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      Exploring Efficacy of a Serious Game (Tobbstop) for Smoking Cessation During Pregnancy: Randomized Controlled Trial

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          Tobacco use during pregnancy entails a serious risk to the mother and harmful effects on the development of the child. Europe has the highest tobacco smoking prevalence (19.3%) compared with the 6.8% global mean. Between 20% to 30% of pregnant women used tobacco during pregnancy worldwide. These data emphasize the urgent need for community education and implementation of prevention strategies focused on the risks associated with tobacco use during pregnancy.


          The aim of this study was to investigate the efficacy of an intervention that incorporates a serious game (Tobbstop) to help pregnant smokers quit smoking.


          A two-arm randomized controlled trial enrolled 42 women who visited 2 primary care centers in Catalonia, Spain, between March 2015 and November 2016. All participants were pregnant smokers, above 18 years old, attending consultation with a midwife during the first trimester of pregnancy, and had expressed their desire to stop smoking. Participants were randomized to the intervention (n=21) or control group (n=21). The intervention group was instructed to install the game on their mobile phone or tablet and use it for 3 months. Until delivery, all the participants were assessed on their stage of smoking cessation during their follow-up midwife consultations. The primary outcome was continuous tobacco abstinence until delivery confirmed by the amount of carbon monoxide at each visit, measured with a carboxymeter.


          Continuous abstinence until delivery outcome was 57% (12/21) in the intervention group versus 14% (3/21) in the control group (hazard ratio=4.31; 95% CI 1.87-9.97; P=.001). The mean of total days without smoking until delivery was higher in the intervention group (mean 139.75, SD 21.76) compared with the control group (mean 33.28, SD 13.27; P<.001). In addition, a Kapplan-Meier survival analysis showed that intervention group has a higher abstinence rate compared with the control group (log-rank test, χ 2 1=13.91; P<.001).


          Serious game use is associated with an increased likelihood to maintain abstinence during the intervention period if compared with those not using the game. Pregnancy is an ideal opportunity to intervene and control tobacco use among future mothers. On the other hand, serious games are an emerging technology, growing in importance, which are shown to be a good tool to help quitting smoking during pregnancy and also to maintain this abstinent behavior. However, because of the study design limitations, these outcomes should be interpreted with caution. More research, using larger samples and longer follow-up periods, is needed to replicate the findings of this study.

          Trial Registration

 NCT01734421; (Archived by WebCite at

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          Most cited references 31

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          Mobile phone-based interventions for smoking cessation.

          Access to mobile phones continues to increase exponentially globally, outstripping access to fixed telephone lines, fixed computers and the Internet. Mobile phones are an appropriate and effective option for the delivery of smoking cessation support in some contexts. This review updates the evidence on the effectiveness of mobile phone-based smoking cessation interventions.
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            A content analysis of popular smartphone apps for smoking cessation.

            Smartphone applications (apps) are increasingly available for smoking cessation. This study examined the content of popular apps for smoking cessation for both iPhone and Android operating systems in February 2012. A total of 252 smoking-cessation apps were identified for the iPhone and 148 for the Android. Across both operating systems, the most popular apps were identified (n=47 for the iPhone and n=51 for the Android) and analyzed for their (1) approach to smoking cessation and (2) adherence to an index based on the U.S. Public Health Service's Clinical Practice Guidelines for Treating Tobacco Use and Dependence. Where available, apps were coded for frequency of downloads. The analysis took place in 2012. Overall, popular apps have low levels of adherence, with an average score of 12.9 of a possible 42 on the Adherence Index. No apps recommended calling a quitline, and only a handful of apps recommended using approved medications (4.1%). Android apps in the sample were downloaded worldwide between 310,800 and 1,248,000 times per month. For both the iPhone and Android, user ratings were positively associated with scores on the Adherence Index. For the iPhone, display order was also positively associated with scores on the Adherence Index. Apps could be improved by better integration with the Clinical Practice Guidelines and other evidence-based practices. Copyright © 2013 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
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              Randomized, controlled pilot trial of a smartphone app for smoking cessation using acceptance and commitment therapy.

              There is a dual need for (1) innovative theory-based smartphone applications for smoking cessation and (2) controlled trials to evaluate their efficacy. Accordingly, this study tested the feasibility, acceptability, preliminary efficacy, and mechanism of behavioral change of an innovative smartphone-delivered acceptance and commitment therapy (ACT) application for smoking cessation vs. an application following US Clinical Practice Guidelines. Adult participants were recruited nationally into the double-blind randomized controlled pilot trial (n=196) that compared smartphone-delivered ACT for smoking cessation application (SmartQuit) with the National Cancer Institute's application for smoking cessation (QuitGuide). We recruited 196 participants in two months. SmartQuit participants opened their application an average of 37.2 times, as compared to 15.2 times for QuitGuide participants (p<0001). The overall quit rates were 13% in SmartQuit vs. 8% in QuitGuide (OR=2.7; 95% CI=0.8-10.3). Consistent with ACT's theory of change, among those scoring low (below the median) on acceptance of cravings at baseline (n=88), the quit rates were 15% in SmartQuit vs. 8% in QuitGuide (OR=2.9; 95% CI=0.6-20.7). ACT is feasible to deliver by smartphone application and shows higher engagement and promising quit rates compared to an application that follows US Clinical Practice Guidelines. As results were limited by the pilot design (e.g., small sample), a full-scale efficacy trial is now needed. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

                Author and article information

                JMIR Serious Games
                JMIR Serious Games
                JMIR Serious Games
                JMIR Publications (Toronto, Canada )
                Jan-Mar 2019
                27 March 2019
                : 7
                : 1
                [1 ] Servei d'Atenció Primària d'Osona Gerència Territorial de la Catalunya Central Institut Català de la Salut Vic Spain
                [2 ] Unitat de Suport a la Recerca Catalunya Central Institut Universitari d'Investigació en Atenció Primària Jordi Gol Sant Fruitós de Bages Spain
                [3 ] Health Promotion in Rural Areas Research Group Institut Català de la Salut Sant Fruitós de Bages Spain
                [4 ] Digital Care Research Group Universitat de Vic–Universitat Central de Catalunya Centre for Health and Social Care Research Vic Spain
                [5 ] Sexual and Reproductive Health Unit Servei d'Atenció Primària d'Osona Institut Català de la Salut Vic Spain
                [6 ] Grup de Recerca en Tecnologies de la Informació en Atenció Primaria Unitat de Suport a la Recerca Tarragona-Reus Institut Universitari d'Investigació en Atenció Primària Jordi Gol Reus Spain
                [7 ] Unitat d’Anàlisi i Qualitat Xarxa Sanitària i Social Santa Tecla Tarragona Spain
                [8 ] Departament d'Infermeria Facultat d'Infermeria Universitat Rovira i Virgili Tarragona Spain
                [9 ] Centre d'Atenció Primària Horts de Miró (Reus-4) Gerència d'Àmbit d'Atenció Primària Camp de Tarragona Institut Català de la Salut Tarragona Spain
                [10 ] Centre d’Atenció Primària La Granja (Tarragona-2) Gerència d’Àmbit d’Atenció Primària Camp de Tarragona Institut Català de la Salut Torreforta, Tarragona Spain
                [11 ] Departament d'Enginyeria Informàtica i Matemàtiques Universitat Rovira i Virgili Tarragona Spain
                Author notes
                Corresponding Author: Francesc X Marin-Gomez xavy.marin@
                ©Francesc X Marin-Gomez, Rocio Garcia-Moreno Marchán, Anabel Mayos-Fernandez, Gemma Flores-Mateo, Esther Granado-Font, Maria Luisa Barrera Uriarte, Jordi Duch, Cristina Rey-Reñones. Originally published in JMIR Serious Games (, 27.03.2019.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (, 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 well as this copyright and license information must be included.

                Original Paper
                Original Paper

                video games, pregnancy, smoking cessation


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