Still smoking? Let's game it out.

Do you remember learning about the asymptote in high school geometry? It’s that funny curve that gets closer and closer to a line through infinity, but never actually touches it. We say the curve “asymptotically” approaches zero.

Smokers are a little like this. As the rate of smoking asymptotically approaches zero, we are left with a population that is more and more “hardened” in its smoking habit. Around 70% of current smokers have no interest in quitting. So the smoking behaviors of the ~14% of people still smoking now are, person-for-person, harder to change than they were in the much larger fraction of the population who smoked five years ago. That is, as the population of smokers shrinks, it becomes ever harder to get the remaining smokers to stop. So most studies of smoking interventions like drugs, nicotine replacement, or therapy, ignore people who express little interest in quitting. Coordinators for most studies instead recruit people whose “readiness to change” is higher:

But a new study (paywall) takes this population of hardened smokers head-on with, of all things, a video game. Investigators recruited 433 smokers who reported they were not ready to quit. They randomized the smokers to get usual care with nicotine replacement therapy lozenges, or to get access to nicotine replacement therapy plus “Take a Break,” a 3-week mobile “game experience” that included 5 behavioral components: motivational messaging, challenge quizzes, brief abstinence goal setting, mobile health apps for cravings management (three “relaxation” apps were offered), and reward points for participation (in the form of gift cards).

To determine if the game had an effect, they looked at the time to their first quit attempt and tested carbon monoxide levels at 6 months to verify any claims of smoking cessation (smoking increases carbon monoxide levels in your blood, which, blech).

Apps are tricky because people tend to lose interest pretty quickly. Only about half of the game participants got through 100% of their daily challenge quizzes in the first week in the study. Roughly three-fourths set a brief abstinence goal of 1-2 days away from cigarettes, and 75% used the apps to manage their nicotine cravings. The game-treated participants set a sooner “time to quit,” and at six months, 18% (28 of 160) of game participants versus 10% (17 of 171) of nicotine replacement-only participants had carbon monoxide level–verified smoking cessation, roughly a doubling of the likelihood of smoking cessation once the fancy statistical analysis was done.

Those numbers look kind of sad, but remember that we’re talking about a very difficult population in the study, people who had expressed almost no interest in changing at the study’s onset. Through that lens, this is really a remarkable outcome, albeit in a small study. The best-performing clinics in the U.S. only get around 15% of their smokers to quit in any given year, and that is in a group of patients whose readiness to quit is undoubtedly higher than the population of this study.

As far as I can tell, the app isn’t available commercially yet. When “Take A Break” or its descendant products are available, though, we should think hard about using them. Smoking is still one of the leading causes of death, disability, and medical expenditures, so even a hefty price tag for such a product would be worth doubling the number of smokers who successfully quit in any six-month period.

As we’ve talked about before, we get pitched a lot of apps at KBGH. Do you have any positive experiences with skill-building or behavior change apps? If so, please share!

As the Medical Director of the Kansas Business Group on Health, I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Super four-pack of links July 11, 2017: the five percent and healthcare money, video game addiction, exercise to prevent diabetes, activity inequality, and evil coconut oil

Super-user sounds great, right? Who doesn't want to be super at something? Only this video (in Memphis-style) refers to the 5% of Americans that account for ~50% of health care spending in a year.

To paraphrase the end of the video: "There's almost nothing insurance companies won't charge, and Americans won't pay." How do you keep yourself from becoming a super-user? Everything medical is a matter of risk, so don't believe anyone who tells you there's a rock-solid simple way to keep from falling into that 5%, at least temporarily. But overwhelmingly, if you can keep a steady job you don't hate, if you can abstain from smoking, if you can get even a small amount of daily exercise (more is better, obviously), if you can keep your alcohol intake to a minimum, if you can abstain from recreational drugs (this includes marijuana, obviously), and if you can choose to eat mostly plant-based foods in semi-sane quantities, you're gonna stay out of The Five Percent.

Dara Lind and Dylan Matthews join Ezra to talk about the updated travel ban, how Trumpism has translated into policy, and the impact that increasingly awesome video games have had on young men's work habits.


Links!


White Paper: Leisure Luxuries and the Labor Supply of Young Men


Peter Suderman's piece about young men playing video games instead of getting jobs


What does excess immersion into video games mean for young men?

I've tried to set the Weeds audio above to play at about the 46 minute mark. But if that doesn't work, fast forward to the 46 minute mark. Not because the discussion of what "Trumpism" is isn't interesting (it is), but because the discussion that follows helped me think more deeply about the problem of excess immersion into video games that young people, especially young men, are experiencing. I've blogged about this before, and I talked about it at a recent speaking engagement. We seem to be creating a generation of youths who are increasingly isolated in very immersive video games, and then they're growing up into increasingly isolated and lonely people, particularly after age 40. As Ezra Klein says in the piece: if this were a problem of drug abuse, I think we would be acting collectively to do something about it. That's an apt comparison, since game addiction and drug addiction seem to have some physiology in common. But since the solution to technological problems currently seems to be "more technology," we are kinda-sorta just plowing ahead and hoping that video games fix themselves. I'm not optimistic. I think we need to start introducing programs to help kids moderate their exposure to video games and increase their exposure to the world at a young age. Dylan Matthews, who generally defends the idea of video games as a pacifying technology for people who can't or won't work, ends with this quote: "When we're in our eighties, we're all gonna be doing, like, flight simulator stuff. That's, like, how we'll spend--or, VR stuff, at least--that's what retirement's going to look like." Yuck. No. No. No. 

A new meta-analysis shows that African-Americans who exercise may not derive the same protective benefit from type 2 diabetes as other races

(brief Healio write-up here)

 I'm not ready to sign on to this point; race is a very blunt instrument when it comes to genetics. As the cost of gene sequencing falls, I think we'll not only be able to tease out drug effects in people with specific genetic features; we'll be able to more precisely target interventions like physical activity. Maybe certain people in this collection of studies would have benefited more from strength training, while others needed more endurance-oriented activities. Maybe some would have benefited from a specific combination of drug and activity. We don't know the answers to these things now, but we will soon. 

Smartphone data shows that countries with the highest "activity inequality" are more likely to have large obese populations: 

More differences in activity within the population equals more obese people. 

More differences in activity within the population equals more obese people. 

So it isn't a surprise that the same investigators found that the higher the walkability of a city, the lower the "activity inequality":

Texas is not a place with a great deal of walkability. 

Texas is not a place with a great deal of walkability. 

The cynical take on this study is something like, "Of course people who are inactive weigh more!" Fair enough. But the obvious policy implication of the study is that, to affect the activity level of the inhabitants of a city, the built environment must give opportunities for activity.

ADDENDUM (make it a five-pack): How coconut oil got a reputation for being healthy in the first place. I don't love coconut oil, but even if I did, I'd think of it like I think of butter: an ingredient to be used sparingly, mostly for flavor.