Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Mindfulness training shows promise for improving smoking cessation and lapse recovery, and between-session mHealth messages could enhance treatment engagement and effectiveness. Personalized, in-the-moment text messaging support could be particularly useful for low-income smokers with fewer smoking cessation resources. Objective: This pilot study examined feasibility of a text messaging program (“iQuit Mindfully”) as an adjunct to in-person Mindfulness-Based Addiction Treatment (MBAT) for smoking cessation. Methods: Participants (N=71; 70% (50/71) African American, 61% (43/71) annual household income <$30K) were randomly assigned to MBAT (N=33) or iQuit Mindfully (N=38; MBAT + between-session text messages). All participants received 8 weekly group counseling sessions, nicotine patches, and self-help materials. Outcomes were: feasibility (attrition, engagement, participant ratings), participant feedback regarding the text messaging intervention, and smoking cessation. Results: Strong retention was achieved (76% (54/71) at end-of-treatment; 89% (63/71) at 1-month follow-up). In the iQuit Mindfully group, engagement was high (88% (29/33) indicated reading all or most texts, and 89% (34/38) engaged in interactive texting); and participants provided positive ratings (on 1-10 scale, average rating for recommending the program to others was 8.4 [SD = 2.5]). Participants indicated benefiting from the texts (e.g., appreciating encouraging reminders, coping strategies, and social support) and suggested improvements (e.g., more personalization). Overall biochemically-confirmed smoking cessation rates were 22% (12/55) at end of treatment and 19% (12/62) at 1-month follow-up, with no differences between conditions. Living below the poverty level predicted worse cessation outcomes at 1-month follow-up among participants receiving in-person only treatment (P = .03) but not among those receiving iQuit Mindfully. Conclusions: Text messaging appears to be a feasible and acceptable modality for supporting mindfulness-based smoking cessation treatment. The availability of 24/7 text messaging might be particularly helpful for low-income smokers, who have access to fewer cessation resources and experience significant day-to-day barriers to quitting. Clinical Trial: This trial was registered on clinicaltrials.gov (NCT03029819).

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Mindfulness-based programs show promise for promoting smoking cessation in diverse populations. mHealth strategies could increase treatment engagement and in-the-moment support, thus enhancing effects of mindfulness-based smoking cessation interventions. However, most mHealth programs have been developed without sufficient input from the target population. Objective: By eliciting input from the target population (predominantly low-SES African American adult smokers) throughout the development of a text messaging program that teaches mindfulness for smoking cessation, we aimed for the resulting program to be optimally effective and consistent with participants’ needs and preferences. Methods: Two qualitative studies (N=25) were conducted with predominantly low-SES, African American adult smokers. In Study 1 (initial qualitative input; n=15), participants engaged in focus groups to provide suggestions for program development. In Study 2 (abbreviated trial; n=10), participants received a 1-week version of the text messaging program and provided feedback through in-depth interviews. Results: In Study 1, participants suggested that the text messaging program be personalized; interactive; provide strategies for coping with cravings and recovering from smoking lapses; involve relatively short, to-the-point messages; and include pictures. In Study 2, participants were highly engaged with the texts, indicated that the program was useful, and provided additional suggestions for improvement. Conclusions: Eliciting feedback from the target population throughout the intervention development process allowed for iterative revisions to increase feasibility, acceptability, and effectiveness. Overall, text messaging appears to be a feasible, appealing way to provide in-the-moment personalized support and encourage mindfulness among low-income African American smokers. Clinical Trial: N/A

Background: Smoking is the leading cause of preventable morbidity and mortality in the United States. Individuals with low socioeconomic status have disproportionately high smoking rates and greater difficulty quitting smoking. Efficiently connecting underserved smokers to effective tobacco cessation programs is crucial for disease prevention and the elimination of health disparities. Smartphone-based interventions have the potential to enhance the reach and efficacy of smoking cessation treatments targeting underserved smokers, but there is little efficacy data for these interventions. In this study, we will partner with a large, local hunger-relief organization to evaluate the efficacy and economic impact of a theoretically-based, fully-automated, and interactive smartphone-based smoking cessation intervention.Methods: This study will consist of a 2-group randomized controlled trial. Participants (N = 500) will be recruited from a network of food distribution centers in West Central Florida and randomized to receive either Standard Treatment (ST,n = 250) or Automated Treatment (AT,n = 250). ST participants will be connected to the Florida Quitline for telephone-based treatment and will receive a 10-week supply of nicotine replacement therapy (NRT; transdermal patches and lozenges). AT participants will receive 10 weeks of NRT and a fully-automated smartphone-based intervention consisting of interactive messaging, images, and audiovisual clips. The AT intervention period will span 26 weeks, with 12 weeks of proactive content and 26 weeks of on-demand access. ST and AT participants will complete weekly 4-item assessments for 26 weeks and 3-, 6-, and 12-month follow-up assessments. Our primary aim is to evaluate the efficacy of AT in facilitating smoking abstinence. As secondary aims, we will explore potential mediators and conduct economic evaluations to assess the cost and/or cost-effectiveness of ST vs. AT.Discussion: The overall goal of this project is to determine if AT is better at facilitating long-term smoking abstinence than ST, the more resource-intensive approach. If efficacy is established, the AT approach will be relatively easy to disseminate and for community-based organizations to scale and implement, thus helping to reduce tobacco-related health disparities.Trial registration: Clinical Trials RegistryNCT05004662. Registered August 13, 2021.

Background: Smoking is the leading cause of premature death, and low-income adults experience disproportionate burden from tobacco. Mindfulness interventions show promise for improving smoking cessation. A text messaging program “iQuit Mindfully” was developed to deliver just-in-time support for quitting smoking among low-income adults. A pilot study of iQuit Mindfully was conducted in spring 2020, during the COVID-19 pandemic, among low-income and predominantly African American smokers. Objective: This pilot study examined the acceptability and feasibility of delivering Mindfulness-Based Addiction Treatment via mHealth during the COVID-19 pandemic. Methods: Participants were adult cigarette smokers (n=23), of whom 8 (34.8%) were female, 19 (82.6%) were African American, and 18 (78.3%) had an annual income of <US $24,000. They were randomly assigned to either 8 weeks of iQuit Mindfully as a fully automated standalone intervention or iQuit Mindfully in combination with therapist-led in-person group treatment. For participant safety, in-person mindfulness groups were transitioned to the internet and assessments also took place over the internet. Survey questions asked participants about changes in their stress, smoking habits and quit attempts, and their perceptions of the mindfulness and text messaging intervention in the context of the pandemic. Results: Most participants (n=15 of 21, 71.4%) indicated a change in stress due to the pandemic, of whom 14 (93.3%) indicated higher stress. Participants shared concerns about finances, homelessness, health, and social isolation. Most (n=17 of 21, 80.9%) believed that smoking increases the risk of contracting COVID-19, and although that was motivating for some, others expressed lower motivation to quit smoking because of higher stress. Most (n=18 of 21, 85.7%) stated that practicing mindfulness was helpful during the pandemic. Mean ratings of the helpfulness of text messages and the extent to which they would recommend the program to others were 7.1 (median 8 on a 10-point scale, SD 2.9) and 8.2 (median 9, SD 2.5), respectively. Through open-ended program evaluations, participants shared details about how mindfulness practices and the text messages helped them manage stress and feel a sense of social support during the pandemic. Moreover, 10 of 19 (52.6%) of participants achieved 7-day abstinence from smoking, with no differences between conditions. Conclusions: This study supports the promise of text messaging and the use of teleconferencing to provide mindfulness and smoking cessation services to underserved populations during a pandemic.

Background: Little is known about the use of electronic nicotine delivery systems (ENDS) among low-income adult cigarette smokers, who experience severe tobacco-related health disparities. Methods: This study conducted interviews to examine experiences and perceptions associated with ENDS use among predominantly low-income adult smokers (n = 30; mean age 30.2 ± 12.9; 60% male, 46.7% African American, 30% white, 10% more than one race; 76.7% annual household income ≤USD 24,000). Interviews were transcribed verbatim and coded in NVivo 11. Results: Overall, participants reported complementing rather than substituting their smoking with ENDS use (e.g., using ENDS only when smoking is not allowed). Predominant reasons for vaping were convenience, smoking reduction/cessation, stress management, social acceptability, lower long-term costs than smoking, and appealing flavors. Common reasons for not switching to exclusive vaping were that ENDS did not satisfy cigarette cravings and concerns about ENDS health effects. Participants indicated higher likelihood of switching to exclusive ENDS use if the products were more affordable, perceived as substantially less harmful, tasted and felt more like smoking a cigarette, and more effective for reducing cravings. Conclusions: Continued research is needed to maximize any harm reduction potential of ENDS and ensure that these products do not contribute to worsening health disparities.

Low-income and African American adults experience severe tobacco-related health disparities. Mindfulness-based interventions show promise for promoting smoking cessation, but most mindfulness research has focused on higher income, Caucasian samples. “iQuit Mindfully” is a personalized, interactive text messaging program that teaches mindfulness for smoking cessation. This qualitative study sought feedback from predominantly low-income African American smokers, to improve the intervention for this priority population. After receiving 8 weekly group sessions of Mindfulness-Based Addiction Treatment for smoking cessation and between-session iQuit Mindfully text messages, participants (N=32) completed semi-structured interviews. Participants were adult cigarette smokers (90.6% African American, 62.6% annual income <$30,000, mean age 45.1 [±12.9]). Interviews inquired about participants’ experiences with and suggestions for improving iQuit Mindfully, including message content, number, and timing. Interviews were audio-recorded, transcribed verbatim, and coded by a team of 5 coders in NVivo. The coding manual was developed based on response categories from the interview guide and themes emerging from the data. Themes were organized into a conceptual model of factors related to engagement with the mHealth program. Response categories included helpful aspects (e.g., themes of social support, mindfulness, personalization); unhelpful/disliked aspects (e.g., too many/repetitive messages); links between in-person sessions and texts; and suggestions (e.g., changes to number/timing and more personalization). Findings provide insight into participants’ day-to-day experiences with iQuit Mindfully and suggest ways to improve mHealth programs among low-income and African American adults.