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Of the 14.3 million Mexicans who smoke, only a minority take advantage of evidence-based approaches to smoking cessation. Mobile health interventions have the potential to increase the reach of effective cessation interventions in Mexico.
This study aimed to assess the feasibility and acceptability of an innovative, personalized, and interactive smoking cessation mobile intervention developed for Mexican smokers.
We recruited 40 Mexican smokers to participate in
Average age of the participants was 36 years (SD 10.7), and they were primarily male (65%, 26/40) with at least an undergraduate degree (62%, 25/40). Most participants (95%, 38/40) smoked daily and were interested in quitting in the next 7 days. As an indicator of participant interactivity, participants sent an average of 21 text messages during the 12-week intervention (SD 17.62). Of the 843 messages that participants sent to the program, only 96 messages (11.3%, 96/843) used keywords. At 12 weeks, 40% (16/40) of participants were biochemically verified (87%, 35/40, follow-up rate). The majority of participants (85%, 30/35) reported being very satisfied or extremely satisfied with the program.
The
Currently, 14.3 million Mexican adults (16.4%) smoke [
Currently, 8 in 10 Mexican smokers are interested in quitting smoking [
Mexicans are more likely to be nondaily and light smokers (<10 cigarettes per day [CPD]) [
Developments in the sophistication of mobile technologies allow for flexible delivery of text messages, with algorithms used to tailor content to individual motivational and behavioral needs for smoking cessation [
This pilot study aimed to assess the feasibility and acceptability of
This study was conducted between March and August 2017 at the Medical Center of the Autonomous University of the State of Morelos, located in Cuernavaca, Morelos, Mexico. This urban primary health care clinic serves an average of 100 individuals on a daily basis. None of the services provided by the clinic address smoking cessation.
Participants were recruited through printed posters and multimedia venues including ads through the National Institute of Public Health’s website and Facebook and local radio announcements. Potential participants emailed or called the study personnel to learn more about the study. Eligibility assessment was conducted over the phone. Eligible participants were of Mexican origin, aged 18 years or older, had smoked for at least 6 months, smoked at least 3 days per week, were interested in quitting within the next 30 days, had a cell phone with text messaging capacity, and were willing to complete baseline and 12-week follow-up surveys. Participants were excluded from the study if they were planning to move within the next 6 months, consumed other forms of tobacco (including electronic cigarettes) or illicit drugs in Mexico (eg, cannabis and cocaine), or had another household member enrolled in the study. All subjects gave informed consent before participation in the study. Participants received 300 Mexican pesos (approximately US $17) at baseline and follow-up as an incentive for their time and transportation. The Human Subjects Committee of the National Institute of Public Health approved the study procedures.
The tablet-based, decision support tool was designed to help smokers create a personalized smoking cessation plan and to collect data that tailored the text messages delivered over the ensuing 12 weeks [
We developed a library of 304 text messages in Spanish to support a 12-week cessation program [
The main goal of the prescheduled standard messages was to provide counseling through
These messages consisted of automated immediate responses sent to participants who texted 1 of the following keywords:
Taking advantage of the text message platform’s capability to recognize free texting (nonkeyword) from participants,
Types of messages, stages, duration, number, and examples of text messages.
Type of message | Stage | Duration | Number | Examples |
Prescheduled standard messages | Prequit | 29 days | 2 to 3 messages a day | |
Prescheduled standard messages | Quit day | 1 day | 4 messages | |
Prescheduled standard messages | Maintenance | 28 days | 3 to 4 messages a day | |
Prescheduled standard messages | Relapse prevention | 56 days | 1 to 2 messages a day | |
Prescheduled standard messages | Relapse | 3 days | 4 messages a day | |
Keyword-triggered standard messages | Family | Per participant request | 14 messages | |
Keyword-triggered standard messages | Crave | Per participant request | 10 messages | |
Keyword-triggered standard messages | Stress | Per participant request | 11 messages | |
Keyword-triggered standard messages | Advice | Per participant request | 9 messages | |
Keyword-triggered standard messages | Sadness | Per participant request | 24 messages |
The choice of pharmacotherapy followed the practice guidelines for treating smokers in Mexico [
To implement the text messages system, we worked with
The in-person baseline survey assessed sociodemographic variables such as age, gender, education level, marital status, and type of health insurance. Other variables collected were physical nicotine dependence (the Fagerström Test for Nicotine Dependence [
The primary outcome was cotinine-verified 7-day point prevalence abstinence (no cigarettes in the past 7 days) at 12 weeks. This was biochemically verified using urinary cotinine testing, with a cutoff of 200 ng/ml cotinine [
We calculated simple frequencies for categorical variables and means and SDs for continuous variables. The primary analysis on cessation was conducted using an intention-to-treat analysis, in which participants lost to follow-up are considered smokers.
During a single week of recruitment, 122 smokers contacted the study personnel via phone or email for information; among them, 106 were contacted and assessed for eligibility by telephone and 72 were identified as eligible for the study. Overall, 41 smokers consented to participate and completed the baseline assessment in person; 1 smoker was removed from the study because of a carrier blockage that could not be solved, resulting in 40 smokers enrolled in the study (
Participants’ age at baseline ranged from 20 to 59 years (mean 36.0, SD 10.7); 65% (26/40) of the participants were men, 50% (20/40) were single, 62% (25/40) had college or postgraduate education, and 80% (32/40) had health insurance coverage. Most participants smoked daily (95%, 38/40) and were interested in quitting in the next 7 days (95%, 38/40). Half of the participants were light smokers (smoked 10 or less CPD) and, according to the Fagerström test, 70% (28/40) of the participants reported low levels of nicotine dependence (
Vive Sin Tabaco… ¡Decídete! intervention flow.
Baseline characteristics of participants (n=40).
Profile characteristics | Statistics | |
Age, mean (SD) | 36.0 (10.7) | |
Men | 26 (65) | |
Less than high school graduate | 3 (7) | |
High school graduate | 7 (17) | |
Technical school | 5 (12) | |
College graduate | 18 (45) | |
Postgraduate | 7 (17) | |
Married or cohabitating | 16 (40) | |
Single | 20 (50) | |
Divorced, separated, or widowed | 4 (10) | |
Instituto Mexicano del Seguro Social (English: Mexican Social Security Institute) | 25 (62) | |
Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (English: Institute for Social Security and Services for State Workers) | 7 (17) | |
None | 8 (20) | |
Nondaily | 2 (5) | |
Daily, 1-9 CPDa | 20 (50) | |
Daily, 10-19 CPD | 12 (30) | |
Daily, 20 or more CPD | 6 (15) | |
Low dependence | 28 (70) | |
Moderate dependence | 11 (27) | |
High dependence | 1 (2) | |
Yes | 26 (65) | |
No | 14 (35) |
aCPD: cigarettes per day.
Participants received approximately 180 automated messages during the 12 weeks; none of the participants texted the word STOP to disenroll from the program. During the 12-week intervention period, participants sent 843 text messages, an average of 21 text messages per participant (SD 17.62). Of the 843 messages that participants sent to the program, only 96 (11.3%) used keywords. Participants varied in the frequency of sending text messages: 3 (7%, 3/40) never interacted with the program, 16 (40%, 16/40) had low interaction (1-9 messages), 17 (37%, 17/40) had medium interaction (10-49 messages), and 4 (10%, 4/40) had high interaction (>50 messages). Interaction varied across the different stages of the program (
Three-quarters (75%, 30/40) of the participants were eligible to use NRT, all of whom requested an initial supply of NRT. Of these 30 participants who requested NRT at baseline, 18 (60%) requested a refill at 4 weeks (
Text messages interaction by participants during the intervention. QD: quit day.
Utilization of nicotine replacement therapy (NRT) during the intervention. CPD: cigarettes per day.
At 12 weeks, 16 participants (40%, 16/40) were biochemically verified abstinent using intent-to-treat analysis (
The 3-month follow-up outcomes.
Outcome | n (%) | |
Self-reported 7-days smoking abstinence | 18 (45) | |
Biochemically verified abstinence urine cotinine (≤200 ng/ml) | 15 (37) | |
Biochemically verified abstinence exhaled carbon monoxide (≤6 ppm) | 1 (2) | |
Extremely satisfied | 13 (37) | |
Very satisfied | 17 (48) | |
Satisfied | 5 (14) |
aIntention-to-treat analysis was used.
To the best of our knowledge,
A smoking cessation mobile intervention can only be effective and sustainable if it is properly deployed in an environment that reaches a large number of smokers in need of evidence-based services. In Mexico, the most logical setting for the deployment of
The text messaging program appears to be a promising, low-cost alternative to in-person or telephone counseling to prompt smoking cessation, although additional strategies to eliminate the costs incurred by participants generating text messages to interact with the program may be needed. In this study, participants preferred to send their own, self-composed text messages rather than relying on keywords from the program for a response. This suggests that reliance on keywords may be insufficient for smoking cessation counseling via text messaging in Mexico. Hence, there may be additional costs involved in having trained personnel responding to participants’ text messages, as occurred in this study. Participants’ text messages content should be analyzed using qualitative methods to identify common themes. These methods can guide the creation of a categorized codebook that would be able to retrieve and send responses automatically, thus reducing the need for trained personnel responding to self-composed participants’ text messages.
This study had a number of limitations. This was a pilot study and did not have a control group. Due to the small sample size, the results are not generalizable to all Mexican smokers. Follow-up was limited to a single assessment at week 12, when the program ended. Analyses were limited to quantitative assessments of participant interactions. Furthermore, the sample was more highly educated and smoked more heavily than the general population of smokers in Mexico; future research is warranted to determine whether the effectiveness of this type of intervention is generalizable to those who are from lower socioeconomic status groups. Contrary to the US clinical guidelines [
The
cigarettes per day
nicotine replacement therapy
This study was funded by the National Institutes of Health 3P30CA168524-04S1.
None declared.