Ildiko Tombor, PhD Student Health Behaviour Research Centre

1. Development and evaluation of SmokeFree Baby: A smoking cessation smartphone app for pregnant smokers Ildiko Tombor, PhD Student Health Behaviour Research Centre UCL Tobacco and Alcohol Research Group (UTARG) SSA annual conference 2014

2. Acknowledgements Research team Contributors Dr Joanne Neale Dr Caitlin Notley Aleksandra Herbec Milagros Ruiz Farah Desai & the Pregnancy Network Claire Garnett Daniel West Jamie West Matthew West Professor Robert WestProfessor Susan MichieDr Lion ShahabDr Jamie BrownDavid Crane Funding

3. Background Intervention development Next steps

4. Smoking during pregnancy: Health effects Preterm delivery Placental abruption Placenta previa CHD Stroke Atherosclerosis Low birth weight Sudden infant death syndrome Fetal growth restriction COPD Pneumonia Periodontitis Nuclear cataract Decreased lung function Middle ear disease Behaviour and learning problems At least 13 different types of cancer U.S. Department of Health and Human Services, 2004, 2006, 2014; Ross et al., 2014

5. Smoking during pregnancy: Prevalence 26% smoke in the 12 months before or during pregnancy 12% smoke throughout pregnancy NHS Information Centre. Infant Feeding Survey, 2010

6. Smoking during pregnancy: Support Nicotine Replacement Therapy Behavioural support • Face-to-face/telephone/group support1 • Financial incentives1-3 • Self-help materials2,4 • Insufficient evidence of its safety and efficacy5 • Combination NRT can be effective6 • Better health of the infants at age 27 Low uptake and poor adherence among pregnant smokers5,8. Numerous barriers: fear of judgment and disappointment, poor access to support etc. 9 1Chamberlain et al., 2013; 2Bauld & Coleman, 2009; 3Higgins et al., 2012; 4Naughton et al., 2008; 5Coleman et al., 2012; 6LBrose et al., 2013; 7Cooper et al., 2014; 8Tappin et al., 2010; 9Ingall et al., 2010.

7. Digital smoking cessation interventions • Digital aids can be effective in the general population1-6 • Heterogeneity in quality, outcomes and design • Lack or poor description of intervention content • Poor adherence to established guidelines • Effectiveness is yet to be confirmed in pregnancy • Relative benefit in low socioeconomic groups (‘StopAdvisor’)7 • Women and young people are more likely to engage with digital aids8 • Websites, text-messaging can be feasible and acceptable for pregnant smokers9-11 1Myung et al., 2009; 2Shahab & McEwen, 2009,; 3Whittaker et al., 2009; 4Civljak et al., 2010; 5Hutton et al., 2011; 6Chen et al., 2012; 7Brown et al., 2014; 8Devris et al., 2013; 9Naughton et al., 2012; 10Pollak et al., 2013; 11Herbec et al., 2014

8. A priori principles Multi-phase strategy Theoretical basis West & Brown, 2013 Craig et al., 2008 Michie et al., 2011 Collins et al., 2011 Transparency in reporting Evidence-base

9. Development stage Phase 1 – Exploratory work Development stage Phase 2 – Intervention design Feasibility & Piloting stage Piloting phases Step 1 Identify theoretical base & Review of the literature • Positive smoker identity as a barrier to quitting smoking [published in: Drug Alcohol Depen, 2013, 133(2)] • Post-quit non-smoker identity as a predictor of maintained quit success [under review: in Addictive Behaviors] • Meta-ethnographic systematic review of smoker identity [accepted in: Health Psychology] • Health Care providers views on digital interventions [in press: Journal of Smoking Cessation] • COM-B behavioural analysis of pregnant smokers [paper in preparation] • Behaviour change techniques used in a smoking cessation website for pregnant smokers (‘MumsQuit’) [paper in preparation] Step 3 Identify intervention components Step 5 User testing and refinement of the SmokeFree Baby app Step 2 Exploratory work & Needs assessment (Study 1-6) Step 4 Design prototype intervention Step 6 Evaluation of intervention components

10. Review goal Target behaviour Goal setting

11. 80 Pre-quit features Built-in user testing Push notifications Self-monitoring Social support Feedback & Reward Engagement

12. Identity change To foster a new ‘non-smoker’ identity (reflective motivation) • Building on identity motives (continuity, belonging, meaning etc.) (Vignoles et al., 2011) • Providing potential role models • Facilitating emotional attachment with the baby Minimal Intensive

13. Stress relief • To improve mental skills to cope with stress and negative emotional states (psychological capability) • Facilitating action planning • Prompting relaxation exercise Minimal Intensive

14. Health effects • To improve knowledge of health consequences of smoking and benefits of quitting (psychological capability) • Delivering content through interactive features • Using a life-span perspective to provide information about health consequences Minimal Intensive

15. Face-to-Face support • To provide easy access to and facilitate the uptake of stop-smoking support resources in the locality (physical opportunity) • Including videos of a real-life advisor talking about the support offered • Providing access to quitlines and local services Minimal Intensive

16. Behavioural substitution • To provide distraction from urges to smoke • (automatic motivation) • Facilitating action planning • Using built-in distraction quiz • Using built-in distraction game Minimal Intensive

17. What happens next? www.smokefreebaby.co.uk Factorial experiment (25 design) to test the effectiveness (main effects) of individual intervention components (‘modules’) Think-aloud user-testing study with pregnant smokers Analysis of helpfulness/usability ratings of intervention contents

18. Thank you! Email: ildiko.tombor.11@ucl.ac.uk