Background
Tobacco use is the main cause of preventable morbidity and mortality in the world, directly accounting for five million deaths yearly [
1]. The number of smokers who attempt quitting on their own every year is high, but only 2–3% remain abstinent after 12 months [
2]. Healthcare professionals are very effective and efficient in their interventions on the smoker, with over threefold success rates of long-term abstinence. Combining behavioral and pharmacological treatment yields the best results [
2‐
4].
However, only 1 in 20 attempt to quit is supervised by a professional [
2]. In the public healthcare system of the Community of Madrid (Madrid Regional Health Service), 84% of smokers who attended an outpatient consultation in 2008 did not receive advice for tobacco cessation [
5], a figure similar to those observed in other countries [
6,
7]. Factors related to these low intervention rates have been identified, and these include lack of training for healthcare professionals and their perception that such interventions are not useful and they lack the time to implement them [
8].
A possible solution is developing effective, brief, and simpler interventions, such as the “Very Brief Advice “that consists of offering the patient help to quit smoking regardless of their motivation. Many patients respond positively to this proposal, even those who had not considered making an attempt previously to the offer [
9]. Compared to the usual intervention, this results in over 50% more attempts to cease smoking [
10]. However, to achieve this, a resource backed by scientific evidence and easy to access must be available, such as the tobacco cessation consultations in the British National Health System (NHS).
The boom in information and communication technologies, like the internet or smartphones, open up new therapeutic perspectives. In 2016, there were 7 billion customers of mobile phone services, almost 97% of the population worldwide. Mobile broadband has continuously grown, with 84% of the world population using it [
11], and the smartphone has become the main and most accessible personal computer in the majority of countries. On the other hand, patients aspire to play a greater role in their health management and increasingly search for more information in the internet (Table
1). The resulting opportunities create a new framework to empower the patient and improve clinical outcomes and health expenditure [
12].
Table 1Characteristics of the web search for health information
Ubiquity | Unequal quality of information |
Immediacy | An identified source cannot always be found |
Ability to access specific population segments | The date when the content was updated cannot always be found |
Automation of messages | Need to adapt the message to the targeted population |
Possibility of contact and learning among peers | Risk of information overload for the patient |
In terms of scientific evidence, a systematic review of 59 clinical trials on interventions to quit smoking via smartphones [
13] concluded that text messages double the success rates of nicotine abstinence with biochemical validation, showing a risk ratio (RR) of 2.16 (Confidence interval -CI- 95%: 1.77–2.62). The relevant Cochrane review [
14] comprised 12 clinical trials that included 11,885 patients, with a combined RR = 1.7 (CI 95%: 1.46–1.90) for abstinence at 6 months, and a RR = 1.83 (CI 95%: 1.54–2.19) using the data of the six clinical trials that chemically validated the abstinence, both compared to usual practice. The evaluated trials were based on interventions mainly using Short Message Service (SMS), although one employed videos, and all were conducted in high-income countries with strong policies for tobacco control. They also did not find clinical trials, published or in-progress, studying the effectiveness of applications (app) for mobile phones or tablets, despite their proliferation.
In a 2013 review about the adequacy of scientific evidence for existing apps to aid people cease smoking in the USA at the time, Abroms et al. [
15] could not find any that followed science-based recommendations by clinical practice guidelines and warned about the potential negative effects on the population’s health.
In 2017, a new review [
16] aimed to assess the scientific content of the most used commercial apps in the USA for helping to quit smoking as well as the ones available. Only six apps were identified as being partially science-based, of which three (50%) were available in at least one app store, and just two of the top 50 recommended apps in app stores (4%) had some scientific basis, but it was not possible to differentiate them from those not based on scientific evidence.
A chat-bot is not a software that needs to be installed in a smartphone or tablet, it respects the privacy of the patient scrupulously, and its learning curve is very short [
17]. This computer software has a conversation interface that can both answer questions posed by the user in a natural language (that commonly used by people with all their variants) and ask them questions [
18]. Although it is not a new technology, the recent technical revolution for the interpretation of natural languages, together with the above-mentioned advantages and certain downsides of apps, make chat-bots ideal tools for the purposes of this intervention. Since chat-bots “understand” requests expressed with the complexity and variability of human language, they provide a component of technological “humanization” that other interfaces based on menus and chat-buttons lack. This way, they are capable of returning a personalized answer and add a component of user loyalty and usability of the tool [
18,
19].
The chat-bot to be evaluated in this trial has been specifically designed by experts in tobacco addiction and artificial intelligence incorporating gamification, cognitive-behavioral, motivational, problem-solving, and relapse-preventing components. Such components form an integral part of science-based interventions recommended by clinical practice guidelines [
3,
4].
We aim to assess whether the effectiveness of the usual intervention in primary care can be improved [
2] by providing healthcare professionals with guidance to help patients accept the offer to quit smoking [
10], so that their motivation to intervene on their patients will increase by decreasing their workload. We also estimate that this type of intervention will improve the accessibility of patients to an evidence-based treatment.
The wide scale and severity of consequences of tobacco use, benefits derived from cessation, low rates of intervention by healthcare professionals, and new opportunities stemming from novel communications technologies in addition to the absence of scientific evidence on its effectiveness and the lack of such tools designed by experts according to the guidelines of the evidence-based clinical practice guidelines are the main factors motivating this project.
Acknowledgements
We would like to thank the Research Support Unit from the Primary Healthcare Management of the Community of Madrid regional government, the Fundación para la Investigación e Innovación Biomédica en Atención Primaria (FIIBAP) team, each of the many personnel of the 38 participating health centers and Bumpho team.
Dejal@ Group (Contributor group) consists of the following researchers:
CS Ramón y Cajal (Alcorcón-Madrid): Garcia-Mesa, AM; Gomez, C; Liebana-Nistal, E; Molina-Alameda, L.
CS Castillos (Alcorcón-Madrid): Andrade-Rosa, C, Caballero-Jiménez, A; Escribano-Romo, G; Espejo-Romero, M; Ferrero-Brenes, A; Hernandez-Garcia, JL; Perez-Perez, E; Zambrano-Alvarez, J.
CS Gregorio Marañon (Alcorcón-Madrid): Ayuso-Hernandez, E; Cuesta-Monedero, MJ; Sanchez-Jimenez, FJ; Vigil-Escalera, A.
CS Ribota (Alcorcón-Madrid): Casado-Nistal, S; Garcia-Alva, M; Martin-Gomez, I; Puyo-Rodriguez, N; Rodriguez-Cosio, A; Sanchez-Vazquez, I.
CS Dr Trueta (Alcorcón-Madrid): Alcala-Olmo, MA; Garcia-Alegre, MT; Garcia-Alva, M; Hurtado-Monterrubio, C; Martin-Burillo, T; Moral-Moraleda, C.
CS Dr Luengo (Móstoles-Madrid): Ciria Holgado, E; Hermoso-Duran, C; Hernandez-Rodriguez, S; Lafraya-Puente, AL; Melero-Serrano, JL; Molina-Sanchez, MJ; Muñiz-Dominguez, E; Saiz-Loma-Osorio, C.
CS Alcalde Bartolomé (Móstoles-Madrid): Aparicio-Velasco, J; Cerezo-Pascual, E; Fonte-Elizondo, L; Gomez-Martinez, MI; Marin-Osorio, C; Orozco-Diaz, P; Prieto-Villegas, E; Rodriguez-Donoso, J; Rodriguez-Huete, A; Romero-Blanco, FJ; Urbano-Fernandez, JP.
CS Felipe II (Móstoles-Madrid): Castillo-Portales, SJ; Collados-Navas, R; Gutierrez-Sordo, P; Martin-Sacristan-Martin, MB; Sanchez-Quejido, M.
CS Barcelona (Móstoles-Madrid): Abad-Schilling, C; Arenas-Gonzalez, S; Calonge-Garcia, ME; Capitan-Jurado, M; Menendez-Alvarez, S; Regalado-Valle, MA.
CS Francia (Fuenlabrada-Madrid): Alache-Zuñiga, HC; Cerrada-Cerrada, E; Garcia-Camps, R; Gutierrez-Notario, MJ; Mendez-Cabezas-Velazquez, J; Molina-Paris, J; Pensado-Freire, H; Viñas-Fernandez, G.
CS Castilla La Nueva (Fuenlabrada-Madrid): Jaenes-Barrios, B; Jurado-Sueiro, M; Ortiz-Sanchez, M; Santiago-Hernando, ML.
CS Cuzco (Fuenlabrada-Madrid): Arjona-Perez, S; Delgado-Mellado, I; Diaz-Martin, R; Fandiño-Garcia, B; Gomez-Ortiz, MC; Lopez-Martin-Aragon, MT; Martinez-Alvaro, C; Miguel-Abanto, MA; Noguerol-Alvarez, M; Parra-Roman, S; Pascual-Garcia, Z; Ranz-Granados, AL; Rey-Rodriguez, S; Sanz-Perez, C.
CS Parque Loranca (Fuenlabrada-Madrid): Aguilar-Hurtado, E; Aguilera-Rubio, M; Carbonero-Martin, AI; Esteban-Garcia, M; Esteban-Peña, C; Fernandez-Sanchez, M; Garcia-Contreras, C; Hernandez-Sanchez, AM; Herrera-Garcia, ML; Herrero-Fuentes, A; Oria-Rodriguez, M; Parra-Martin, MS; Rojas-Giraldo, MJ; Saiz-Ordoño, A; Sanchez-Fernandez, YB; Villasevil-Robledo, P.
CS Panaderas (Fuenlabrada-Madrid): Alonso-Ovies, M; Diaz-Martin, A; Garcia-Arpa, N; Garcia-Rodriguez, F; Gonzalez-Carpio-Paredes, O; Grandes-Muñoz, MJ; Jara-Peñacoba, M; Lopez-Villalbilla, A; Parellada-Ruiz-Cuesta, MJ; Rabadan-Velasco, AI; Rodriguez-Bastida, M; Sobrado-Cemeño, C; Valdez-Jaquez, A; Vicente-Perez, S.
CS Humanes de Madrid (Humanes de Madrid-Madrid): Matin-Porras, B.
CS Los Fresnos (Torrejón de Ardoz-Madrid): Gonzalez-Valls, A; Joglar-Alcubilla, V; Santa-Cruz-Hernandez, J; Serrano-Serrano, ME.
CS Las Fronteras (Torrejón de Ardoz-Madrid): Castilla-Alvarez, C; Garcia-Abad-Fernandez, MA; Garcia-Viada, M; Hernandez-Lachehab, S; Lopez-Kollmer, L; Miguel-Ballano, A; Molina-Barcena, V; Ortega-Pineda, R; Sepulveda-Gomez, I.
CS Las Veredillas (Torrejón de Ardoz-Madrid): Cuadrado-Gonzalez, P.
CS Luis Vives (Alcalá de Henares-Madrid):Jimenez-Moreno, MJ; Linares-Sanchez, C; Pardo-Garcia, MA; Sanchez-Martin, F; Simon-Gutierrez, R; Solans-Aisa, B.
CS Juan de Austria (Alcalá de Henares-Madrid): Francisco-Romanillos, T; Garcia-Ortega, A; Hernandez-Garcia-Alcala, P; Huguet-Vivas, F; Juarez-Zapatero, ML; Lopez-Garcia, C; Manzano-Martin, MJ; Martinez-Torres, JA; Miguel-Garzon, M; Rodrigo-Rodrigo, MP; Ruano-Dominguez, MA; Serna-Urnicia, A.
CS Reyes Magos (Alcalá de Henares-Madrid): Altares-Arriola, N; Aranzo-Pacheco, R; Casado-Rodriguez, C; Cascao-Moutinho-Pereira, C; Escudero-Araus, M; Fuentes-Manrique, C; Guijarro-Abanades, S; Hombrados-Gonzalo, P; Lopez-Carabaño, AM; Meiriño-Perez, ML; Moneva-Vicente, GD; Noguera-Martinez, I; Perez-Fernandez, M; Robres-Olite, M; Rubio-Rubio, T; Venegas-Gato, MF.
CS Miguel de Cervantes (Alcalá de Henares-Madrid): Bernal-Hertfelder, F; Blas-Escribano, M; Castro-Fouz, MM; Castro-Sanchez, B; Dominguez-Perez, L; Garcia-Gomez, PA; Herrero-Dios, A; Lor-Leandro, M; Lozano-Martin, I; Pacho-Pinto, S; Pastor-Sanchez, R.
CS Los Hueros (Villalbilla-Madrid): Moreno-Chaparro, MD.
CS Villalbilla (Villalbilla-Madrid): Yagüe-Fernandez, E.
CS Dr. Cirajas (Madrid): Lopez, MJ; Mateo-Madruga, A; Palancar-Torre, JL; Pumar-Sainz, P.
CS Guayaba (Madrid): Aragon-Marente, C; Gomez-Medina, MA; Granados-Garrido, JA; Gutierrez-Sanchez, I; Heras-Alonso, MJ; Lopez-Gomez, MJ; Martin-Peces, B; Martinez-Suberbiola, FJ; Medran-Gomez, A; Nuevo-Rodriguez, G; Ochoa-Vilor, S; Vargas-Machuca, C.
CS Perales del Río (Perales del Rio-Madrid): Fernandez-Montes-Lopez-Morato, O; Jimenez-Rojas, R; Marcos-Frutos, C; Minguet-Arenas, C; Minue-Lorenzo, C; Ruiz-Pascual, V; Sanchez-Fonseca, I; Sanchez-Gonzalez, JM.
CS Sta. Isabel (Leganés-Madrid): Alba-Gomez, F; Avila-Tomas, JF; Cayuela-Mate, A; Cidoncha-Calderon, E; Cifuentes-Muñoz, AB; Fernandez-Garcia, RM; Gala-Paniagua, JL; Gongora-Marin, A; Herrero-Municio, P; Moreno-Chocano-Garcia-Carpintero, E; Perez-Cuadrado, S; Redondo-Horcajo, A; Vicente-Sanchez, C; Villena-Romero, RM.
CS Leganés Norte (Leganés-Madrid): Hakami-Hakami, O.
CS María Jesús Hereza (Leganés-Madrid): Alvarez-Villalba, MM; Bedoya-Frutos, MJ; Camarero-Palacios, J; Escobar-Gallegos, M; Hormigos-Agraz, A; Innerarity-Martínez, J; Lopez-Lopez, MT; Perez-Ballesto, B; Perez-Gutierrez, E; Tardaguila-Lobato, MP.; Terron-Barbosa, R.
CS El Greco (Getafe-Madrid): Ballarin-Gonzalez, A; Fernandez-Fernandez, Y; Ferrer-Zapata, I; Gomez-Suarez, E; Lamonaca-Guasch, M; Morales-Ortiz, F; Pelaez-Laguno, C; Quintana-Gomez, JL; Rioja-Delgado, E.
CS Sector III (Getafe-Madrid): Aza-Pascual, JI; Fuente-Arriaran, D; Garcia-Perez, RA; Garriz-Aguirre, A; Gomez-Diaz, S; Gonzalez-Palacios, P; Gonzalez-Sanchez, N; Peralta-Alvarez, G; Sanz-Velasco, C; Vazquez-Gallego, J; Vazquez-Garcia, C.
CS El Restón (Valdemoro-Madrid): Fernandez-Duran, C; Peña-Anton, N.
CS Valle de la Oliva (Majadahonda-Madrid): Blanco-Canseco, JM; Gamez-Cabero, I; Minguela-Puras, E; Serrano-Vega, J.