Edited by: Cyrille Delpierre, INSERM U1027 Epidémiologie et analyses en santé publique: Risques, Maladies Chroniques et Handicap, Université Toulouse III Paul Sabatier, France
Reviewed by: Nadia Mignolli, Italian National Institute of Statistics (ISTAT), Italy; Julia Katherine Rohr, Harvard University School of Public Health, United States
This article was submitted to Inequalities in Health, a section of the journal Frontiers in Public Health
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Tobacco use remains the leading preventable cause of disease and death among Latinos (
A myriad of factors account for low utilization of smoking cessation treatment among Latinos. Overall, Latinos report a lack of knowledge about smoking cessation treatment options and perceive a lack of cultural sensitivity when smoking cessation resources are available in Spanish (
The literature demonstrates that text messaging-based smoking cessation interventions are effective (
This is a single-arm pilot study with 50 Latino smokers who received a culturally- and linguistically-adapted smoking cessation text messaging intervention and Nicotine Replacement Therapy (e.g., nicotine patches, gum, and lozenges; NRT). The study was based at JUNTOS Center for Advancing Latino Health, an academic and community partnership at the University of Kansas Medical Center (KUMC). Study procedures were approved and monitored by the KUMC Institutional Review Board (#STUDY00002725). Participants were compensated a $30 retail store gift card both at baseline and follow-up for their time and transportation.
Latino smokers were recruited by
Individuals were eligible if they (1) self-identified as Hispanic or Latino, (2) were ≥21 years of age, (3) smoked a minimum of 3 days in the past week, (4) had a cellphone with unlimited text messaging capability, and (5) were willing to complete a baseline and 12-week follow-up assessment. Individuals were not eligible if they (1) were currently enrolled in a smoking cessation program or using smoking cessation medication, (2) had an additional household member participating in this study, (3) consumed other forms of tobacco (including e-cigarettes), (4) were currently pregnant, breast-feeding or planning to do so in the next year, or (5) were planning to move from their residential city in the following 6 months.
Bilingual (English and Spanish) trained research staff determined participant eligibility. Individuals who were eligible to participate in the study were scheduled an in-person appointment by research staff. During the in-person appointment, staff discussed all aspects of study participation and confidentiality, answered any questions, and guided eligible smokers through the process of written informed consent. Eligibility assessment and consent were available in the participant's language of preference.
Pre-scheduled standard messages. Messages were tailored to the participant's name(s) and their selected quit date. The text messaging system delivered these messages according to an algorithm based on four sequential phases of the quitting process: (1) Pre-quit (14 days); (2) Quit-day (1 day); (3) Post-quit Intensive (28 days); and (4) Post-quit Maintenance (8 weeks). Keyword triggered standard messages. These messages consisted of automated responses sent immediately to participants who sent the program one of the following keywords: Alcohol, Crave, Relapse, Slip Up, and Stress. Participants could withdraw from the text messaging program at any time by texting the word Stop. Personalized responses. The text messaging system had the ability to receive free texts (not keywords) from study participants. Trained research staff monitored, triaged, and responded (if needed) to text messages sent by participants. Responses occurred within 48 h of receiving the texts.
An additional new first text-based stage, Decision Support, was created and integrated with the already existing four stages of Kick Buts (pre-quit, quit-day, post-quit intensive, and post-quit maintenance). The aim of this 10-day stage was to enhance motivation and readiness among Latino smokers who were not ready to quit smoking. The Decision Support stage was informed from two web-based smoking cessation decision-making tools developed for Latinos in the U.S. (
Using the Cultural Accommodation of Substance Abuse Treatment framework (
The use of NRT followed the Clinical Practice Guidelines for Treatment of Tobacco Use (
All assessments were completed in the language of preference of the participant. The in-person baseline survey collected sociodemographic variables such as gender, age, education level, country of birth, language spoken at home, marital status, and type of health insurance. Smoking-related variables collected included number of cigarettes per day (CPD), time to first cigarette, if they made a quit attempt in the previous year, smoking in the social network, contraindications of NRT, and the smoking self-efficacy questionnaire (SEQ-12). The SEQ-12 is a questionnaire measuring the confidence of smokers (current and former) in their ability to abstain from smoking in high-risk situations (
Two brief surveys were done over the phone after baseline: (1) 24–27 h after the end of the Decision Support stage, and (2) 24–72 h after participants' quit date. The survey at the end of the Decision Support stage collected data on participants' quit date and NRT of preference. The survey after participants' quit date collected data on the receipt of NRT and participants' determination to quit smoking on their quit date (Did you try to quit smoking on your quit date?).
During the 12-week duration of the intervention, we assessed the frequency of text messages that participants sent to the program. Participants' texts were categorized as keywords and free-text response to the counselor.
Twelve weeks after enrollment, a second in-person assessment was conducted by trained research staff. Moreover, saliva samples and exhaled carbon monoxide (CO) were collected to verify cessation status. The survey collected data on self-reported prevalence of smoking abstinence, therapeutic alliance, and self-efficacy. Cotinine-verified 7-day point prevalence abstinence (no cigarettes in the past 7 days) at 12 weeks was the primary outcome. Cotinine verification was conducted using saliva samples with a cutoff point of 15 ng/ml cotinine (
Frequencies were calculated for categorical variables. Means and standard deviations were calculated for continuous variables. For the primary analysis on smoking cessation, participants lost to follow-up were considered smokers. The secondary analysis on satisfaction, therapeutic alliance, and self-efficacy were conducted using complete case analysis, in which missing values in the outcome were considered to be missing. Self-efficacy at baseline and follow-up was compared using a paired sample
The average readability score of final messages in English and Spanish was classified as “very easy”. The reading levels of each text category were “very easy” (50%) and “quite easy” (50%). Scores averaged 80.01 (range 73.41–86.46, 6th−7th grade levels) and 83.39 (range 77.80–90.56, 4th−6th grade levels) using the Flesch–Kincaid and Fernández Huerta tests, respectively. Readability levels were similar in English and Spanish for all stages of the text message library (see
Readability results of text messages.
Decision support | 74.23 | Fairly easy | 7th grade | 78.00 | Quite easy | 6th grade |
Pre-quit | 81.00 | Easy | 6th grade | 83.40 | Easy | 5th grade |
Quit-day | 80.10 | Easy | 6th grade | 84.58 | Easy | 5th grade |
Post-quit intensive | 76.19 | Fairly easy | 7th grade | 80.65 | Easy | 5th grade |
Post-quit maintenance | 77.77 | Fairly easy | 7th grade | 82.20 | Easy | 5th grade |
Health | 86.46 | Easy | 6th grade | 90.56 | Very easy | 4th grade |
Family | 84.75 | Easy | 6th grade | 88.85 | Easy | 5th grade |
Patch | 82.09 | Easy | 6th grade | 86.22 | Easy | 5th grade |
Lozenge | 76.58 | Fairly easy | 7th grade | 80.86 | Easy | 5th grade |
Gum | 73.41 | Fairly easy | 7th grade | 77.80 | Quite easy | 6th grade |
Crave | 79.91 | Fairly easy | 7th grade | 80.11 | Easy | 5th grade |
Stress | 82.19 | Easy | 6th grade | 84.44 | Easy | 5th grade |
Alcohol | 84.30 | Easy | 6th grade | 86.12 | Easy | 5th grade |
Slip up | 81.22 | Easy | 6th grade | 83.78 | Easy | 5th grade |
Average | 80.01 | Easy | 6th grade | 83.39 | Easy | 5th grade |
A total of 288 Latino smokers were identified. Among these, 186 were contacted and assessed for study eligibility; 115 were eligible to participate in the study. Overall, 53 Latino smokers consented to participate the study and completed the baseline assessment. Three smokers were removed from the study because they did not know how to send/receive text messages, resulting in 50 individuals enrolled in the study (
Study design flow diagram.
At baseline, participants' mean age was 44.8 years old (SD 9.80), 66% of the participants were male, 64% were married or cohabitating, 60% had completed high school education or greater, and the majority (78%) had no health insurance. Most of the participants (82%) were born in Mexico and 60% only spoke Spanish at home. Most participants (68%) were light smokers (1–10 CPD) and tried to quit in the past year (70%). Half (52%) of the participants smoked their first cigarette more than 60 min after waking up. A third of the sample (32%) reported that none of their five closest family or friends smoked. The mean SEQ-12 score was 32.18 (SD 10.29), which is considered to be in the low to moderate range of self-efficacy for quitting smoking (see
Baseline characteristics of participants (
Age, Mean (SD) | 44.8 (9.8) |
Gender | |
Female | 17 (34%) |
Male | 33 (66%) |
Marital status | |
Married/cohabitating | 32 (64%) |
Single | 3 (6%) |
Divorced/separated/widowed | 15 (30%) |
Education level | |
Less than high school graduate | 20 (40%) |
High school graduate | 22 (44%) |
Technical school | 5 (10%) |
College graduate | 3 (6%) |
Health insurance coverage | |
No health coverage | 39 (78%) |
Private | 8 (16%) |
Public (Medicare, Medicaid) | 3 (6%) |
Country of birth | |
Mexico | 41 (82%) |
Guatemala | 3 (6%) |
United States | 2 (4%) |
Honduras | 2 (4%) |
Chile | 1 (2%) |
Nicaragua | 1 (2%) |
Language spoken at home | |
Only Spanish | 30 (60%) |
More Spanish than English | 15 (30%) |
Spanish and English equally | 4 (8%) |
More English than Spanish | 1 (2%) |
Only English | 0 |
Smoking pattern | |
Non-daily | 2 (4%) |
Daily, 1–10 CPD | 34 (68%) |
Daily, 11–20 CPD | 13 (26%) |
Daily, 21 or more CPD | 1 (2%) |
Time to first cigarette after waking up | |
>60 min | 26 (52%) |
31–60 min | 8 (16%) |
6–30 min | 5 (10%) |
≤ 5 min | 11 (22%) |
Attempted to quit smoking in previous year | |
Yes | 35 (70%) |
No | 15 (30%) |
Number of 5 closest friends/family who smoke | |
0 | 16 (32%) |
1 | 12 (24%) |
2 | 6 (12%) |
3 | 8 (16%) |
4 | 3 (6%) |
5 | 5 (10%) |
Self-efficacy (SEQ-12), Mean (SD) | 32.18 (10.29) |
All participants were reached at the end of the decision support stage and set up a quit date. All participants requested the first order of NRT. Thirty-six participants (72%) requested nicotine patches, 10 participants (20%) requested nicotine gum, and four participants (8%) requested nicotine lozenges. Forty-two participants were reached after their quit day (84% retention rate). All participants reported receiving their first order of NRT. A total of 95.23% participants (40/42) reported doing an NRT-assisted attempt on their quit day.
During the 12-week period of the intervention, levels of text messaging interactivity varied among participants: 11 participants (22%) had a low interaction with the program (1–9 text messages), 18 (36%) had a medium interaction (10–49 text messages), 11 (22%) had a high interaction (50–99 text messages), and 10 (20%) had a very high interaction (≥100 text messages). All participants interacted with the program and had on average of 39.78 (SD 82.70) interactions. Of the 1,989 messages that participants sent to the program, 280 (14.07%) used keywords. Only 3 participants (6%) discontinued the program prior to completion by texting Stop. Of the 50 participants, 33 (66%) requested a refill of NRT via a text message.
At 12 weeks, 15 participants (30%) were biochemically verified abstinent (
12 weeks follow-up outcomes.
Biochemically verified abstinence ( |
15 (30%) |
Satisfaction ( |
|
Extremely satisfied | 16 (36.4%) |
Very satisfied | 24 (54.6%) |
Somewhat satisfied | 4 (9.0%) |
Working Alliance ( |
79.2 (9.04) |
Self-efficacy (SEQ-12) ( |
40.05 (17.65) |
Associations between smoking cessation and sample characteristics.
Gender | |||
Female | 17 | 4 (23.5%) | 0.533 |
Male | 33 | 11 (33.3%) | |
Education level | |||
Less than high school graduate | 20 | 8 (40.0%) | 0.228 |
High school graduate | 22 | 6 (27.3%) | |
Technical school | 5 | 1 (20.0%) | |
College graduate | 3 | 0 (0%) | |
Health insurance coverage | |||
No | 39 | 13 (33.3%) | 0.468 |
Private | 8 | 2 (25.0%) | |
Public (Medicare, Medicaid) | 3 | 0 (0%) | |
Smoking pattern | |||
Non-daily | 2 | 1 (50%) | 0.507 |
Daily, 1–10 CPD | 34 | 11 (32.4%) | |
Daily, 11–20 CPD | 13 | 3 (23.6%) | |
Daily, 21 or more CPD | 1 | 0 (0%) |
To our knowledge, this is the first culturally- and linguistically adapted smoking cessation text messaging intervention for Latino smokers. In this study, participants expressed high levels of interest in using NRT combined with high engagement in the text messaging program, with 100% requesting NRT at baseline. Two-thirds of participants (66%) requested additional NRT via the text messaging program, suggesting that participants completed at least a 4-week course of medication. Finally, the 30% smoking cessation rate seen at week 12 (end of treatment) is consistent with end-of-treatment cessation rates seen in trials that combine NRT with substantial in-person counseling (
This work demonstrates that it is feasible to recruit Latino smokers, a traditionally hard-to-reach group, into a smoking cessation study. As suggested by Cupertino et al., trained
We carefully considered the eligibility criteria with the goal of maximizing participation of Latino smokers. Latinos are among the racial/ethnic minority groups with the highest rates of non-daily smoking (
Moreover, three subjects were removed from the study after consenting because of not knowing how to read text messages. This decision was based on the rationale that to test the impact of the text messaging intervention in smoking cessation, participants need to know how to read the messages. Future studies that aim to test the impact of text messaging interventions, should include an eligibility criteria in which participants must know how to read text messages.
Four studies have assessed participant interactivity in smoking cessation text messaging programs (
This study provided preliminary evidence that a smoking cessation text messaging intervention significantly increases self-efficacy. As results from myriad cross-sectional and prospective correlational studies show that self-efficacy is a consistent predictor of smoking abstinence (
This study had a number of limitations. This was a pilot study with a small sample size and no comparison group was available. Thus, assessing the efficacy of this intervention was not possible. Furthermore, follow-up was limited to a single assessment at the end of treatment at 12-week, and does not include assessment of sustained behavior change after treatment. Despite these limitations, the study suggests that this intervention holds promise as an effective smoking cessation program for Latino smokers, and further testing in a randomized clinical trial is warranted.
We recognize while Latinos come from a variety of countries, most Latinos in this study were Mexican. It remains unknown whether these preliminary results can be generalized to the entire Latino population, especially since smoking rates vary significantly by country of origin. For instance, a U.S. population-based longitudinal study reported that current smoking rates was highest among Puerto Ricans (men 35.0% and women 32.6%) and Cubans (men 31.3% and women 21.9%), with significantly high smoking intensity measured by pack-years and cigarettes per day among Cubans (
A culturally- and linguistically-adapted smoking cessation text messaging intervention for Latinos was well-accepted by participants, generated high satisfaction and frequent interactivity, significantly increased self-efficacy, produced high therapeutic alliance, and resulted in noteworthy cessation rates at the end of treatment. Moreover, the intervention offers a promising strategy to increase the use and adherence of Nicotine Replacement Therapy. Additional testing in a formal randomized clinical trial is warranted to identify the effectiveness of the intervention and to determine individual characteristics related to treatment response.
The datasets generated for this study are available on request to the corresponding author.
The study was reviewed and approved by University of Kansas Medical Center Institutional Review Board. Participants provided their written informed consent to participate in this study.
AC, LS, and EE designed the study. FC-B, MR, and JP-P implemented the study. FC-B, EA-C, MR, JP-P, and FD analyzed the data. FC-B, LS, EA-C, MR, JP-P, PV, FD, DC, EE, and AC wrote and revised multiple versions of the manuscript and including the final version. All authors contributed to the article and approved the submitted version.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Special acknowledgment to the research team: Kendra Cruz, MPH, Mitzi Ramirez, and Drew Cox. We also recognize our Promotores de Salud (Catalina Reyes, Karen Yepez-Maza, Lucia Martinez, and Norma Molina) and Agile Health Inc., the text messaging company (Gary Slagle, Scott Werntz, Vova Kagan, and Julieta Rodriguez). Finally, the authors also acknowledge Carolina Uribe, Dora Ponce, Ernesto Suarez, Lilia Castillo, Lucia Jones, and Oscar Monterroso for being part of the Community and Communication Advisory Board.