In today’s world, apps and websites are how people get a great deal of their mental and behavioral health information.
That’s a good thing, in principle. Technology can reduce barriers and help address that fact that there will never be enough specialists or professionals to go around.
If you smoke, there is no better single thing you can do to improve your health than to quit. But very few people can afford a therapist to help them do that.
I’ve done several studies on smoking using Acceptance and Commitment Therapy (ACT), beginning in 2004 with a study headed up by Elizabeth Gifford (doi: 10.1016/S0005-7894(04)80015-7). It found that that ACT could beat the patch. Later studies found better outcomes than smoking cessation medications.
Super. But therapists are expensive. Our original 2004 protocol was 14 sessions long.
Ouch! Who can afford such a thing?
Perhaps very few. But several labs (not just ours) also found that people who quit using ACT did it by learning how to accept their urges, to defuse from the thoughts that “trigger” use, and to motivate quitting by focusing on their values. That could be important … if we can teach such skills.
Why not apps?
Mind you, there are apps out there, but most are based on the US Clinical Practice Guidelines (USCPG) — a scientific consensus developed under the guidance of the US Department of Health and Human Services. They tell people to avoid triggers; to sweep away difficult affect and cognition; to quit because it’s a logical way to maintain health.
There is science behind these ideas. They are virtually common sense. But sometimes science can help you find uncommon sense and that might be even better.
And there is clearly room for improvement. The quit rates for smartphone apps vary between 4% and 18%, which is not very good. A 2019 “Cochrane Review” (a formal, high quality summary of the literature) could not conclude that they were better than minimal support interventions.
Enter Jonathan Bricker at the Fred Hutchinson Cancer Research Center at the University of Washington. In a series of studies over the last decade Jonathan and his team have tested ACT based websites, phone calls, and apps in larger and larger studies. His team has figured out how to avoid dropouts; and how to engage people using clear language, appealing graphics, interesting exercises, and clever learning aids.
Importantly, he has held tight to the vision of delivering on the promise of psychological flexibility. His own research showed that these processes predicted success in quitting. Psychological flexibility is counterintuitive, but he refused to underestimate people. He believed that normal folks get what the science says is key from an app, if the app was good enough. So, he and his team kept at it.
Today is a day that the world can see why a science journey like that matters to the world.
In large (N = 2,415) and extremely well-done randomized trial just released minutes ago in JAMA Internal Medicine, Bricker found that the ACT app his team developed called iCanQuit has cessation rates one year later of 28.2%, the highest ever found for an app, vs. 21.1% (p < .001) for the app deployed by the US National Cancer Institute (“QuitGuide”), which is based on the USCPG. I’ll call it here the “mainstream consensus app”.
Scientists will appreciate the care behind this study (stratified; double-blind; stunningly low dropout rates; 3, 6, and 12 month follow ups; intent to treat analyses) which is why it has today appeared in one of the premier medical journals in the world.
The general public needs to know two major things about It.
First, people using the ACT app were 1.49 times more likely to quit smoking a year later than those using the mainstream consensus app, with similar or even larger differences in all of the other ways that outcomes were measured (e.g., any tobacco use; outcomes at 3 and 6 months; etc.)
Second, these two apps are very different in what they teach.
The mainstream consensus app taught people to avoid or to try to change internal triggers and provided logical reasons to quit linked to health outcomes. The ACT-based smoking cessation application taught psychological flexibility skills: acceptance of internal smoking triggers such as urges, thoughts, and emotions and motivating themselves to quit via their own values. A clear contrast.
Said simply, ACT beat the best by pursuing a set of novel ideas. Don’t misunderstand me: the mainstream consensus is good – but this study suggests it is not the best.
The ACT and contextual behavioral science community has spent decades digging into processes of change. When teams have spent the time to figure out how to apply them in given areas extraordinary things can happen, whether we are talking about reducing opiate use in post-operative care; improving cancer recovery programs, fostering more effective exercise programs, improving intellectual achievement, or walking through a mental health challenge.
Now you can say that if 100,000 smokers used the ACT app, a year from now more than 28,000 of them would likely be smoke free, several thousand more than what a mainstream consensus approach would be likely to accomplish.
Smoking reduces one’s life expectancy nearly 10 years, but a very large chunk of the harm can be undone if people can quit. And an ACT app can help people do it.
Why does good science matter?
It’s because life matters.
The new study is Bricker, J. B., Watson, N. L., Mull, K. E., Sullivan, B. M., & Heffner, J. L. (2020). Efficacy of smartphone applications for smoking cessation: A randomized clinical trial. JAMA Internal Medicine. Doi: 10.1001/jamainternmed.2020.4055
You can learn more about psychological flexibility in my new book, A Liberated Mind.