An intervention “game” that included education, skills building, and an abstinence challenge proved to be an effective strategy for helping smokers kick the cigarette habit, even if they said they weren’t quite ready to quit, a randomized, clinical trial reported.

Close to one in five (18%) study participants who received nicotine-replacement therapy (NRT) and took part in the interactive smoking cessation game developed by the researchers had stopped smoking 6 months later, compared to one in ten (10%) study participants who received NRT alone (P=0.048).

Findings from the study, published Jan. 24 in JAMA Internal Medicine, show that cigarette smokers do not necessarily need to be highly motivated to benefit from smoking cessation interventions, according to researchers Thomas K. Houston, MD, of Wake Forest School of Medicine, Winston-Salem, North Carolina and Rajani Sadasivam, PhD, of University of Massachusetts Medical School, Worcester.

In an interview with BreakingMED, Houston and Sadasivam said the vast majority of people recruited for smoking cessation studies express a high motivation to quit. Socioeconomically vulnerable groups have also been underrepresented in the trials, even though smoking rates among these groups are much higher than among the general population.

Their intervention game, which they have named Take a Break, is designed to prepare cigarette smokers for quit attempts.

Their study included 433 adult, active smokers who answered a questionnaire designed to assess their motivation to quit smoking. Those who said they had set a quit date were excluded from the trial, while those who said they were not thinking about quitting or were thinking about it but had not set a quit date, were considered eligible.

“The research community and the clinical systems have largely been focused on people who express their readiness to quit, but a lot of smokers aren’t quite there yet,” Houston told BreakingMED. “The question has been, ’Should we wait until people say they are ready, or are there things we can do to help smokers along the path?”

Their 3-week ’Take a Break’ intervention included an initial week-long training period, followed by an abstinence challenge, in which participants set abstinence goals for the following 2 weeks.

The abstinence length could range from 0 to 14 days, but the participants were encouraged to limit their goal to a day or two during the challenge to increase their chances of success, Houston and Sadasivam said.

The first week of the intervention involved an initial 20- to 30-minutes telephone call with a smoking cessation coach, followed by daily motivational text messages and challenge quizzes designed to assess smoking intake. The motivational messages continued during subsequent weeks.

Participants got points for responding over the course of the initial week, and they were also encouraged to use relaxation and distraction apps during all 3 weeks and beyond to help them cope with cravings.

At the end of the 3-week study period, those with the highest participation received a gold medal and a $15 gift card; those with less participation received a silver medal and $10 gift card; and those who participated least got a bronze medal and $5 gift card. Participants could track their participation progress compared to others during the 3-week period.

“We utilized a number of gamification strategies such as rewarding small steps and making the intervention palatable,” Houston said.

Study outcomes included time to first quit attempt, as well as carbon monoxide level-verified smoking cessation at 6 months follow-up.

Roughly half (48%) the study participants were male, the average participant age was 54 years, and more than half (53%) completed all of the daily challenge quizzes during the first week.

Close to three out of four participants (73%) who completed the goal-setting call set a brief abstinence goal (generally 1-2 days) and a similar percentage reported using the relaxation/distraction mobile health apps to manage cigarette cravings.

Compared to the NRT-only study participants, those who participated in the Take a Break intervention:

  • Had shorter time to first quit attempt (hazard ratio, 1.68; 95% CI, 1.09-2.60; P=0.02).
  • Had significantly more quit attempts during the 6 month period (incidence ratio, 1.67; 95% CI, 1.26-2.20).
  • Had higher verified cigarette abstinence at 6 months (18% versus 10%; odds ratio, 1.92; 95% CI, 1.01-3.68; P=0.048).

“Sustaining engagement in interventions (especially digital health) is challenging, particularly for groups not yet ready for health behavior change,” the researchers wrote. “Take a Break adopted gamification as a strategy to engage participants, and was structured based on principles of designing gamified health behavior interventions.”


This research was funded by the National Institutes of Health and the National Heart, Lung and Blood Institute. Thomas reported receiving grants from the NIH, NHLBI, and the National Cancer Institute during the conduct of the study and advisory board member fees from the Minneapolis VA Medical Center unrelated to this research.



Salynn Boyles, Contributing Writer, BreakingMED™

Kaiser Health News

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.