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Am Fam Physician. 2020;102(3):148-149

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

Clinical Question

Do cell phone–based smoking cessation interventions increase cessation rates in people who smoke?

Evidence-Based Answer

Automated text messaging interventions are more effective than minimal smoking cessation support (absolute risk reduction [ARR] = 3%; 95% CI, 1% to 5%). (Strength of Recommendation [SOR]: A, based on consistent, good-quality patient-oriented evidence.) Adding text messaging to other smoking cessation interventions is more effective than other smoking cessation interventions alone (ARR = 4%; 95% CI, 1% to 10%). (SOR: A, based on consistent, good-quality patient-oriented evidence.) When smartphone smoking cessation apps are compared with lower intensity smoking cessation support, such as printed educational materials, they have not been shown to increase the likelihood of smoking cessation.1 (SOR: C, based on consensus, disease-oriented evidence, usual practice, expert opinion, or case series.)

Practice Pointers

In 2015, 68% of adults in the United States who smoked cigarettes reported they wanted to quit completely.2 Cell phone interventions such as text messaging and smartphone apps are being explored as options to support smoking cessation. The potential benefits of cell phone interventions include the ease of use, cost-effective delivery and scalability to large populations, the ability to individualize and send time-sensitive messages, the opportunity to provide content that can distract from cravings, and the ability to provide social support.1

This Cochrane review included 26 randomized controlled trials (RCTs; N = 33,849) that compared quit rates among individuals who received text messages or smartphone app interventions vs. either a lower intensity intervention (less frequent messaging) or alternate educational interventions (such as printed cessation materials or general health information).1 The settings, recruitment methods, and control interventions varied considerably across studies. Study settings included the United States, Canada, Europe, and Asia. Most study samples included a general adult population with similar proportions of women and men, although four focused specifically on young adults, one on pregnant patients, one on people living with HIV infection, and one primarily on military veterans. Several studies specifically included pharmacotherapy; however, in these studies pharmacotherapy was offered as standard of care with the texting and app interventions being added to support cessation efforts and, in some cases, medication adherence. Control interventions also varied considerably across studies. The primary outcome was smoking abstinence at longest follow-up, which was at least six months from baseline and was measured by self-report and/or biochemical validation.

Thirteen RCTs (n = 14,133) evaluated text messaging interventions compared with minimal smoking cessation support. The text messaging interventions included a wide range of text message styles and frequencies. Examples included automated text messaging tailored to the individual's current quit status, interactive text messaging that allowed for more support in cases of increased cravings, and a regular “check in” via text. The control groups received no or minimal smoking cessation support interventions, which also were varied. These ranged from receiving text messages that were not smoking cessation–related but pertained to general health to written materials about smoking cessation to general in-person health advice from a clinician. Moderate certainty evidence indicated that six months of text messaging was more effective than minimal smoking cessation support at achieving abstinence from smoking (ARR = 3%; 95% CI, 1% to 5%; number needed to treat = 33; 95% CI, 20 to 100).

Four RCTs (n = 997) evaluated text messaging interventions in addition to other smoking cessation support. The text messaging interventions varied in frequency and style as previously described. The smoking cessation support offered in addition to the text messaging varied across studies and included in-person smoking cessation counseling sessions and/or pharmacotherapy. Moderate certainty evidence indicated that text messaging plus other smoking cessation support was more effective than smoking cessation support alone for achieving long-term abstinence from smoking (ARR = 4%; 95% CI, 1% to 10%; number needed to treat = 25; 95% CI, 10 to 100).

Five RCTs (n = 3,079) evaluated smartphone apps that varied significantly in content and components, ranging from a positive reinforcement/behavior tracking app to supportive messages and evidence-based cessation services. The smartphone app interventions were compared with a basic app that provided general smoking cessation information or minimal non-app support such as printed educational materials about smoking cessation. There was no evidence that smartphone apps increased the rate of smoking cessation.

The U.S. Public Health Service–sponsored guideline, “Treating Tobacco Use and Dependence,” recommends that physicians offer patients tobacco addiction counseling and pharmacotherapy, and include the use of telephone “quit” lines and telephone counseling for smoking cessation.3

The practice recommendations in this activity are available at http://www.cochrane.org/CD006611.

Editor's Note: The numbers needed to treat reported in this Cochrane for Clinicians were calculated by the authors based on raw data provided in the original Cochrane review. Dr. Salisbury-Afshar is a contributing editor for AFP.

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