Pilot Randomized Controlled Trial of a Digital Storytelling Intervention for Smoking Cessation in Women Living With HIV

Abstract

Background

People living with HIV in the USA smoke at a rate nearly three times that of the general population, and Black women are disproportionately affected by HIV infection.

Purpose

This study was conducted to test the preliminary efficacy of a digital storytelling intervention for smoking cessation in U.S. women living with HIV.

Methods

Participants in the treatment arm viewed a film in which women living with HIV talk about quitting smoking, and those in the control arm viewed an attention-control film in which women talk about living with HIV infection. Participants in both arms received eight weekly video-call counseling sessions focused on smoking cessation and nicotine patches or gum during the same period. Participants were followed on a monthly basis from quit day for 3 months.

Results

Of the 53 participants randomized, four withdrew before receiving any intervention, one dropped out during the intervention, and 48 (90.6%) completed the study. No difference was found in the baseline characteristics between the two arms with the exception that the treatment arm had higher nicotine dependence scores [t_(1.51) = 2.30, p = .03] than the control arm. Seven day point-prevalence abstinence rates at 3 month follow-up were not found to differ between the two arms. However, the odds of achieving 3 month prolonged abstinence were four times greater (odds ratio = 4.23, 95% confidence interval = 1.10, 16.23) in the treatment arm than the control arm when the analysis was performed with those (n = 49, 92.5%) who received any part of the allotted intervention.

Conclusions

A digital storytelling intervention seems to be a valuable strategy to enhance the effect of conventional tobacco dependence treatment for women living with HIV. However, the underlying mechanism of the effect of digital storytelling necessitates further investigations in a large RCT.

Clinical Trials Registration No. NCT03289676

Women living with HIV who received a smoking cessation intervention via telehealth and a storytelling narrative communication video showing HIV infected women who successfully quit smoking are more likely to have a short-term abstinence than those who received the same smoking cessation intervention but no video.

Introduction

Despite the known detrimental effects of smoking, people living with HIV (PLWH) smoke at a rate nearly three times that of the general U.S. population (1,2). Presently, there is no evidence to support the effectiveness of tobacco dependence treatment for PLWH. According to a recent meta-analysis of smoking cessation studies conducted with PLWH, the pooled long-term abstinence rate of treatment conditions (e.g., a combination of intensive individualized counseling and pharmacotherapy) was found to be 8%, which was exactly the same for control conditions that usually received brief advice and pharmacotherapy (3). Both men and women living with HIV are found to smoke at rates similar to each other, but few smoking cessation studies have been conducted with women (4–6). Black women in the USA are disproportionately affected by HIV infection and confront significant impediments in accessing health care services due to factors such as a lack of transportation to a treatment center, housing instability, and social stigma (7,8).

Digital storytelling narrative communication as an intervention component is growing interest due to their effectiveness in delivering tailored messages to groups with specific health conditions. Stories conveyed by real persons facing similar health issues enable viewers to empathize and identify with the storytellers and consequently seek healthy behaviors (9,10). This approach helps increase emotional engagement and break down cognitive resistance through absorption in the storyline and identification with characters in the narratives (11). Only one smoking cessation study was identified that tested the effect of a digital storytelling intervention for smoking cessation, which was served as an augmentation of standard treatment (brief advice and pharmacotherapy) for African Americans, although it was not found to have a significant effect when compared with the standard treatment only (12).

The present study was conducted to test the preliminary efficacy of a digital storytelling intervention provided as an additive strategy to our manual-based video-call cessation counseling and nicotine replacement therapy (NRT) for women living with HIV (13). The study was guided by Bandura’s Self-Efficacy Theory (14). This theory postulates that self-efficacy is the driving force for behavioral change, and that belief in oneself that she or he can change the desired behavior is strengthened by the following four sources: performance accomplishment, vicarious experience, verbal persuasion, and physiological state. In this study, the digital storytelling intervention was implemented as a source of vicarious experience in order to increase self-efficacy.

Method

Research Design

The study, which was approved by the institutional review board of University of Massachusetts Boston, was a two-arm randomized controlled trial (Clinical Trials Registration No. NCT03289676) in order to test the preliminary efficacy of a digital storytelling intervention for smoking cessation in women living with HIV. All participants were offered (1) eight weekly video-call counseling sessions of smoking cessation, (2) nicotine patches or gum for 8 weeks, and (3) a storytelling narrative film. The only difference between the two arms of this study was the content of the film: participants in the treatment arm viewed a smoking cessation film in which six women living with HIV talk about their experience with quitting smoking. On the other hand, those in the control arm viewed an attention-control film wherein four women talk about their everyday lives before and after the diagnosis of HIV infection.

Participants

Participants included women who were: (a) able to provide documents supporting their HIV infection, (b) between the ages of 18 and 65, (c) English speakers, (d) smoking five or more cigarettes a day for the past 6 months, (e) able to access a video-call app such as IMO and Messenger, and (f) willing to use an approved form of birth control during the study period. Women were excluded if they were: (a) pregnant or lactating, (b) having an active skin disease, (c) reporting a history of serious mental illness such as schizophrenia and bipolar disorder, or (d) current users of any illegal substances except for marijuana.

Participants were recruited from all over the country between September 2017 and July 2018 by the following means: (a) online advertisements, (b) referrals from health care providers at HIV/AIDS treatment centers, and (c) snowball sampling. All participants were asked to send via telephone a photo of their recent blood work with CD4 and viral load counts in order to verify their HIV-seropositive status. They then received a photocopy of an informed consent form as a text message and replied to the text message by typing their name, date, and the following statement: “I have read the consent form and voluntarily agree to participate in this research study.”

Interventions

Participants were randomly assigned to either the treatment arm or the control arm, using computer-generated random numbers. The sequence of this assignment was blinded to the research team and participants. Notably, participants in both arms received the same counseling sessions and NRT and either the smoking cessation or the attention-control film that is further described in the next section. The therapists included the first and third authors of this paper who had completed a tobacco treatment specialist training program at an academic institution and a minimum of 40 hr practical training sessions. They provided counseling to either arm assigned at a random order. Counseling sessions were audio-taped and then randomly selected for fidelity assessment by a third person. The eight weekly counseling sessions and NRT were the same intervention components that had been implemented in our previous study (13).

Digital storytelling narrative intervention

The film for the treatment arm was created involving six Black women living with HIV who made powerful statements about why and how they quit smoking. The 18 min long film was named “Women in Search of Empowerment (WiSE).” It was sent to participants in four video clips with the following subheadings: “Made a decision to live,” “Bumps in the road,” “Believe in yourself,” and “Group reflection.” Meanwhile the attention-control film titled “Women’s Voices and Women’s Lives (WVWL)©” was divided into four video clips with the following subheadings: “Testing positive,” “Everything changed,” “Pleasing him,” and “Surviving” (15). Both films were matched in terms of running time (3–5 min per clip) and the number of clips (four video clips). Participants in both arms received the four video clips via text messages 1 day prior to the first counseling session, on the quit day, as well as a few days before 1 and 3 month follow-ups. Therapists asked participants whether they watched the videos and which part they liked most in order to facilitate participants’ compliance with the digital storytelling intervention. Therefore, the therapists were not blinded to the assigned condition.

Data Collection

Baseline assessment was conducted by a trained research assistant via a telephone interview and took approximately 28 min on average. Participants were followed on a monthly basis over a period of 3 months from quit day. These follow-up assessments were made via a telephone interview by one research assistant who was blinded to intervention condition. Smoking behavior including nicotine dependence and self-efficacy was assessed both at baseline and each follow-up. Participants received a gift card worth US$25 at baseline and each follow-up. They could earn up to US$225 by participating in baseline and three follow-up assessments and conducted a salivary cotinine test at 3 month follow-up.

Measures

Baseline data included (a) demographic information (e.g., race, ethnicity, and age), (b) HIV-related information (the year of HIV diagnosis, most recent CD4 counts, and viral loads), (c) smoking-related information (e.g., age at smoking onset and the number of cigarettes smoked per day on average), and (d) history of any illegal substance use. Self-reported importance of quitting smoking and confidence in quitting smoking were assessed on a 10-point ladder scale, with a lower score denoting less importance and less confidence. In addition, the following measures were used.

Fagerström test for nicotine dependence

This scale consists of six items assessing the intensity of physiological dependence on nicotine, with each item having a weighted score ranging from 0 to 3: two with 0 to 3 and the remaining four with 0 to 1 (16). The scale score can range from 0 to 10. The scale yielded a low Cronbach’s alpha at times, ranging from .55 to .74 due to the violation of tau equivalence that is assumed in the estimation of internal reliability (17,18). Nevertheless, the Fagerström test for nicotine dependence scale has been used widely in tobacco dependence treatment studies, and its Cronbach’s alpha was found to be .59 in the present study.

Self-efficacy in resisting smoking temptation scale

This scale examines participants’ confidence in resisting smoking temptation in nine specific situations (19). Each item score ranges from 1 (completely unconfident) to 5 (completely confident), and the scale score is the sum of each item score. A Cronbach’s alpha of .85 was obtained in the present study.

Smoking abstinence

Two types of abstinence were assessed: 7 day point-prevalence and 3 month prolonged abstinence. Seven day point-prevalence abstinence was the primary outcome of this study and defined as not having smoked a single puff during the past 7 days (20). Three month prolonged abstinence was defined as having been continuously abstinent for 3 months from quit day with the exception of the grace period of the first 2 weeks (20). It was assessed by asking participants as to whether they had smoked any single cigarette since last follow-up, and if they said “no,” it was further clarified by asking whether they had smoked any single cigarette following the grace period.

Abstinence at 3 month follow-up was verified with a salivary cotinine test using the NicAlert test strip (Nymox Pharmaceutical Corporation, Hasbrouck Heights, NJ) with the cutoff level of 0 (1–10 ng/mL) (21). Those who were missing at any follow-up or refused to perform the salivary cotinine test were treated as smokers. As the major proximate metabolite of nicotine, cotinine has a long half-life approximately 15–19 hr (22). The test kit was mailed to each participant who self-reported 7 day point-prevalence abstinence prior to testing. Participants conducted the test at home following instructions that were provided by a research assistant who remotely monitored the entire process through a video call. Detailed description of conducting the test and subsequently reading the result has been published elsewhere (23).

Narrative engagement scale

This scale assesses the extent to which a participant becomes engaged, transported, or immersed in storytellers’ narratives (11). The scale has 12 items with four subscales—Narrative Understanding, Attentional Focus, Narrative Presence, and Emotional Engagement. In turn, each subscale has three items, and the score of each item can range from “1” (strongly disagree) through “7” (strongly agree). The scale score is the mean score of three items of each subscale. This scale was administered only once at 3 month follow-up, and Cronbach’s alphas for four subscales were found to vary from .41 to .83. Narrative Presence and Emotional Engagement subscales yielded low alphas below .70.

Data Analyses

Data were analyzed using SPSS 25 (IBM, Armonk, NY). Baseline data were compared between both arms using independent t-tests for continuous variables and χ ² tests for categorical variables. Odds ratios (OR) with 95% confidence intervals (CI) were estimated for differences in 7 day point-prevalence and 3 month prolonged abstinence rates premised on the intent-to-treat analysis. Binary logistic regression analyses were performed to identify variables predicting cotinine-verified 7 day point-prevalence abstinence at 3 month follow-up. The interaction effect of self-efficacy with the intervention condition on smoking abstinence was analyzed via repeated-measures analysis of variance. The listwise deletion method was used to treat missing variables.

Results

Fifty-three women were recruited from 13 states. Participants in the treatment arm were found to have higher nicotine dependence scores on average when compared with the control arm [t_(1.51) = 2.30, p = .03, Table 1]. No other variables were found to differ between the two arms. Four participants in the treatment arm withdrew from the study before receiving any intervention (Fig. 1). Two withdrew due to a problem related to the installation of a video-call application, one due to the death of a family member, and the other due to change of mind. In contrast, none in the control arm withdrew from the study before initiating the intervention. None in the treatment arm, with the exception of the four women who withdrew before the start of the intervention, was lost to follow-up, whereas one in the control arm was lost to follow-up, yielding a 90.6% (48/53) retention rate.

Table 1.

Characteristics of the participants at baseline between the two arms

Variable (range)	Treatment (Na = 27)	Control (N = 26)	Total (N = 53)	p-value
	n (%) /Mean ± SDb	n (%) /Mean ± SD	n (%) /Mean ± SD
Age (31–65)	51.81 ± 7.02	50.92 ± 6.76	51.38 ± 6.84	0.64
Race/ethnicity				0.24
Black, non-Hispanic	21 (77.78%)	24 (92.31%)	45 (81.13%)
White, non-Hispanic	4 (14.81%)	2 (7.69%)	6 (11.32%)
Hispanic/all others	2 (7.4%)	0 (0.00%)	2 (3.8%)
Marital status				0.76
Single with never marriage	13 (48.15%)	10 (38.46%)	23 (43.39%)
Married or living with partner	4 (14.81%)	4 (15.38%)	8 (15.09%)
All others	10 (37.04%)	12 (46.15%)	22 (41.51%)
Employment (= yes)	4 (14.81%)	6 (23.08%)	10 (18.87%)	0.50
Educational level				0.99
<12 Grade	8 (29.63%)	8 (30.77%)	16 (30.19%)
High school or GED	6 (22.22%)	6 (23.08%)	12 (22.64%)
Some college education	13 (48.15%)	12 (46.15%)	25 (47.17%)
Years after HIV diagnosis (2–32)	21.11 ± 8.88	18.04 ± 8.09	19.60 ± 8.56	0.19
CD4 count (126–1585)	756.52 ± 340.60	727.85 ± 350.65	742.45 ± 342.53	0.76
Viral load (= detectable)	4 (14.81%)	5 (19.23%)	9 (16.98%)	0.73
Age at smoking onset (10–37)	17.78 ± 6.02	18.62 ± 6.51	18.19 ± 6.22	0.63
Number of cigarettes per day (6–41)	19.24 ± 11.37	15.37 ± 8.25	17.34 ± 10.06	0.16
Nicotine dependence (1–10)	6.19 ± 2.42	4.73 ± 2.16	5.47 ± 2.39	0.03
Serious quit attempt in the past year (= yes)	12 (44.4%)	15 (57.69%)	27 (50.94%)	0.41
History of illegal drug use (= yes)	17 (62.96%)	11 (42.31%)	28 (52.83%)	0.17
Self-efficacy in quitting (9–39)	20.55 ± 7.83	20.75 ± 5.30	20.64 ± 6.64	0.91
Importance of quitting	9.28 ± 0.27	9.33 ± 0.21	9.31 ± 0.17	0.90
Confidence in quitting	7.02 ± 0.56	7.62 ± 0.30	7.34 ± 0.30	0.34

Note: a = number, b = standard deviation.

Fig. 1.

CONSORT diagram showing a flow of participants in the study.

Among the 49 participants who received any part of the allotted intervention, the treatment and control arms had an average of 6.30 (standard deviation [SD] = 2.08) and 6.54 (SD = 1.84) counseling sessions and an average of 20.93 (SD =5.45) and 22.39 (SD = 5.90) min per session, respectively. Therefore, both arms demonstrated nearly the same rate of adherence to counseling sessions. On average, participants in the treatment and control arm reported use of 28.65 (SD = 17.99) and 27.15 (SD = 18.36) nicotine patches, respectively, and the difference was not found to be statistically significant. Participants in the treatment arm reported having watched an average of 3.83 (SD = 0.49) videos, whereas those in the control arm watched an average of 3.28 (SD = 1.24) videos, which had a marginal significance [t_{(1, 48)} = 1.97, p = .06). However, the mean scores of four subscales assessing narrative engagement did not reveal any difference between both arms (Table 2).

Table 2.

Comparison of narrative engagement scores by intervention condition

Narrative Engagement Subscale	Treatment Arm (Na=23) N (%)/Mb ± SDc	Control Arm (N = 23) N (%)/M ± SD	Total (N = 46) N (%)/M ± SD	p-value
Narrative Understanding	6.06 ± 1.35	6.43 ± 0.88	6.25 ± 1.15	0.39
Attentional Focus	5.91 ± 1.48	6.35 ± 1.14	6.13 ± 1.32	0.38
Narrative Presence	3.64 ± 1.62	3.74 ± 1.77	3.69 ± 1.68	0.83
Emotional Engagement	5.22 ± 1.32	5.22 ± 1.19	5.22 ± 1.24	0.99
Total	5.21 ± 0.67	5.43 ± 0.74	5.32 ± 0.71	0.32

Note: a = number, b = mean, c = standard deviation.

Abstinence rates by self-report and cotinine test are shown in Table 3, which did not reveal any difference between the two arms. Among the 49 (92.5%) participants who received any part of the intervention, 7 day point-prevalence abstinence rate at 3 month follow-up was 43.5% and 23.1% for the treatment arm and control arm, respectively, with the difference not being found to be significant. However, 3 month prolonged abstinence rates (43.5% vs. 15.4%) among the 49 did show a significant difference. The odds of achieving 3 month prolonged abstinence were four times (OR = 4.23, 95%, CI =1.10, 16.27) greater in the treatment arm when compared with the control arm.

Table 3.

Abstinence rates at follow-ups by treatment condition (N = 53)

Treatment condition	7-day Point-prevalence Abstinence Self-report                    Cotinine test				3-M prolonged abstinence Self-report and Cotinine test
	1-Ma F/Ub	2-M F/U	3-M F/U	3-M F/U	3-M F/U
Treatment arm	63.0%	74.1%	40.7%	37.0%	37.0%
Control arm	61.5%	57.7%	26.9%	23.1%	15.4%

Note: a= month, b = follow-up.

Self-efficacy scores in both arms showed a significant increase (all p’s < .001) during and after the intervention, but the increase was not found to differ between the two arms. Participants achieving 3 month prolonged abstinence had higher self-efficacy scores [F_(3,45) = 5.93, p = .001] than their counterparts even after controlling for their baseline self-efficacy scores. Neither the number of counseling session attended nor the number of nicotine patches used was a significant predictor of 3 month prolonged abstinence. The relationship between the number of videos viewed and 3 month prolonged abstinence approached statistical significance (OR =2.67, 95% CI = 0.91, 7.85, p = .08).

Discussion

To the best of our knowledge, the present study is the first pilot study that tested the efficacy of a digital storytelling intervention for smoking cessation in PLWH. It was found that women living with HIV who received the intervention allotted for the treatment arm were four times more likely to achieve 3 month prolonged abstinence than those in the control arm. The rates of cotinine-verified 7 day point-prevalence abstinence achieved by women in the treatment arm are relatively high when compared with those (e.g., 8%–13%) reported in previous studies (3,6). Most previous smoking cessation interventions conducted among PLWH that provided a combination of intensive cessation counseling and pharmacotherapy yielded no difference or a very small effect when compared with brief cessation advice and pharmacotherapy (3).

Self-reported 7 day point-prevalence abstinence rates were found to substantially decrease from the 2 to 3 month follow-up at which time participants were asked to perform a salivary cotinine test. Self-reported abstinence rates at the 3 month follow-up were higher for both arms than those verified with a cotinine test. All these findings are supportive of what we found in our previous studies with women living with HIV (13) and Korean American women (24). Since the public increasingly perceive smoking negatively, individuals participating in a smoking cessation study may be more likely than ever to underreport smoking, especially when they relapsed after an attempt to quit. Therefore, irrespective of sample size and treatment intensity, studies should conduct a biochemical test in order to verify self-reported abstinence.

Women in the treatment arm tended to view more videos than those in the control arm, and the relationship between the number of videos viewed and three-month prolonged abstinence was found to be marginally significant. These findings could be attributed to the fact that the women in the study were all living with HIV and hence, some of them could have been uninterested in viewing the attention-control film (WVWL). Contrastingly, those in the treatment arm were willing to view the WiSE film in order to get help for quitting smoking. However, among those who viewed either film, the score of Narrative Engagement Scale did not show any difference between both arms. Two factors could have played a role in this finding. First, there could be a possibility of recall bias because the scale was administered nearly 3 months after sending the first two videos. Second, some participants might have shared videos with others in a different arm, thus causing cross-contamination, although we repeatedly advised that they should avoid doing it.

Findings of the present study should be interpreted with caution. In addition to the aforementioned limitations, biochemical verification of self-reported abstinence was done only once at 3 month follow-up. Furthermore, the attention-control film contained narratives promoting healthy behaviors (15), which might have inadvertently affected the smoking behavior of women in the control arm. All women in the film were non-Hispanic black, which in turn could limit non-black women in fully identifying with the storytellers. Notably, we did not conduct a thorough assessment of the use of other tobacco products such as electronic cigarettes and smokeless tobacco at baseline and follow-ups, which could have affected cessation outcomes in this study. Lastly, 3 month follow-up might be a too short period to determine the actual effect of the storytelling intervention on abstinence.

The present study has several strengths. To begin with, the abstinence rate in the treatment arm was substantially higher when compared with the rates that were generally found among women living with HIV in previous studies (3–7). In addition, this study had a higher retention rate than our previous study that had a 64.3% retention rate (13), which might be attributed to the differences in incentive payment schedule and amount. Many researchers posit that PLWH, particularly women, require more intensive tobacco dependence treatment than standard treatment to be able to successfully quit smoking owing to their high level of nicotine dependence and psychiatric comorbidity (3–7).

Findings from the present study suggest that tobacco dependence treatment for women living with HIV may be effective if it provides intensive counseling, pharmacotherapy, and digital storytelling intervention. This is particularly true if the storytelling intervention is offered longitudinally as a booster session, because it is more likely to have a positive effect on the cessation outcome. In this regard, future research studies should test whether a digital storytelling intervention with intensive counseling plus pharmacotherapy will have any additive effect on smoking cessation in this population above and beyond standard tobacco dependence treatment, such as brief cessation advice and NRT.

Compliance with Ethical Standards

Authors’ Statement of Conflict of Interest and Adherence to Ethical Standards The authors declare that they have no conflict of interest.