Darion Rapoza

Background: Approximately half of smokers attempt to quit, but 90% of these attempts fail. Video game–based interventions have the potential to address common barriers to evidence-based smoking cessation treatment, including high cost, lack of health care access, and low engagement. Objective: The purpose of this study was to evaluate the feasibility and acceptability of a video game–based smoking cessation intervention called Inspired and its impact on the 7-day smoking point prevalence at the 30-day follow-up. Methods: US adults (n=48) were recruited via the web to use Inspired on their smartphones for 7 weeks. The object of the game was to defend a healing tree against attackers. Levels of the game were unlocked twice daily when participants self-reported the number of cigarettes they smoked since the previous entry. Completion of the levels awarded players in-game currency, which could strengthen in-game abilities. Participants received additional in-game rewards to aid gameplay by submitting either smoking self-reports only or self-reports indicating abstinence, determined through random assignment. In addition, participants completed a web-based survey at intake, week 4, week 7, and the 30-day follow-up. Results: Of the 48 participants, who had an average age of 39.8 (SD 10.7) years, 27 (56%) were female, 4 (8%) Hispanic, 37 (77%) White, and 27 (56%) employed; 26 (54%) earned <US $40,000 a year; and 14 (29%) lived in nonurban areas (eg, rural and suburban). There were no significant differences between the groups, so all outcome data were combined. Participants averaged 20.6 (SD 15.3) days of gameplay and reached a mean highest game level of 10.7 (SD 8.4), although there was a high degree of variability. Participants reported abstinence on 31.4% (SD 38.2%) of all cessation phase reports and averaged 5.4 (SD 9.8) consecutive abstinent smoke reports. For every 1 SD increase in the highest level achieved, there was a 27% increase in the percentage of abstinent samples and a 405% increase in longest continuous abstinence. At the 30-day follow-up, 23% (11/48) of the participants reported having not taken a cigarette puff in the prior 7 days and 31% (15/48) had spent at least 24 hours without smoking in the prior 14 days. On an 11-point scale, participants rated the intervention moderately favorably: if they had to do it again, they would use Inspired to help them quit (mean 6.4, SD 3.4), and Inspired was helpful in their current attempt to quit (mean 5.4, SD 3.6). Conclusions: These results support the acceptability of Inspired. Although high dropout rates prevent conclusions on feasibility, a subset of the participants responded favorably. Scalable and accessible video game–based smoking cessation interventions could be the key to addressing the foremost cause of preventable morbidity and mortality in the United States. Trial Registration: ClinicalTrials.gov NCT03929003; https://clinicaltrials.gov/ct2/show/NCT03929003

BACKGROUND The majority of smokers express an interest in quitting and about half make an attempt to quit, but about 90% of these attempts fail. Videogame-based interventions have the potential to address common barriers to evidence-based smoking cessation treatment including cost, lack of access to healthcare settings, and low engagement. OBJECTIVE The purpose of this study was to evaluate the feasibility and acceptability of a videogame-based smoking cessation intervention called InspiredTM. METHODS U.S. adults (n=48) were recruited online to use InspiredTM on their smartphone for 7 weeks (the final 6 of which had a goal of smoking abstinence for all participants). The object of the game was to grow and defend one healing tree per level against attackers. In each level, players allocated different colored gems from their bank to activate either healing or defensive structures. Levels of the game were unlocked twice daily when participants reported the number of cigarettes they smoked since the previous entry. Completion of the levels awarded players in-game currency, which was used to strategically strengthen their structures. Participants received additional in-game rewards from either submitting smoking self-reports (i.e., submission contingent) or for submitting self-reports indicating smoking abstinence (i.e., abstinent contingent), consisting of gem prisms (used to power their structures for longer) and larger amounts of in-game currency. Additionally, participants completed an online survey at intake, week 4, week 7, and during the 30-day follow-up. RESULTS Participants were 56.3% female, 8.3% Hispanic, 77.1% white, 56.2% employed, 54.2% earning less than $40,000 a year, and had an average age of 39.79 (SD=10.72). Geographically, 29.2% of the sample lived in non-urban areas (e.g., rural, suburban). There were no significant differences between groups, so all outcome data are combined. Participants reached a mean highest level of 10.71 in the game (SD=8.43), though there was a high degree of variability. Participants reported abstinence on 31.36% (SD=38.16%) of all cessation phase reports and averaged 5.40 samples of continuous abstinence (SD=9.78). For every one-standard deviation increase in highest level achieved, there was a 27% increase in the percentage of abstinent samples reported and a 405% increase in longest period of continuous abstinence. During the abstinence phase, 52.10% of participants submitted at least one abstinent report. On an 11-point scale, participants rated the intervention moderately favorably: if they had to do it again, they would use Inspired to help them quit (M=6.43, SD=3.44) and InspiredTM was helpful in this current attempt to quit (M=5.37, SD=3.57). CONCLUSIONS These results support acceptability a videogame-based smoking cessation intervention for a geographically diverse population. Though high rates of dropout prevent conclusions on the intervention’s feasibility (possibly due to the game being imbalanced), a subset of the participants responded favorably to the intervention. Scalable and accessible smoking cessation interventions could be the key to addressing the number one cause of preventable morbidity and mortality in the U.S. CLINICALTRIAL ClinicalTrials.gov NCT03929003

Cigarette smoking results in an estimated seven million deaths annually. Almost half of all smokers attempt to quit each year, yet only approximately 6% are successful. Although there are multiple effective interventions that can increase these odds, substantial room remains for improvement. One effective approach to helping smokers quit is contingency management, where quitting is incentivized with the delivery of monetary rewards in exchange for objective evidence (eg, exhaled carbon monoxide levels) of abstinence. We assessed the feasibility and promise of Inspired, a contingency management mobile app for smoking cessation that uses game-based rewards to incentivize abstinence from smoking instead of the monetary (or material) rewards typically used. We sought participant feedback and limited objective data on: the features and design of Inspired, interest in using Inspired when it becomes available, the likelihood of Inspired being an effective cessation aid, and the rank order preference of Inspired relative to other familiar smoking cessation aids. Twenty-eight treatment-seeking smokers participated in this study. Participants attended a single one-hour session in which they received an overview of the goals of the Inspired mobile game, practiced submitting breath carbon monoxide (CO) samples, and played representative levels of the game. Participants were then told that they could play an extra level, or they could stop, complete an outcome survey, receive payment, and be dismissed. A sign-up sheet requesting personal contact information was available for those who wished to be notified when the full version of Inspired becomes available. Using binary criteria for endorsement, participants indicated that, assuming it was currently available and fully developed, they would be more likely to use Inspired than: any other smoking cessation aid (21/28, 75%), the nicotine patch (23/28, 82%), a drug designed to reduce smoking cravings (23/28, 82%), or a program involving attendance in training sessions or support group meetings (27/28, 96%). In the questionnaire, participants indicated that both the Inspired program (26/28, 93%) and the Inspired game would be "Fun" (28/28, 100%), and 71% (20/28) reported that the program would help them personally quit smoking. Fifty-eight percent of participants (15/26) chose to continue playing the game rather than immediately collecting payment for participation and leaving. Eighty-two percent of participants (23/28) signed up to be notified when the full version of Inspired becomes available. This was the first study to evaluate a game-based contingency management app that uses game-based virtual goods as rewards for smoking abstinence. The outcomes suggest that the completed app has potential to be an effective smoking cessation aid that would be widely adopted by smokers wishing to quit.

BACKGROUND Cigarette smoking results in an estimated seven million deaths annually. Almost half of all smokers attempt to quit each year, yet only approximately 6% are successful. Although there are multiple effective interventions that can increase these odds, substantial room remains for improvement. One effective approach to helping smokers quit is contingency management, where quitting is incentivized with the delivery of monetary rewards in exchange for objective evidence (eg, exhaled carbon monoxide levels) of abstinence. OBJECTIVE We assessed the feasibility and promise of Inspired, a contingency management mobile app for smoking cessation that uses game-based rewards to incentivize abstinence from smoking instead of the monetary (or material) rewards typically used. We sought participant feedback and limited objective data on: the features and design of Inspired, interest in using Inspired when it becomes available, the likelihood of Inspired being an effective cessation aid, and the rank order preference of Inspired relative to other familiar smoking cessation aids. METHODS Twenty-eight treatment-seeking smokers participated in this study. Participants attended a single one-hour session in which they received an overview of the goals of the Inspired mobile game, practiced submitting breath carbon monoxide (CO) samples, and played representative levels of the game. Participants were then told that they could play an extra level, or they could stop, complete an outcome survey, receive payment, and be dismissed. A sign-up sheet requesting personal contact information was available for those who wished to be notified when the full version of Inspired becomes available. RESULTS Using binary criteria for endorsement, participants indicated that, assuming it was currently available and fully developed, they would be more likely to use Inspired than: any other smoking cessation aid (21/28, 75%), the nicotine patch (23/28, 82%), a drug designed to reduce smoking cravings (23/28, 82%), or a program involving attendance in training sessions or support group meetings (27/28, 96%). In the questionnaire, participants indicated that both the Inspired program (26/28, 93%) and the Inspired game would be “Fun” (28/28, 100%), and 71% (20/28) reported that the program would help them personally quit smoking. Fifty-eight percent of participants (15/26) chose to continue playing the game rather than immediately collecting payment for participation and leaving. Eighty-two percent of participants (23/28) signed up to be notified when the full version of Inspired becomes available. CONCLUSIONS This was the first study to evaluate a game-based contingency management app that uses game-based virtual goods as rewards for smoking abstinence. The outcomes suggest that the completed app has potential to be an effective smoking cessation aid that would be widely adopted by smokers wishing to quit.