Overview

  • This intervention sent proactive text messages with behavioral advice for primary care patients in an effort to support smoking cessation in all smokers, including those not actively seeking treatment.  

Organization Name

Massachusetts General Hospital (MGH)

Organization Type
  • Academic Medical Center
  • Community health center
National/Policy Context

  • Less than one ­third of smokers in the US use any assistance (pharmacologic or behavioral) when they try to quit smoking.
  • Text messaging shows promise as a means for assisting smokers in quitting via delivery of behavioral advice. Previous text messaging studies’ scopes have been limited to those seeking treatment.
  • In the United States, 80% of smokers report that they are not ready to quit in the next 30 days. Yet, smokers who are not ready to quit report substantial interest in mobile health interventions. Proactive models allow health systems to reach out to all smokers, not just those seeking treatment.
  • Primary care practices are well positioned to promote smoking cessation because 70% of smokers visit a physician each year. However, although physicians often recommend quitting during visits, competing priorities and time constraints prevent them from offering further assistance. Thus, new proactive models of care delivery are being developed for smokers.

Patient Population Served and Payor Information

  • In 2016-2017 at MGH, 42% of patients had Medicare, 16% had Medicaid, and 31% had private insurance.

Funding

  • This project was funded by Partners Health Care System, Inc.
  • Gina Kruse, MPH, MD, has been supported by the National Cancer Institute grant #5 R25 CA 0571120 for a postdoctoral fellowship, Harvard School of Public Health, Dept of Social and Behavioral Sciences and the National Institute on Drug Abuse grant #K23 DA 038717.

Tools or Products Developed

  • GetReady2Quit (R2Q): a text messaging program designed by the research team that includes content for both smokers ready to quit in the next 30 days and also smokers not ready to quit within that time period.

Training

  • No specific training was required for this project.

Workflow Steps

  • PCPs were asked to screen potentially eligible patients using the EHR.
    • Inclusion criteria for this study included smokers receiving primary care at Massachusetts General Hospital­ affiliated community health centers in Charlestown and Revere, Massachusetts. Participants also were required to have a primary language of English, be age 18 years and older, a current smoker, and with a mobile telephone number.
  • The eligible patients were sent an opt­-out letter informing them of the study’s purpose and logistics and letting them know that they would be sent a text message in the next week unless they called to opt out.
  • Patients who did not opt out were sent a single text message inviting them to opt in to the R2Q program. Opting in was considered to be consent.
  • All participants were sent four text message queries assessing nicotine dependence, readiness to quit, and a quit date. These text messages determined whether or not participants were thought to be ready to quit in the next 30 days or not.
    • For smokers ready to quit in the next 30 days:
      • The downloadable QuitNowTXT library was used. QuitNowTXT includes 118 messages delivered over 6 weeks tailored to a user ­entered quit date. These messages include behavioral advice and motivational and educational messages about the harms of tobacco and the benefits of quitting. The program has limited two-way communication including keywords to request help by texting “CRAVE,” “MOOD,” or “SLIP.”
      • There were also weekly smoking status assessment messages that invited a user response. If a user did not respond to an assessment, no further messages were sent. Maximum message volume was 25 messages per week with the highest volume in the two weeks before and after the quit date.
    • For smokers who were not ready to quit in the next 30 days:
      • 31 novel messages were sent to these patients. Content included 16 motivational messages to encourage individuals to identify personal reasons for change and internal motivations to quit. 15 messages encouraged smokers to try a practice quit attempt explained as an attempt to not smoke for hours or days without a commitment to stop for good.
      • This group was sent three to five messages per week. At the end of this message campaign, users were asked again if they were ready to quit in the next 30 days. Those that were ready were sent the QuitNowTXT messages. Those that were not ready were sent a final recommendation to contact their doctor or the state quitline.

Budget Details

  • Time spent by PCPs reviewing EHRs to determine those eligible for the program
  • Time spent developing R2Q text messaging service
  • Time spent monitoring technology

Where We Are

  • The intervention took place between March 2014 and June 2015.

Outcomes

  • The research team used portions of the Reach Effectiveness Adoption Implementation Maintenance (RE­ AIM) methodology to measure program reach, engagement, and adoption.
      • Reach: Defined as the proportion of users sent a proactive text invitation who opted in
        • Among 949 eligible smokers, 88 (9.3%) enrolled after receiving a single proactive text message.
        • 28% (19/67) of enrollees reported they were not ready to quit in the next 30 days, 61% (41/67) were ready to quit, and 11% (7/67) already quit.
      • Engagement: Measured as sending one or more keywords to the server.
        • Of current smokers, 25% (15/60) sent one or more keyword requests to the server. These requests did not differ by readiness to quit.
      • Adoption: Defined as days in the text messaging program before the participant texted “STOP” or failed to respond to an assessment message.
  • Among current smokers, the median time in the program was 9 days (interquartile range 2­32 days). The median time did not differ by readiness to quit.

Benefits

  • A text messaging program targeting primary care patients who smoke reached as many smokers with a single text as more intense and costly telephone calls­ or mail-based outreach methods.
  • This method engaged both smokers ready to quit and those not ready to quit, showing promise as part of a proactive care model for addressing smoking in primary care populations.

Unique Challenges

  • The research team did not have enough resources to assess smoking outcomes or receipt of text messages and therefore could not account for invalid telephone numbers or failed message delivery.

Sources

Innovators
  • Gina Kruse, MD MPH
  • Nancy A Rigotti, MD
  • Karen Chase, BA
  • Jennifer HK Kelley, RN, MSN
Editors
  • Jennifer Kizza, BA
Location

Boston, MA

Talk to the Innovators