Gamification to Motivate the Unmotivated Smoker: The “Take a Break” Digital Health Intervention

Abstract

Objective: Digital health technologies most often reach only those more motivated to engage, particularly when preventive health is targeted. To test whether gamification could be used to engage low-motivation smokers, we conceptualized “Take a Break”—a 3-week technology-assisted challenge for smokers to compete in setting and achieving brief abstinence goals.

Materials and Methods: In the feasibility study of the multi-technology Take a Break challenge, low-motivation smokers were given (1) daily motivational messages, (2) brief “challenge quizzes” related to smoking behaviors, (3) a telehealth call to personalize their abstinence goal for the challenge, (4) “coping minigames” to help manage cravings while attempting to achieve their brief abstinence goals, and (5) a leaderboard “webApp,” providing comparative feedback on smokers' participation, and allowing for competition. Heterogeneity of engagement was tracked.

Results: All 41 smokers initially reported that they were not actively quitting. Over half were employed less than full time (51%), completed less than a 4-year college education (76%), and experienced financial stress (54%). No smokers opted out of the motivational messages, and mean proportion of response to the challenge quizzes was 0.88 (SD = 0.19). Half of the smokers reported using the “coping minigames.” Almost all set abstinence goals (78%), with over half lasting 1–2 days (51%); median = 1 day (IQR 1-7). Leaderboard points ranged widely.

Conclusions: Rates of smoking in the developed world have declined, and those who remain smokers are complex and have lower motivation to quit. Using a game-inspired challenge, we achieved high levels of engagement from low-motivation smokers.

Introduction

The last decade has seen a rapid proliferation of digital technology to support health management and health care delivery.^1–5 Examples of such digital technology include wearable activity monitors, smart phone apps, electronic and mobile health (eHealth and mHealth) interventions, and patient portals. There is considerable hope that these technologies will help improve health and health care.^1–5 These technologies often only successfully engage a subset of the most motivated users. Data on wearable activity monitors have shown that those currently using this technology are those already leading a healthy and active lifestyle.^5,6 Much of the population who might benefit most from health technologies belong to the unmotivated majority.⁷ Even among the motivated subset, data show that these health technologies are discarded after initial use.⁸ Innovative approaches to expand the use of digital health technologies by low-motivation users and to keep users engaged are needed.

Gamification, a promising approach to increase engagement, is the use of game design elements in nongame contexts.⁹ Although gamification has been shown to promote engagement beyond the realm of games,¹⁰ it has not been used to reach and continually engage low-motivation populations in behavioral support using digital technology. Using behavior change and game design theory, we conceptualized a set of gamified mobile health tools for inveterate smokers, called Take a Break. Because there is a high prevalence of current smokers unmotivated to quit, novel strategies to induce a higher number of quit attempts with smokers is needed in this population.¹¹

Our mobile health tools, primarily text-based, attempt to engage low-motivation smokers (smokers initially unwilling to quit) in a brief experience designed to increase motivation for cessation and prepare them with confidence and skills needed to be successful during a future attempt to quit tobacco. Our goal in the use of gamification in the Take a Break project is to increase the engagement of low-motivation smokers in evidence-based behavior support. While gamification primarily enhances external motivation (e.g., gaining momentary rewards), research has shown that additional changes in internal motivation (long-lasting resolve) and user behavior are possible with careful design.^9,12,13 In this article, we describe (1) our conceptual frameworks for the development of five gamified intervention elements, and (2) the usability and feasibility testing of the gamified intervention elements.

Methods

The purpose of feasibility testing is to evaluate the study design and collect process measures (such as engagement in the intervention), but not clinical outcomes.^14,15 Implementing any new system requires careful planning, and testing the game elements in a real-world setting is helpful in highlighting areas that need improvement and refinement.^16,17 We will describe the conceptualization of intervention elements using game design and behavioral theory for enhanced motivation, as well as usability and the feasibility testing of the intervention elements. We do not present clinical data, including behavioral or physiological outcomes. This study was approved by the University of Massachusetts Medical School Institutional Review Board.

Intervention elements conceptualized

A recent review suggests that tobacco cessation interventions must provide smokers the opportunity to reflect upon smoking, briefly practice behaviors used while quitting, and develop new skills for managing smoking urges.¹⁸ The Take a Break game experience provides smokers these opportunities using content supporting reflection on tobacco use and skill development. The Self-Determination Theory (SDT), a theory of motivation, purports three psychological needs that are necessary for optimal motivation to be developed: relatedness to others, autonomy, and perceived competence.¹⁹ These three needs were used to guide the content of the intervention elements to affect smoker motivation. Game design concepts identified to support motivation²⁰ were then mapped to the three psychological needs of SDT (relatedness to others, autonomy, and perceived competence) to guide gamification of the intervention elements.

Overall, five gamified intervention elements were created and coordinated into a 3-week experience for low-motivation smokers. This experience was constructed to move participants along motivation continuum (Fig. 1). The technology is briefly described in Table 1. The first week is a training and assessment period, verifying that participants can receive and respond to the following: (1) Motivational Messages written by smokers for other smokers to enhance game play and motivate cessation (Supplementary Appendix A); (2) Challenge Quizzes to assess daily smoking behavior and attitudes about smoking that could help smokers be more mindful of their behavior and feelings; and (3) a call with a Tobacco Treatment Specialist (TTS). During a telehealth call with the TTS, the participant sets a goal for the number of days during the challenge that they will attempt to be abstinent from smoking. After the call, the 2-week challenge begins. Intervention elements 1–3 are continued, along with two others: (4) Coping Minigames that are designed to help smokers overcome cravings for cigarettes and (5) Recognition and Rewards, including points for participation. Participants return for carbon monoxide testing at the completion of the challenge. Further description of these intervention elements is reported in Table 2. Several SDT concepts were used to inform the five gamified intervention elements (Table 3). The “affiliation with others” concept creates a sense of connectedness with other smokers, and was supported using smoker-generated messages, goal-setting, or participation shown on a leaderboard. The “autonomy” concept was supported through designing elements to contain choices, for those choices to contain novelty and variety, and by allowing participants the freedom to choose a focused goal. Finally, opportunities to gain “perceived competence” were designed into some of the gamified intervention elements, including “protection from adverse consequences from initial failures,” “affirmation of performance,” “challenging tasks” and “clear & compelling standards.”

FIG. 1.

Take a Break Participant Experience: The Five Elements.

Table 1.

Characteristics of a Mobile Multitechnology Intervention: Take a Break

Health topics:	Tobacco cessation, cravings, low-motivation smokers
Targeted age group:	Adults
Other targeted group characteristics:	Unmotivated to quit tobacco use
Short description of game idea:	Mobile messaging and applications to support a personal challenge to take a break from smoking.
Target player:	Individuals
Guiding knowledge or behavior theories, models or conceptual frameworks:	Self-Determination Theory (SDT), game design concepts based on the Theory of Intrinsically Motivating Instruction, Organismic Integration Theory (OIT)
Intended health behavior changes:	Days of abstinence during challenge and long-term cessation from tobacco
Knowledge elements to be learned:	Benefits of quitting tobacco and how to deal with cravings]
Behavior change procedures (based on Michie inventorya) or therapeutic procedures used:	Self-reward [10.9], Anticipation of future rewards or removal of punishment [14.10], Incentive [10.1], Behavioral rehearsal/practice [8.1], Distraction [12.4], Goal setting (outcome) [1.3], Review of outcome goal(s) [1.7],
Clinical or parental support needed:	Tobacco treatment specialist telehealth call after 1 week is provided, with session focused on goal setting.
Data shared with parent or clinician:	Week 1 answers reviewed before telehealth call
Type of game:	Educational, casual, experiential, motivational
Game components	Technology	Goal/objective
1. Motivational messages:	Daily SMSb	Set expectations on the benefits of taking a break from smoking.
2. Challenge quizzes:	Daily SMSb	Engage smokers and enhance self-awareness of smoking behaviors.
3. Goal setting:	Telehealth	Encourage the smoker to set a realistic goal for the challenge period.
4. Coping Minigames:	Mobile appsc made by third party providers	Help smokers manage cravings.
5. Recognition & Rewards:	Webappd	Link the external goal of scoring points by replying to daily challenge quizzes along with the internal goal.
Player's game goal/objectives:	Enhance motivation to take a short-term break from smoking and a long-term quit attempt from tobacco.
Procedures to generalize or transfer what's learned in the game to outside the game:	Enhance intrinsic motivation to quit tobacco through the message content, encouraging view and use of content via gamification of points and rewards.
Game platform needed to play the game:	Smartphone
Estimated play time:	All components are point-of-need access via smartphone over 3 weeks.
	Motivational messages and challenge quizzes: Sent daily over 3 weeks, estimated <1 minute per message or quiz.
	Goal setting: one-time telehealth call of 15 minutes.
	Coping Minigames: self-initiated, 5 minutes per use.
	Recognition & Rewards: accessed briefly to check points.

^aBehavior Change Techniques (BCT) Taxonomy.²¹

^bSecure messaging system.

^cMobile applications.

^dWebapps are placed on smartphone home screen, but still accessed through a web browser and URL.

Table 2.

Take a Break Intervention Elements

Element 1. Motivational messages	Daily motivational messages set expectations on the benefits of taking a break from smoking and were written by experts and smokers. Expert-written messages were developed iteratively through a group review, and the content was guided by current guidelines22 and Social Cognitive Theory.23 Smoker-written messages were written by smokers responding to scenarios that varied by a character's readiness to quit smoking. These messages were previously evaluated within the context of a web-assisted tobacco intervention.24,25
Element 2. Challenge quizzes	The purpose of the challenge quizzes is three-fold: (1) to engage smokers, (2) enhance self-awareness of smoking behaviors, and (3) collect data on situational characteristics, abstinence behaviors, and cravings to inform the telehealth call at the end of week 1. Two challenge questions are sent daily over text messaging, asking the number of cigarettes that were smoked in the last 24 hours and, if answered, asking an additional question prompting self-assessment of their cravings. The self-assessment of cravings come from the anger and anxiety subscales in the 28-item Wisconsin Smoking Withdrawal Scale,26 and were adapted for text messaging. Affirmation of response is given by congratulating the participant and notifying them of points earned.
Element 3. Goal-setting	The gamification strategy of giving smokers control over the goal increases the meaningfulness of the game element.27 After the initial 1-week training period the smokers receive a 15–30 minute telehealth call by a Tobacco Treatment Specialist, with the primary goals of this call to increase self-awareness of personal smoking behaviors and encourage the smoker to set a realistic goal of the number of days they will stay quit during the challenge period.
Element 4. Coping minigames	Cravings, an intense desire or longing for a cigarette,28 are a major contributor to quit attempt failure.29 Relaxation and distraction are commonly recommended approaches to help smokers manage cravings.22,30 Coping minigames include distraction and relaxation mobile applications (apps) that can help distract smokers during their cravings.
Element 5. Recognition & Rewards	We promote engagement using a gamification system based on Organismic Integration Theory (OIT),27 linking the external goal of scoring points by replying to daily challenge quizzes along with the internal goal of reflecting on the content of the challenge quiz questions. Smokers receive points for replying to challenge quizzes, with each reply earning them a greater number of points. After the first reply, smokers receive 10 points. The following reply earns them 20 additional points. By rewarding an easily achievable behavior (replying to daily challenge quizzes and participating in in-person visits) and increasing the value of the reward with each subsequent reply, smokers are more likely to remain self-motivated, or hooked, in the game. Smokers are directed to a leader board that allows them to track their points throughout the challenge and to compare their points to other participants in the study. At the end of the challenge period, smokers receive a reward for completing the challenge. Smokers with a score in the top 25% of the leaderboard receive a “Gold” medal and $15 gift card to a local pharmacy as a reward. Smokers completing the challenge in the middle 50% of scores receive a “Silver” medal and $10 pharmacy gift card. Smokers in the bottom 25% receive a “Bronze” medal and a pharmacy $5 gift card. A set of key principles to guide the scoring and reward structure include (1) points are rewarded immediately after participation, (2) points earned increase as participation increases, (3) points are displayed on a leader board accessible to participants, and (4) rewards and recognitions are distributed to all participants, with participants who score the most points receiving the greatest reward.

References of in-text citations are located at the end of the document.

Table 3.

Game Design Concepts Informing Intervention Elements

Self- determination theory	Related game design concept(s)a		Take a break	Intervention	Elements
		Motivational messages	Challenge quizzes	Abstinence challenge goal-settingb	Coping mobile apps	Recognition & rewards
Relatedness	Affiliation with others	Includes Messages written “by smokers for smokers”		Range of goals from past participants shared with new smokers		“Leaderboard”allows smokers to compare their points with others
Autonomy	Choice	Message goal is to inform, motivate, but not to promote long-term cessation	End of week 1, motivational interview with TTS focuses on lessons learned	Smokers Choose goal during abstinence challenge	Smokers choose Apps Provided a menu of downloadable Apps
	Novelty & variety	Topics vary from health related to social and economic consequences of smoking	Questions on elements of nicotine withdrawal gives daily self-assessment opportunities	Autonomy supported by allowing any goal, including zero days	Apps for both relaxation and distraction	Points collected for a variety of tasks related to participation.
	Short-term, Focused Goals		Each question separate “quiz”	Abstinence Challenge only 2 weeks, creates sense of urgency and focus		Rewards for self-report of tobacco use and end-of-challenge COd measure
Perceived competence	Protection from adverse consequences for initial failures		Given second chance for each question	Providing a 2-week period for smokers allows for multiple attempts at abstinence goal		Points rewarded for participation, not achievement of abstinence
	Affirmation of Performance		Two-way texts provide positive feedback			Reward messages note daily points achieved
	Challenging tasks		Questions challenge smokers to think about behaviors	Recognize that abstinence even for one day is a challenging task	Managing cravings is key to short-term abstinence
	Clear & compelling standards			Setting a numerical goal for abstinence days give smokers a clear target		Comparison of rewards with others compels smokers to work for self-identified standard
Timeline		Weeks 1–3	Weeks 1–3	End of Week 1 on telehealth call	Weeks 1–3	Weeks 1–3 and end celebration

^aGame Design Concepts that support motivation²⁰ originate from Theory of Intrinsically Motivating Instruction.³¹

^bGoal setting for abstinence with a Tobacco Treatment Specialist (TTS) over the phone.

^cNicotine Replacement Therapy.

^dCarbon monoxide.

Usability and feasibility testing

The development of intervention elements included a usability inspection process by our team of experts and panel of smokers on each intervention element. The usability inspection methods used included heuristic evaluation and cognitive walkthrough with a team of experts in game design, behavioral interventions, and tobacco cessation.³² We recruited a panel of eight smokers to gain in-depth feedback on each gamified intervention element. Not every smoker gave feedback on each element; only those who were available to test the element were asked to provide feedback, as needed. We report this process and changes to the intervention elements by game element.

To test the feasibility of the elements in a 3-week experience, we recruited 41 participants through a mailing and a phone call over a period of 1 year. Participants were identified using a “smoker registry” created from multiple Northeast medical centers' electronic health record databases of current smokers, with current tobacco use verified over the phone at the time of recruitment. Smokers needed to be older than 18 years of age, English speaking, actively smoking cigarettes, and not willing to quit smoking or attempting to quit smoking at the time of recruitment (Motivation phase smokers; low-motivation smokers). A baseline assessment (44 questions), including demographics and tobacco use questions, and a 3-week follow-up assessment (37 questions) were administered in person. To assess motivational messages, coping minigames, and goal setting, we collected self-assessment of the element “helpfulness” with five-point Likert scale questions (strongly disagree, disagree, neutral, agree, strongly agree response options). Challenge quiz engagement was assessed using proportion of responses to the challenge quiz questions, obtained from the messaging system. Finally, points were collected from the leaderboard, determining the rewards, and recognition achieved through participation. Descriptive results from survey responses, the messaging system, and leaderboard data are reported by game element.

We analyzed subjects with complete data for the responses of interest. Percentages are reported for categorical variables. For continuous variables, we report means and standard deviations (SD) for normally distributed variables and medians and interquartile ranges (IQR) for skewed variables. Analyses were performed using SAS 9.4 software (SAS Institute, Inc., Cary, NC).

Results

Study sample

Between three and seven smokers participated in the testing of each gamified intervention element during usability testing. A total of 41 smokers' feasibility tested the full 3-week experience. The majority of participants were female (56%) and white (90%). In terms of the range of socioeconomic status vulnerability in this sample of smokers, over half are employed less than full time (51%), completed less than a college education (76%), and experienced financial stress (54%) (Table 4). In this sample of low-motivation smokers, they reported that the 3-week experience influenced them to cut down on smoking (86%; N = 30/35), use behavioral strategies such as distraction or substitution (66%; N = 23/35), make a list of reasons to quit smoking (57%; N = 20/35), or quit smoking at some point in the challenge (51%; N = 18/35).

Table 4.

Baseline Demographic and Tobacco Use Characteristics of Study Participants (N = 41)

Participant characteristics	Mean	SD
Age	51	11
	N	%
Gender
Female	23	56%
Male	18	44%
Race
White	35	90%
Othera	4	10%
Education Level
High School	13	32%
Some college or Associate's degree	18	44%
Bachelor's degree or higher	10	24%
Employment
Full time	20	49%
Part time	6	15%
Other	15	37%
Financial stress
Never or rarely	19	46%
Sometimes, usually or always	22	54%
Tobacco use characteristics	N	%
Number of daily cigarettes
0–10 cigarettes (0 to 1/2 pack)	20	49%
11–20 cigarettes (1/2 pack to 1 pack)	15	37%
Over 21 cigarettes (over 1 pack)	6	15%
First cigarette of the day after awakingb
Within 5 minutes	8	21%
6–30 minutes	19	50%
31–60 minutes	8	21%
After 60 minutes	3	8%
Stopped smoking for at least 1 day in last 12 months	22	54%

^aRace Other includes black, Asian, or Pacific Islander and individuals with more than one race.

^bAn item from the Fagerstrom Test for nicotine dependence.³³

Motivational messages

Motivational messages were rigorously tested in a previous trial.²⁷ For Take a Break, our goal was to select a subset of messages to use during the 2-week challenge, and to collect user feedback on whether these messages were helpful to motivational phase smokers. We used a previously developed procedure,²⁴ where team experts separately rated 50 messages, with each message receiving a score ranging from 1 to 5 in perceived usefulness. The questions that received the highest ratings from team experts were discussed. Fourteen of the messages were selected.

Panel members (N = 3) piloted the motivational messages for 2 weeks, reporting messages were easy to read and delivered at an acceptable time of the day. In feasibility testing (N = 41), the majority of smokers thought that the motivational messages were helpful for quitting smoking (83%; N = 30/36), 36% of whom strongly agreed (N = 13/36).

Challenge quizzes

Heuristic evaluation of the challenge quizzes was performed with experts receiving the challenge quiz questions on their phones and trialing responses. Panel members (N = 3) tested the challenge quizzes for 1 week and were asked for feedback. Panel members felt that the number of messages sent per day was appropriate and questions were clearly worded. A panel member suggestion of adding an example of the desired response language for the number of cigarettes smoked each day (i.e., “0 or 12 or 20”) was incorporated.

During feasibility testing (N = 41), the mean proportion for response to challenge quizzes was high at 0.88 (SD = 0.19), with a median proportion of 0.96 (IQR = 0.89–1.0). The proportion of response was sustained from the first week training period with a mean proportion of 0.87 (SD = 0.25) and median proportion of 1.0 (IQR = 0.86–1.0) to the 2-week challenge with a mean proportion of response of 0.88 (SD = 0.21) and a median of 1.0 (IQR = 0.86–1.0). For those who responded to the daily challenge quiz in week 1, a bonus question was delivered, with a mean proportion of response of 0.93 (SD = 0.16) and median of 1.0 (IQR = 0.86–1.0).

Goal setting

The TTS developed a protocol to guide the telehealth call. Key components of the telehealth call included reviewing the first week of participation in Take a Break, such as engagement with the daily challenge quizzes, as well as identification of personal craving triggers and barriers to cessation along with suggested techniques to address each (including use of nicotine replacement therapy [NRT]), and concluded with a shared goal setting exercise to set the number of abstinence days during the 2-week challenge. The TTS practiced the telehealth call with team members to refine techniques to assist smokers to identify a goal. Panel members (N = 3) then participated in a telehealth call, leading to an additional revision of the protocol to assist smokers in choosing a realistic goal that fit within the 2-week challenge period.

During feasibility testing (N = 41), the majority of smokers (78%, N = 32/41) set an abstinence goal of at least one day for the challenge, with a median goal of 1 day (IQR = 1–7) and range of 1–14 days (Fig. 2). The most common goal set was 1 day (33%, N = 11/33), followed by a goal of a full 2 weeks (15%; N = 5/33). The majority of smokers agreed that the telehealth call with the TTS was helpful in setting a goal for abstinence (89%; N = 33/37).

FIG. 2.

Abstinence Goal Set by Participants for the Challenge (N = 41).

Coping minigames

Coping minigames for smokers to use during their smoking cravings needed to be identified. First, distraction and relaxation mobile apps were selected from Google and Apple for evaluation. Search criteria included compatibility across interfaces, no cost, high download rate, and short duration. Fifteen apps fit the criteria. Experts discussed the strengths and weaknesses of each app, resulting in six apps being selected for panel member testing. A Think Aloud evaluation was used, with panel members asked to vocalize thoughts, feelings, and opinions while using the apps.^34,35

Panel members (N = 7) varied on their app preferences. For example, one member responded, “I love this game. It's challenging and distracts you, keeps you busy…it's addicting.” In contrast, another member responded, “Games like this are stressful for me, maybe because I am a stressful smoker.” The panel preferred multiple apps to choose from. Thus, a suite of apps was included in this gamified intervention element, including three distraction apps (Piano Tiles, Flow Free, and Word Streak) and three relaxation apps (Calm, Breathe2Relax, and Take a Break!) (Table 5).

Table 5.

Usability Testing of Coping Minigames

Description	Participant feedback
Distraction apps
Don't Tap The White Tile (Piano Tiles)1 Features:    Variety of game modes, colors and songs/rhythms; customizable  Rank against friends and support from friends using Facebook or Twitter	“I love this game. It's challenging and distracting, keeps you busy…it's addicting.” “This game is long enough, it keeps me distracted and away from smoking” “Games like this are stressful for me, maybe because I am a stressful smoker.”
Flow free2    Puzzle game    Solve levels and with accuracy, efficiency and speed  Customizable time trials, scores included	“I'm not a pattern person but I think I like this game better than I thought. I like the bright colors.” “I get stressed while playing this game, it makes me more stressful.” “It might be somewhat helpful to control.”
Word streak3    Varying speeds, badges    Challenge and chat with friends using Facebook	“Game is very engaging, it keeps my mind alert.” “It's a good game but it has to be longer to keep me from cravings.”
Relaxation apps
Calm–meditate, sleep, relax4    Guided meditation sessions  Varying lengths of sessions, topics, music/sounds and depth for beginners and advanced  Track daily streaks and time	“Love the beach scene.” “Different scenes and sounds are really helpful.” “Running water, rain and ocean breezes are very good.”
Free meditation–take a break5    Voice-guided meditations  2 meditations to choose from, choice of with or without music	“I like scenery, like beach, lakes.” “I like sound of rain, ocean, beach and water running. I love sounds.” “Don't like meditation, it's not for me.”
Breathe2Relax6    Stress management  Learn skill: diaphragmatic breathing  Practice exercises	“Breathing exercise is really helpful to relax.” “I love the blue scenery and the tutorial, it's very helpful.” “Don't like the stress tracker.”

Sources: ¹https://piano-tiles.com/dont-tap-the-white-tile.html

²https://www.bigduckgames.com/flowfree

³https://www.zynga.com/games/words-with-friends-2

⁴https://www.calm.com/; https://itunes.apple.com/us/app/calm.com/id571800810

⁵https://www.meditationoasis.com/app-support; ⁶http://telehealth.org/apps/behavioral/breathe2relax-mobile-app

In feasibility testing (N = 41), around half of the smokers reported using at least one relaxation app (51%, N = 19/37) and at least one distraction app (48%, N = 18/37) during the 2-week period. For those who used the respective apps, the majority thought that the distraction apps (83%, N = 15/18) and relaxation apps (74%, N = 14/19) were helpful during a craving. Participants also reported that they would use the relaxation apps (65%, N = 24/37) and distraction apps (61%, N = 22/36) during a future quit attempt.

Recognition and rewards

The team performed a cognitive walk-through of the points system and discussed tangible rewards to be given that reflect the virtual awards smokers earned. Virtual awards (gold, silver, or bronze medals) translated into tangible rewards of gift cards for a pharmacy that sells NRT and not tobacco. Panel members (N = 3) gave qualitative feedback on the likeability of the leaderboard and rewards. Smokers preferred point distributions of 10 to promote a sense of accomplishment and approved of receiving gift cards and the varying amounts that correspond with the medals. In feasibility testing (N = 41), the mean number of points earned was 3638 (SD = 2049) and median 3780 with interquartile range (3000, 4060), with a range from 780 to 6300. Participants remained on the leaderboard after the completion of their 3-week challenge, making it possible for new participants to compete and improve upon their score. In four of the 9 months with five or more total participants, the “top 5” leaders changed positions. In the first three of the 9 months, there was frequent upheaval of the “top 5” positions. In contrast, in the next 4 months the five leaders steadily held the top positions, with only small leader changes in the 7th and 8th months. Finally, in the 9th month, the undefeated champion was unseated by a new participant, continuing the competition for top place.

Discussion

A State of the Science conference on tobacco research emphasized that interventions need to be more palatable and engaging for all smokers.³⁶ We developed smoking cessation intervention elements informed by behavioral theory and gaming theory, with a focus on enhancing user motivation. We packaged these smoking cessation intervention elements into a 3-week experience and further refinement was achieved through usability and feasibility testing. We found that smokers with low motivation to quit smoking engaged with our intervention. The majority of low-motivation smokers responded continually to the challenge quizzes sent via text message (84.7%) and thought that the motivational messages were helpful (83%). This rate of response is particularly encouraging, given that our system is being tested with low-motivation smokers and responding to the assessments is not mandatory.

There were several participants who have markers of socioeconomic status vulnerability, including low educational attainment, underemployment, and who report experiencing financial stress. Adults who live below the poverty line have less success in quit attempts than adults with higher socioeconomic status.³⁷ Behavioral interventions, such as Take a Break, that extend their reach and motivate vulnerable populations to use evidence-based strategies that increase their success in behavior change, such as during quit attempts, are needed.³⁸

During usability testing for Take a Break, the intervention elements were tested and modified based on smoker panel feedback. Important information on the acceptability and likeability of the gamified intervention elements was ascertained before testing them in combination during the 3-week Take a Break experience. For instance, smokers found the number of messages sent per day appropriate, with a maximum of three per day. Similarly, a text-messaging intervention NEXit, tested in Sweden, found that two to four text messages were acceptable.³⁹ Multiple studies testing text messaging for smokers found that five messages per day were reported by users as too many.^39,40 Maintaining a balance between prompting a user versus irritating a user is important in design. Usability testing can help studies understand the number of text messages that is palatable to a user in their targeted population.

The gamified intervention elements were then feasibility tested, with a main outcome of smoker engagement. Engagement with intervention elements varied, with some elements used more than others. Goal setting made before the 2-week challenge and coping minigames use during the 2-week challenge were good examples of this.

In preparation for the 2-week challenge, not every smoker set a goal to take a break from smoking during the telehealth call with the TTS. In addition, the smokers who did set an abstinence goal chose to attempt abstinence from cigarettes for a short number of days. However, even among these low-motivation smokers, the intervention did succeed in engaging smokers to set a short-term goal for abstinence from smoking during the challenge period. Although these were short goals, it is the act of setting a goal, not the length of the goal itself, which is an important step toward long-term tobacco cessation for low-motivation smokers.⁴¹ As noted, over half of the smokers indicated that participation in the 2-week challenge influenced them to set a quit date for abstinence. In our larger randomization trial, we will follow smokers for 6 months and determine the intervention's effect on self-efficacy and tobacco cessation.

Engagement in elements used during the 2-week challenge also varied. Based on usability testing, where consensus on one distraction and one relaxation app was not reached, a suite of apps was created for smokers to choose from for combating cravings. Feasibility testing resulted in only half of smokers using the relaxation and distraction apps during the 3-week experience. However, smokers indicated that they would use these distraction and relaxation tools again in future quit attempts. Giving low-motivation smokers effective tools to quit that they would use again was a key goal in preparing them to be successful in future quit attempts.

Finally, points for participation may have had a large effect on engagement, which is consistent with other studies and populations.⁴² As noted above, participants responded at a high rate to challenge quizzes, and even commented on motivational messages, causing their leaderboard score to become high. Considering that the majority of smokers attempting to quit do not incorporate evidence-based methods in their efforts, with subsequently low success rates (7%),²² the willingness of these low-motivation smokers to participate in the intervention elements is a key finding.

Limitations

In our feasibility testing, a racially homogenous sample of smokers participated. In addition, a formal measure of smoker motivation at the time of screening for inclusion was not used, yet, only smokers in the motivation phase (unwilling to quit and not actively quitting) were included in the sample. As our feasibility trial was designed to evaluate process measures rather than the ultimate outcome of the intervention, we have yet to determine the impact of participating in the game on smoking cessation. In our larger Take a Break trial, we will compare the effect of the intervention elements described in this article with an attention control of NRT sampling and a phone call with a TTS on the main outcome of tobacco cessation.

Conclusions

This article describes the development and testing of a digital health technology for a behavioral intervention in low-motivation smokers, Take a Break. First, we used behavior change and game design theory to conceptualize and design intervention elements. Second, we used usability testing to further refine the elements. Third, we tested the feasibility of implementing the intervention by examining the process measures of smoker perceptions and engagement. We found that smokers had high engagement with the game, set realistic goals for abstinence, and were motivated to set a quit date for future long-term abstinence. Meaningful gamification was successful in engaging low-motivation smokers. Further testing of Take a Break in a larger trial is needed to determine the game elements' effect on tobacco cessation.

Author Disclosure Statement

Not competing financial interests exist.

Supplementary Material

Supplementary Data