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Randomized Controlled Trial
. 2025 Aug 1;8(8):e2526691.
doi: 10.1001/jamanetworkopen.2025.26691.

Just-in-Time Adaptive Intervention for Smoking Cessation in Low-Income Adults: A Randomized Clinical Trial

Emily T Hébert  1   2 , Darla E Kendzor  1   2 , Damon J Vidrine  3   4 , Jeremy S Langford  1 , Krista M Kezbers  1 , Audrey Montgomery  1 , Meng Chen  5 , Summer G Frank-Pearce  1   6 , Sara K Vesely  6 , Sixia Chen  6 , Zachary C W Barrett  1 , Michael S Businelle  1   2
Affiliations
Randomized Controlled Trial

Just-in-Time Adaptive Intervention for Smoking Cessation in Low-Income Adults: A Randomized Clinical Trial

Emily T Hébert et al. JAMA Netw Open. .

Abstract

Importance: Smoking prevalence remains alarmingly high among low-income adults, who face disproportionate barriers to cessation and experience unique smoking lapse triggers.

Objective: To compare the efficacy of the Smart-T smartphone intervention, featuring tailored, just-in-time adaptive interventions, with the National Cancer Institute QuitGuide intervention in supporting smoking cessation among adults with low income.

Design, setting, and participants: This randomized clinical trial was conducted from August 2019 to November 2023 among US adults with household incomes below 200% of the federal poverty line. Participants were randomized to Smart-T or QuitGuide and followed-up for 27 weeks. Data were analyzed from July 2024 to March 2025.

Interventions: Both groups received nicotine replacement therapy. The Smart-T intervention provided ecological momentary assessment-driven tailored feedback and prompts to use nicotine replacement therapy, while QuitGuide delivered smoking cessation content based on clinical guidelines.

Main outcomes and measures: The primary outcome was biochemically verified 7-day point prevalence abstinence at 26 weeks after quitting, and group differences were evaluated via multivariable logistic regression. Secondary outcomes included 30-day point prevalence abstinence and continuous abstinence. Outcomes were analyzed using logistic regression with intention-to-treat and complete-case approaches.

Results: A total of 454 participants (mean [SD] age, 52.0 [11.2] years; 333 [73.3%] female; mean [SD], 17.7 [9.5] cigarettes/d) were enrolled, with 225 randomized to Smart-T and 229 randomized to QuitGuide. Biochemically verified 7-day point prevalence abstinence at 26 weeks was higher in the Smart-T group than in the QuitGuide group (37 participants [16.4%] vs 23 participants [10.0%] in intention-to-treat analysis; 37 of 160 participants [23.1%] vs 23 of 161 participants [14.3%] in complete-case analysis). Adjusted odds of abstinence were significantly higher for Smart-T (adjusted odds ratio, 1.81; 95% CI, 1.03-3.18). No significant differences were found for 30-day or continuous abstinence. Smart-T users interacted with the app more often and rated it as more helpful (r = 0.21; P < .001).

Conclusions and relevance: In this randomized clinical trial of 454 adults with low income, the Smart-T intervention led to significantly higher smoking abstinence at 26 weeks compared with QuitGuide. These findings suggest that digital health interventions tailored for low-income populations hold promise for reducing smoking-related health disparities.

Trial registration: ClinicalTrials.gov Identifier: NCT03740490.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Kendzor reported receiving royalties from Insight Mobile Health Platform for external (outside University of Oklahoma Health Sciences Center [OUHSC]) use of the platform and personal fees from Qnovia for serving on a scientific advisory board outside the submitted work. Dr Vidrine reported owning a patent for the Insight platform, on which he is listed as coinventor, with royalties paid. Dr Businelle reported having a patent for the Insight mHealth Platform on which he is listed as an inventor and receiving royalties for non-OUHSC use outside the submitted work; in addition, Dr Businelle had a patent for Patent application pending with OUHSC for on a carbon monoxide detection device that can verify recent smoking status. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Participant Enrollment Flowchart
CCA indicates complete case analysis; ITT, intention-to-treat.
Figure 2.
Figure 2.. Screenshot of the Smart-T App
This figure illustrates the main interface of the Smart-T app, which provides participants with access to key smoking cessation resources. Features include app instructions, helpful quit tips, medication tips, a call counselor button, options to order nicotine replacement therapy (patches, gum, lozenges), a tool to record cigarette use, payment tracking, contact update functionality, and a direct call option for study staff support.
See this image and copyright information in PMC

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