Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Quittr: The Design of a Video Game to Support Smoking Cessation

Quittr: The Design of a Video Game to Support Smoking Cessation Background: Smoking is recognized as the largest, single, preventable cause of death and disease in the developed world. While the majority of smokers report wanting to quit, and many try each year, smokers find it difficult to maintain long-term abstinence. Behavioral support, such as education, advice, goal-setting, and encouragement, is known to be beneficial in improving the likelihood of succeeding in a quit attempt, but it remains difficult to effectively deliver this behavioral support and keep the patient engaged with the process for a sufficient duration. In an attempt to solve this, there have been numerous mobile apps developed, yet engagement and retention have remained key challenges that limit the potential effectiveness of these interventions. Video games have been clearly linked with the effective delivery of health interventions, due to their capacity to increase motivation and engagement of players. Objective: The objective of this study is to describe the design and development of a smartphone app that is theory-driven, and which incorporates gaming characteristics in order to promote engagement with content, and thereby help smokers to quit. Methods: Game design and development was informed by a taxonomy of motivational affordances for meaningful gamified and persuasive technologies. This taxonomy describes a set of design components that is grounded in well-established psychological theories on motivation. Results: This paper reports on the design and development process of Quittr, a mobile app, describing how game design principles, game mechanics, and game elements can be used to embed education and support content, such that the app actually requires the user to access and engage with relevant educational content. The next stage of this research is to conduct a randomized controlled trial to determine whether the additional incentivization game features offer any value in terms of the key metrics of engagement–how much content users are consuming, how many days users are persisting with using the app, and what proportion of users successfully abstain from smoking for 28 days, based on user-reported data and verified against a biochemical baseline using cotinine tests. Conclusions: We describe a novel, and theoretically-informed mobile app design approach that has a broad range of potential applications. By using the virtual currency approach, we remove the need for the game to comprehensively integrate the healthy activity as part of its actual play mechanics. This opens up the potential for a wide variety of health problems to be tackled through games where no obvious play mechanic presents itself. The implications of this app are that similar approaches may be of benefit in areas such as managing chronic conditions (diabetes, heart disease, etc), treating substance abuse (alcohol, illicit drugs, etc), diet and exercise, eating disorders (anorexia, bulimia, and binge eating), and various phobias. (JMIR Serious Games 2016;4(2):e19) doi: 10.2196/games.6258 KEYWORDS smoking cessation; video games; mobile phone; motivation http://games.jmir.org/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bindoff et al improve engagement in tasks not generally considered “fun,” Introduction such as learning, exercising, and practicing. Smoking and Cessation Within the health domain there have been a wide range of successful serious games initiatives trialed. A 2008 review of Smoking is recognized as the largest, single, preventable cause 27 publications reporting on 25 video games that promoted of death and disease in the developed world. It is associated health-related behavior change, identified that most of the with an increased risk of heart disease, stroke, cancer, studies demonstrated positive health-related changes from emphysema, bronchitis, asthma, renal disease, and eye disease. playing the video games [13]. While the majority of smokers report wanting to quit, and many try each year, smokers find it difficult to maintain long-term More recently, a 2012 review included 38 publications regarding abstinence [1-3]. video games that provide physical therapy, psychological therapy, improved disease self-management, health education, The delivery of education and support to smokers has been the distraction from discomfort, increased physical activity, and backbone of smoking cessation programs for decades. Such skills training for clinicians [14]. Among the 38 studies, a total programs were traditionally delivered in face-to-face sessions of 195 health outcomes were examined. Results indicated that with trained tobacco cessation counselors, or via self-help video games improved 69% of psychological therapy outcomes, booklets and websites, but more recently researchers have turned 59% of physical therapy outcomes, 50% of physical activity to technological solutions such as mobile phone apps in order outcomes, 46% of clinician skills outcomes, 42% of health to deliver content to smokers in a way that can be easily scaled education outcomes, 42% of pain distraction outcomes, and up to population levels [4-6]. Regardless of the delivery 37% of disease self-management outcomes. Further, in 2014, modality, behavioral support programs have been found to be a meta-analysis of 54 serious digital game studies for healthy mildly effective [7], with the educational content involved in lifestyle promotion reviewed the overall effectiveness of serious such programs (including advice on when and how to use digital games on healthy lifestyle [15], and demonstrated small pharmacological support) appearing to have the greatest impact positive effects on healthy lifestyle promotion outcomes. on cessation rates. Video Games and Smoking Cessation Despite significant investment in the development of such programs, a persistent issue is that smokers do not readily The concept of using games to promote smoking cessation is engage with the cessation content delivered. Failure to engage not entirely new. There is some existing work that explores the with the “active content” of cessation programs is problematic potential of the idea, and even some existing game-based as it limits the potential effectiveness of such programs: the interventions have been developed. Most early attempts at education and support delivered cannot hope to be effective if incorporating video game elements have focused on the delivery it is not used by smokers during their quit attempt. Even if users of a distraction, to help the smoker get through an episode of engage initially, it is difficult to keep them interested beyond craving. Crave-Out was an early attempt at this style of game, the first few days (retention). Identifying mechanisms that producing a pattern matching memory game and using the encourage smokers to engage with smoking cessation content Questionnaire of Smoking Urge-Brief measurement before and requires ongoing investigation. after play to determine if it helped to reduce cravings. A small but insignificant reduction in cravings was measured. Critically Video Games and Health Interventions however, the authors determined during pilot testing that Video games are immensely popular, with recent statistics negative reinforcement had a deleterious effect on smokers, as indicating that in the United States 63% of households are home it reminded them of smoking, and this finding is worth bearing to at least 1 person who plays video games regularly (3 hours in mind in future designs [16]. Subsequently, similar “distraction or more per week) and 65% of households own a device used minigames” have also been incorporated into other to play video games [8]. Rather than video games being seen mHealth-based smoking cessation apps such as SmokeFree 28 as simply time-wasting entertainments, they are now recognized [5]. as an integral part of our modern society, with games and play The most grass-roots evidence to support the idea of game-based increasingly informing other domains of our everyday life. smoking cessation interventions comes from Raiff et al [17], Research on video games now shows that games have the ability who explored the link between video game usage and smoking. to keep people engaged for a long time, build relationships and They determined that 74.5% of smokers play video games (more communities among players, and cultivate their creative than nonsmokers), and that 63.7% of participants believed that potential. Furthermore, games have been shown to have the a video game–based intervention would motivate smokers to power to support knowledge acquisition and even to bring about quit [17]. There is some speculation that the “addictive behavior change [9-11]. tendencies” of smokers makes them more likely to become frequent video game players. Games with a purpose, also known as “serious games,” look much like traditional entertainment games, but differ in that Hall et al [18] tried to qualitatively determine, from expert they have a defined purpose, outcome, or message that the opinion, key design characteristics for a successful video creators of the game are trying to get across to a particular game–based smoking cessation intervention. After interviewing audience [12]. By employing all the fun and engaging elements experts in game development, tobacco, and health behavior a found in games and applying them to real-world or productive number of themes emerged. In particular, it was noted that activities, they have the potential to influence behavior or http://games.jmir.org/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bindoff et al targeting youths through games was likely to be an effective that support the acquisition of smoking cessation content, and strategy that extensive iterative prototyping was required to build a game that provides an engaging environment for players create a compelling game experience, and that incorporating to remain engaged with such content, we may be able to behavioral change techniques was likely to result in improved positively influence smoking cessation outcomes. outcomes. Theoretical Basis for Design There is also some preliminary evidence exploring Internet This focus aligns with the assessment that reflective and implementations. QuitIT is an Internet-based video game that automatic motivation toward smoking cessation can be enhanced is designed to help smokers practice coping strategies for by interventions, such as education, persuasion, intensification, cravings. Initial evaluation suggests the game was useful in coercion, and modelling [20]. However, the actual content teaching strategies for coping with urges [19], although there component of the app itself is flexible and has been designed is not yet any data to suggest that it improves quit success rates. to be easily updatable as new content is developed. Traditionally, serious games in the health behavior change space Game Mechanic and Game Elements Design Phase have focused on directly encouraging the behavior of interest Within the cycle of design and development, the initial Game (eg, promoting physical activity by requiring movement as part Mechanic and Elements design phase was informed by a of the game play). An alternate possible use of games–one that taxonomy of motivational affordances for meaningful gamified we explore here–is that games could be embedded with and persuasive technologies (Figure 1) [20]. This taxonomy education and support content, such that the game play simply describes a set of design components that is grounded in acts as the hook that compels the user to access and engage with well-established psychological theories on motivation [20]. relevant educational content, in exchange for incentives that further the players goals in the game. Such game play may To allow for meaningful gamified and persuasive systems, encourage engagement with proven educationally based designers should choose components depending on both the intervention strategies, and thereby improve health outcomes. objectives and the users of the system [20]. To guide this activity, the taxonomy outlines both general design principles It has been suggested that games are fun because they appeal and mechanics that game designers might benefit from to some core drives that motivate us toward certain activities, considering, and that might assist in ensuring theoretically such as meaning, empowerment, social influence, grounded serious game development, as is required in this unpredictability, avoidance, scarcity, ownership, and intervention. accomplishment [15]. If we can identify the elements of games Figure 1. Design principles and mechanics for persuasive game design [17]. http://games.jmir.org/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bindoff et al would enable the delivery of proven effective smoking cessation Methods support content, but with game elements integrated throughout to improve user engagement and retention. Overview of the Design An app was produced compatible with both Android and iOS Based on the theoretical underpinnings described above, we mobile phones and tablets. Upon opening the app, users are designed and developed a mobile phone game called Quittr to greeted with a dashboard system separated into 3 main pages, support people in their attempt to quit smoking. This design which they can swipe between (Figure 2), styled in adherence borrowed many elements from existing literature [21,22] and with the popular Google Material user interface design examples of mHealth smoking cessation apps, most notably guidelines [23]. SmokeFree 28 [5]. The focus was on creating a platform that Figure 2. The main dashboard of Quittr. unique identifier so that we can track a given user across Data Collection potentially many quit attempts. When the user first opens the app they are prompted to complete Progress an entry survey, which includes questions about the user’s smoking status, demographics, health, and financial goals, as The first page of the main dashboard is titled “Progress,” and well as questions about the user’s intentions in using the app. includes tracked statistics relating to the financial, health, and On subsequent openings, the user is asked if they have smoked social outcomes of the user associated with their current quit any cigarettes that haven’t been entered into the app. If the user attempt. It delivers an easily accessible snapshot of the statistics indicates yes to this question, they are asked to indicate how that are most relevant/important to the user at the current time many cigarettes they smoked on each day that has elapsed since (based on their current status and data collected during a their last log. If the user has not opened Quittr for 12 hours they commencement survey). The user can optionally explore a are prompted with a notification on their device asking them to comprehensive list of every tracked statistic. These progress come back and log their cigarettes. This will repeat daily for bars provide meaningful feedback to the user as well as several days if they still fail to check-in. educating them about the benefits of quitting, and have proven to be a valuable feature in a range of successful smoking At the end of 28 days or when the user indicates their current cessation apps [20,24]. quit attempt has failed, they are also asked to complete an exit survey. This asks questions about their opinions of the app, the The progress page also includes an achievements section, with games, and if appropriate, their reasons for giving up their quit a range of predefined goals for the user to strive toward, as well attempt early. Having indicated that their quit attempt has failed, as the ability to set their own financial savings goals to target. the user is able to start a new quit attempt at any time, which The progress page displays the next several achievements that will reset all their existing data, triggering a new entry survey, the user is close to achieving, but the user can click on the tile and so on. to review the full list of achievements, including achievements they have already obtained. This style of achievement system All collected data is stored and uploaded to our webserver for is a proven staple across the games industry, and is a mainstay analysis and review. For the sake of privacy, we do not collect in any “gamified” apps. The achievements system ensures that any personally identifying information, although we do use a http://games.jmir.org/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bindoff et al the user always has both short and longer term goals in sight, We have designed the content in this section to be readily as well as having a set of accomplishments they can reflect upon customized and expanded upon, with updates being pulled from to remind themselves how far they’ve come [20]. our webserver as required whenever Internet connectivity is available. The content is also tagged with a set of metadata that Support enables it to be tailored to the user based on the data collected The support page includes a range of helpful information and during the entry survey and the state of their current quit attempt support, including a button, which simply dials the local Quit (ie, content about smoking during pregnancy would be more Support hotline, and the “Quick Tips” button that displays relevant to pregnant women than to men, and content regarding helpful tips about how to use the app. Perhaps the most cardiovascular disease would be more important to older interesting feature of this section is the “Information Toolbox” smokers). (Figure 3). Games The Information Toolbox includes a wide variety of educational The games page lists a range of games that the user can engage material, which can support the user on their quit attempt. This with (Figure 4). The games are split into 2 categories, those that includes information about the various therapies and treatment are intended purely as a distraction from cravings, and those plans available, as well as information on cravings, coping that are used as an incentive to engage with the broader app. strategies, the benefits of quitting, and the consequences of Currently, 2 games are available, with plans to include more. smoking. The information is neatly structured into ‘bite-sized By providing a variety of games that will appeal to different chunks’ to make it easy for the user [22]. After reading a section users, we can improve the likelihood that a given user will be the user is challenged by a multiple choice quiz that asks one able to find a game they enjoy playing, and that they find it to of several basic questions that relate to the material they just be an effective distraction. read. Figure 3. The Information Toolbox. http://games.jmir.org/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bindoff et al Figure 4. The games currently available in Quittr. to those who have played free-to-play mobile and Facebook Distraction games, wherein the user can spend a premium currency The distraction games are simple minigames that can be played (traditionally obtained by spending real money or engaging with in a stand-alone 1- to 5-minute session. They are designed to video ads) to obtain bonuses in the game. In this case, instead demand mental focus and both hands, so as to provide a of purchasing QuitCoins using real money, the user is rewarded meaningful and effective distraction or an alternative from the with QuitCoins in return for engaging with the smoking act of smoking [5,16,22]. cessation content of the broader app in a meaningful way (see Textbox 1). This is the key innovation that our approach adds, There is currently only one distraction minigame included in distinguishing it from earlier attempts in this space. Quittr. This is a hidden object style game where the user must search for and tap particular objects in an increasingly cluttered Currently, we have only created 1 incentivization game. It is a environment, and under time pressure. There are also 2 “city builder” style game, which we have called “Tappy Town.” additional games being prepared for inclusion: a fruit-ninja style In Tappy Town, the user has an empty plot of land to fill and a game where the user must swipe across missiles, which are large range of structures they can build to improve that land. launched while avoiding bombs; and an endless-runner style As the user grows their town the town’s economy will also game where the user must navigate a plane through a series of grow, enabling them to afford increasingly grand and powerful winding caverns without crashing while collecting coins and structures. The town will passively collect resources over time, powerups. but users are rewarded for frequent check-ins by the intermittent availability of significant bonus resources that require manual Incentivization collection by tapping the associated buildings. This ensures that Incentivization games are designed to be played incrementally every 1 to 2 hours (corresponding to when we might expect the over the 28-day duration of the quit attempt. These are games next major craving to hit) the user will have something that are designed to involve longer term goal setting and productive to do in their town, and also provides an additional planning, as well as frequent monitoring/check-ins by the user. mechanism by which the user can distract themselves from their Most importantly, they make use of a premium currency system, cravings. which we have called QuitCoins. This system will be familiar http://games.jmir.org/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bindoff et al Textbox 1. The ways the user can earn QuitCoins. Completing the entry survey Opening the app Reporting how many cigarettes they’ve smoked Reading through their dashboard statistics Reading support content Successfully completing quizzes Playing a distraction minigame Earning achievements Setting up and achieving personal goals Completing the exit survey However, the QuitCoin rewards for a given piece of content Having earned QuitCoins, the user can redeem these coins in can only be earned periodically. For example, after reading a Tappy Town (or any other incentivization game we might add particular piece of advice the user might be rewarded with a at a later date). The highest performing and most visually QuitCoin, but they cannot reread the same piece of advice to impressive structures can only be purchased using QuitCoins. earn another QuitCoin; they must wait a day before they can The intention is that the user will become hooked on the reward earn rewards from reading that particular piece of advice again. mechanisms on display in Tappy Town, and will develop a QuitCoins are awarded immediately after performing the related sense of ownership of the town they are gradually building. action, and this is made visible to the user by an animation and This will inspire them to engage more with the various contents sound-effect that plays in the top right corner of the dashboard. in the Quittr app so that they can afford to build these impressive When the user taps the QuitCoin icon they are presented with showcase structures in their town. These mechanisms are readily a list of all the QuitCoin rewards they have been awarded apparent to the user, who is regularly notified that they are recently. This ensures that the user understands clearly why earning QuitCoins through natural interactions with Quittr, and they earned the reward (Figure 5). who are then encouraged to go to Tappy Town to redeem them. Figure 5. Collecting QuitCoin rewards. http://games.jmir.org/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bindoff et al By comparing the results of these 2 groups, we will be able to Results determine whether the additional incentivization game features we have developed offer any value in terms of the key metrics At the time of publication Quittr is largely complete, with only of engagement–how much content users are consuming; content revision still required. It has been in closed (invite only) retention–how many days that users are persisting with using beta testing using Apple TestFlight and on the Android Play the app; and smoking cessation rates–what proportion of users Store since August 9, 2016, and has at the time of writing successfully abstain from smoking for given period of time (October 4, 2016) been installed by 7 users on iOS and 11 users (based on user-reported data and biochemically verified). on Android. The feedback received during this beta testing period has resulted in 6 iterative beta releases during this period Going beyond this, we would ultimately like to compare our to date. At this time, we are confident that Quittr is stable and approach against a usual care scenario, to see how it compares all features are working as intended. The open beta test is more directly against current practice. We would also like to planned to become available for 2017, pending ethics board do a more specific evaluation in the younger demographic approval. because we believe that our approach may be particularly useful for younger smokers, who are perhaps more willing to engage Discussion with a mobile phone–based intervention, and with game-based approaches in general. Further Work Closing Thoughts It has yet to be determined whether the innovative game systems If this model proves successful there is a broad range of potential we have added into the traditional mHealth smoking cessation applications for this approach. By using the virtual currency recipe provide the additional value we are hoping for in terms approach in the way we have done here, we remove the need of engagement, retention, and ultimately cessation rates. To test for the game to comprehensively integrate the healthy activity the impact of the gaming elements, we are currently planning as part of its actual play mechanics. This opens up the potential a research project using a randomized controlled trial design. for a wide variety of health problems to be tackled through Users will be randomized into 1 of 2 groups, either the control games where no obvious play mechanic presents itself. This group that gets access to a “baseline” version of the game may be of benefit in areas such as managing chronic conditions without the incentivization game features and the QuitCoin (diabetes, heart disease, etc), treating substance abuse (alcohol, premium currency system, and the intervention group, which illicit drugs, etc), diet and exercise, eating disorders (anorexia, receives a copy of the game with the full feature set. bulimia, and binge eating), and various phobias. Conflicts of Interest None declared. References 1. Burns DM. Epidemiology of smoking-induced cardiovascular disease. Prog Cardiovasc Dis 2003;46:11-29. [Medline: 12920698] 2. Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA 2003;290:86-97. [doi: 10.1001/jama.290.1.86] [Medline: 12837716] 3. US Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health 2004:62. 4. Ghorai K, Akter S, Khatun F, Ray P. mHealth for smoking cessation programs: a systematic review. J Pers Med 2014;4:412-423 [FREE Full text] [doi: 10.3390/jpm4030412] [Medline: 25563359] 5. Ubhi HK, Michie S, Kotz D, Wong WC, West R. A mobile app to aid smoking cessation: preliminary evaluation of SmokeFree28. J Med Internet Res 2015;17:e17 [FREE Full text] [doi: 10.2196/jmir.3479] [Medline: 25596170] 6. Whittaker R, McRobbie H, Bullen C, Borland R, Rodgers A, Gu Y. Mobile phone-based interventions for smoking cessation. Cochrane Database Syst Rev 2012;11:CD006611. [doi: 10.1002/14651858.CD006611.pub3] [Medline: 23152238] 7. Brown J. A review of the evidence on technology-based interventions for the treatment of tobacco dependence in college health. Worldviews Evid Based Nurs 2013;10:150-162. [doi: 10.1111/wvn.12000] [Medline: 23421669] 8. Entertainment Software Association. Essential facts about the computer and video game industry. 2016 Apr.. URL: http:/ /essentialfacts.theesa.com/Essential-Facts-2016.pdf [accessed 2016-09-21] [WebCite Cache ID 6kfyg6sPI] 9. Gee J. What video games have to teach us about learning and literacy. Computers in Entertainment (CIE) 2003;1(1):20. 10. Granic I, Lobel A, Engels Rutger C M E. The benefits of playing video games. Am Psychol 2014 Jan;69(1):66-78. [doi: 10.1037/a0034857] [Medline: 24295515] 11. Boot WR, Blakely DP, Simons DJ. Do action video games improve perception and cognition? Front Psychol 2011;2:226 [FREE Full text] [doi: 10.3389/fpsyg.2011.00226] [Medline: 21949513] 12. Susi T, Johannesson M, Backlund P. Serious Games: An Overview. Skövde: University of Skövde; 2007. http://games.jmir.org/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bindoff et al 13. Baranowski T, Buday R, Thompson DI, Baranowski J. Playing for real: video games and stories for health-related behavior change. Am J Prev Med 2008;34:74-82 [FREE Full text] [doi: 10.1016/j.amepre.2007.09.027] [Medline: 18083454] 14. Primack BA, Carroll MV, McNamara M, Klem ML, King B, Rich M, et al. Role of video games in improving health-related outcomes: a systematic review. Am J Prev Med 2012;42:630-638 [FREE Full text] [doi: 10.1016/j.amepre.2012.02.023] [Medline: 22608382] 15. DeSmet A, Van Ryckeghem D, Compernolle S, Baranowski T, Thompson D, Crombez G, et al. A meta-analysis of serious digital games for healthy lifestyle promotion. Prev Med 2014;69:95-107. [doi: 10.1016/j.ypmed.2014.08.026] [Medline: 25172024] 16. DeLaughter KL, Sadasivam RS, Kamberi A, English TM, Seward GL, Chan SW, et al. Crave-Out: a distraction/motivation mobile game to assist in smoking cessation. JMIR Serious Games 2016;4:e3 [FREE Full text] [doi: 10.2196/games.4566] [Medline: 27229772] 17. 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;14:1453-1457. [doi: 10.1093/ntr/nts079] [Medline: 22422929] 18. Hall AK, Mercado R, Anderson-Lewis C, Darville G, Bernhardt JM. How to design tobacco prevention and control games for youth and adolescents: a qualitative analysis of expert interviews. Games Health J 2015;4:488-493. [doi: 10.1089/g4h.2015.0013] [Medline: 26230046] 19. 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:e35 [FREE Full text] [doi: 10.2196/resprot.2416] [Medline: 24025236] 20. Weiser P, Bucher D, Cellina F, De Luca V. A taxonomy of motivational affordances for meaningful gamified and persuasive technologies. Acsr Adv Comput 2015;22:271-280. 21. Free C, Phillips G, Galli L, Watson L, Felix L, Edwards P, et al. The effectiveness of mobile-health technology-based health behaviour change or disease management interventions for health care consumers: a systematic review. PLoS Med 2013;10:e1001362 [FREE Full text] [doi: 10.1371/journal.pmed.1001362] [Medline: 23349621] 22. Michie S, Churchill S, West R. Identifying evidence-based competences required to deliver behavioural support for smoking cessation. Ann Behav Med 2011;41:59-70. [doi: 10.1007/s12160-010-9235-z] [Medline: 20936389] 23. Google. Material design. 2016. URL: https://material.google.com/ [accessed 2016-09-21] [WebCite Cache ID 6kfzNNkTW] 24. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 2011;6:42 [FREE Full text] [doi: 10.1186/1748-5908-6-42] [Medline: 21513547] Edited by G Eysenbach; submitted 22.06.16; peer-reviewed by M Businelle, H Ubhi; comments to author 28.07.16; revised version received 05.10.16; accepted 28.10.16; published 01.12.16 Please cite as: Bindoff I, de Salas K, Peterson G, Ling T, Lewis I, Wells L, Gee P, Ferguson SG JMIR Serious Games 2016;4(2):e19 URL: http://games.jmir.org/2016/2/e19/ doi: 10.2196/games.6258 PMID: 27908844 ©Ivan Bindoff, Kristy de Salas, Gregory Peterson, Tristan Ling, Ian Lewis, Lindsay Wells, Peter Gee, Stuart G Ferguson. Originally published in JMIR Serious Games (http://games.jmir.org), 01.12.2016. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), 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/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 9 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Quittr: The Design of a Video Game to Support Smoking Cessation

Download PDF
9 pages

Loading next page...
 
/lp/jmir-publications/quittr-the-design-of-a-video-game-to-support-smoking-cessation-FLk4arkzQZ

References (24)

Publisher
JMIR Publications
Copyright
Copyright © The Author(s). Licensed under Creative Commons Attribution cc-by 4.0
ISSN
2291-9279
DOI
10.2196/games.6258
Publisher site
See Article on Publisher Site

Abstract

Background: Smoking is recognized as the largest, single, preventable cause of death and disease in the developed world. While the majority of smokers report wanting to quit, and many try each year, smokers find it difficult to maintain long-term abstinence. Behavioral support, such as education, advice, goal-setting, and encouragement, is known to be beneficial in improving the likelihood of succeeding in a quit attempt, but it remains difficult to effectively deliver this behavioral support and keep the patient engaged with the process for a sufficient duration. In an attempt to solve this, there have been numerous mobile apps developed, yet engagement and retention have remained key challenges that limit the potential effectiveness of these interventions. Video games have been clearly linked with the effective delivery of health interventions, due to their capacity to increase motivation and engagement of players. Objective: The objective of this study is to describe the design and development of a smartphone app that is theory-driven, and which incorporates gaming characteristics in order to promote engagement with content, and thereby help smokers to quit. Methods: Game design and development was informed by a taxonomy of motivational affordances for meaningful gamified and persuasive technologies. This taxonomy describes a set of design components that is grounded in well-established psychological theories on motivation. Results: This paper reports on the design and development process of Quittr, a mobile app, describing how game design principles, game mechanics, and game elements can be used to embed education and support content, such that the app actually requires the user to access and engage with relevant educational content. The next stage of this research is to conduct a randomized controlled trial to determine whether the additional incentivization game features offer any value in terms of the key metrics of engagement–how much content users are consuming, how many days users are persisting with using the app, and what proportion of users successfully abstain from smoking for 28 days, based on user-reported data and verified against a biochemical baseline using cotinine tests. Conclusions: We describe a novel, and theoretically-informed mobile app design approach that has a broad range of potential applications. By using the virtual currency approach, we remove the need for the game to comprehensively integrate the healthy activity as part of its actual play mechanics. This opens up the potential for a wide variety of health problems to be tackled through games where no obvious play mechanic presents itself. The implications of this app are that similar approaches may be of benefit in areas such as managing chronic conditions (diabetes, heart disease, etc), treating substance abuse (alcohol, illicit drugs, etc), diet and exercise, eating disorders (anorexia, bulimia, and binge eating), and various phobias. (JMIR Serious Games 2016;4(2):e19) doi: 10.2196/games.6258 KEYWORDS smoking cessation; video games; mobile phone; motivation http://games.jmir.org/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bindoff et al improve engagement in tasks not generally considered “fun,” Introduction such as learning, exercising, and practicing. Smoking and Cessation Within the health domain there have been a wide range of successful serious games initiatives trialed. A 2008 review of Smoking is recognized as the largest, single, preventable cause 27 publications reporting on 25 video games that promoted of death and disease in the developed world. It is associated health-related behavior change, identified that most of the with an increased risk of heart disease, stroke, cancer, studies demonstrated positive health-related changes from emphysema, bronchitis, asthma, renal disease, and eye disease. playing the video games [13]. While the majority of smokers report wanting to quit, and many try each year, smokers find it difficult to maintain long-term More recently, a 2012 review included 38 publications regarding abstinence [1-3]. video games that provide physical therapy, psychological therapy, improved disease self-management, health education, The delivery of education and support to smokers has been the distraction from discomfort, increased physical activity, and backbone of smoking cessation programs for decades. Such skills training for clinicians [14]. Among the 38 studies, a total programs were traditionally delivered in face-to-face sessions of 195 health outcomes were examined. Results indicated that with trained tobacco cessation counselors, or via self-help video games improved 69% of psychological therapy outcomes, booklets and websites, but more recently researchers have turned 59% of physical therapy outcomes, 50% of physical activity to technological solutions such as mobile phone apps in order outcomes, 46% of clinician skills outcomes, 42% of health to deliver content to smokers in a way that can be easily scaled education outcomes, 42% of pain distraction outcomes, and up to population levels [4-6]. Regardless of the delivery 37% of disease self-management outcomes. Further, in 2014, modality, behavioral support programs have been found to be a meta-analysis of 54 serious digital game studies for healthy mildly effective [7], with the educational content involved in lifestyle promotion reviewed the overall effectiveness of serious such programs (including advice on when and how to use digital games on healthy lifestyle [15], and demonstrated small pharmacological support) appearing to have the greatest impact positive effects on healthy lifestyle promotion outcomes. on cessation rates. Video Games and Smoking Cessation Despite significant investment in the development of such programs, a persistent issue is that smokers do not readily The concept of using games to promote smoking cessation is engage with the cessation content delivered. Failure to engage not entirely new. There is some existing work that explores the with the “active content” of cessation programs is problematic potential of the idea, and even some existing game-based as it limits the potential effectiveness of such programs: the interventions have been developed. Most early attempts at education and support delivered cannot hope to be effective if incorporating video game elements have focused on the delivery it is not used by smokers during their quit attempt. Even if users of a distraction, to help the smoker get through an episode of engage initially, it is difficult to keep them interested beyond craving. Crave-Out was an early attempt at this style of game, the first few days (retention). Identifying mechanisms that producing a pattern matching memory game and using the encourage smokers to engage with smoking cessation content Questionnaire of Smoking Urge-Brief measurement before and requires ongoing investigation. after play to determine if it helped to reduce cravings. A small but insignificant reduction in cravings was measured. Critically Video Games and Health Interventions however, the authors determined during pilot testing that Video games are immensely popular, with recent statistics negative reinforcement had a deleterious effect on smokers, as indicating that in the United States 63% of households are home it reminded them of smoking, and this finding is worth bearing to at least 1 person who plays video games regularly (3 hours in mind in future designs [16]. Subsequently, similar “distraction or more per week) and 65% of households own a device used minigames” have also been incorporated into other to play video games [8]. Rather than video games being seen mHealth-based smoking cessation apps such as SmokeFree 28 as simply time-wasting entertainments, they are now recognized [5]. as an integral part of our modern society, with games and play The most grass-roots evidence to support the idea of game-based increasingly informing other domains of our everyday life. smoking cessation interventions comes from Raiff et al [17], Research on video games now shows that games have the ability who explored the link between video game usage and smoking. to keep people engaged for a long time, build relationships and They determined that 74.5% of smokers play video games (more communities among players, and cultivate their creative than nonsmokers), and that 63.7% of participants believed that potential. Furthermore, games have been shown to have the a video game–based intervention would motivate smokers to power to support knowledge acquisition and even to bring about quit [17]. There is some speculation that the “addictive behavior change [9-11]. tendencies” of smokers makes them more likely to become frequent video game players. Games with a purpose, also known as “serious games,” look much like traditional entertainment games, but differ in that Hall et al [18] tried to qualitatively determine, from expert they have a defined purpose, outcome, or message that the opinion, key design characteristics for a successful video creators of the game are trying to get across to a particular game–based smoking cessation intervention. After interviewing audience [12]. By employing all the fun and engaging elements experts in game development, tobacco, and health behavior a found in games and applying them to real-world or productive number of themes emerged. In particular, it was noted that activities, they have the potential to influence behavior or http://games.jmir.org/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bindoff et al targeting youths through games was likely to be an effective that support the acquisition of smoking cessation content, and strategy that extensive iterative prototyping was required to build a game that provides an engaging environment for players create a compelling game experience, and that incorporating to remain engaged with such content, we may be able to behavioral change techniques was likely to result in improved positively influence smoking cessation outcomes. outcomes. Theoretical Basis for Design There is also some preliminary evidence exploring Internet This focus aligns with the assessment that reflective and implementations. QuitIT is an Internet-based video game that automatic motivation toward smoking cessation can be enhanced is designed to help smokers practice coping strategies for by interventions, such as education, persuasion, intensification, cravings. Initial evaluation suggests the game was useful in coercion, and modelling [20]. However, the actual content teaching strategies for coping with urges [19], although there component of the app itself is flexible and has been designed is not yet any data to suggest that it improves quit success rates. to be easily updatable as new content is developed. Traditionally, serious games in the health behavior change space Game Mechanic and Game Elements Design Phase have focused on directly encouraging the behavior of interest Within the cycle of design and development, the initial Game (eg, promoting physical activity by requiring movement as part Mechanic and Elements design phase was informed by a of the game play). An alternate possible use of games–one that taxonomy of motivational affordances for meaningful gamified we explore here–is that games could be embedded with and persuasive technologies (Figure 1) [20]. This taxonomy education and support content, such that the game play simply describes a set of design components that is grounded in acts as the hook that compels the user to access and engage with well-established psychological theories on motivation [20]. relevant educational content, in exchange for incentives that further the players goals in the game. Such game play may To allow for meaningful gamified and persuasive systems, encourage engagement with proven educationally based designers should choose components depending on both the intervention strategies, and thereby improve health outcomes. objectives and the users of the system [20]. To guide this activity, the taxonomy outlines both general design principles It has been suggested that games are fun because they appeal and mechanics that game designers might benefit from to some core drives that motivate us toward certain activities, considering, and that might assist in ensuring theoretically such as meaning, empowerment, social influence, grounded serious game development, as is required in this unpredictability, avoidance, scarcity, ownership, and intervention. accomplishment [15]. If we can identify the elements of games Figure 1. Design principles and mechanics for persuasive game design [17]. http://games.jmir.org/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bindoff et al would enable the delivery of proven effective smoking cessation Methods support content, but with game elements integrated throughout to improve user engagement and retention. Overview of the Design An app was produced compatible with both Android and iOS Based on the theoretical underpinnings described above, we mobile phones and tablets. Upon opening the app, users are designed and developed a mobile phone game called Quittr to greeted with a dashboard system separated into 3 main pages, support people in their attempt to quit smoking. This design which they can swipe between (Figure 2), styled in adherence borrowed many elements from existing literature [21,22] and with the popular Google Material user interface design examples of mHealth smoking cessation apps, most notably guidelines [23]. SmokeFree 28 [5]. The focus was on creating a platform that Figure 2. The main dashboard of Quittr. unique identifier so that we can track a given user across Data Collection potentially many quit attempts. When the user first opens the app they are prompted to complete Progress an entry survey, which includes questions about the user’s smoking status, demographics, health, and financial goals, as The first page of the main dashboard is titled “Progress,” and well as questions about the user’s intentions in using the app. includes tracked statistics relating to the financial, health, and On subsequent openings, the user is asked if they have smoked social outcomes of the user associated with their current quit any cigarettes that haven’t been entered into the app. If the user attempt. It delivers an easily accessible snapshot of the statistics indicates yes to this question, they are asked to indicate how that are most relevant/important to the user at the current time many cigarettes they smoked on each day that has elapsed since (based on their current status and data collected during a their last log. If the user has not opened Quittr for 12 hours they commencement survey). The user can optionally explore a are prompted with a notification on their device asking them to comprehensive list of every tracked statistic. These progress come back and log their cigarettes. This will repeat daily for bars provide meaningful feedback to the user as well as several days if they still fail to check-in. educating them about the benefits of quitting, and have proven to be a valuable feature in a range of successful smoking At the end of 28 days or when the user indicates their current cessation apps [20,24]. quit attempt has failed, they are also asked to complete an exit survey. This asks questions about their opinions of the app, the The progress page also includes an achievements section, with games, and if appropriate, their reasons for giving up their quit a range of predefined goals for the user to strive toward, as well attempt early. Having indicated that their quit attempt has failed, as the ability to set their own financial savings goals to target. the user is able to start a new quit attempt at any time, which The progress page displays the next several achievements that will reset all their existing data, triggering a new entry survey, the user is close to achieving, but the user can click on the tile and so on. to review the full list of achievements, including achievements they have already obtained. This style of achievement system All collected data is stored and uploaded to our webserver for is a proven staple across the games industry, and is a mainstay analysis and review. For the sake of privacy, we do not collect in any “gamified” apps. The achievements system ensures that any personally identifying information, although we do use a http://games.jmir.org/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bindoff et al the user always has both short and longer term goals in sight, We have designed the content in this section to be readily as well as having a set of accomplishments they can reflect upon customized and expanded upon, with updates being pulled from to remind themselves how far they’ve come [20]. our webserver as required whenever Internet connectivity is available. The content is also tagged with a set of metadata that Support enables it to be tailored to the user based on the data collected The support page includes a range of helpful information and during the entry survey and the state of their current quit attempt support, including a button, which simply dials the local Quit (ie, content about smoking during pregnancy would be more Support hotline, and the “Quick Tips” button that displays relevant to pregnant women than to men, and content regarding helpful tips about how to use the app. Perhaps the most cardiovascular disease would be more important to older interesting feature of this section is the “Information Toolbox” smokers). (Figure 3). Games The Information Toolbox includes a wide variety of educational The games page lists a range of games that the user can engage material, which can support the user on their quit attempt. This with (Figure 4). The games are split into 2 categories, those that includes information about the various therapies and treatment are intended purely as a distraction from cravings, and those plans available, as well as information on cravings, coping that are used as an incentive to engage with the broader app. strategies, the benefits of quitting, and the consequences of Currently, 2 games are available, with plans to include more. smoking. The information is neatly structured into ‘bite-sized By providing a variety of games that will appeal to different chunks’ to make it easy for the user [22]. After reading a section users, we can improve the likelihood that a given user will be the user is challenged by a multiple choice quiz that asks one able to find a game they enjoy playing, and that they find it to of several basic questions that relate to the material they just be an effective distraction. read. Figure 3. The Information Toolbox. http://games.jmir.org/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bindoff et al Figure 4. The games currently available in Quittr. to those who have played free-to-play mobile and Facebook Distraction games, wherein the user can spend a premium currency The distraction games are simple minigames that can be played (traditionally obtained by spending real money or engaging with in a stand-alone 1- to 5-minute session. They are designed to video ads) to obtain bonuses in the game. In this case, instead demand mental focus and both hands, so as to provide a of purchasing QuitCoins using real money, the user is rewarded meaningful and effective distraction or an alternative from the with QuitCoins in return for engaging with the smoking act of smoking [5,16,22]. cessation content of the broader app in a meaningful way (see Textbox 1). This is the key innovation that our approach adds, There is currently only one distraction minigame included in distinguishing it from earlier attempts in this space. Quittr. This is a hidden object style game where the user must search for and tap particular objects in an increasingly cluttered Currently, we have only created 1 incentivization game. It is a environment, and under time pressure. There are also 2 “city builder” style game, which we have called “Tappy Town.” additional games being prepared for inclusion: a fruit-ninja style In Tappy Town, the user has an empty plot of land to fill and a game where the user must swipe across missiles, which are large range of structures they can build to improve that land. launched while avoiding bombs; and an endless-runner style As the user grows their town the town’s economy will also game where the user must navigate a plane through a series of grow, enabling them to afford increasingly grand and powerful winding caverns without crashing while collecting coins and structures. The town will passively collect resources over time, powerups. but users are rewarded for frequent check-ins by the intermittent availability of significant bonus resources that require manual Incentivization collection by tapping the associated buildings. This ensures that Incentivization games are designed to be played incrementally every 1 to 2 hours (corresponding to when we might expect the over the 28-day duration of the quit attempt. These are games next major craving to hit) the user will have something that are designed to involve longer term goal setting and productive to do in their town, and also provides an additional planning, as well as frequent monitoring/check-ins by the user. mechanism by which the user can distract themselves from their Most importantly, they make use of a premium currency system, cravings. which we have called QuitCoins. This system will be familiar http://games.jmir.org/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bindoff et al Textbox 1. The ways the user can earn QuitCoins. Completing the entry survey Opening the app Reporting how many cigarettes they’ve smoked Reading through their dashboard statistics Reading support content Successfully completing quizzes Playing a distraction minigame Earning achievements Setting up and achieving personal goals Completing the exit survey However, the QuitCoin rewards for a given piece of content Having earned QuitCoins, the user can redeem these coins in can only be earned periodically. For example, after reading a Tappy Town (or any other incentivization game we might add particular piece of advice the user might be rewarded with a at a later date). The highest performing and most visually QuitCoin, but they cannot reread the same piece of advice to impressive structures can only be purchased using QuitCoins. earn another QuitCoin; they must wait a day before they can The intention is that the user will become hooked on the reward earn rewards from reading that particular piece of advice again. mechanisms on display in Tappy Town, and will develop a QuitCoins are awarded immediately after performing the related sense of ownership of the town they are gradually building. action, and this is made visible to the user by an animation and This will inspire them to engage more with the various contents sound-effect that plays in the top right corner of the dashboard. in the Quittr app so that they can afford to build these impressive When the user taps the QuitCoin icon they are presented with showcase structures in their town. These mechanisms are readily a list of all the QuitCoin rewards they have been awarded apparent to the user, who is regularly notified that they are recently. This ensures that the user understands clearly why earning QuitCoins through natural interactions with Quittr, and they earned the reward (Figure 5). who are then encouraged to go to Tappy Town to redeem them. Figure 5. Collecting QuitCoin rewards. http://games.jmir.org/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bindoff et al By comparing the results of these 2 groups, we will be able to Results determine whether the additional incentivization game features we have developed offer any value in terms of the key metrics At the time of publication Quittr is largely complete, with only of engagement–how much content users are consuming; content revision still required. It has been in closed (invite only) retention–how many days that users are persisting with using beta testing using Apple TestFlight and on the Android Play the app; and smoking cessation rates–what proportion of users Store since August 9, 2016, and has at the time of writing successfully abstain from smoking for given period of time (October 4, 2016) been installed by 7 users on iOS and 11 users (based on user-reported data and biochemically verified). on Android. The feedback received during this beta testing period has resulted in 6 iterative beta releases during this period Going beyond this, we would ultimately like to compare our to date. At this time, we are confident that Quittr is stable and approach against a usual care scenario, to see how it compares all features are working as intended. The open beta test is more directly against current practice. We would also like to planned to become available for 2017, pending ethics board do a more specific evaluation in the younger demographic approval. because we believe that our approach may be particularly useful for younger smokers, who are perhaps more willing to engage Discussion with a mobile phone–based intervention, and with game-based approaches in general. Further Work Closing Thoughts It has yet to be determined whether the innovative game systems If this model proves successful there is a broad range of potential we have added into the traditional mHealth smoking cessation applications for this approach. By using the virtual currency recipe provide the additional value we are hoping for in terms approach in the way we have done here, we remove the need of engagement, retention, and ultimately cessation rates. To test for the game to comprehensively integrate the healthy activity the impact of the gaming elements, we are currently planning as part of its actual play mechanics. This opens up the potential a research project using a randomized controlled trial design. for a wide variety of health problems to be tackled through Users will be randomized into 1 of 2 groups, either the control games where no obvious play mechanic presents itself. This group that gets access to a “baseline” version of the game may be of benefit in areas such as managing chronic conditions without the incentivization game features and the QuitCoin (diabetes, heart disease, etc), treating substance abuse (alcohol, premium currency system, and the intervention group, which illicit drugs, etc), diet and exercise, eating disorders (anorexia, receives a copy of the game with the full feature set. bulimia, and binge eating), and various phobias. Conflicts of Interest None declared. References 1. Burns DM. Epidemiology of smoking-induced cardiovascular disease. Prog Cardiovasc Dis 2003;46:11-29. [Medline: 12920698] 2. Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA 2003;290:86-97. [doi: 10.1001/jama.290.1.86] [Medline: 12837716] 3. US Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health 2004:62. 4. Ghorai K, Akter S, Khatun F, Ray P. mHealth for smoking cessation programs: a systematic review. J Pers Med 2014;4:412-423 [FREE Full text] [doi: 10.3390/jpm4030412] [Medline: 25563359] 5. Ubhi HK, Michie S, Kotz D, Wong WC, West R. A mobile app to aid smoking cessation: preliminary evaluation of SmokeFree28. J Med Internet Res 2015;17:e17 [FREE Full text] [doi: 10.2196/jmir.3479] [Medline: 25596170] 6. Whittaker R, McRobbie H, Bullen C, Borland R, Rodgers A, Gu Y. Mobile phone-based interventions for smoking cessation. Cochrane Database Syst Rev 2012;11:CD006611. [doi: 10.1002/14651858.CD006611.pub3] [Medline: 23152238] 7. Brown J. A review of the evidence on technology-based interventions for the treatment of tobacco dependence in college health. Worldviews Evid Based Nurs 2013;10:150-162. [doi: 10.1111/wvn.12000] [Medline: 23421669] 8. Entertainment Software Association. Essential facts about the computer and video game industry. 2016 Apr.. URL: http:/ /essentialfacts.theesa.com/Essential-Facts-2016.pdf [accessed 2016-09-21] [WebCite Cache ID 6kfyg6sPI] 9. Gee J. What video games have to teach us about learning and literacy. Computers in Entertainment (CIE) 2003;1(1):20. 10. Granic I, Lobel A, Engels Rutger C M E. The benefits of playing video games. Am Psychol 2014 Jan;69(1):66-78. [doi: 10.1037/a0034857] [Medline: 24295515] 11. Boot WR, Blakely DP, Simons DJ. Do action video games improve perception and cognition? Front Psychol 2011;2:226 [FREE Full text] [doi: 10.3389/fpsyg.2011.00226] [Medline: 21949513] 12. Susi T, Johannesson M, Backlund P. Serious Games: An Overview. Skövde: University of Skövde; 2007. http://games.jmir.org/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bindoff et al 13. Baranowski T, Buday R, Thompson DI, Baranowski J. Playing for real: video games and stories for health-related behavior change. Am J Prev Med 2008;34:74-82 [FREE Full text] [doi: 10.1016/j.amepre.2007.09.027] [Medline: 18083454] 14. Primack BA, Carroll MV, McNamara M, Klem ML, King B, Rich M, et al. Role of video games in improving health-related outcomes: a systematic review. Am J Prev Med 2012;42:630-638 [FREE Full text] [doi: 10.1016/j.amepre.2012.02.023] [Medline: 22608382] 15. DeSmet A, Van Ryckeghem D, Compernolle S, Baranowski T, Thompson D, Crombez G, et al. A meta-analysis of serious digital games for healthy lifestyle promotion. Prev Med 2014;69:95-107. [doi: 10.1016/j.ypmed.2014.08.026] [Medline: 25172024] 16. DeLaughter KL, Sadasivam RS, Kamberi A, English TM, Seward GL, Chan SW, et al. Crave-Out: a distraction/motivation mobile game to assist in smoking cessation. JMIR Serious Games 2016;4:e3 [FREE Full text] [doi: 10.2196/games.4566] [Medline: 27229772] 17. 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;14:1453-1457. [doi: 10.1093/ntr/nts079] [Medline: 22422929] 18. Hall AK, Mercado R, Anderson-Lewis C, Darville G, Bernhardt JM. How to design tobacco prevention and control games for youth and adolescents: a qualitative analysis of expert interviews. Games Health J 2015;4:488-493. [doi: 10.1089/g4h.2015.0013] [Medline: 26230046] 19. 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:e35 [FREE Full text] [doi: 10.2196/resprot.2416] [Medline: 24025236] 20. Weiser P, Bucher D, Cellina F, De Luca V. A taxonomy of motivational affordances for meaningful gamified and persuasive technologies. Acsr Adv Comput 2015;22:271-280. 21. Free C, Phillips G, Galli L, Watson L, Felix L, Edwards P, et al. The effectiveness of mobile-health technology-based health behaviour change or disease management interventions for health care consumers: a systematic review. PLoS Med 2013;10:e1001362 [FREE Full text] [doi: 10.1371/journal.pmed.1001362] [Medline: 23349621] 22. Michie S, Churchill S, West R. Identifying evidence-based competences required to deliver behavioural support for smoking cessation. Ann Behav Med 2011;41:59-70. [doi: 10.1007/s12160-010-9235-z] [Medline: 20936389] 23. Google. Material design. 2016. URL: https://material.google.com/ [accessed 2016-09-21] [WebCite Cache ID 6kfzNNkTW] 24. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 2011;6:42 [FREE Full text] [doi: 10.1186/1748-5908-6-42] [Medline: 21513547] Edited by G Eysenbach; submitted 22.06.16; peer-reviewed by M Businelle, H Ubhi; comments to author 28.07.16; revised version received 05.10.16; accepted 28.10.16; published 01.12.16 Please cite as: Bindoff I, de Salas K, Peterson G, Ling T, Lewis I, Wells L, Gee P, Ferguson SG JMIR Serious Games 2016;4(2):e19 URL: http://games.jmir.org/2016/2/e19/ doi: 10.2196/games.6258 PMID: 27908844 ©Ivan Bindoff, Kristy de Salas, Gregory Peterson, Tristan Ling, Ian Lewis, Lindsay Wells, Peter Gee, Stuart G Ferguson. Originally published in JMIR Serious Games (http://games.jmir.org), 01.12.2016. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), 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/2016/2/e19/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e19 | p. 9 (page number not for citation purposes) XSL FO RenderX

Journal

JMIR Serious Games – JMIR Publications

Published: Dec 1, 2016

Keywords: smoking cessation; video games; mobile phone; motivation

There are no references for this article.