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.

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