Randomized Controlled Trial

. 2024 Oct 30:26:e57839.

doi: 10.2196/57839.

Evaluating the Impact of a Game (Inner Dragon) on User Engagement Within a Leading Smartphone App for Smoking Cessation: Randomized Controlled Trial

Justin S White^{1

2

3}, Séverine Toussaert⁴, Bethany R Raiff⁵, Marie K Salem^{2

6}, Amy Yunyu Chiang², David Crane⁷, Edward Warrender⁷, Courtney R Lyles⁸, Lorien C Abroms⁹, J Lee Westmaas^#¹⁰, Johannes Thrul^#^{11

12

13}

Affiliations

¹ Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, United States.
² Philip R Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, United States.
³ Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States.
⁴ Department of Economics, University of Oxford, Oxford, United Kingdom.
⁵ Department of Psychology, Rowan University, Glassboro, NJ, United States.
⁶ Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, United States.
⁷ 23 Limited, London, United Kingdom.
⁸ Department of Public Health Sciences, University of California, Davis, Davis, CA, United States.
⁹ Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, DC, United States.
¹⁰ Population Science, American Cancer Society, Atlanta, GA, United States.
¹¹ Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
¹² Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, United States.
¹³ Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia.

^# Contributed equally.

PMID: 39475840
PMCID: PMC11561441
DOI: 10.2196/57839

Randomized Controlled Trial

Evaluating the Impact of a Game (Inner Dragon) on User Engagement Within a Leading Smartphone App for Smoking Cessation: Randomized Controlled Trial

Justin S White et al. J Med Internet Res. 2024.

. 2024 Oct 30:26:e57839.

doi: 10.2196/57839.

Authors

Affiliations

¹ Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, United States.
² Philip R Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, United States.
³ Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States.
⁴ Department of Economics, University of Oxford, Oxford, United Kingdom.
⁵ Department of Psychology, Rowan University, Glassboro, NJ, United States.
⁶ Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, United States.
⁷ 23 Limited, London, United Kingdom.
⁸ Department of Public Health Sciences, University of California, Davis, Davis, CA, United States.
⁹ Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, DC, United States.
¹⁰ Population Science, American Cancer Society, Atlanta, GA, United States.
¹¹ Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
¹² Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, United States.
¹³ Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia.

^# Contributed equally.

PMID: 39475840
PMCID: PMC11561441
DOI: 10.2196/57839

Abstract

Background: Smartphone apps are a convenient, low-cost approach to delivering smoking cessation support to large numbers of individuals. Yet, the apps are susceptible to low rates of user engagement and retention.

Objective: This study aims to test the effects of a new game module (called Inner Dragon) integrated into Smoke Free (23 Limited), a leading smoking cessation app with established efficacy. The primary outcomes measured user engagement with the app.

Methods: A 2-arm, parallel-group, randomized controlled trial was conducted in the United States with an 8-week follow-up. Adult individuals who smoked ≥1 cigarettes daily and planned to quit smoking within 7 days were recruited and randomized (N=500), with equal allocation. Both groups received free access to the original Smoke Free app with "core" features of its smoking cessation program (eg, a diary and craving log). The treated group received additional access to the integrated Inner Dragon game that incorporated several game mechanics designed to increase user engagement. User engagement outcomes were the number of unique app sessions, average minutes per session, days with a session, and program adherence. Self-reported and verified smoking abstinence and app satisfaction were also assessed. The main analysis estimated the intention-to-treat effect of access to Inner Dragon on each outcome. Further analyses assessed effect modification by participant characteristics and the association of intensity of game use with program adherence and abstinence.

Results: Overall, user engagement was greater for treated versus control participants: they had 5.3 more sessions of Smoke Free (mean 29.6, SD 36.5 sessions vs mean 24.3, SD 37.9 sessions; P=.06), 0.8 more minutes per session (mean 6.9, SD 5.4 min vs mean 6.1, SD 5.2 min; P=.047), and 3.4 more days with a session (mean 14.3, SD 15.3 days vs mean 11.9, SD 14.3 days; P=.03). Program adherence, based on the number of times core features of the original Smoke Free app were used, was higher for treated versus control participants (mean 29.4, SD 41.3 times vs mean 22.6, SD 35.6 times; P=.03). Self-reported 7-day and 30-day point-prevalence abstinence and verified 7-day point-prevalence abstinence at 8 weeks did not significantly differ by study group. The mean repeated 1-day prevalence of quitting was higher among the treated group versus the control group (mean 17.3%, SD 25.6 vs mean 12.4%, SD 21.3; P=.01). App satisfaction and the motivation to (stay) quit did not differ by study group. Higher intensity of game use was associated with increased program adherence and self-reported abstinence.

Conclusions: Findings suggest that the Inner Dragon game increased user engagement and program adherence. Additional refinements to the game design may clarify whether the game increases abstinence rates. Overall, it is feasible to deploy games and gamification to enhance user engagement in existing smoking cessation interventions.

Trial registration: ClinicalTrials.gov NCT05227027; https://clinicaltrials.gov/study/NCT05227027.

Keywords: engagement; games for health; gamification; mobile app; mobile phone; randomized controlled trial; smoking cessation.

©Justin S White, Séverine Toussaert, Bethany R Raiff, Marie K Salem, Amy Yunyu Chiang, David Crane, Edward Warrender, Courtney R Lyles, Lorien C Abroms, J Lee Westmaas, Johannes Thrul. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 30.10.2024.

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Conflict of interest statement

Conflicts of Interest: BRR is the founder of Re-Connect Health, Inc, a company that develops mobile apps for health behavior change. CRL was a visiting researcher at Google LLC during the preparation of this manuscript. DC is the founder and chief executive officer and EW is the chief technology officer of the Smoke Free app, and both derive income from it. LCA receives royalties for the sale of Text2Quit, a quit smoking program. JT reports membership on the scientific advisory board of MindCotine, Inc, which offers a smoking cessation program. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflicts of interest policies. All other authors declare no other conflicts of interest.

Figures

**Figure 2**
Percentage of participants with any sessions of Smoke Free app use by day in the game intervention (treated) group versus the control group (N=479).

**Figure 3**
Percentage of participants with self-reported repeated 1-day point-prevalence abstinence by day in the game intervention (treated) group versus control group. (A) This panel assumes that missing reports are current smokers. (B) This panel uses complete cases only.

**Figure 4**
Association of intensity of game use with selected outcomes. The shaded area denotes the 95% CI.

See this image and copyright information in PMC

References

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Evaluating the Impact of a Game (Inner Dragon) on User Engagement Within a Leading Smartphone App for Smoking Cessation: Randomized Controlled Trial

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Evaluating the Impact of a Game (Inner Dragon) on User Engagement Within a Leading Smartphone App for Smoking Cessation: Randomized Controlled Trial

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