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A Mobile Game to Support Smoking Cessation: Prototype Assessment

A Mobile Game to Support Smoking Cessation: Prototype Assessment Background: Cigarette smoking results in an estimated seven million deaths annually. Almost half of all smokers attempt to quit each year, yet only approximately 6% are successful. Although there are multiple effective interventions that can increase these odds, substantial room remains for improvement. One effective approach to helping smokers quit is contingency management, where quitting is incentivized with the delivery of monetary rewards in exchange for objective evidence (eg, exhaled carbon monoxide levels) of abstinence. Objective: We assessed the feasibility and promise of Inspired, a contingency management mobile app for smoking cessation that uses game-based rewards to incentivize abstinence from smoking instead of the monetary (or material) rewards typically used. We sought participant feedback and limited objective data on: the features and design of Inspired, interest in using Inspired when it becomes available, the likelihood of Inspired being an effective cessation aid, and the rank order preference of Inspired relative to other familiar smoking cessation aids. Methods: Twenty-eight treatment-seeking smokers participated in this study. Participants attended a single one-hour session in which they received an overview of the goals of the Inspired mobile game, practiced submitting breath carbon monoxide (CO) samples, and played representative levels of the game. Participants were then told that they could play an extra level, or they could stop, complete an outcome survey, receive payment, and be dismissed. A sign-up sheet requesting personal contact information was available for those who wished to be notified when the full version of Inspired becomes available. Results: Using binary criteria for endorsement, participants indicated that, assuming it was currently available and fully developed, they would be more likely to use Inspired than: any other smoking cessation aid (21/28, 75%), the nicotine patch (23/28, 82%), a drug designed to reduce smoking cravings (23/28, 82%), or a program involving attendance in training sessions or support group meetings (27/28, 96%). In the questionnaire, participants indicated that both the Inspired program (26/28, 93%) and the Inspired game would be “Fun” (28/28, 100%), and 71% (20/28) reported that the program would help them personally quit smoking. Fifty-eight percent of participants (15/26) chose to continue playing the game rather than immediately collecting payment for participation and leaving. Eighty-two percent of participants (23/28) signed up to be notified when the full version of Inspired becomes available. Conclusions: This was the first study to evaluate a game-based contingency management app that uses game-based virtual goods as rewards for smoking abstinence. The outcomes suggest that the completed app has potential to be an effective smoking cessation aid that would be widely adopted by smokers wishing to quit. (JMIR Serious Games 2018;6(2):e11) doi: 10.2196/games.9599 http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al KEYWORDS smoking; smoking cessation; contingency management; mobile apps; virtual rewards; health games; video games; digital games; carbon monoxide; incentives CM procedures require biochemical verification of abstinence Introduction because participants are much more likely to falsify self-reports when rewards are delivered contingent on abstinence [19]. Worldwide, cigarette-smoking–related death and illness are Carbon monoxide (CO) is one method to biochemically verify leading public health concerns, resulting in an estimated seven abstinence; however, the half-life of CO is short (approximately million deaths each year [1]. There are almost one billion 3-6 hours), requiring at least twice-daily check-ins to verify smokers worldwide [1]. Thus, smoking cessation is a critical, abstinence [20]. To address this barrier, Dallery and colleagues worldwide public health concern [2]. developed an efficacious CM intervention that is delivered over Many efficacious smoking cessation interventions have been the internet [11,17,21,22], in which participants are provided developed, yet ample room remains for improvement. Each with a breath CO monitor, and remotely record and submit video year, one-third to one-half of all smokers attempt to quit at least clips of themselves providing their breath CO samples. More once [3], but the annual incidence of successful quitting is less recently, mobile CM for smoking cessation (where participants than 5% [4]. Media campaigns and cessation programs can use the camera on their smartphone to record and submit the increase quit attempts and successful cessation rates, video clips) has been shown to be feasible, acceptable, and respectively, by a margin of nearly 50% [3,5]. Smoking efficacious in supporting smoking abstinence [23-25]. However, cessation rates that are better than those obtained with a placebo even these internet and mobile CM interventions rely on are achieved with: physician advice; counseling by health monetary incentives to support abstinence; thus, cost remains professionals; a variety of cognitive-behavioral, social-influence, a barrier to widespread dissemination. and motivation-enhancement cessation programs; and drug To directly address the remaining barriers for widely treatments, including nicotine replacement therapies (gum, disseminating CM (ie, cost and sustainability), we proposed to patch, spray, lozenge, and inhaler), selected antidepressant develop a mobile game–based CM intervention for smoking therapies (eg, bupropion), and nicotinic receptor agonist therapy cessation. As with existing mobile CM for smoking cessation, (varenicline) [5,6]. Nevertheless, nearly 80% of smokers who participants would be provided with a breath CO monitor and attempt to quit do so without the assistance of any of these required to remotely record and submit video clips of themselves approaches [7]. Half or more consider counseling and cessation providing their breath CO samples twice daily. In our proposed programs ineffective, and over a third consider pharmacotherapy mobile app, the monetary rewards typically used to incentivize ineffective [8]. Most young smokers report they would never bio-verified abstinence will be replaced with in-game use any of these methods, other than the nicotine patch (which virtual-good rewards that can immediately be used to help only 50% would use) [9]. Thus, three major weaknesses of players meet game objectives. Virtual goods can be provided current approaches to smoking cessation are: underutilization, by software at essentially no cost, yet they can have significant lack of appeal to smokers who wish to quit, and in general, economic and monetary value (as evidenced by the modest efficacy in supporting smoking cessation. Clearly, more multi-billion-dollar market for game-based virtual items) appealing and more efficacious smoking cessation interventions [26,27]. This suggests that rewards in the form of in-game are needed. content may readily substitute for monetary rewards in a CM Contingency management (CM) is one of the most efficacious procedure, drastically reducing cost while maintaining efficacy. aids for initiating smoking abstinence [10-12]. Contingency The game will have the benefit of maximizing reward potency management for smoking cessation consists of delivering by minimizing delays to the receipt of rewards for abstinence rewards (typically financial) contingent on objective evidence once they are earned, as participants can immediately “consume” of smoking abstinence (eg, low levels of the combustion product the rewards in the game. The proposed game design carbon monoxide (CO) in the exhaled breath). Unfortunately, operationally encourages social support for smoking abstinence the effectiveness of CM on a population level has been limited by imposing group contingencies [28], such as assembling by several constraints leading to low adoption rates and shorter players into teams and providing a reward that is only obtainable than optimal treatment durations. These factors include the cost if all, or a majority of members reach a specified smoking of providing the cash or cash-equivalent rewards [13-16], the cessation milestone (eg, no smoking for 24 hours). Operationally distances that must be traveled, and the time required for this design leverages self-interest (in obtaining access to the participation in supervised monitoring procedures at a clinic team reward) to incentivize social support (through interteam [13,15]. Monetary rewards for smoking cessation can range messaging) for others’ smoking cessation. The app will also from $100-$500 per person for approximately two 12-week enable standard, nonincentivized social support (eg, “click here interventions [11,17,18]. The cost of these payments limits the to send congratulations to player C for <meeting a cessation feasibility of widespread CM adoption. Furthermore, the milestone>”). ongoing nature of these costs limits the acceptability of We previously published the results of an online survey of longer-term treatment or booster sessions that could otherwise smokers to assess the social validity of a mobile game–based extend program effects (by reducing relapse). CM intervention for smoking cessation which uses virtual goods, instead of money, as rewards [29]. From a sample of 235 http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al smokers recruited through Craigslist (ranging in age from 18-64 failure to respond to emails (N=28; see Table 1 for participant years), 75% reported playing video games. Among most characteristics). smokers, 78% reported playing social games (ie, played casual The advertisement specified that Rowan University researchers games online). This rate is slightly higher than the population were seeking cigarette smokers to test a prototype of a game to at large. Approximately 73% of all smokers and 70% of all help people quit smoking, and that they would be compensated video game players reported that contingent access to virtual $40 for their participation. Participants were eligible if they rewards in the place of money would motivate smokers to reported smoking cigarettes, expressed a desire to quit smoking, abstain. Additionally, 75% of those surveyed would recommend and were available during the testing session times. All study or use a treatment such as this if they knew someone who procedures were approved by the Rowan University Institutional wanted to quit, or if they were trying to quit themselves [29]. Review Board. All participants provided informed consent With the support of these promising outcomes, we developed before beginning the session. and evaluated a prototype of Inspired (working title), a mobile Materials and Procedure game–based CM intervention to promote smoking cessation. The goal of the current project is to assess the feasibility and Prototype/Demo promise of Inspired by having treatment-seeking smokers play Because this was a prospective assessment of a planned several levels of a prototype of the game and then ask them for intervention, a complete product was not yet available for qualitative feedback through a survey. We also indirectly evaluation in this study. Instead, led by one of the project observed feasibility and promise by recording users’ decisions investigators, subjects participated in a guided “walk-thru” of to play an optional, extra level of the prototype. the proposed intervention in which they had hands-on experience utilizing the key components of the intervention that had been Methods developed to date (“demo”), and were presented with mock-ups of planned features and when and where they would otherwise Participants appear in the normal sequence of events in a fully developed Participants were recruited online through Craigslist, a free version of the product. classified advertisement service, and Facebook, a social Specifically, participants experienced recording and submitting networking website. One hundred and eight individuals breath CO readings, using a piCO+ breath carbon monoxide responded to our advertisements, reporting that they were monitor (Bedfont, United Kingdom). In addition to submitting smokers and indicating when they would be available to come an initial breath CO sample, participants were also asked to in for a one-hour prototype testing session. All participants met imagine scenarios in which they had passed or failed various the prescreening qualification criteria; therefore, no one who breath tests for a period and were told what rewards they would expressed an interest was excluded for any reason other than or would not have received given each scenario. Table 1. Participant demographics (N=28). Variable Value Gender, n (%) Female 10 (36) Race, n (%) White 10 (36) Black 11 (39) Asian 1 (4) Unknown 6 (21) Ethnicity, n (%) Hispanic 5 (18) Not Hispanic 19 (68) Unknown 4 (14) Cigarettes per day, n (%) 10 or less 16 (57) 11-20 10 (36) 21-30 2 (7) Fagerström Test for Nicotine Dependence, mean (SD) 3.39 (2.6) http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al The demo version of the game that participants played illustrated out of four matching sets. Each level was designed for casual the “core game experience.” The abstract objective of the game gameplay, lasting approximately five minutes. was “growth.” The core game experience was set in a lush Features that were mocked-up or only verbally described vegetative environment, and the activity involved holding the included: push-notifications on the platform device (eg, “It’s tablet with both hands in landscape view and swiping different time to take a breath test”); player-to-player messaging; gifting colored pollen-gems from a rotating queue center-screen into and social support for smoking cessation (players could “send” specific locations on lotus flowers to the left or right of the gifts on the gift screen, but receipt of the gifts by another player screen (see Figure 1). The challenge in this activity was to match was not implemented, Figures 3 and 4); group contingencies; color patterns under the pressure of time where the lotus flowers specific rewards for not-smoking (eg, a side-cache of various would eventually expire. The colored pollen-gems would also pollen-gems that persisted until used, or resources to build only remain in the queue for a limited time before being structures); and a requirement to submit a breath sample (pass replaced. Better performance led to more lotus flowers being or fail) to unlock access to the next game level. Players were available within a level. At the end of the level, participants also shown that there would be growth of structures displayed could see a hypothetical number of resources earned for on the home page as they progressed through the game over completing that level (see Figure 2), which were awarded for time (in step with ever increasing abstinence through the course completing sets, according to the difficulty of making the set of the intervention; Figure 5 versus Figure 6), but they were (the least to most points were awarded as follows: no pattern < instructed that in the full version of the game the structures all same color < 4/4 matched the color template on the lotus would produce different virtual resources that the player could flower). The levels became increasingly difficult because of the then utilize in core game play, to advance their progress in the speed of the falling pollen and the difficulty with making four game, to make and exchange gifts with other players, and more. Figure 1. Screenshot of core game activity. Figure 2. Screenshot of virtual rewards. http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al Figure 3. Screenshot of receiving a social reward. Figure 4. Screenshot showing how to give a social reward. Figure 5. Screenshot of home screen early in game. http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al Figure 6. Screenshot of home screen later in game. (eg, how much they would be willing to pay to use the program, Study Participation Sessions what did they like most and least about the game, and more). Seven groups (n=3-7 participants per group) of The third part of the survey consisted of multiple-choice treatment-seeking smokers participated in the prototype demographic questions to collect information about race, evaluation sessions. Each group participated in one session, ethnicity, and gender. The fourth and final part of the survey lasting approximately one hour. Sessions began with the consent was comprised of the six-item Fagerström Test for Nicotine process. Participants were then told how smoking releases Dependence [30]. carbon monoxide (CO) into the lungs as a by-product of Before leaving, participants were told that a sign-up sheet was combustion, and how our intervention could reliably detect if available on which they could provide their contact information they had been smoking by measuring CO in the exhaled breath. if they were interested in being contacted when the full version A brief presentation described how the app would be designed of the game was released. to integrate breath monitoring with gameplay and in-game rewards to function as a smoking cessation aid. Each participant Data Analysis was loaned an Android tablet (Nexus 7 2013; Google, Asus) The median and interquartile range (0-100 mm) for each item and a piCO+ CO meter (Bedfont; Kent, United Kingdom) and on the outcome evaluation were calculated. Additionally, the were asked to submit a video sample of their CO using the percentage of participants who “endorsed” each statement was camera on the tablet. The video samples showed them exhaling defined in the following two ways: (1) ratings of 51 or higher into the CO meter and showing their CO value to the camera. on the VAS translate as an endorsement on a binary scale (eg, All prototype game evaluation sessions were video recorded anchors “Disagree, Agree”), whereas (2) ratings of 67 or higher using a Samsung HMX-F90 camcorder. translate as an endorsement on a three-choice scale (eg, using One of the authors and game developers (NF) provided an the anchors “Definitely Not,” “Maybe,” and “Yes, Absolutely”). overview of the game objectives to players, after which they were asked to begin playing the game on the Android tablet. Results Participants could ask questions about the game at any time. Twenty-eight individuals participated in the prototype evaluation When subjects completed all the levels scheduled for use in the study (see Table 1 for demographic information). To analyze demonstration, they were told that there was one extra level that the VAS scores, prototype evaluations and their median they had the option to play. They could either end the game at (interquartile range, IQR) scores are presented in Table 2. that point and finish the last few steps of the study (ie, complete an exit survey and receive payment), or they could stay a few When an endorsement was defined by a ranking of 51 or higher minutes longer and play one extra level before completing the (binary), at least 71% of participants endorsed statements that final steps. It was made clear that the choice was entirely theirs they would use Inspired (Q1), recommend Inspired to a friend and that there would be no penalty for skipping the extra level. (Q2), expect Inspired would help themselves (Q3) and others (Q4) quit smoking, consider both the game (Q6) and the At the end of the prototype evaluation session, participants intervention as a whole (Q5) to be “fun,” and that they would completed a brief prototype evaluation survey, which consisted be more likely to use Inspired than any other smoking cessation of four parts. The first part asked participants to classify how aid they were familiar with (Q10a-e), including the nicotine well they agreed with each item using a 100-mm visual analog patch (Q10b range 71%-100% , n=20-28, depending on the scale (VAS; anchors, 0 mm= “Definitely Not,” 50 , item; see Table 2). mm=“Maybe,” and 100 mm=“Yes, Absolutely”). The second part consisted of multiple-choice and free-response questions http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al Table 2. Prototype evaluation median (interquartile range, IQR) of visual analog scale (VAS) ratings and percent of endorsements at rankings of ≥51 (binary) and ≥67 (trinary; all % out of 28 total participants). Item # Median (IQR) VAS Endorsed, % (≥51) Endorsed, % (≥67) Item Q1 84 (67-98) 86 75 Would you use the proposed full version of Inspired to help you quit smoking and stay smoke-free? Q2 95 (79-99) 93 89 Would you recommend Inspired to a friend that wants to quit smok- ing? Q3 63 (50-94) 71 46 Do you think using the Inspired program would help you to quit smoking? Q4 93 (69-98) 93 79 Do you think the Inspired program could help some smokers quit smoking? Q5 86 (65-98) 93 71 Do you think using the Inspired program as a whole (including breath monitoring, playing the game, and giving and receiving rewards for not smoking) will be FUN? Q6 86 (72-98) 100 79 Do you think the Inspired game will be FUN to play? Q7 62 (51-68) 79 29 In terms of FUN, where do you think you would rank the Inspired game compared to all other games you have ever played on a smart- phone (including games you played only once)? Q8 70 (51-98) 75 50 Do you think incorporating information about the health benefits of not smoking directly into the game would make the Inspired program more effective in helping people quit smoking? Q9 76 (69-99) 100 79 Do you think incorporating tips about how to quit smoking such as ways to deal with cravings directly into the game would make the Inspired program more effective in helping people quit smoking? Q10 If the full version of Inspired were currently available, and you were selecting a smoking cessation aid to use in your next attempt to quit smoking, do you think you would be more likely to use Inspired than... Q10a 72 (51-97) 75 54 …any other smoking aid? Q10b 92 (59-98) 82 71 …the nicotine patch? Q10c 98 (59-100) 82 68 …a drug designed to help reduce your cravings? Q10d 92 (74-99) 96 86 …a program that involves you attending multiple training sessions or support group meetings? Q10e 87 (59-100) 93 68 …hypnosis? The items with the lowest percentages of endorsement were Q3 the monitoring program, and a CO monitor that was yours to (would help me), Q8 (add health benefit tips), and 10a (1st keep, how much would you be willing to pay for the program?”, choice, 21/28, at least 75%), and the highest percentages of the mean (SD) responses were $14.40 per month (SD $16.20) endorsement were Q6 (fun), and Q9 (add tips about cravings: or $133 for a one-time purchase (SD $186). 28/28, 100%). Alternatively, if endorsement was defined as a In the free-response portion of the survey, when participants ranking of 67 or higher (trinary), at least 29% of participants were asked what they liked best about the Inspired game, the (8/ 28) endorsed every item, at least 50% (14/28) endorsed all most frequent response was that they liked the game itself, either but two items (Q3 and Q7), and at least 75% (21/28) endorsed because it was fun, creative, challenging, or because they liked all but six items (Q3, Q7, Q8, Q10a, Q10c, and Q10e), with a the puzzle style of the game (12/28, 43%). Participants also range of at least 29%-89% (n=8-25) across all the items. The reported that they liked the rewards delivered for abstinence item that received the lowest percentage of endorsements was (8/28, 29%), the community and social support aspects of the Q7 (fun relative to other games: 8/28, 29%), whereas the item game (7/28, 24%), the simple instructions (5/28, 19%), the that received the highest percentage of endorsements was Q2 graphics (4/28, 14%), and the ability of the game to serve as a (would recommend to a friend: 25/28, 89%). Additionally, when distraction from smoking (4/28, 14%). A couple of participants asked a multiple-choice question whether the game was fun, also mentioned that they liked the CO monitor (3/28, 10%). 63% (17/27) said “Yes,” 22% (6/27) said “Maybe, it has the When asked what they liked least, the most frequent response potential to be fun,” and 15% (4/27) said, “No.” When asked was that they thought the game lacked variety (8/28, 29%). the question, “If the Inspired program had been demonstrated Participants also noted that glitches with the game needed to to be just as effective as other smoking cessation aids (such as be resolved (eg, swiping gems to the correct location, screen the nicotine patch), and included ongoing access to the game, http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al loading, and more; 4/28, 14%), the graphics could be improved and yet evidence-based complement to these existing (4/28, 14%), and that the game was too easy (3/28, 10%). Other interventions. comments included: the CO meter was too bulky, there were Item Q7 on the prototype evaluation survey was included to too many screens, the game was too challenging, they did not help inform the game design team of how they were doing, at like the idea of social support, and that the game felt this early stage of development. Participants were asked to rank disconnected from the rewards. Two participants did not indicate the intervention game relative to every other game they had any weaknesses with the proposed intervention (2/28, 7%). ever played on their smartphone. Because participants were Participants were also asked to give suggestions about how to asked to compare this prototype of the game, which was less move forward with the game, and the only response that than 10% developed at the time of testing, to existing and fully appeared more than once was to improve variety in the game developed mobile games, a median VAS of 64 was a promising (9/28, 33%). Other suggestions were to provide real rewards outcome. Furthermore, the question asking how much for abstinence, resolve glitches, improve graphics, and to explore participants would be willing to pay for the intervention suggests having insurance companies cover the cost of the game. that there may be commercial viability of the proposed game, Fifty-eight percent of participants (15/26) given the option to with answers ranging from $1.99-$60 per month, or $9.99-$700 play an extra level of the game chose to do so, and 86% (23/28) as a one-time fee. Finally, 85% (23/27) of study participants signed up to be notified when the full version of the game was signed up to be notified when Inspired becomes available so released. they can use it if they have not yet successfully quit smoking by that time, further supporting the potential commercial Discussion viability of the game. Participants provided useful feedback for moving forward with This was the first evaluation of a mobile game–based CM game development, probably the most consistent of which intervention for smoking cessation. The prototype of Inspired involved adding variation to the game to keep it interesting and was endorsed on multiple dimensions by a group of engaging. Overall, feedback about the type of game, the game treatment-seeking smokers. Most participants reported that they graphics, as well as the social elements and CO monitoring in felt the game would help them, or a friend, quit smoking. For the game, were viewed favorably. Smaller, portable versions Inspired to be effective at motivating smokers to quit using of the CO monitor have come to market since this prototype game-based rewards as incentives for abstinence, it is critically evaluation was conducted, thereby addressing concerns about important that the game be fun. If the game is not fun, the virtual the meter being bulky (eg, CO by Bedfont). rewards will not be effective at reinforcing abstinence. In the current study, the extent to which the prototype of Inspired was It should be noted that Inspired was designed to address smoking fun was evaluated in multiple ways. To begin, VAS responses cessation specifically; therefore, multiple game design decisions in the prototype evaluation survey (see Table 2), addressed were made to address the unique needs of individuals trying to whether participants thought the Inspired intervention program quit. First, the core game mechanic, which required players to was fun (Q5), and 71%-93% (n=20-26) of participants agreed, hold the device with both hands in landscape view and swipe depending on how an “endorsement” was defined. Additionally, pollen-gems into locations on various lotus flowers (see Figure 82% (23/28) of participants reported that the game was either 1), was chosen to make it difficult to simultaneously smoke already fun or had the potential to become fun with further while playing the game. Second, each level of the game was development. Finally, probably one of the strongest indicators designed for casual gameplay, lasting approximately that the game has potential to be both fun and effective at five-minutes, to reflect how long it might normally take to supporting smoking cessation was the behavior of participants smoke a cigarette [31]. Third, visual elements of the game motif when they were given the option to play an extra level. More were associated with wellbeing and growth. The design than half of participants (16/ 28, 58%) decided to play the extra, intentionally avoided anything that might serve as a cue for optional level, which meant they may have delayed smoking smoking (eg, smoke, certain words, and more). This was done their next cigarette (following about one hour of abstinence; ie, to avoid having the game elicit cue-induced cravings and the duration of the study), as well as getting paid, by at least subsequent smoking, and to enhance the ability of the game to five additional minutes. The goal of the game is to decrease displace smoking. Although not asked to comment on this smoking, and the fact that the prototype for Inspired may have directly, participants were asked to indirectly address this been capable of displacing smoking for even a brief period is decision with Q8 and Q9 on the survey (see Table 2), where encouraging. Between 57%-76% of participants (n=16-21) said they reported the mobile game would be stronger if it they were more likely to use Inspired than any other smoking incorporated messages about the health benefits of smoking cessation aid, including evidence-based pharmacological cessation and tips about avoiding cravings. High endorsements interventions such as varenicline and the nicotine patch, which on these two items suggested that future iterations of the game are endorsed in the Clinical Practice Guidelines for smoking should explore incorporating this information in to the game, cessation [6]. This finding supports previous research suggesting but in a way that does not also elicit cravings or trigger smoking. that the use of pharmacological or other evidence-based The current study has a few limitations worth noting. First, interventions may be not be preferred among individuals because of the small sample size it was not possible to determine attempting to quit [8,9]. It should also be noted that mobile whether there were differences in endorsements, or other game–based smoking cessation is not incompatible with these measures, between high and low nicotine dependent participants. other interventions but could instead serve as a fun, alternative, http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al Some items seemed to suggest differences, but it was not commercially available games (Q7 received the lowest scores), possible to evaluate the potential differences using inferential as well as other available smoking cessation aids. In the free statistics. Second, information about the participants' individual response section participants provided useful feedback for histories with playing games, particularly mobile games, was improving the program. Finally, the fact that over half of the not collected. Anecdotally, it was made clear that there was a participants voluntarily played an extra, unrequired level of the range of past experiences. However, because the game is being game alleviates some concerns about bias; however, it cannot designed as a smoking cessation aid, a level of heterogeneity be ruled out. of past experiences with video games is expected among the Although there are other digital games that have been evaluated target population of treatment-seeking smokers as well. A third for smoking cessation, none are based on the empirically limitation is the possibility that participants rated the game supported procedures and theoretical foundations of contingency favorably to avoid offending the experimenters and game management and behavior analysis [32-34]. This study is the designers (ie, demand characteristics). To mitigate this concern, first to show that a mobile game–based CM intervention has we made it clear to participants at the beginning of the group potential to be both helpful and fun to smokers who wish to sessions that they were being asked to give an honest evaluation quit. The prototype evaluation suggests that the proposed game of a very early version of the game, and that their feedback would not only reduce the cost of delivering CM for smoking could help shape the future development of the game. Although cessation and enable extended program reach and duration, it it is impossible to rule out potential bias, participants felt might also be preferred over currently extant smoking cessation comfortable giving the game a low rank-order relative to other, aids and interventions. Acknowledgments This grant was funded by a National Institutes of Health, National Institute of Drug Abuse Small Business Innovations Research Grant (SBIR R44DA036252). 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Addiction 2004 Aug;99(8):1042-1048. [doi: 10.1111/j.1360-0443.2004.00754.x] [Medline: 15265101] 9. Leatherdale ST, McDonald PW. Youth smokers' beliefs about different cessation approaches: are we providing cessation interventions they never intend to use? Cancer Causes Control 2007 Sep;18(7):783-791. [doi: 10.1007/s10552-007-9022-8] [Medline: 17549592] 10. Stitzer ML, Rand CS, Bigelow GE, Mead AM. Contingent payment procedures for smoking reduction and cessation. J Appl Behav Anal 1986;19(2):197-202 [FREE Full text] [doi: 10.1901/jaba.1986.19-197] [Medline: 3733589] 11. Dallery J, Raiff BR, Kim SJ, Marsch LA, Stitzer M, Grabinski MJ. Nationwide access to an internet-based contingency management intervention to promote smoking cessation: a randomized controlled trial. Addiction 2016 Dec 06. [doi: 10.1111/add.13715] [Medline: 27923264] http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al 12. Dallery J, Meredith S, Jarvis B, Nuzzo PA. Internet-based group contingency management to promote smoking abstinence. Exp Clin Psychopharmacol 2015 Jun;23(3):176-183 [FREE Full text] [doi: 10.1037/pha0000013] [Medline: 25821915] 13. Kirby K, Amass L, McLellan A. Disseminating contingency-management research to drug abuse treatment practitioners. In: Higgins ST, Silverman K, editors. Motivating behavior change among illicit-drug abusers: research on contingency management interventions. Washington, D. C. Washington DC: American Psychological Association; 1998. 14. Olmstead TA, Petry NM. The cost-effectiveness of prize-based and voucher-based contingency management in a population of cocaine- or opioid-dependent outpatients. Drug Alcohol Depend 2009 Jun 01;102(1-3):108-115 [FREE Full text] [doi: 10.1016/j.drugalcdep.2009.02.005] [Medline: 19324501] 15. Petry N, Alessi S. Lowering costs in drug abuse treatment clinics. New York, NY: Contingency management in substance abuse treatment. Contingency management in substance abuse treatment; Eds Higgins, Silverman, Heil; 2008:261-279. 16. Petry NM, Alessi SM, Hanson T, Sierra S. Randomized trial of contingent prizes versus vouchers in cocaine-using methadone patients. J Consult Clin Psychol 2007 Dec;75(6):983-991. [doi: 10.1037/0022-006X.75.6.983] [Medline: 18085914] 17. Dallery J, Glenn IM, Raiff BR. An Internet-based abstinence reinforcement treatment for cigarette smoking. Drug Alcohol Depend 2007 Jan 12;86(2-3):230-238. [doi: 10.1016/j.drugalcdep.2006.06.013] [Medline: 16930854] 18. Dunn KE, Saulsgiver KA, Sigmon SC. Contingency management for behavior change: applications to promote brief smoking cessation among opioid-maintained patients. Exp Clin Psychopharmacol 2011 Feb;19(1):20-30 [FREE Full text] [doi: 10.1037/a0022039] [Medline: 21341920] 19. Higgins S, Silverman K, Heil S. editors. Contingency Management in Substance Abuse Treatment. New York, NY: Guilford Press; 2007. 20. SRNT Subcommittee on Biochemical Verification. Biochemical verification of tobacco use and cessation. Nicotine Tob Res 2002 May;4(2):149-159. [doi: 10.1080/14622200210123581] [Medline: 12028847] 21. Dallery J, Meredith S, Glenn IM. A deposit contract method to deliver abstinence reinforcement for cigarette smoking. J Appl Behav Anal 2008;41(4):609-615 [FREE Full text] [Medline: 19192864] 22. Stoops WW, Dallery J, Fields NM, Nuzzo PA, Schoenberg NE, Martin CA, et al. An internet-based abstinence reinforcement smoking cessation intervention in rural smokers. Drug Alcohol Depend 2009 Nov 01;105(1-2):56-62 [FREE Full text] [doi: 10.1016/j.drugalcdep.2009.06.010] [Medline: 19615830] 23. Dan M, Grabinski MJ, Raiff BR. Smartphone-based contingency management for smoking cessation with smokers diagnosed with attention-deficit/hyperactivity disorder. Translational Issues in Psychological Science 2016;2(2):116-127. [doi: 10.1037/tps0000062] 24. Hertzberg JS, Carpenter VL, Kirby AC, Calhoun PS, Moore SD, Dennis MF, et al. Mobile contingency management as an adjunctive smoking cessation treatment for smokers with posttraumatic stress disorder. Nicotine Tob Res 2013 Nov;15(11):1934-1938 [FREE Full text] [doi: 10.1093/ntr/ntt060] [Medline: 23645606] 25. Raiff BR, Arena A, Meredith SE, Grabinksi MJ. Feasibility of a Mobile Group Financial-Incentives Intervention Among Pairs of Smokers With a Prior Social Relationship. Psychol Rec 2017 Apr 25;67(2):231-239. [doi: 10.1007/s40732-017-0238-z] 26. Lehdonvirta V. Virtual item sales as a revenue model: identifying attributes that drive purchase decisions. Electron Commer Res 2009 Mar 10;9(1-2):97-113. [doi: 10.1007/s10660-009-9028-2] 27. Startup Grind. 2017 Jan 10. Five Lessons From The +$15B Virtual Goods Economy URL: https://medium.com/startup-grind/ five-lessons-from-the-15b-virtual-goods-economy-636be6a44043 [accessed 2018-03-30] [WebCite Cache ID 6yJOzuWV6] 28. Meredith SE, Dallery J. Investigating group contingencies to promote brief abstinence from cigarette smoking. Exp Clin Psychopharmacol 2013 Apr;21(2):144-154 [FREE Full text] [doi: 10.1037/a0031707] [Medline: 23421358] 29. Raiff BR, Jarvis BP, Rapoza D. Prevalence of video game use, cigarette smoking, and acceptability of a video game-based smoking cessation intervention among online adults. Nicotine Tob Res 2012 Dec;14(12):1453-1457. [doi: 10.1093/ntr/nts079] [Medline: 22422929] 30. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. Br J Addict 1991 Sep;86(9):1119-1127. [Medline: 1932883] 31. Lee EM, Malson JL, Waters AJ, Moolchan ET, Pickworth WB. Smoking topography: reliability and validity in dependent smokers. Nicotine Tob Res 2003 Oct;5(5):673-679. [Medline: 14577984] 32. Girard B, Turcotte V, Bouchard S, Girard B. Crushing virtual cigarettes reduces tobacco addiction and treatment discontinuation. Cyberpsychol Behav 2009 Oct;12(5):477-483. [doi: 10.1089/cpb.2009.0118] [Medline: 19817561] 33. Jamalian A, Mezei J, Levitan P, Garber A, Hammer J, Kinzer C. The Lit2Quit Mobile App: Evoking Game-Based Physiological Effects that Mimic Smoking. 2012 Sep 24 Presented at: Martin, C., Ochsner, A, & Squire, K. (Eds.), Proceedings, GLS 8.0 Games Learning Society Conference; 2012; Madison, WI p. 484-485. 34. Krebs P, Burkhalter JE, Snow B, Fiske J, Ostroff JS. Development and Alpha Testing of QuitIT: An Interactive Video Game to Enhance Skills for Coping With Smoking Urges. JMIR Res Protoc 2013;2(2):e35 [FREE Full text] [doi: 10.2196/resprot.2416] [Medline: 24025236] http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al Abbreviations CM: contingency management CO: carbon monoxide IQR: interquartile range VAS: visual analog scale Edited by G Eysenbach; submitted 07.12.17; peer-reviewed by P Krebs, J Dallery; comments to author 04.01.18; revised version received 30.03.18; accepted 17.04.18; published 07.06.18 Please cite as: Raiff BR, Fortugno N, Scherlis DR, Rapoza D JMIR Serious Games 2018;6(2):e11 URL: http://games.jmir.org/2018/2/e11/ doi: 10.2196/games.9599 PMID: ©Bethany R Raiff, Nicholas Fortugno, Daniel R Scherlis, Darion Rapoza. Originally published in JMIR Serious Games (http://games.jmir.org), 07.06.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 11 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

A Mobile Game to Support Smoking Cessation: Prototype Assessment

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JMIR Publications
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2291-9279
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10.2196/games.9599
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Abstract

Background: Cigarette smoking results in an estimated seven million deaths annually. Almost half of all smokers attempt to quit each year, yet only approximately 6% are successful. Although there are multiple effective interventions that can increase these odds, substantial room remains for improvement. One effective approach to helping smokers quit is contingency management, where quitting is incentivized with the delivery of monetary rewards in exchange for objective evidence (eg, exhaled carbon monoxide levels) of abstinence. Objective: We assessed the feasibility and promise of Inspired, a contingency management mobile app for smoking cessation that uses game-based rewards to incentivize abstinence from smoking instead of the monetary (or material) rewards typically used. We sought participant feedback and limited objective data on: the features and design of Inspired, interest in using Inspired when it becomes available, the likelihood of Inspired being an effective cessation aid, and the rank order preference of Inspired relative to other familiar smoking cessation aids. Methods: Twenty-eight treatment-seeking smokers participated in this study. Participants attended a single one-hour session in which they received an overview of the goals of the Inspired mobile game, practiced submitting breath carbon monoxide (CO) samples, and played representative levels of the game. Participants were then told that they could play an extra level, or they could stop, complete an outcome survey, receive payment, and be dismissed. A sign-up sheet requesting personal contact information was available for those who wished to be notified when the full version of Inspired becomes available. Results: Using binary criteria for endorsement, participants indicated that, assuming it was currently available and fully developed, they would be more likely to use Inspired than: any other smoking cessation aid (21/28, 75%), the nicotine patch (23/28, 82%), a drug designed to reduce smoking cravings (23/28, 82%), or a program involving attendance in training sessions or support group meetings (27/28, 96%). In the questionnaire, participants indicated that both the Inspired program (26/28, 93%) and the Inspired game would be “Fun” (28/28, 100%), and 71% (20/28) reported that the program would help them personally quit smoking. Fifty-eight percent of participants (15/26) chose to continue playing the game rather than immediately collecting payment for participation and leaving. Eighty-two percent of participants (23/28) signed up to be notified when the full version of Inspired becomes available. Conclusions: This was the first study to evaluate a game-based contingency management app that uses game-based virtual goods as rewards for smoking abstinence. The outcomes suggest that the completed app has potential to be an effective smoking cessation aid that would be widely adopted by smokers wishing to quit. (JMIR Serious Games 2018;6(2):e11) doi: 10.2196/games.9599 http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al KEYWORDS smoking; smoking cessation; contingency management; mobile apps; virtual rewards; health games; video games; digital games; carbon monoxide; incentives CM procedures require biochemical verification of abstinence Introduction because participants are much more likely to falsify self-reports when rewards are delivered contingent on abstinence [19]. Worldwide, cigarette-smoking–related death and illness are Carbon monoxide (CO) is one method to biochemically verify leading public health concerns, resulting in an estimated seven abstinence; however, the half-life of CO is short (approximately million deaths each year [1]. There are almost one billion 3-6 hours), requiring at least twice-daily check-ins to verify smokers worldwide [1]. Thus, smoking cessation is a critical, abstinence [20]. To address this barrier, Dallery and colleagues worldwide public health concern [2]. developed an efficacious CM intervention that is delivered over Many efficacious smoking cessation interventions have been the internet [11,17,21,22], in which participants are provided developed, yet ample room remains for improvement. Each with a breath CO monitor, and remotely record and submit video year, one-third to one-half of all smokers attempt to quit at least clips of themselves providing their breath CO samples. More once [3], but the annual incidence of successful quitting is less recently, mobile CM for smoking cessation (where participants than 5% [4]. Media campaigns and cessation programs can use the camera on their smartphone to record and submit the increase quit attempts and successful cessation rates, video clips) has been shown to be feasible, acceptable, and respectively, by a margin of nearly 50% [3,5]. Smoking efficacious in supporting smoking abstinence [23-25]. However, cessation rates that are better than those obtained with a placebo even these internet and mobile CM interventions rely on are achieved with: physician advice; counseling by health monetary incentives to support abstinence; thus, cost remains professionals; a variety of cognitive-behavioral, social-influence, a barrier to widespread dissemination. and motivation-enhancement cessation programs; and drug To directly address the remaining barriers for widely treatments, including nicotine replacement therapies (gum, disseminating CM (ie, cost and sustainability), we proposed to patch, spray, lozenge, and inhaler), selected antidepressant develop a mobile game–based CM intervention for smoking therapies (eg, bupropion), and nicotinic receptor agonist therapy cessation. As with existing mobile CM for smoking cessation, (varenicline) [5,6]. Nevertheless, nearly 80% of smokers who participants would be provided with a breath CO monitor and attempt to quit do so without the assistance of any of these required to remotely record and submit video clips of themselves approaches [7]. Half or more consider counseling and cessation providing their breath CO samples twice daily. In our proposed programs ineffective, and over a third consider pharmacotherapy mobile app, the monetary rewards typically used to incentivize ineffective [8]. Most young smokers report they would never bio-verified abstinence will be replaced with in-game use any of these methods, other than the nicotine patch (which virtual-good rewards that can immediately be used to help only 50% would use) [9]. Thus, three major weaknesses of players meet game objectives. Virtual goods can be provided current approaches to smoking cessation are: underutilization, by software at essentially no cost, yet they can have significant lack of appeal to smokers who wish to quit, and in general, economic and monetary value (as evidenced by the modest efficacy in supporting smoking cessation. Clearly, more multi-billion-dollar market for game-based virtual items) appealing and more efficacious smoking cessation interventions [26,27]. This suggests that rewards in the form of in-game are needed. content may readily substitute for monetary rewards in a CM Contingency management (CM) is one of the most efficacious procedure, drastically reducing cost while maintaining efficacy. aids for initiating smoking abstinence [10-12]. Contingency The game will have the benefit of maximizing reward potency management for smoking cessation consists of delivering by minimizing delays to the receipt of rewards for abstinence rewards (typically financial) contingent on objective evidence once they are earned, as participants can immediately “consume” of smoking abstinence (eg, low levels of the combustion product the rewards in the game. The proposed game design carbon monoxide (CO) in the exhaled breath). Unfortunately, operationally encourages social support for smoking abstinence the effectiveness of CM on a population level has been limited by imposing group contingencies [28], such as assembling by several constraints leading to low adoption rates and shorter players into teams and providing a reward that is only obtainable than optimal treatment durations. These factors include the cost if all, or a majority of members reach a specified smoking of providing the cash or cash-equivalent rewards [13-16], the cessation milestone (eg, no smoking for 24 hours). Operationally distances that must be traveled, and the time required for this design leverages self-interest (in obtaining access to the participation in supervised monitoring procedures at a clinic team reward) to incentivize social support (through interteam [13,15]. Monetary rewards for smoking cessation can range messaging) for others’ smoking cessation. The app will also from $100-$500 per person for approximately two 12-week enable standard, nonincentivized social support (eg, “click here interventions [11,17,18]. The cost of these payments limits the to send congratulations to player C for <meeting a cessation feasibility of widespread CM adoption. Furthermore, the milestone>”). ongoing nature of these costs limits the acceptability of We previously published the results of an online survey of longer-term treatment or booster sessions that could otherwise smokers to assess the social validity of a mobile game–based extend program effects (by reducing relapse). CM intervention for smoking cessation which uses virtual goods, instead of money, as rewards [29]. From a sample of 235 http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al smokers recruited through Craigslist (ranging in age from 18-64 failure to respond to emails (N=28; see Table 1 for participant years), 75% reported playing video games. Among most characteristics). smokers, 78% reported playing social games (ie, played casual The advertisement specified that Rowan University researchers games online). This rate is slightly higher than the population were seeking cigarette smokers to test a prototype of a game to at large. Approximately 73% of all smokers and 70% of all help people quit smoking, and that they would be compensated video game players reported that contingent access to virtual $40 for their participation. Participants were eligible if they rewards in the place of money would motivate smokers to reported smoking cigarettes, expressed a desire to quit smoking, abstain. Additionally, 75% of those surveyed would recommend and were available during the testing session times. All study or use a treatment such as this if they knew someone who procedures were approved by the Rowan University Institutional wanted to quit, or if they were trying to quit themselves [29]. Review Board. All participants provided informed consent With the support of these promising outcomes, we developed before beginning the session. and evaluated a prototype of Inspired (working title), a mobile Materials and Procedure game–based CM intervention to promote smoking cessation. The goal of the current project is to assess the feasibility and Prototype/Demo promise of Inspired by having treatment-seeking smokers play Because this was a prospective assessment of a planned several levels of a prototype of the game and then ask them for intervention, a complete product was not yet available for qualitative feedback through a survey. We also indirectly evaluation in this study. Instead, led by one of the project observed feasibility and promise by recording users’ decisions investigators, subjects participated in a guided “walk-thru” of to play an optional, extra level of the prototype. the proposed intervention in which they had hands-on experience utilizing the key components of the intervention that had been Methods developed to date (“demo”), and were presented with mock-ups of planned features and when and where they would otherwise Participants appear in the normal sequence of events in a fully developed Participants were recruited online through Craigslist, a free version of the product. classified advertisement service, and Facebook, a social Specifically, participants experienced recording and submitting networking website. One hundred and eight individuals breath CO readings, using a piCO+ breath carbon monoxide responded to our advertisements, reporting that they were monitor (Bedfont, United Kingdom). In addition to submitting smokers and indicating when they would be available to come an initial breath CO sample, participants were also asked to in for a one-hour prototype testing session. All participants met imagine scenarios in which they had passed or failed various the prescreening qualification criteria; therefore, no one who breath tests for a period and were told what rewards they would expressed an interest was excluded for any reason other than or would not have received given each scenario. Table 1. Participant demographics (N=28). Variable Value Gender, n (%) Female 10 (36) Race, n (%) White 10 (36) Black 11 (39) Asian 1 (4) Unknown 6 (21) Ethnicity, n (%) Hispanic 5 (18) Not Hispanic 19 (68) Unknown 4 (14) Cigarettes per day, n (%) 10 or less 16 (57) 11-20 10 (36) 21-30 2 (7) Fagerström Test for Nicotine Dependence, mean (SD) 3.39 (2.6) http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al The demo version of the game that participants played illustrated out of four matching sets. Each level was designed for casual the “core game experience.” The abstract objective of the game gameplay, lasting approximately five minutes. was “growth.” The core game experience was set in a lush Features that were mocked-up or only verbally described vegetative environment, and the activity involved holding the included: push-notifications on the platform device (eg, “It’s tablet with both hands in landscape view and swiping different time to take a breath test”); player-to-player messaging; gifting colored pollen-gems from a rotating queue center-screen into and social support for smoking cessation (players could “send” specific locations on lotus flowers to the left or right of the gifts on the gift screen, but receipt of the gifts by another player screen (see Figure 1). The challenge in this activity was to match was not implemented, Figures 3 and 4); group contingencies; color patterns under the pressure of time where the lotus flowers specific rewards for not-smoking (eg, a side-cache of various would eventually expire. The colored pollen-gems would also pollen-gems that persisted until used, or resources to build only remain in the queue for a limited time before being structures); and a requirement to submit a breath sample (pass replaced. Better performance led to more lotus flowers being or fail) to unlock access to the next game level. Players were available within a level. At the end of the level, participants also shown that there would be growth of structures displayed could see a hypothetical number of resources earned for on the home page as they progressed through the game over completing that level (see Figure 2), which were awarded for time (in step with ever increasing abstinence through the course completing sets, according to the difficulty of making the set of the intervention; Figure 5 versus Figure 6), but they were (the least to most points were awarded as follows: no pattern < instructed that in the full version of the game the structures all same color < 4/4 matched the color template on the lotus would produce different virtual resources that the player could flower). The levels became increasingly difficult because of the then utilize in core game play, to advance their progress in the speed of the falling pollen and the difficulty with making four game, to make and exchange gifts with other players, and more. Figure 1. Screenshot of core game activity. Figure 2. Screenshot of virtual rewards. http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al Figure 3. Screenshot of receiving a social reward. Figure 4. Screenshot showing how to give a social reward. Figure 5. Screenshot of home screen early in game. http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al Figure 6. Screenshot of home screen later in game. (eg, how much they would be willing to pay to use the program, Study Participation Sessions what did they like most and least about the game, and more). Seven groups (n=3-7 participants per group) of The third part of the survey consisted of multiple-choice treatment-seeking smokers participated in the prototype demographic questions to collect information about race, evaluation sessions. Each group participated in one session, ethnicity, and gender. The fourth and final part of the survey lasting approximately one hour. Sessions began with the consent was comprised of the six-item Fagerström Test for Nicotine process. Participants were then told how smoking releases Dependence [30]. carbon monoxide (CO) into the lungs as a by-product of Before leaving, participants were told that a sign-up sheet was combustion, and how our intervention could reliably detect if available on which they could provide their contact information they had been smoking by measuring CO in the exhaled breath. if they were interested in being contacted when the full version A brief presentation described how the app would be designed of the game was released. to integrate breath monitoring with gameplay and in-game rewards to function as a smoking cessation aid. Each participant Data Analysis was loaned an Android tablet (Nexus 7 2013; Google, Asus) The median and interquartile range (0-100 mm) for each item and a piCO+ CO meter (Bedfont; Kent, United Kingdom) and on the outcome evaluation were calculated. Additionally, the were asked to submit a video sample of their CO using the percentage of participants who “endorsed” each statement was camera on the tablet. The video samples showed them exhaling defined in the following two ways: (1) ratings of 51 or higher into the CO meter and showing their CO value to the camera. on the VAS translate as an endorsement on a binary scale (eg, All prototype game evaluation sessions were video recorded anchors “Disagree, Agree”), whereas (2) ratings of 67 or higher using a Samsung HMX-F90 camcorder. translate as an endorsement on a three-choice scale (eg, using One of the authors and game developers (NF) provided an the anchors “Definitely Not,” “Maybe,” and “Yes, Absolutely”). overview of the game objectives to players, after which they were asked to begin playing the game on the Android tablet. Results Participants could ask questions about the game at any time. Twenty-eight individuals participated in the prototype evaluation When subjects completed all the levels scheduled for use in the study (see Table 1 for demographic information). To analyze demonstration, they were told that there was one extra level that the VAS scores, prototype evaluations and their median they had the option to play. They could either end the game at (interquartile range, IQR) scores are presented in Table 2. that point and finish the last few steps of the study (ie, complete an exit survey and receive payment), or they could stay a few When an endorsement was defined by a ranking of 51 or higher minutes longer and play one extra level before completing the (binary), at least 71% of participants endorsed statements that final steps. It was made clear that the choice was entirely theirs they would use Inspired (Q1), recommend Inspired to a friend and that there would be no penalty for skipping the extra level. (Q2), expect Inspired would help themselves (Q3) and others (Q4) quit smoking, consider both the game (Q6) and the At the end of the prototype evaluation session, participants intervention as a whole (Q5) to be “fun,” and that they would completed a brief prototype evaluation survey, which consisted be more likely to use Inspired than any other smoking cessation of four parts. The first part asked participants to classify how aid they were familiar with (Q10a-e), including the nicotine well they agreed with each item using a 100-mm visual analog patch (Q10b range 71%-100% , n=20-28, depending on the scale (VAS; anchors, 0 mm= “Definitely Not,” 50 , item; see Table 2). mm=“Maybe,” and 100 mm=“Yes, Absolutely”). The second part consisted of multiple-choice and free-response questions http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al Table 2. Prototype evaluation median (interquartile range, IQR) of visual analog scale (VAS) ratings and percent of endorsements at rankings of ≥51 (binary) and ≥67 (trinary; all % out of 28 total participants). Item # Median (IQR) VAS Endorsed, % (≥51) Endorsed, % (≥67) Item Q1 84 (67-98) 86 75 Would you use the proposed full version of Inspired to help you quit smoking and stay smoke-free? Q2 95 (79-99) 93 89 Would you recommend Inspired to a friend that wants to quit smok- ing? Q3 63 (50-94) 71 46 Do you think using the Inspired program would help you to quit smoking? Q4 93 (69-98) 93 79 Do you think the Inspired program could help some smokers quit smoking? Q5 86 (65-98) 93 71 Do you think using the Inspired program as a whole (including breath monitoring, playing the game, and giving and receiving rewards for not smoking) will be FUN? Q6 86 (72-98) 100 79 Do you think the Inspired game will be FUN to play? Q7 62 (51-68) 79 29 In terms of FUN, where do you think you would rank the Inspired game compared to all other games you have ever played on a smart- phone (including games you played only once)? Q8 70 (51-98) 75 50 Do you think incorporating information about the health benefits of not smoking directly into the game would make the Inspired program more effective in helping people quit smoking? Q9 76 (69-99) 100 79 Do you think incorporating tips about how to quit smoking such as ways to deal with cravings directly into the game would make the Inspired program more effective in helping people quit smoking? Q10 If the full version of Inspired were currently available, and you were selecting a smoking cessation aid to use in your next attempt to quit smoking, do you think you would be more likely to use Inspired than... Q10a 72 (51-97) 75 54 …any other smoking aid? Q10b 92 (59-98) 82 71 …the nicotine patch? Q10c 98 (59-100) 82 68 …a drug designed to help reduce your cravings? Q10d 92 (74-99) 96 86 …a program that involves you attending multiple training sessions or support group meetings? Q10e 87 (59-100) 93 68 …hypnosis? The items with the lowest percentages of endorsement were Q3 the monitoring program, and a CO monitor that was yours to (would help me), Q8 (add health benefit tips), and 10a (1st keep, how much would you be willing to pay for the program?”, choice, 21/28, at least 75%), and the highest percentages of the mean (SD) responses were $14.40 per month (SD $16.20) endorsement were Q6 (fun), and Q9 (add tips about cravings: or $133 for a one-time purchase (SD $186). 28/28, 100%). Alternatively, if endorsement was defined as a In the free-response portion of the survey, when participants ranking of 67 or higher (trinary), at least 29% of participants were asked what they liked best about the Inspired game, the (8/ 28) endorsed every item, at least 50% (14/28) endorsed all most frequent response was that they liked the game itself, either but two items (Q3 and Q7), and at least 75% (21/28) endorsed because it was fun, creative, challenging, or because they liked all but six items (Q3, Q7, Q8, Q10a, Q10c, and Q10e), with a the puzzle style of the game (12/28, 43%). Participants also range of at least 29%-89% (n=8-25) across all the items. The reported that they liked the rewards delivered for abstinence item that received the lowest percentage of endorsements was (8/28, 29%), the community and social support aspects of the Q7 (fun relative to other games: 8/28, 29%), whereas the item game (7/28, 24%), the simple instructions (5/28, 19%), the that received the highest percentage of endorsements was Q2 graphics (4/28, 14%), and the ability of the game to serve as a (would recommend to a friend: 25/28, 89%). Additionally, when distraction from smoking (4/28, 14%). A couple of participants asked a multiple-choice question whether the game was fun, also mentioned that they liked the CO monitor (3/28, 10%). 63% (17/27) said “Yes,” 22% (6/27) said “Maybe, it has the When asked what they liked least, the most frequent response potential to be fun,” and 15% (4/27) said, “No.” When asked was that they thought the game lacked variety (8/28, 29%). the question, “If the Inspired program had been demonstrated Participants also noted that glitches with the game needed to to be just as effective as other smoking cessation aids (such as be resolved (eg, swiping gems to the correct location, screen the nicotine patch), and included ongoing access to the game, http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al loading, and more; 4/28, 14%), the graphics could be improved and yet evidence-based complement to these existing (4/28, 14%), and that the game was too easy (3/28, 10%). Other interventions. comments included: the CO meter was too bulky, there were Item Q7 on the prototype evaluation survey was included to too many screens, the game was too challenging, they did not help inform the game design team of how they were doing, at like the idea of social support, and that the game felt this early stage of development. Participants were asked to rank disconnected from the rewards. Two participants did not indicate the intervention game relative to every other game they had any weaknesses with the proposed intervention (2/28, 7%). ever played on their smartphone. Because participants were Participants were also asked to give suggestions about how to asked to compare this prototype of the game, which was less move forward with the game, and the only response that than 10% developed at the time of testing, to existing and fully appeared more than once was to improve variety in the game developed mobile games, a median VAS of 64 was a promising (9/28, 33%). Other suggestions were to provide real rewards outcome. Furthermore, the question asking how much for abstinence, resolve glitches, improve graphics, and to explore participants would be willing to pay for the intervention suggests having insurance companies cover the cost of the game. that there may be commercial viability of the proposed game, Fifty-eight percent of participants (15/26) given the option to with answers ranging from $1.99-$60 per month, or $9.99-$700 play an extra level of the game chose to do so, and 86% (23/28) as a one-time fee. Finally, 85% (23/27) of study participants signed up to be notified when the full version of the game was signed up to be notified when Inspired becomes available so released. they can use it if they have not yet successfully quit smoking by that time, further supporting the potential commercial Discussion viability of the game. Participants provided useful feedback for moving forward with This was the first evaluation of a mobile game–based CM game development, probably the most consistent of which intervention for smoking cessation. The prototype of Inspired involved adding variation to the game to keep it interesting and was endorsed on multiple dimensions by a group of engaging. Overall, feedback about the type of game, the game treatment-seeking smokers. Most participants reported that they graphics, as well as the social elements and CO monitoring in felt the game would help them, or a friend, quit smoking. For the game, were viewed favorably. Smaller, portable versions Inspired to be effective at motivating smokers to quit using of the CO monitor have come to market since this prototype game-based rewards as incentives for abstinence, it is critically evaluation was conducted, thereby addressing concerns about important that the game be fun. If the game is not fun, the virtual the meter being bulky (eg, CO by Bedfont). rewards will not be effective at reinforcing abstinence. In the current study, the extent to which the prototype of Inspired was It should be noted that Inspired was designed to address smoking fun was evaluated in multiple ways. To begin, VAS responses cessation specifically; therefore, multiple game design decisions in the prototype evaluation survey (see Table 2), addressed were made to address the unique needs of individuals trying to whether participants thought the Inspired intervention program quit. First, the core game mechanic, which required players to was fun (Q5), and 71%-93% (n=20-26) of participants agreed, hold the device with both hands in landscape view and swipe depending on how an “endorsement” was defined. Additionally, pollen-gems into locations on various lotus flowers (see Figure 82% (23/28) of participants reported that the game was either 1), was chosen to make it difficult to simultaneously smoke already fun or had the potential to become fun with further while playing the game. Second, each level of the game was development. Finally, probably one of the strongest indicators designed for casual gameplay, lasting approximately that the game has potential to be both fun and effective at five-minutes, to reflect how long it might normally take to supporting smoking cessation was the behavior of participants smoke a cigarette [31]. Third, visual elements of the game motif when they were given the option to play an extra level. More were associated with wellbeing and growth. The design than half of participants (16/ 28, 58%) decided to play the extra, intentionally avoided anything that might serve as a cue for optional level, which meant they may have delayed smoking smoking (eg, smoke, certain words, and more). This was done their next cigarette (following about one hour of abstinence; ie, to avoid having the game elicit cue-induced cravings and the duration of the study), as well as getting paid, by at least subsequent smoking, and to enhance the ability of the game to five additional minutes. The goal of the game is to decrease displace smoking. Although not asked to comment on this smoking, and the fact that the prototype for Inspired may have directly, participants were asked to indirectly address this been capable of displacing smoking for even a brief period is decision with Q8 and Q9 on the survey (see Table 2), where encouraging. Between 57%-76% of participants (n=16-21) said they reported the mobile game would be stronger if it they were more likely to use Inspired than any other smoking incorporated messages about the health benefits of smoking cessation aid, including evidence-based pharmacological cessation and tips about avoiding cravings. High endorsements interventions such as varenicline and the nicotine patch, which on these two items suggested that future iterations of the game are endorsed in the Clinical Practice Guidelines for smoking should explore incorporating this information in to the game, cessation [6]. This finding supports previous research suggesting but in a way that does not also elicit cravings or trigger smoking. that the use of pharmacological or other evidence-based The current study has a few limitations worth noting. First, interventions may be not be preferred among individuals because of the small sample size it was not possible to determine attempting to quit [8,9]. It should also be noted that mobile whether there were differences in endorsements, or other game–based smoking cessation is not incompatible with these measures, between high and low nicotine dependent participants. other interventions but could instead serve as a fun, alternative, http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al Some items seemed to suggest differences, but it was not commercially available games (Q7 received the lowest scores), possible to evaluate the potential differences using inferential as well as other available smoking cessation aids. In the free statistics. Second, information about the participants' individual response section participants provided useful feedback for histories with playing games, particularly mobile games, was improving the program. Finally, the fact that over half of the not collected. Anecdotally, it was made clear that there was a participants voluntarily played an extra, unrequired level of the range of past experiences. However, because the game is being game alleviates some concerns about bias; however, it cannot designed as a smoking cessation aid, a level of heterogeneity be ruled out. of past experiences with video games is expected among the Although there are other digital games that have been evaluated target population of treatment-seeking smokers as well. A third for smoking cessation, none are based on the empirically limitation is the possibility that participants rated the game supported procedures and theoretical foundations of contingency favorably to avoid offending the experimenters and game management and behavior analysis [32-34]. This study is the designers (ie, demand characteristics). To mitigate this concern, first to show that a mobile game–based CM intervention has we made it clear to participants at the beginning of the group potential to be both helpful and fun to smokers who wish to sessions that they were being asked to give an honest evaluation quit. The prototype evaluation suggests that the proposed game of a very early version of the game, and that their feedback would not only reduce the cost of delivering CM for smoking could help shape the future development of the game. Although cessation and enable extended program reach and duration, it it is impossible to rule out potential bias, participants felt might also be preferred over currently extant smoking cessation comfortable giving the game a low rank-order relative to other, aids and interventions. Acknowledgments This grant was funded by a National Institutes of Health, National Institute of Drug Abuse Small Business Innovations Research Grant (SBIR R44DA036252). 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JMIR Res Protoc 2013;2(2):e35 [FREE Full text] [doi: 10.2196/resprot.2416] [Medline: 24025236] http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Raiff et al Abbreviations CM: contingency management CO: carbon monoxide IQR: interquartile range VAS: visual analog scale Edited by G Eysenbach; submitted 07.12.17; peer-reviewed by P Krebs, J Dallery; comments to author 04.01.18; revised version received 30.03.18; accepted 17.04.18; published 07.06.18 Please cite as: Raiff BR, Fortugno N, Scherlis DR, Rapoza D JMIR Serious Games 2018;6(2):e11 URL: http://games.jmir.org/2018/2/e11/ doi: 10.2196/games.9599 PMID: ©Bethany R Raiff, Nicholas Fortugno, Daniel R Scherlis, Darion Rapoza. Originally published in JMIR Serious Games (http://games.jmir.org), 07.06.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/2/e11/ JMIR Serious Games 2018 | vol. 6 | iss. 2 | e11 | p. 11 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Jun 7, 2018

Keywords: smoking; smoking cessation; contingency management; mobile apps; virtual rewards; health games; video games; digital games; carbon monoxide; incentives

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