Scale for Mexican Americans–II (ARSMA-II) and other accul­turation markers were used. Multinomial lo­gistic regression models were implemented to assess the association between smoking levels (nondaily, light daily, and moderate/ heavy daily) with acculturation markers.</p><p><strong>Results: </strong>Greater ARMSA-II scores (rela­tive risk ratio, <em>RRR</em>=.81, 95% CI: .72-.91) and being born inside the United States (<em>RRR</em>=.42, 95% CI: .24-.74) were associated with lower relative risk of nondaily smoking. Greater Latino orientation (<em>RRR</em>=1.29, 95% CI: 1.11-1.48) and preference for Spanish language (<em>RRR</em>=1.06, 95% CI: 1.02-1.10) and media (<em>RRR</em>=1.12, 95% CI: 1.05-1.20) were associated with higher relative risk of nondaily smoking. The relationship between acculturation and smoking level did not differ by sex.</p><p><strong>Conclusion: </strong>This study found that among both male and female, English-speaking Latino smokers, nondaily smoking was associated with lower acculturation, while daily smoking was linked with higher ac­culturation.</p><p><em>Ethn Dis. </em>2018.28(2):105-114; doi:10.18865/ed.28.2.105.</p>