E-cigarette Cessation SMS Program: A Randomized Clinical Trial Study Targeting Adolescent E-cigarette Users

Background

In recent years, e-cigarettes have become the most widely used tobacco product among American adolescents. Statistics from 2023 show that over 2.1 million adolescents reported current use of e-cigarettes, including 10% of high school students and 4.6% of middle school students. Any level of e-cigarette use among adolescents is unsafe because nicotine has significant negative effects on learning, memory, and attention during this age, and increases the risk of future mental health issues and addiction to other substances. Additionally, e-cigarettes expose adolescents to numerous toxic substances, leading to health issues such as asthma, bronchitis, and respiratory irritation. Therefore, developing interventions for e-cigarette cessation has become an important public health task.

Research Origin

This study was authored by Dr. Amanda L. Graham, Sarah Cha MSPh, Megan A. Jacobs MPH, Dr. Michael S. Amato, Anna L. Funsten MSN, Giselle Edwards MHS, and Dr. George D. Papandonatos. The authors are from Truth Initiative (Washington, D.C.), Mayo Clinic College of Medicine and Science (Rochester, Minnesota), Georgetown University Medical Center/Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center (Washington, D.C.), and Brown University (Providence, Rhode Island). The paper was published in JAMA on August 7, 2024.

Study Design and Methods

Study Design

To compare the effects of an e-cigarette cessation SMS program with an assessment-only control group in nicotine e-cigarette cessation, this study conducted a parallel, double-blind, individually randomized clinical trial. The study period was from October 1, 2021, to October 18, 2023. Participants were recruited through social media advertisements, and the interventions were delivered via SMS, with assessments completed online or by phone.

Participants

Inclusion criteria were: aged 13 to 17 years, e-cigarette use in the past 30 days, intention to quit within 30 days, ownership of a mobile phone with an active SMS plan, and residence in the United States. Participants were recruited via social media ads on platforms such as Instagram, Facebook, and Snapchat. After baseline assessments, participants were randomly assigned to either the intervention group or the assessment-only group.

Interventions

Participants in the assessment-only group (n=744) received only study retention messages. Participants in the intervention group (n=759) received retention messages along with an automated interactive SMS program (“This is Quitting”), designed to provide training in cognitive and behavioral coping skills, as well as social support, to help participants quit e-cigarette use.

Data Collection and Evaluation

The primary outcome measure was the self-reported 30-day point-prevalence abstinence from e-cigarettes. Assessments were conducted at baseline, 1 month, and 7 months, and data were analyzed using an intention-to-treat approach.

Results

Baseline Characteristics

A total of 1,503 adolescents were randomly assigned, with an average age of 16.4 years, 50.6% were female, 42.1% male, and 7.4% non-binary; 10.2% were Black/African American, 62.6% White, 18.5% multiracial, and 8.7% other races; 16.2% were Hispanic. Among the sample, 42.5% were sexual minorities, and 76.2% of participants used e-cigarettes within 30 minutes of waking.

Quit Rates Analysis

At the 7-month follow-up, 70.8% of participants completed the follow-up assessment. The quit rate for the intervention group was 37.8% (95% CI, 34.4%-41.3%), while the quit rate for the assessment-only group was 28.0% (95% CI, 24.9%-31.3%), with a relative risk of 1.35 (95% CI, 1.17-1.57; p < .001). Baseline variables did not significantly affect the treatment outcome, and there was no evidence that adolescents who quit e-cigarettes transitioned to combustible tobacco products.

Conclusions and Significance

The study demonstrates that a tailored interactive SMS intervention significantly increases the quit rate among adolescents using e-cigarettes. The effectiveness of this intervention highlights the potential for digital approaches to achieve behavioral change, particularly among young people. This study fills a gap in empirical research on adolescent e-cigarette cessation interventions and offers new perspectives for future public health interventions.

Study Highlights

1. Key Findings: Adolescents in the intervention group showed a significant advantage in quitting e-cigarettes, with 30-day point-prevalence abstinence and repeated point-prevalence abstinence both indicating the effectiveness of the SMS intervention.
2. Innovation: This is the first randomized clinical trial to report the effectiveness of an adolescent e-cigarette cessation intervention, involving a diverse sample covering various demographic and psychosocial characteristics.
3. Practical Application: SMS intervention is a scalable and cost-effective method of intervention with practical value for reducing the prevalence of adolescent e-cigarette use.

Limitations and Challenges

Despite the significant findings, this study has some limitations. First, cessation was not biochemically verified. Second, the intervention group may have been influenced by social desirability bias. Finally, the results may only apply to adolescents who are motivated to quit and may not be generalizable to other groups. Future research should further explore the mediating mechanisms of the intervention and its impact on changes in cannabis and alcohol use.

Summary

This important study demonstrates the effectiveness of a tailored interactive SMS program in adolescent e-cigarette cessation, emphasizing the significant potential of digital health interventions in public health. Future intervention designs can draw from this study’s experience, expanding and deepening efforts to further promote healthy behavior among adolescents.