BecomeAnEX: Digital Tobacco Cessation Intervention

Challenge: Smoking is the leading cause of preventable death, responsible for nearly 6 million deaths per year worldwide. Despite all we know about the health problems caused by using tobacco, people continue to smoke, dip, or chew. While two thirds of current smokers are interested in quitting, fewer than one third make their way to proven methods for quitting, with 95% unable to sustain their quit longer than 6 months.

Mission: An updated and improved user experience, grounded in tobacco dependence treatment guidelines and behavioral science, that promotes engagement, quit attempts, and ultimately, sustained quit rates.

Over the past 20 years, Truth Initiative has been leading the fight against Big Tobacco. From their iconic anti-tobacco campaigns and activism targeting youth, to public health research and policy, to evidence-based tobacco dependence treatment innovations, the Truth teams have been working tirelessly to shift the landscape of tobacco usage and improve public health. One such treatment innovation is the BecomeAnEx program, a digital tobacco cessation program developed in 2008 in collaboration with Mayo Clinic. As one of the longest running digital cessation programs, “EX” has supported over 800,000 people on their journey to quitting for good. Truth Initiative’s Innovations Team enlisted Mad*Pow to conceptualize an unrestrained future vision of digital cessation and then execute on the first step of the plan by redesigning the BecomeAnEx program.

Methodology: Digital interventions have the potential for enormous public health impact given their broad reach and consistent delivery of the content, features, tone, and functionality intended to change offscreen behaviors. However, most users engage only minimally with even the best designed websites and apps, diminishing the potential for impact due to insufficient engagement and exposure. Our future vision work and near-term implementation needed to focus on delivering a redesigned cessation experience that effectively supports and engages every user along the spectrum of quitting, from being uncertain about quitting, to actively trying to quit, to maintaining a life-long quit.

The first step in our approach was to immerse the Mad*Pow team in a discovery phase so every member could better understand the experience of attempting to quit smoking; the cues and cravings associated with having a cigarette; the evidence base and success rates underpinning different intervention techniques commonly used to assist quitting; and the specific strategies used by BecomeAnEx to support users along their quit journey along with what usage data showed people engaged with and how helpful/unhelpful people thought certain features, functions, and content were in building their resolve to not smoke. We did this through a series of semi-structured interviews with current and former smokers, both that had used BecomeAnEx, successfully or not, those who had not yet tried to quit, and those that had adopted other methods to assist in their quit attempts. Other important research included performing usability and desirability tests on the current site, rapid evidence review integrating Truth Initiative research and Cochrane database review, a behavior change techniques and content audit of the existing site and text message platform, and interviews and close collaboration with extended Truth Initiative and Mayo Clinic teams throughout the project.

The core findings from our formative research indicated that the digital intervention needed to be adapted from a desktop only experience to a responsive mobile design to better support smokers in the moment when they experience cravings. Our future vision supported a contextually-aware, dynamic, machine-learning, based approach that could deliver highly tailored and just-in-time interventions to each individual user while our near-term redesign focused on ensuring that users could self-identify where they were on their quit journey, their level of nicotine dependence, their motivation for quitting, and their potential barriers and supports for making and/or maintaining a quit attempt. To maximize users accessing and engaging with the most relevant support methods, it was critical for us to improve the overall site navigation and content hierarchy, along with reworking the visual aesthetic and content tonality.

From an intervention perspective, it was important for us to acknowledge that most, if not all, smokers have an understanding about the negative consequences of smoking and have “heard it all before” but may not know what is triggering their urge to smoke, what they can do to reduce those urges when they occur, and how to build resolve and stay motived to quit when slips and setbacks occur.

Empowering smokers to break the craving cycle required us to prioritize expert advice, quit aids, tools, and motivational support to individuals based on their personal profile and where they were in their cessation journey. The core components of the redesigned digital intervention consist of:

1. The EX Plan, which is a self-paced and self-guided, interactive quit plan containing educational and skills-building content and tools based on national treatment guidelines and Mayo Clinic protocols. The EX plan helps build motivation and confidence to quit through setting a quit date, identifying smoking triggers and preparing If/Then plans to avoid or counter identified trigger events. Both active and passive content are provided to help smokers develop positive coping strategies to deal with stress, cravings, weight gain, interpersonal conflict, and relapses. The interventions empathic voice-and-tone treats each lapse as an opportunity to accept the challenges of quitting smoking, learn a new tactic, and try again.
2. Proactive Messaging, through tailored email campaigns, and two-way text messaging is used to help drive effective engagement with the platform. Tailored messaging support is available to support users through all stages of the quitting journey, even if they haven’t decided to set a quit date yet. Individuals in earlier phases receive motivational/decisional-support to quit smoking, while those making a quit attempt receive personalized tips and motivational messaging, on-demand support for cravings, relapse, or stress, tailored support for medication use and adherences, and specialized content for pregnant women and new mothers.
3. EX Community provides social support from peers and experts through an online forum, public post’s on member profile ‘wall’ pages, direct messaging, or blog post comment threads. The EX Community is one of the largest and most active online social networks dedicated to quitting tobacco and Truth Initiative Innovation team research suggest that EX’s social interactions lead to improved quitting outcomes. Smokers who get involved in the community are more than twice as likely to quit as smokers who don’t participate. In terms of engagement, the improved quit rates seem to be strongest for those who actively post and engage with others (21% of active users remain quit after 3 months) compared to those with more passive engagement such as simply reading others’ posts (11% of “lurkers” remain quit after 3 months).
4. Quit Aides such as Nicotine Replacement Therapies (NRT) and prescription medications can double a person’s chances of quitting for good but many smokers are hesitant to include them as part of their quitting plan. Our redesign sought to provide a clear path to access – Truth Initiative has a partnership with GlazoSmithKline to ship medications directly to EX user’s homes in time for their quit date -  and to dispel myths and misperceptions about what may be most effective (e.g., NRT, medication, counseling) or not effective (e.g., acupuncture, hypnosis) in maintaining a quit attempt.
5. EX Coaching rounds out the core components of the 2018 redesign and was rolled out after an initial soft-launch period. BecomeAnEX provides unlimited access to tobacco treatment specialists through a digital chat interface. EX Coaches are there to help support users throughout their quit experience from building confidence and motivation, to choosing the right medication and dosage, coordinating delivery, helping choose a quit date and counseling on managing cravings and stress to keep their quit. The added human element also plays a crucial role for assisting users with lower reading or computer literacy levels making EX a more inclusive experience.

Outcomes: Ongoing evaluation is an integral part of the intervention design process and Truth Initiative utilizes both federally funded research efforts and regular monitoring and testing to better determine “what works for whom” when it comes to digital engagement and tobacco cessation. Research studies involving the redesigned BecomeAnEX have demonstrated that the combination of evidence-based cessation techniques, quit-aid provision, and social support delivered through an online program can enhance digital engagement, adherence to core treatment components, and cessation rates. From an engagement perspective, target behaviors and digital actions we wanted to enable or increase through our redesign were: Setting a quit date from which point no further cigarettes will be smoked increased 32% (up from 64% to 96% of users); Reflecting on personal reasons for quitting and entering them into a user profile in order to strengthen motivational resources increased 43% (up from 3% to 47% of users); Tracking cigarette usage to identify triggers and patterns of use and engage in targeted strategies to counter those patterns increased 27% (up from 19% to 46% of users); Opting-in to text messages to receive tailored proactive and on-demand support increased 12% (up from 64% to 76% of users); Visiting the community as a new user increased from increased 8% (up from 19% to 27%); and finally 50% of smokers are using an NRT through BecomeAnEX as part of their treatment.

Conclusion: Nicotine use is a complex addiction that requires specialized treatment tailored to the individual. The evidence-based treatments delivered by BecomeAnEX aim to balance presenting what is known to promote abstinence for most smokers, with flexibility and choice for users to decide for themselves when and how they want to quit. The redesigned EX lays the foundation of a credible and effective digital intervention and sets the stage for future enhancements that will bring the best of what science and technology can offer to support all smokers in any stage of their quit journey.