Smartphones become personal health coaches

In absence of national smoking "quit-line" omnipresent cellphones, websites become cheap, easy ways to help smokers kick habit.

By JUDY SIEGEL-ITZKOVICH
smoking (illustrative) (photo credit: Thinkstock/Imagebank)
smoking (illustrative)
(photo credit: Thinkstock/Imagebank)
Most Israelis love their smartphones and feel lost without them, while their Internet use is among the heaviest in the world. So it would seem very logical that these technologies, which can also have a downside, would be used for good – to motivate the million residents over 21 (and tens of thousands of younger ones) to kick the tobacco habit.
What’s the connection? The deadly nicotine in tobacco is so addictive and habit forming that smokers quickly become both physically and psychologically hooked, making it very difficult to quit. As the Health Ministry has declined to provide a phone “quit-line” – making Israel the only developed nation to lack such a state service – automated services have been developed through smartphone “apps” and websites for those who want to give up smoking or have recently done so. They are hugely popular in the US and some other parts of the world.
Now a US expert on using digital technology to promote smoking cessation is here on a three-month sabbatical at the Hadassah-Hebrew University Braun School for Public Health and Community Medicine in Jerusalem, working on creating such a model for Israeli smokers.
Prof. Lorien Abroms has developed during her stay an Israeli version of the text-messaging program called Text2Quit for local smokers. An associate professor of prevention and community health at George Washington University’s School of Public Health and Health Service in Washington, DC, Abroms was the guest speaker at a recent symposium at Hadassah University Medical Center in Ein Kerem.
The title was “Smoking Cessation Through the Use of Modern Media” and the symposium was attended by about 100 people in the public health field.
“As a tourist, I have noticed that Israelis eat well, are very good in English and love their technology – especially their cellphones. So there are good opportunities here for reducing smoking rates and second-hand smoke exposure. Health-related services delivered by mobile communications devices – known as mHealth – can advance research, prevent disease, enhance diagnostics, improve treatment, reduce disparities, increase access to health services and lower healthcare costs in ways previous unimaginable,” she continued.
“The UN has even created the m-Health Alliance especially to promote the technology in developing countries.
One can go to a remote African village where there is no running water. But it is likely that even some people have cellphones there.”
Of the 91 percent of Israelis who have at least one cellphone, 68% of the devices are the more expensive smartphones.
“They’ve infiltrated our lives. A survey has shown that 82% of Americans never leave home without their cellphones, 68% sleep with the phone at their bedside. We’re almost married to them,” declared the US expert. “The reach of mHealth programs are scalable; one can start small on a local basis and then expand to be a national service. The price is low, cheaper than other public health alternatives and even cheaper than smoking quit-lines that are manned by humans around the clock.”
Smokers can easily enroll in such services. The Amazon bookselling site has patented one-click shopping, storing all the purchase details and requiring customers to click a computer mouse only once to order a book. One can now do the same thing on a smartphone to enroll in a smoking-cessation program.
Even before there were smartphones, New Zealand health authorities began to offer in 2008 the ability to send and receive text messages; Australia followed, and the US now has two such free services, Text2Quit and SmokefreeTXT.
Smokers can contact them anytime to receive interactive messages if they feel the urge to light up but want to fight the nicotine cravings.
“I work with pregnant smokers. They suffer a lot of stigma, as they don’t like to admit they smoke and can harm their fetuses. With smartphone messages, the service can be unobtrusive and confidential. Nobody will single them out. And as smokers often light up when they’re on their cellphone, learning to change health behaviors from the phone is perfect.”
It’s like having a health coach in your pocket. Instead of going to a doctor for an appointment to discuss quitting smoking, one can learn how to do it, set goals and get feedback on one’s performance around the clock.
Among the text messages are encouragement such as “By not smoking since Thursday, you have saved NIS 80,” or you will live at least two days longer by not lighting up.”
Smokers who quit but were overwhelmed and had the urge to buy cigarettes can even get a human “buddy” who would talk them out of it any time of the day or night. The technology can work well for other health behaviors including weight loss and diabetes management.
A study using ordinary text messaging to quit smoking that was published in The Lancet included 5,800 people and a control group. They received five messages a day for five weeks, then three daily for 26 weeks. Saliva samples were tested for cotinine, a substance that shows a person smoked recently.
Thanks to the text messaging, 10.7% stopped smoking, compared to only 4.9% in the control group that lacked this service. While this is not extremely high, conceded Abroms, it was higher than other interventions. It reaches a lot of people, so it can have an important impact. There were published studies since then, giving enough evidence to recommend mobile phone-based interventions.
Studies showing the effect of smartphone apps for smoking cessation have not yet been published, but she is certain that they will be shown just as effective or even more so.
“In 2009, there were 47 such apps available through the iPhone,” Abroms reported. “Today, there are over 200 for iPhone and a similar number for Android phones.” Some of them offer “hypnosis by smartphone,” but the George Washington University professor said she doubted that this would be effective.
“Apps could take better advantage of social networking.
But we have shown that text messaging on any cellular phone works well to promote smoking cessation.
Most participants say they give them confidence.
They liked the regularity of texts and information sent to them and to pass the quit date they had committed themselves to observe. It’s as if somebody is with you.
It gives good ideas on fighting cravings.”
The Israeli version of Text2Quit that Abroms has developed here, called the iStopSmoke program, was produced in English rather than Hebrew to save money while checking feasibility and user preference.
Thus English-speaking Israeli smokers over 18 were recruited for a pilot study to see how the US version had to be adapted for locals.
“There is no human support now, as it is all computer generated, with text messages and alerts to guide behavior change. But if a smoker tells the smartphone that they lapsed, they could be connected to a human they could speak to,” she concluded.
“As Israel is way ahead of the US in universal digital medical records in the health funds, these services could be very effective. The future for the use of such smoking cessation technology is very bright. The country can be a real world leader in smoking cessation.
Doctors will be able to see on your electronic medical file if you are a smoker and want to quit. Then you would need only one click to join. We hope to have quitline information on cigarette packs. The same thing can be done on Text2Quit.”
It was at the symposium that Hadassah Medical Organization director-general Prof. Ehud Kokia and Hebrew University Medical Faculty dean Prof. Eran Leitersdorf announced that the Ein Kerem campus will voluntarily be totally smoke free in three years, the first public notobacco zone in the country.
“It’s not simple,” said Kokia, “but we are working on it. The electronic media are different, and we have to learn how to use them for this purpose.”
Leitersdorf added that a few months ago, the university and Hadassah announced that the outdoor Ben-Gurion Square was officially smoke free, even though the law then did not bar it.
“We installed signs, and I often look out the window to check if it was being observed. I saw a pharmacy student smoking near the signs. I pointed to to them, and she said: ‘Very interesting!’ When I ask smokers if they saw the warnings, they say: ‘I got used to it’ or ‘It’s good that it says so!’ So there is a way to go. Staffers who smoke will in three years no longer be able to leave the buildings on campus and take a smoke. They will have to wait until they leave the area.”
But making Hadassah’s Mount Scopus hospital campus smoke free will certainly take longer, as half of all patients are Arabs due to the east Jerusalem location, and 44% of Arab men are addicted to tobacco.
Health Ministry public health chief Prof. Itamar Grotto confessed, to the shock of the audience, that he was a smoker himself – until he was asked during an interviewed by Army Radio journalist Razi Barkai whether he smoked. He was head of the IDF medical branch at the time.
“I said I didn’t, too embarrassed to admit that I did.
The soldiers I worked with were shocked when I threw my pack of cigarettes into the garbage can, and I never smoked since,” he recalled. “It was real shock therapy.”
Dr. Shani Afek, chairman of the Medical Society for Smoking Prevention and Cessation, noted that from his experience, changing health behavior is very complicated.
Smoking cessation through technology is still young, he said.
“Our society will continue to promote quitting smoking in every way. Our skills have to grow with experience and technology.”
School of Public Health dean Prof. Orly Manor said that the future smoking ban on campus is a stage in her school’s program to promote public health among students and staff. She too admitted that she started smoking as a postdoctoral student in England in her 30s but quit.
Dr. Haggai Levine, a researcher at Manor’s school with a special emphasis on smoking cessation, conducted a live poll of the audience using special broadcast devices and found that 85% of those present thought medical professionals must give the public a personal example and not be smokers.
With the Health Ministry abandoning its responsibility for a quit-line, only Maccabi Health Services has offered such a telephone service for its own members since 2009.
“It’s not in the basket of health services,” said Haim Filosof, director of Maccabi’s quit-line. “It is free for members but at our expense. We would be happy if it became a national service provided by the government.
When we thought of launching ours, we worried at first, as a lot of eyebrows were raised about using it, but it works very successfully. The best part is that it’s anonymous; the person who answers the call doesn’t see the smoker or know his name. It is not threatening.
“Our aim is to raise the number of Maccabi members who are smokers and want to quit by 30% to 1,000 members a year. We took on Pfizer, which makes Champix, the drug to help people quit, as a strategic partner. Sixty percent of smokers we contacted said they would join a quit-line if we had one.”
The health fund doctor is updated on the results of the counseling by phone. The Maccabi cessation adviser calls the patient every week. Members who enroll receive a coupon for a two-week supply of nicotine patches, but few have used them. The conversations average 20 minutes each. Maccabi, who which has so far handled only 2,800 people under the program, with 200 new requests every month, realizes that it’s only a drop in the bucket. But every member who quits smoking means a healthier person and fewer medical expenses.
Of those who finish the quit-line course, about two-thirds actually quit, and of these, about 45% are still tobacco free a year later. Maccabi hopes to add a website for smoking cessation as well.


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