Catharina Linderoth

Background: A steady decline of the smoking prevalence in Sweden has been recorded over the past decade; however, people still start and continue to smoke. There is a need for effective smoking cessation interventions that can scale to a national level and that are designed to reach individuals requiring smoking cessation support in the general population. Objective: Previous randomized controlled trials of smoking cessation interventions among high school and university students in Sweden have found consistent evidence that text messaging interventions are effective in helping students quit smoking. However, there are no studies that investigate the effects of text messaging interventions in a more general population. The objective of this study is to estimate the effects of a text messaging intervention on individuals seeking help to quit online and individuals visiting primary health care units. Methods: A 2-arm, parallel-group (1:1), randomized controlled trial will be employed to address the study objectives. The trial will follow a Bayesian group sequential design. Recruitment will be conducted using online advertisement (Google, Bing, and Facebook) and through health care professionals at primary health care units. All participants will receive treatment as usual; however, participants who are allocated to the intervention arm will also be given access to a 12-week text message smoking cessation intervention. Primary outcomes are 8-week prolonged abstinence and 4-week point prevalence, measured 3 months and 6 months postrandomization. Mediator variables (self-efficacy, importance, and know-how) will be measured to estimate causal mediation models. Results: Recruitment commenced in September 2020 and will not exceed 24 months. This means that a complete dataset will be available at the latest towards the end of 2022. We expect to publish the findings from this trial by June 2023. Conclusions: This trial will further our understanding of the effects of text messaging interventions among a more general population than has previously been studied. We also aim to learn about differential effects between those who seek support online and those who are given facilitated support at primary health care units. Trial recruitment is limited to the Swedish population; however, a strength of this study is the pragmatic way in which participants are recruited. Through online advertisements, individuals are recruited in reaction to their own interest in seeking help to quit. At primary health care units, individuals who were not necessarily looking for smoking cessation support are given information about the trial. This closely mimics the way the intervention would be disseminated in a real-world setting and may therefore strengthen the argument of generalizability of findings.

Background: Mobile electronic platforms provide exciting possibilities for health behavior promotion. For instance, they can promote smoking cessation, moderate alcohol consumption, healthy eating, and physical activity. Young adults in Sweden are proficient in the use of technology, having been exposed to computers, smartphones, and the internet from an early age. However, with the high availability of mobile health (mHealth) interventions of varying quality, it is critical to optimize the usability of mHealth interventions to ensure long-term use of these health promotion interventions. Objective: This study aims to investigate the usability of an mHealth intervention (LIFE4YOUth) targeting health behaviors among high school students through heuristic evaluation and usability testing. Methods: A preliminary version of the LIFE4YOUth mHealth intervention, which was aimed at promoting healthy eating, physical activity, smoking cessation, and nonrisky drinking among high school students, was developed in early 2019. We completed a total of 15 heuristic evaluations and 5 usability tests to evaluate the usability of the mHealth intervention prototype to improve its functioning, content, and design. Results: Heuristic evaluation from a total of 15 experts (10 employees and 5 university students, both women and men, aged 18-25 years) revealed that the major usability problems and the worst ratings, a total of 17 problems termed usability catastrophes, concerned shortcomings in displaying easy-to-understand information to the users or technical errors. The results of the usability testing including 5 high school students (both girls and boys, aged 15-18 years) showed that the design, quality, and quantity of content in the intervention may impact the users’ level of engagement. Poor functionality was considered a major barrier to usability. Of the 5 participants, one rated the LIFE4YOUth intervention as poor, 2 rated as average, and 2 assessed it as good, according to the System Usability Scale. Conclusions: High school students have high expectations of digital products. If an mHealth intervention does not offer optimal functions, they may cease to use it. Optimizing the usability of mHealth interventions is a critical step in the development process. Heuristic evaluation and usability testing in this study provided valuable knowledge about the prototype from a user’s perspective. The findings may lead to the development of similar interventions targeting the high school population.

Background: There is strong evidence that short-term smoking cessation before surgery can reduce postoperative morbidity. There are, however, several structural problems in health care systems concerning how to implement smoking cessation interventions in routine practice for preoperative patients. Objective: This study aimed to analyze the implementation of a text messaging, smoking cessation intervention targeting patients having elective surgery. Implementation of facilitated access (ie, referral from practitioners) and the perceived usefulness among patients were investigated. Elective surgery is defined as scheduled, nonacute surgery. Methods: A qualitative study was carried out at two medium-sized hospitals in the south of Sweden. The implementation of facilitated access was investigated during a 12-month period from April 2018 to April 2019. Facilitated access was conceptualized as specialists recommending the text messaging intervention to patients having elective surgery. Implementation was explored in terms of perceptions about the intervention and behaviors associated with implementation; that is, how patients used the intervention and how specialists behaved in facilitating usage among patients. Two focus groups with smoking cessation specialists and 10 individual interviews with patients were carried out. Qualitative content analysis was used to analyze the data. Results: Two main categories were identified from the focus group data with smoking cessation specialists: implementation approach and perceptions about the intervention. The first category, implementation approach, referred to how specialists adapted their efforts to situational factors and to the needs and preferences of patients, and how building of trust with patients was prioritized. The second category, perceptions about the intervention, showed that specialists thought the content and structure of the text messaging intervention felt familiar and worked well as a complement to current practice. Two categories were identified from the patient interview data: incorporating new means of support from health care and determinants of use. The first category referred to how patients adopted and incorporated the intervention into their smoking cessation journey. Patients were receptive, shared the text messages with friends and family, humanized the text messages, and used the messages as a complement to other strategies to quit smoking. The second category, determinants of use, referred to aspects that influenced how and when patients used the intervention and included the following: timing of the intervention and text messages, motivation to change, and perceptions of the mobile phone medium. Conclusions: Smoking cessation specialists adopted an active role in implementing the intervention by adapting their approach and fitting the intervention into existing routines. Patients showed strong motivation to change and openness to incorporate the intervention into their behavior change journey; however, the timing of the intervention and messages were important in optimizing the support. A text messaging, smoking cessation intervention can be a valuable and feasible way to reach smoking patients having elective surgery.

BACKGROUND A steady decline of the smoking prevalence in Sweden has been recorded over the past decade; however, people still start and continue to smoke. There is a need for effective smoking cessation interventions that can scale to a national level and that are designed to reach individuals requiring smoking cessation support in the general population. OBJECTIVE Previous randomized controlled trials of smoking cessation interventions among high school and university students in Sweden have found consistent evidence that text messaging interventions are effective in helping students quit smoking. However, there are no studies that investigate the effects of text messaging interventions in a more general population. The objective of this study is to estimate the effects of a text messaging intervention on individuals seeking help to quit online and individuals visiting primary health care units. METHODS A 2-arm, parallel-group (1:1), randomized controlled trial will be employed to address the study objectives. The trial will follow a Bayesian group sequential design. Recruitment will be conducted using online advertisement (Google, Bing, and Facebook) and through health care professionals at primary health care units. All participants will receive treatment as usual; however, participants who are allocated to the intervention arm will also be given access to a 12-week text message smoking cessation intervention. Primary outcomes are 8-week prolonged abstinence and 4-week point prevalence, measured 3 months and 6 months postrandomization. Mediator variables (self-efficacy, importance, and know-how) will be measured to estimate causal mediation models. RESULTS Recruitment commenced in September 2020 and will not exceed 24 months. This means that a complete dataset will be available at the latest towards the end of 2022. We expect to publish the findings from this trial by June 2023. CONCLUSIONS This trial will further our understanding of the effects of text messaging interventions among a more general population than has previously been studied. We also aim to learn about differential effects between those who seek support online and those who are given facilitated support at primary health care units. Trial recruitment is limited to the Swedish population; however, a strength of this study is the pragmatic way in which participants are recruited. Through online advertisements, individuals are recruited in reaction to their own interest in seeking help to quit. At primary health care units, individuals who were not necessarily looking for smoking cessation support are given information about the trial. This closely mimics the way the intervention would be disseminated in a real-world setting and may therefore strengthen the argument of generalizability of findings. CLINICALTRIAL ISRCTN 13455271; http://www.isrctn.com/ISRCTN13455271. INTERNATIONAL REGISTERED REPORT PRR1-10.2196/23677

Background: High positive mental health, including the ability to cope with the normal stresses of life, work productively, and be able to contribute to one’s community, has been associated with various health outcomes. The role of positive mental health is therefore increasingly recognized in national mental health promotion programs and policies. Mobile health (mHealth) interventions could be a cost-effective way to disseminate positive psychological interventions to the general population. Objective: The aim of this study was to estimate the effect of a fully automated mHealth intervention on positive mental health, and anxiety and depression symptomology among Swedish university students using a randomized controlled trial design. Methods: A 2-arm, single-blind (researchers), parallel-groups randomized controlled trial with an mHealth positive psychology program intervention group and a relevant online mental health information control group was employed to estimate the effect of the novel intervention. Participants were recruited using digital advertising through student health care centers in Sweden. Inclusion criteria were (1) university students, (2) able to read and understand Swedish, (3) and have access to a mobile phone. Exclusion criteria were high positive mental health, as assessed by the Mental Health Continuum Short Form (MHC-SF), or high depression and anxiety symptomology, as assessed by the Hospital Anxiety Depression Scale (HADS). The primary outcome was positive mental health (MHC-SF), and the secondary outcomes were depression and anxiety symptomatology (HADS). The subscales of MHC-SF were also analyzed as exploratory outcomes. Outcomes were measured 3 months after randomization through questionnaires completed on the participants’ mobile phones. Results: A total of 654 participants (median age 25 years), including 510 (78.0%) identifying as female, were randomized to either the intervention (n=348) or control group (n=306). At follow-up, positive mental health was significantly higher in the intervention group compared with the control group (incidence rate ratio [IRR]=1.067, 95% CI 1.024-1.112, P=.002). For both depression and anxiety symptomatology, the intervention group showed significantly lower scores at follow-up compared with the control group (depression: IRR=0.820, 95% CI 0.714-0.942, P=.005; anxiety: IRR=0.899, 95% CI 0.840-0.962, P=.002). Follow-up rates were lower than expected (58.3% for primary outcomes and 52.3% for secondary outcomes); however, attrition analyses did not identify any systematic attrition with respect to baseline variables. Conclusions: The mHealth intervention was estimated to be superior to usual care in increasing positive mental health among university students. A protective effect of the intervention was also found on depressive and anxiety symptoms. These findings demonstrate the feasibility of using an automated mobile phone format to enhance positive mental health, which offers promise for the use of mHealth solutions in public mental health promotion. Trial Registration: International Standard Randomized Controlled Trial Registry ISRCTN54748632; http://www.isrctn.com/ISRCTN54748632

Smoking among adolescents remains a global public health issue as youth continue to maintain high prevalence rates. The evidence for the efficacy of text messaging interventions to reduce smoking behavior is well established, yet there is still a need for studies targeting high school students. The aim of the study was to determine the effectiveness of a text-based smoking cessation intervention among high school students in Sweden. The study was a two-arm randomized trial conducted from January 10 2018 to January 11 2019, data were analysed from April 12 2019 to May 21 2019. Inclusion criteria were high school students who were daily or weekly smokers willing to attempt to quit smoking and owned a mobile phone. The study invited all students at 630 high schools units throughout Sweden. The intervention group received text messages based on components of effective smoking cessation interventions for 12 weeks. The control group were offered treatment as usual. The primary outcomes were self-reported prolonged abstinence (not having smoked more than 5 cigarettes over the last 8 weeks) and 4-week point prevalence of smoking abstinence. A total of 535 participants, with a median age of 17 (IQR 16–18), were randomized into the study; 276 (164 [59.4%] women) were allocated to the intervention and 259 (162 [62.5%] women) to the control group. The outcomes of the trial were analyzed on a total of 212 (76.8%) participants in the intervention group and 201 (77.6%) participants in the control group. Prolonged abstinence at the 3-month follow-up was reported by 49 (23.1%) individuals in the intervention group and 39 (19.4%) individuals in the control group (adjusted OR, 1.21; 95% CI, 0.73–2.01; P value, .46). Four-week point prevalence of complete smoking cessation was reported by 53 (25.0%) individuals in the intervention group and 31 (15.4%) individuals in the control group (adjusted OR, 1.87; 95% CI, 1.12–3.17; P value, .018). Estimates of 4-week point prevalence of complete cessation was 10 percentage points higher in the group that were given access to the intervention compared to the control. Findings provide confirmation that text messaging-based smoking cessation programs can affect quit rates among adolescents. ISRCTN15396225; registration date October 13, 2017, https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-018-3028-2.

BACKGROUND Mobile electronic platforms provide exciting possibilities for health behavior promotion. For instance, they can promote smoking cessation, moderate alcohol consumption, healthy eating, and physical activity. Young adults in Sweden are proficient in the use of technology, having been exposed to computers, smartphones, and the internet from an early age. However, with the high availability of mobile health (mHealth) interventions of varying quality, it is critical to optimize the usability of mHealth interventions to ensure long-term use of these health promotion interventions. OBJECTIVE This study aims to investigate the usability of an mHealth intervention (LIFE4YOUth) targeting health behaviors among high school students through heuristic evaluation and usability testing. METHODS A preliminary version of the LIFE4YOUth mHealth intervention, which was aimed at promoting healthy eating, physical activity, smoking cessation, and nonrisky drinking among high school students, was developed in early 2019. We completed a total of 15 heuristic evaluations and 5 usability tests to evaluate the usability of the mHealth intervention prototype to improve its functioning, content, and design. RESULTS Heuristic evaluation from a total of 15 experts (10 employees and 5 university students, both women and men, aged 18-25 years) revealed that the major usability problems and the worst ratings, a total of 17 problems termed usability catastrophes, concerned shortcomings in displaying easy-to-understand information to the users or technical errors. The results of the usability testing including 5 high school students (both girls and boys, aged 15-18 years) showed that the design, quality, and quantity of content in the intervention may impact the users’ level of engagement. Poor functionality was considered a major barrier to usability. Of the 5 participants, one rated the LIFE4YOUth intervention as poor, 2 rated as average, and 2 assessed it as good, according to the System Usability Scale. CONCLUSIONS High school students have high expectations of digital products. If an mHealth intervention does not offer optimal functions, they may cease to use it. Optimizing the usability of mHealth interventions is a critical step in the development process. Heuristic evaluation and usability testing in this study provided valuable knowledge about the prototype from a user’s perspective. The findings may lead to the development of similar interventions targeting the high school population.

BACKGROUND There is strong evidence that short-term smoking cessation before surgery can reduce postoperative morbidity. There are, however, several structural problems in health care systems concerning how to implement smoking cessation interventions in routine practice for preoperative patients. OBJECTIVE This study aimed to analyze the implementation of a text messaging, smoking cessation intervention targeting patients having elective surgery. Implementation of facilitated access (ie, referral from practitioners) and the perceived usefulness among patients were investigated. Elective surgery is defined as scheduled, nonacute surgery. METHODS A qualitative study was carried out at two medium-sized hospitals in the south of Sweden. The implementation of facilitated access was investigated during a 12-month period from April 2018 to April 2019. Facilitated access was conceptualized as specialists recommending the text messaging intervention to patients having elective surgery. Implementation was explored in terms of perceptions about the intervention and behaviors associated with implementation; that is, how patients used the intervention and how specialists behaved in facilitating usage among patients. Two focus groups with smoking cessation specialists and 10 individual interviews with patients were carried out. Qualitative content analysis was used to analyze the data. RESULTS Two main categories were identified from the focus group data with smoking cessation specialists: implementation approach and perceptions about the intervention. The first category, implementation approach, referred to how specialists adapted their efforts to situational factors and to the needs and preferences of patients, and how building of trust with patients was prioritized. The second category, perceptions about the intervention, showed that specialists thought the content and structure of the text messaging intervention felt familiar and worked well as a complement to current practice. Two categories were identified from the patient interview data: incorporating new means of support from health care and determinants of use. The first category referred to how patients adopted and incorporated the intervention into their smoking cessation journey. Patients were receptive, shared the text messages with friends and family, humanized the text messages, and used the messages as a complement to other strategies to quit smoking. The second category, determinants of use, referred to aspects that influenced how and when patients used the intervention and included the following: timing of the intervention and text messages, motivation to change, and perceptions of the mobile phone medium. CONCLUSIONS Smoking cessation specialists adopted an active role in implementing the intervention by adapting their approach and fitting the intervention into existing routines. Patients showed strong motivation to change and openness to incorporate the intervention into their behavior change journey; however, the timing of the intervention and messages were important in optimizing the support. A text messaging, smoking cessation intervention can be a valuable and feasible way to reach smoking patients having elective surgery.

Background: Tobacco smoking is the primary cause of preventable premature disease and death worldwide. Evidence of the efficacy of text messaging interventions to reduce smoking behavior is well established, but there is still a need for studies targeting young people, especially because young adult smokers are less likely to seek treatment than older adults. A mobile health intervention, Nicotine Exit (NEXit), targeting smoking among university students was developed to support university students to quit smoking. Short-term effectiveness was measured through a randomized controlled trial, which found that immediately after the 12-week intervention, 26% of smokers in the intervention group had prolonged abstinence compared with 15% in the control group. Objective: The objective of this study was to explore the experience of being allocated to the control group in the NEXit smoking cessation intervention. Methods: We asked students who were allocated to the control group in the main NEXit randomized controlled trial to report their experiences. An email was sent to the participants with an electronic link to a short questionnaire. We assessed the distribution of the responses to the questionnaire by descriptive analysis. We analyzed free-text comments to 4 questions. Results: The response rate for the questionnaire was 33.8% (258/763), and we collected 143 free-text comments. Of the responders, 60.9% (157/258) experienced frustration, disappointment, and irritation about being allocated to the control group; they felt they were being denied support by having to wait for the intervention. Monthly text messages during the waiting period thanking them for taking part in the trial were perceived as negative by 72.3% (189/258), but for some the messages served as a reminder about the decision to quit smoking. Of the responders, 61.2% (158/258) chose to wait to quit smoking until they had access to the intervention, and 29.8% (77/258) decided to try to quit smoking without support. Of the respondents, 77.5% (200/258) claimed they were still smoking and had signed up or were thinking about signing up for the smoking cessation program at the time of the questionnaire. Conclusions: Most of the respondents reported negative feelings about having to wait for the support of the intervention and that they had decided to continue smoking. A similar number decided to wait to quit smoking until they had access to the intervention, and these respondents reported a high interest in the intervention. Free-text comments indicated that some control group participants believed that they had been excluded from the trial, while others were confused when asked to sign up for the intervention again. Trial Registration: ISRCTN Registry ISRCTN75766527; http://www.isrctn.com/ISRCTN75766527 (Archived by WebCite at http://www.webcitation.org/7678sUKbR)

Several large studies have shown that the risk of cardiovascular, respiratory, and wound-healing complications (including death) within 30 days of surgery is greater for smokers than for nonsmokers. However, there is evidence that even short-term perioperative smoking cessation may reduce postoperative morbidity. Over the past few years, it has become more evident that short message service (SMS)-based interventions can help individuals quit smoking. The overall aim of this project is to fill the knowledge gap on whether an SMS-based smoking-cessation intervention can be effective in helping patients stop smoking perioperatively. The aim of this trial is to evaluate the effectiveness of an SMS-based intervention on smoking behavior of patients undergoing elective surgery. A two-arm parallel-group randomized controlled trial will be conducted at 20 surgical departments in southeast Sweden. Smokers undergoing elective surgery who own a mobile phone will be included. Power calculations indicate that it will be necessary to randomize 434 participants. One group will be given access to a novel 12-week SMS program, which includes daily SMS messages with behavior change-enforcing text content and hyperlinks to interactive modules, while the other group will not be given access to the intervention. Both groups will have access to the surgical departments' current routine for smoking cessation prior to surgery. Primary outcome measures, prolonged abstinence, and point prevalence of smoking cessation will be measured through questionnaires at 3, 6, and 12 months after randomization. Logistic regression models adjusted using baseline characteristics will be explored to identify potential effects of the intervention. Recruitment started in late October 2018 and is expected to last for a maximum of 30 months. The first results are expected to be available approximately 3 months after the final date of recruitment. Owing to the structural problems and scarcity of time and resources, patients at most Swedish surgical departments are simply instructed to quit smoking, and perhaps, referred to a primary health care clinic. An SMS-based smoking-cessation aid can be effective in helping individuals quit smoking and is a very simple and time-efficient tool for surgical departments to use. ISRCTN Registry ISRCTN33869008; http://www.isrctn.com/ISRCTN33869008. PRR1-10.2196/12511.