Feasibility of a Perioperative Text Messaging Smoking Cessation Program for Surgical Patients

Abstract

Although surgical patients who smoke could benefit from perioperative abstinence, few currently receive support. This pilot study determined the feasibility and acceptability of a perioperative text messaging smoking cessation program. One hundred patients (73% of eligible patients approached) enrolled in a surgery-specific messaging service, receiving 1–3 daily messages about smoking and surgical recovery for 30 days. Only 17 patients unenrolled, the majority responded to prompting messages, and satisfaction with the program was high. Surgical patients are amenable to text message–based interventions; a future efficacy trial of text messaging smoking cessation support in surgical patients is warranted.

Surgical patients who smoke cigarettes are at increased risk of surgical complications, including wound-related and cardiopulmonary complications. Fortunately, treatment can help surgical patients quit smoking, and abstinence from cigarettes can reduce the risk of complications.^1–4 However, it has proved difficult to embed tobacco use treatments into routine clinical practice, and only a small fraction of surgical patients are currently treated.⁵ New tools are required to help surgical patients maintain perioperative abstinence.

Short-message service (text message)–based interventions for smoking cessation are efficacious⁶ and have many advantages that lead to the potential for wide dissemination.⁷ These advantages include broad reach across typically hard-to-reach populations, the rise of reasonably priced calling plans with unlimited text messages, and its minimally invasive nature. Studies have not explored the potential use of these interventions among surgical patients. The perioperative period is a busy time for patients, with many competing concerns, and it is not clear whether surgical patients have the capacity or willingness to receive perioperative text message support.

The overall aim of this pilot study was to determine the feasibility and acceptability of a text message–based intervention in the management of smoking behavior during the perioperative period (defined as the time of preoperative evaluation until 4 weeks after surgery).⁸ Secondary aims included describing the smoking behavior of patients enrolled in the program over this period.

METHODS

This study was approved by the Mayo Clinic Institutional Review Board. Cigarette smokers evaluated in the Preoperative Evaluation Clinic at Mayo Clinic, Rochester, were invited to enroll in a perioperative text messaging service, regardless of their intent to quit smoking. Eligibility criteria included being scheduled for any type of elective surgery at Mayo Clinic, Rochester, ≥18 years of age, current smoker (defined as >100 cigarettes lifetime consumption and self-report of smoking every day or most days), and having a mobile phone and data plan capable of sending and receiving messages. Patients with an active diagnosis of psychosis or dementia that would preclude informed consent were excluded. Study personnel obtained written informed consent and assisted the patients in enrolling in the text messaging program. All patients also received a brief (<5 minutes) tobacco cessation intervention emphasizing the importance of quitting or cutting down on smoking in the perioperative period.

The perioperative smoking cessation text messaging service was based on the UbiQUITxt platform, a customizable smoking cessation service designed and operated by Truth Initiative (Washington, DC), a nonprofit public health organization dedicated to combatting tobacco use. The service delivers messages grounded in current clinical practice guidelines for treating tobacco dependence,⁹ which were modified to incorporate 115 surgery-related messages and to remove messages that were not relevant to the perioperative period. Approximately half of the messages were focused on tobacco cessation, and the other half were positive messages about preparation and recovery from surgery. The Table provides examples of surgery-specific messages. Three messages per day were delivered before and for 1 week after surgery, and then 2 messages per day were delivered for postoperative days 7 through 30. In addition, patients had the opportunity to text 3 keywords at any time (“CRAVE,” “MOOD,” and “SLIP”) to indicate cigarette cravings, feeling down or anxious, or cigarette smoking. Automated responses to these concerns included coping strategies and encouragement. Participants were able to unenroll at any time by texting “STOP.”

Table.: Example Messages

Assessments

The program included the following message that assessed smoking status on the day after surgery and then 2, 4, 7, 14, and 21 days postoperatively: “Have you smoked at all, even a puff, in the last 24 hours? Reply YES or NO.” This assessment also provided a means to gauge engagement with the program. At 30 days postoperatively, a phone survey gathered information about current smoking behavior, use of nicotine replacement therapy, feedback about content and frequency of messages, and interest in using the text message service in the future. Utilization data, including the average number of messages sent and received per participant, were recorded. Confidentiality of data was maintained by numerically coding all data, disguising identifying information, and keeping all data electronically protected. Identifying information was not reported, and text messages were standardized for all patients. There was no transmission of personal health information, in compliance with Health Insurance Portability and Accountability Act (HIPPA) privacy rules.¹⁰ In addition, subjects were instructed to call or e-mail study personnel if they lost their mobile phone so that they could be unenrolled from the messaging program.

RESULTS

Between June 2016 and April 2017, 369 patients were screened for study eligibility through chart review: 321 met initial eligibility criteria and were approached to participate; 183 were determined to be ineligible because they had already quit smoking, were not daily smokers, or did not have text messaging capability or experience. Only 4% of those approached did not have a mobile device with texting capability. Of the 138 who were eligible for the study, 100 (73%) consented; 47% were women; and 68% were having an inpatient surgical procedure. The mean age was 52.1 years (standard deviation, 9.7 years), and mean baseline cigarette consumption was 14.9 (7.7) cigarettes per day. The median time from enrollment to surgery was 1 day (interquartile range [IQR], 1–3.25 days), consistent with the usual timing of a preoperative clinic visit. Twenty-eight subjects (30%) reported using pharmacotherapy in the past 30 days: 16 (57%) used the nicotine patch, 8 (29%) used nicotine gum, and 5 (18%) used varenicline.

All 100 subjects successfully enrolled in the text message program by texting their date of surgery to a specified phone number. Three subjects had their surgery cancelled or rescheduled but continued participating in the program and were included in the analyses. Only 17 unenrolled during the study period, at a median of 10 days (IQR, 4–22) after enrollment.

The median number of messages sent to each participant was 81 (IQR, 73–90). The median number of responses received from each participant in response to prompts was 10 (IQR, 6–14). Regarding keyword use, 29% used ≥1 keyword, with 25% of subjects using “CRAVE,” 7% using “MOOD,” and 3% using “SLIP.”

Of the 100 study participants, 95 completed a telephone survey at 30 days postsurgery. Overall satisfaction with the text messaging program was high, with 78 (80%) reporting being somewhat or very satisfied on a 5-point Likert scale. Most subjects (74; 78%) thought the message frequency was “just right,” with 20 (21%) reporting that there were too many on a 3-point scale from “not enough” to “too many.” Most also found the messages to be somewhat (36; 38%) or very (38; 40%) helpful on a 5-point Likert scale. Among the participants who recalled having used a keyword (CRAVE, MOOD, or SLIP) on the 30-day follow-up, 91% found them to be somewhat or very helpful. Almost one-third of subjects (27; 28%) wanted to continue using the text messaging service after the study ended. A majority (65; 68%) stated that they would be somewhat or very interested in utilizing the text messaging service again for future surgeries.

The response rate to messages assessing smoking status ranged from 58% on day 2 after surgery to 40% on day 21. Among those who responded to these prompts, self-reported 24-hour abstinence rates ranged from 37% on day 2 to 71% on day 14. Twenty-five subjects (31%) reported 7-day point prevalence abstinence at the 30-day telephone follow-up. All those who reported abstinence also reported planning to maintain sustained abstinence.

DISCUSSION

Although tobacco use interventions can be efficacious in the perioperative period and can reduce the risk of postoperative complications, there are multiple barriers to their implementation in clinical practice. It is particularly difficult to provide the extended follow-up necessary for a chronic relapsing condition like tobacco dependence, especially in medical populations. Text messaging services are well suited to the surgical setting where many patients are connected with the health care system for a defined period of time (eg, a surgical procedure and a follow-up appointment) but may not have continued follow-up. Although this pilot study was limited in scope and did not have sufficient power to study the efficacy of text messaging in promoting or maintaining abstinence, our findings do suggest that a text messaging program could be an attractive element of perioperative tobacco use interventions. It is noteworthy that 96% of patients (310/322) approached in this surgical population had the ability to receive text messages. This finding is consistent with other work showing a high prevalence of texting capability in the general population, including traditionally hard-to-reach populations (adolescents, socioeconomically disadvantaged groups, and individuals from ethnic/racial minority backgrounds).^11–13 A high proportion of this population (73%) was willing to enroll in the study and try the text messaging program, even though patients were approached regardless of their intent to quit smoking and had numerous other concerns connected with their impending procedure. Enrollment rates in previous studies in this same population examining other smoking cessation interventions, such as behavioral counseling or pharmacotherapy, have been as low as 10%.^14–16 Engagement and satisfaction with the program were also high. Our results clearly demonstrate a high level of interest, technical capability, engagement, and reported satisfaction with this perioperative text messaging program. Further investigation is necessary to determine whether text messaging programs, either alone or as a component of a more comprehensive tobacco use intervention, are efficacious in reducing or eliminating cigarette consumption in the perioperative period. Text messaging could also facilitate interactions with surgical patients in other domains of interest in the perioperative period, such as management of pain and postoperative rehabilitation.

DISCLOSURES

Name: Margaret B. Nolan, MD.

Contribution: This author helped with research design; implementation; evaluation of the intervention program; and drafting the manuscript, with significant revision and data analysis contributions from Megan A. Jacobs, Michael S. Amato, and Amanda L. Graham.

Conflicts of Interest: None.

Name: Matthew A. Warner, MD.

Contribution: This author helped with research design; implementation; evaluation of the intervention program; and drafting the manuscript, with significant revision and data analysis contributions from Megan A. Jacobs, Michael S. Amato, and Amanda L. Graham.

Conflicts of Interest: None.

Name: Megan A. Jacobs, MPH.

Contribution: This author helped with research design, implementation, and evaluation of the intervention program.

Conflicts of Interest: M. A. Jacobs work for Truth Initiative that markets and sells the UbiQUITxt smoking cessation text messaging program to employers, health plans, and community health organizations.

Name: Michael S. Amato, PhD.

Contribution: This author helped with research design, implementation, and evaluation of the intervention program.

Conflicts of Interest: M. S. Amato work for Truth Initiative that markets and sells the UbiQUITxt smoking cessation text messaging program to employers, health plans, and community health organizations.

Name: Amanda L. Graham, PhD.

Contribution: This author helped with research design, implementation, and evaluation of the intervention program.

Conflicts of Interest: A. L. Graham work for Truth Initiative that markets and sells the UbiQUITxt smoking cessation text messaging program to employers, health plans, and community health organizations.

Name: David O. Warner, MD.

Contribution: This author helped with research design, implementation, and evaluation of the intervention program.

Conflicts of Interest: None.

This manuscript was handled by: Tong J. Gan, MD.