Discussion
CPD, depression, depressive symptoms
ABUSE
These results preliminarily indicate that Goal2Quit paired with a mailed sample of NRT (1) is usable by adults with depressive symptoms who smoke cigarettes, (2) is efficacious for depression treatment, and (3) promotes smoking cessation. Regarding usability and treatment engagement, outcomes can be compared to other available digital interventions. A recent, also fully decentralized, trial evaluating 2 app-based smoking cessation interventions found that 42.9% of users continued to use their intervention beyond 1 week of download and only 14.6% beyond 4 weeks [Regarding depression outcomes, Goal2Quit demonstrated efficacy for depression treatment. As compared to TAU, those who received Goal2Quit reported lower depression symptom severity over the course of the trial, with the most pronounced improvements occurring during the first 3 weeks after receiving the intervention, consistent with a prior in-person trial of BA for smoking cessation [Regarding smoking cessation, on all indicators, Goal2Quit outperformed TAU. Those who received Goal2Quit were more likely to attempt to quit and achieve abstinence. Similar to depression outcomes, the greatest decreases in CPD occurred early in the trial, between baseline and week 2. While these decreases also mirror patterns of early app engagement, these changes in smoking behavior are also likely related to the duration of NRT (2 weeks) provided in combination with Goal2Quit. Cessation outcomes can be compared to those of standard, in-person BA-based group therapy for smoking cessation among individuals with depressive symptoms as well as other app-based interventions for broader groups of individuals who smoke cigarettes. Participants in a prior trial who received in-person BA in addition to 8 weeks of NRT patches had biochemically verified cessation rates of 28.6%, 17.1%, 11.4%, and 14.3% at 1, 4, 16, and 26 weeks post the quit date, respectively [Given that the purported mechanism of BA is the completion of goal-driven activities, intervention refinements that specifically promote activity completion may help to bolster therapeutic effects in the future. On average, participants scheduled 72.8 activities across the 12-week study duration. This rate of activity scheduling is consistent with the original BA for smoking cessation treatment manual [The results of this study should be interpreted with limitations in mind. We were unable to disentangle the effects of the Goal2Quit app versus the NRT sample since the intervention group received both. However, this was an a priori decision as digital cessation interventions must be paired with pharmacotherapy to address both behavioral and physical symptoms of nicotine dependence. Additionally, all cessation outcomes were based on self-report. In our team’s prior remote trials, biochemically verified abstinence rates have been somewhat lower than self-reported abstinence [There are a number of additional important future directions stemming from this work. While digital interventions may increase treatment accessibility, sustainability must also be considered. Next steps should focus on the evaluation of effectiveness, implementation, and eventually embedding the intervention in clinical practice or other settings that can benefit [In conclusion, Goal2Quit paired with a brief, mailed sample of NRT was effective for the treatment of depression as well as smoking cessation among remotely enrolled adult smokers with depressive symptoms recruited from across the country. Findings support the utility of this intervention approach for addressing the currently unmet public health treatment need for tailored, scalable depression-specific cessation treatments.Funding for this research was provided by the National Institute on Drug Abuse (K23 DA045766). The funding source had no role in study design, data collection, data analysis, data interpretation, writing this report, or in the decision to submit this paper for publication. The authors would like to thank MountainPass Technology for their partnership in developing Goal2Quit and study staff members, including Johanna Hidalgo and Monika Schindwolf, for assistance in data collection.Authors' Contributions: JD and AEW had full access to all the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design were contributed by JD, MJW, and VAD. Acquisition, analysis, or interpretation of data was conducted by all authors. The drafting of the paper was primarily carried out by JD and AEW. All authors participated in the critical revision of the paper, ensuring important intellectual content was addressed. Statistical analysis was performed by JD and AEW. Acquisition of funding was the responsibility of JD. Administrative, technical, or material support was provided by AEW, JK, and NN. Supervision duties were undertaken by JD and MJW.Conflicts of Interest: JD and JK are co-owners of Behavioral Activation Tech LLC, a small business that develops digital interventions for behavioral health treatment. Behavioral Activation Tech does not have a financial interest in Goal2Quit. JK is the owner and principal of MountainPass Technology LLC, the software development company that led the development of Goal2Quit. MountainPass Technology does not have a commercial interest in Goal2Quit. Intellectual property for Goal2Quit is owned by the Medical University of South Carolina.Goal2Quit uptake.Goal2Quit app retention (N=103).CONSORT-eHEALTH checklist (V 1.6.1).