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SmokefreeTXT for homeless smokers: A pilot randomized controlled trial (Preprint)


 BACKGROUND
 Homeless smokers want to quit smoking but face numerous barriers to doing so, including pervasive smoking among peers and a lack of social support for quitting. A text messaging intervention could address these challenges by providing virtual daily support for homeless smokers who are trying to quit but coping with multiple triggers to smoke.
 
 
 OBJECTIVE
 We assessed whether a free text messaging program, added to evidence-based pharmacotherapy and counseling, improved smoking abstinence among homeless adult smokers.
 
 
 METHODS
 In 10/2015–06/2016, we conducted an 8-week pilot randomized controlled trial of nicotine patch therapy and weekly in-person counseling with (N=25) or without (N=25) SmokefreeTXT, a free text messaging service administered by the National Cancer Institute (NCI), at Boston Health Care for the Homeless Program. All participants were provided with a mobile phone and a 2-month prepaid voice and text plan at no cost. SmokefreeTXT enrollees were sent 1-5 automated text messages daily for up to 8 weeks and could receive on-demand tips for managing cravings, mood symptoms, and smoking lapses. The primary outcome was smoking abstinence, defined as an exhaled carbon monoxide <8 parts per million, assessed 14 times over 8 weeks of follow-up and analyzed using repeated-measures logistic regression with generalized estimating equations. Other outcomes were use of SmokefreeTXT, assessed by data obtained from NCI; perceptions of SmokefreeTXT, assessed by surveys and qualitative interviews; and mobile phone retention, assessed by self-report.
 
 
 RESULTS
 67% of eligible individuals participated. Of SmokefreeTXT arm participants (N=25), 88% enrolled in the program but only 56% had confirmed enrollment for ≥2 weeks. Among 2-week enrollees, the median response rate to interactive messages from SmokefreeTXT was 2.1% (interquartile range 0-10.5%). Across all time points, smoking abstinence did not differ significantly between SmokefreeTXT and control arm participants (odds ratio 0.92, 95% confidence interval 0.30-2.84). Of SmokefreeTXT enrollees who completed exit surveys (N=15), two-thirds were very/extremely satisfied with the program. However, qualitative interviews (N=14) revealed that many participants preferred in-person over phone-based intervention formats, found the text messages impersonal and robotic, and felt that the messages were too frequent and repetitive. Only 40% of SmokefreeTXT arm participants retained their study-supplied mobile phone for the 8-week duration of the trial, with phone theft being most common. The logistics of storing and charging phones were cited as challenges in qualitative interviews.
 
 
 CONCLUSIONS
 SmokefreeTXT, added to nicotine patch therapy and in-person counseling, did not significantly improve smoking abstinence in this 8-week pilot RCT for homeless smokers. Text messaging interventions for this population should be better tuned to the unique circumstances of homelessness and coupled with innovative efforts to promote mobile phone retention over time.
 
 
 CLINICALTRIAL
 ClinicalTrials.gov (NCT02565381)
