Yes, there’s an app for that, but does it work?

Do they REALLY work? iPhone apps in the health & fitness, lifestyle, and medical categories account for 7.7% of downloads* and promise to help you get fit, lose weight, quit smoking, improve your sleep, among many other benefits. In a recently published paper in the American Journal of Preventive Medicine, Lorien Abroms and colleagues at George Washington University School of Public Health set out to determine if iPhone apps for smoking cessation followed established best practice guidelines for treating tobacco dependence (1).

As I’ve dicussed in previous posts, iPhone and other smartphone applications have the potential to support behaviour change, for smoking and other health related lifestyle factors. The ability to track behaviours (e.g. number and time of cigarettes smoked), monitor outcomes (e.g. the amount of money saved since quitting), or send reminders are some of the means by which phones can help create new feedback loops that facilitate making healthy lifestyle choices. At present, there is limited research examining if these apps will meet the promises they make. What is the quality of content provided by these apps? This is the question asked by Abroms and colleagues.

For the study, the authors identified 47 apps for the iPhone aimed at helping individuals quit smoking. Apps were categorized based on the method used to support smoking cessation, including:

  • calculators: apps that count money saved or tracked health benefits of quitting
  • calendars: keep record of the number of days since quitting
  • hyponosis: provided hypnotic therapy
  • rationing: limits cigarettes, times and places to smoke, to help slowly decrease dependency
  • other: apps that did not fit into any of the above categories

To determine if the content of these apps was likely to be beneficial to those that download and use the apps, the authors compared the apps features and functions to the 2008 U.S. Public Health Service Clinical Practice Guidelines for Treating Tobacco Use and Dependence. Using an index of 20 items, modified from Bock et al., (2), each app was ranked on a scale of 0-3, where 0 indicated the guideline was not present in the app and a score of 3 indicated it was fully present, giving a maximum possible score of 60 points. Factors used to assess the quality of content included establishing initial tobacco use status, assessing willingness to quit, helping establish a plan, incorporating strategies to enhance motivation, referring users to a quit line, and recommending counseling and medication.

The highest score for adherence was 30 (going to Quit Smoking-Cold Turkey), a mere half of the maximum possible. The average score for all apps was 7.8. Several apps scored zero. Of the different strategies, calculator type apps were the most likely to adhere to some of the guidelines. The authors also looked at the popularity of each app, finding that the apps that were most frequently downloaded were also the ones with the lowest adherence to established smoking cessation guidelines.

What does this mean? The bottom line is that while mobile technologies hold the promise of tremendous opportunity to help individuals change health behaviours, current apps promoting support for tobacco cessation fail to follow evidence based guidelines. A next step might be to conduct an intervention to further study a smaller selection of the identified apps. The current paper also did not assess usability, an important determinant affecting regular use of an app. Additionally, these results highlight an opportunity for developing an app that is based on established best practice guidelines. For now, those looking to quit smoking may be best off with established programs, such as these resources provided by Health Canada.

*as of May 16, 2011
Abroms LC, Padmanabhan N, Thaweethai L, & Phillips T (2011). iPhone Apps for Smoking Cessation A Content Analysis. American Journal of Preventive Medicine, 40 (3), 279-85 PMID: 21335258

2. Bock B, Graham A, Sciamanna C, et al. (2004) Smoking cessation treatment on the Internet: content, quality, and usability. Nicotine & Tobacco Research: Official Journal of the Society for Research on Nicotine and Tobacco, 6(2):207-19. PMID: 15203794

Image from Flickr by meddygarnety

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9 Responses to Yes, there’s an app for that, but does it work?

  1. Pablo Chang says:

    Just a quick thought about the low adherence rating of the non-calculator apps. When i first read the list of app categories, the calculator seemed the least likely to work (aside from the hypnosis one which seems kind of hokey). The apps in the rationing category, to me, seemed like they would be the most effective because it provided calculated reductions in smoking frequency. Instead of cold turkey it would seemingly help ween the smoker off cigarettes. Perhaps the face validity is high for this app which makes it more popular than the calculator apps.

    Mobile apps clearly have the potential to be viable and valid means to help smokers quit. Perhaps anti-smoking, public health and/or cancer advocacy groups should work together to make an app that actually adheres to the guidelines to see how effective it would be.

    • pennydeck says:

      Hi Pablo! Thanks for your comment.

      I think a key idea that the “calculator” type apps might tap into is motivation, perhaps appealing to the individual’s emotional side. An analogy discussed by Chip and Dan Heath in their book “Switch: How to Change when Change is Hard” is that of an elephant and its rider. While slowly cutting down and rationoing out cigarettes works for the rational rider, the large emotional elephant is hard to convince to change course. Reminders of health benefits (e.g. improved sense of taste, less difficulty breathing, etc..) and money saved may provide that emotional connection and engage the elephant.

      Note though that this study did not actually assess the effectiveness of the apps in a smoking cessation intervention, it just compared how well they followed recommended best practices for quitting smoking.

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  5. Hils says:

    Of course, the assumption that apps that don’t adhere to guidelines won’t work only holds if the guidelines themselves work. Given that the most common method of quitting smoking reported by successful quitters is by simply stopping, without the aid of interventions such as “assessing willingness to quit, helping establish a plan, incorporating strategies to enhance motivation, referring users to a quit line, and recommending counseling and medication”, this is questionable.

    In any event, why would a phone app need to assess willingness to quit? The fact that someone has downloaded and installed the damn thing is evidence enough of that.

    • pennydeck says:

      Yes, about 50% of smokers report that their descision to quite was “unplanned” and evidence suggests that this is more successful that planned attempts (West, 2006: Still, there remains the other 50% – what’s the best way to help these individuals?
      For some, I sure that downloading the app is sufficient evidence of willingness to quit, but not for all (based in behaviour change theories such as the Transtheoretical model).

  6. LKL says:

    I hope that this study isn’t used to tar all ‘health-and-fitness’ apps; I used a weight-loss app to lose 55 lbs year before last, and have maintained a 50 lb reduction since then with the help of the same app. A friend I recommended the app to has lost a similar amount of weight.

    • pennydeck says:

      I doubt it 🙂 This study was focussed specifically on smoking cessation apps so it would be a stretch to apply to others. We’re actually in the process of reviewing “health and fitness” apps that advertise themselves as promoting weight loss. So far we’ve identified over 1000(!) and we’re in the process of categorizing them based on functions. We’ll be comparing their functions to recommended best practices for weight loss (as based on clinical practice guidelines, behaviour change theories, and practices of successful weight loss maintainers). We’re still in the preliminary stage, but there are certainly some apps that provide the potential for the right support.

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