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The Institute for International Internet Interventions for Health at Palo Alto University proposes to develop digital tools specifically to help low-income English- and Spanish-speaking smokers to quit. Individuals from lower-income countries and those with lower social status quit at lower rates than those from high-income countries and those with higher social status.
We plan to launch a project designed to test whether a mobile-based digital intervention designed with systematic input from low-income English- and Spanish-speaking smokers from a public-sector health care system can significantly improve its acceptability, utilization, and effectiveness.
Using human-centered development methods, we will involve low-income patients in the design of a Web app/text messaging tool. We will also use their input to improve our recruitment and dissemination strategies. We will iteratively develop versions of the digital interventions informed by our human-centered approach. The project involves three specific aims: (1) human-centered development of an English/Spanish smoking cessation web app, (2) improvement of dissemination strategies, and (3) evaluation of resulting smoking cessation web app. We will develop iterative versions of a digital smoking cessation tool that is highly responsive to the needs and preferences of the users. Input from participants will identify effective ways of reaching and encouraging low-income English- and Spanish-speaking smokers to use the digital smoking cessation interventions to be developed. This information will support ongoing dissemination and implementation efforts beyond the grant period. We will evaluate the effectiveness of the successive versions of the resulting stop smoking Web app by an online randomized controlled trial. Increased effectiveness will be defined as increased utilization of the Web app and higher abstinence rates than those obtained by a baseline usual care Web app.
Recruitment will begin January 2016, the study is intended to be completed by summer 2018, and the results should be available by fall 2019.
This study will provide useful knowledge in developing, testing, and disseminating mobile-based interventions for low-income smokers.
ClinicalTrials.gov NCT02666482; https://clinicaltrials.gov/ct2/show/NCT02666482 (Archived by WebCite at http://www.webcitation.org/6gtcwaT28)
Smoking is a major health problem. Globally, it is the number one preventable cause of premature death. The World Health Organization estimates as many as 1 billion tobacco-related deaths will occur in this century if smoking trends remain stable [
Low-income populations in the United States have higher smoking rates than high-income populations [
Our work on smoking cessation with Spanish speakers began in the 1990s. With support from a grant from the National Cancer Institute (NCI) (Eliseo J. Pérez-Stable, principal investigator), we attempted to carry out a traditional smoking cessation study involving face-to-face group interventions. Initial attempts to engage smokers in traditional face-to-face cessation groups were not successful. However, an alternative strategy of using surface mail was far more successful in reaching smokers. We found that our smoking cessation guide (
Our studies have yielded proof of concept that efficacy of Internet interventions for smoking cessation are higher than those reported for placebo patches (9% at 6 months [
One of our surface mail interventions was labeled
The TC2 studies [
The TC3 studies [
After recruiting the first 1000 participants, we maintained the TC3 website online, and we conducted a totally automated RCT (that is, we did not follow participants via the phone) in which 16,430 participants from 165 countries were recruited and followed entirely via automated emails [
In the TC4 studies [
Our latest study was on a new sample of participants who were recruited for 18 additional months to the San Francisco Stop Smoking site. A total of 164,182 individuals from 168 countries visited the site during this period: 27,163 were screened for eligibility; 9348 signed consent; 7407 completed the baseline survey; and 1431, 901, 595, and 318 left 1-, 3-, 6-, and 12-month data, respectively. Observed quit rates were 39.20% (561/1431), 43.51% (392/901), 45.71% (272/595), and 50.31% (160/318), respectively. The TC4 studies show that Internet interventions can yield quit rates similar to those found in earlier RCTs and can be disseminated to literally thousands of users across the world with minimal additional costs. We have begun thinking of them as MOOIs (massive open online interventions) [
We have argued that Internet interventions can help reduce health disparities by reaching those who do not have access to smoking cessation aids. Concerns have been raised that, although this approach may be increasing the reach of evidence-based smoking cessation interventions across large segments of the population and thus reducing health disparities across countries, digital interventions may actually increase health disparities. The reason for this concern is that more highly educated people may be more likely to use these interventions and perhaps more likely to benefit from them. To address this concern, we have compared quit rates for participants with differential socioeconomic standing as well as for participants from countries with different gross domestic products. We tested whether smokers in richer countries and smokers higher in self-reported SES are more likely to quit. Our results show that, indeed, our Internet interventions preferentially benefit individuals from countries with higher gross domestic products and/or with higher individual socioeconomic standing [
The SFHN is the city’s only complete care system. It consists of 14 primary care clinics throughout the city as well as San Francisco General and Laguna Honda hospitals. Between July 1, 2013, and June 30, 2014, the SFHN served 72,379 unduplicated patients who had 354,445 outpatient visits. Almost all were covered by Medi-Cal and/or Medicare (251,616/354,4445, 71.00%) or were uninsured (101,466/354,445, 28.60%). Only 60.10% (43,460/72,379) reported English as their primary language; 22.01% (15,905/72,379) reported Spanish as theirs. The next largest language group was Cantonese (8042/72,357, 11.10% ) followed by an additional 37 language groups, all at 1.20% (853/72,357) or less. Latinos are the largest ethnic group being served, at 32.60% (23,575/72,357) of the total, followed by Asians (25.20%, 18,206/72,357), whites (19.01%, 13,721/72,357), African Americans (18.30%, 13,214/72,357), and other groups accounting for less than 2.20% (1585/72,357) each. Slightly more than half of the patients are women (53.10%, 38,398/72,357). Those between the ages of 18 and 64 years (the group most likely to participate in our studies) compose 69.40% (50,355/72,357) of the population. Smoking rates are likely higher than for the general San Francisco population (13%), but rates are not available for the SFHN as a whole. Benowitz et al [
Estimates of how many SFHN patients use digital technology stem from a published report by Schickedanz et al [
We propose to recruit the following number of SFHN smokers who use smartphones: face-to-face field studies (ethnographies and usability tests), 30 in year 1 and 30 in year 2 and online studies, 50 in year 1, 100 in year 2, and 200 in year 3. We believe recruiting 410 out of more than 8000 smokers over a 3-year period is feasible.
We will also be doing open recruitment of smokers who own smartphones throughout California at the following rate: 100 in year 1, 200 in year 2, and 800 in year 3. This effort will provide a large enough sample to carry out adequately powered outcome studies as described in the Methods section.
The proposed study is based on the premise that we cannot presume to know what would be best for our intended users without engaging them. To build a smoking cessation intervention that will be used and be effective with low-income smokers aged 18 years and older, including Spanish-speaking smokers, we must build a deep understanding of their needs and values.
We propose to carry out a research study inspired by the “rapid, responsive, relevant (R3) research” approach described by Riley and colleagues [
There are more than 1.1 billion smokers worldwide [
A major advantage of fully automated self-help digital interventions is their low cost. Bringing a medication to market costs hundreds of millions of dollars [
Our research group has shown that unguided interventions focused on depression have significantly reduced depressive symptoms [
When the principal investigator first began to work at San Francisco General Hospital in 1977, he believed that, given ten years of recruiting and training new Spanish-speaking health care providers, we would be able to hire enough Spanish speakers to meet the demand for services in our hospital. More than 39 years later, we are still having difficulty recruiting Spanish-speaking providers. We are often forced to either not provide Spanish speakers needed services or to use interpreters to communicate with them. Smoking cessation groups in Spanish are hard to maintain. Our group has made the development of interventions in both English and Spanish (and, whenever possible, in other languages) one of its major priorities. Thus, this proposal focuses on low-income Latino smokers, most of whom speak Spanish and have low English proficiency.
When we began our work with online smoking cessation tools, we used skeuomorphic designs. A skeuomorph is a physical ornament or design on an object made to resemble another material or technique. The lights of an electric candelabra are fashioned in the shape of traditional candles, but the candle shape is not necessary to provide light. The shutter sound on cameras built into mobile devices and the floppy disk icons used on computers to save documents are, likewise, skeuomorphs. We included an 8-session mood management intervention modeled after face-to-face clinical appointments, and few people actually completed the sessions. In this proposal, we are attempting to be mindful of not limiting our designs using skeuomorphic thinking [
In a recent paper on rapid, responsive, relevant research [
We will develop iterative versions of a digital smoking cessation tool (a Web app with text messaging components) that is highly responsive to the needs and preferences of low-income English- and Spanish-speaking smokers. Development will take place with systematic input from patients who are part of the SFHN, which serves 70,000 mostly low-income individuals.
Input from SFHN patients will identify effective ways of reaching and encouraging low-income English- and Spanish-speaking smokers to use the digital smoking cessation interventions that are developed. This information will support ongoing dissemination and implementation efforts beyond the grant period.
We will evaluate the effectiveness of the successive versions of the resulting stop smoking Web app by recruiting smokers at two levels—within the SFHN and throughout the state of California—culminating in an online RCT. Increased effectiveness will be defined as increased use of the Web app and higher abstinence rates than those obtained by a baseline (usual care) Web app.
H1: Utilization of the final smoking cessation Web app (number of screens viewed, time spent using app, and amount of data entry) will be significantly higher than that of the baseline Web app.
H2: Recruitment based on dissemination strategies derived from ethnographic interviews will reach a significantly higher number of participants for successive online studies.
H3: Abstinence rates (7-day self-reported abstinence) will be significantly greater for the final Web app than for the baseline Web app.
Design thinking is a user-centered approach to innovation that considers and integrates the needs of people within the possibilities and reach of technology [
There are many variations of user-centered design processes, but they all uphold the same core tenets of being human-centered, prototype-centric, and iterative. The design thinking model presented by Kembel [
Empathize: fully understand the experience of the intended user via observation, interaction, and immersion in their experiences. This entails understanding their lifestyle, physical and emotional needs, how and why they do things, and what is meaningful to them as it relates to their smoking behavior. The goal is to uncover insights that will guide design and distribution of our digital intervention.
Define: process and synthesize data collected from the Empathize step to outline connections and patterns of our target users. The goal is to develop a defined, meaningful, actionable problem statement that will provide focus when developing and evaluating proposed solutions.
Ideate: generate a variety of possible solutions to provide source material for building prototypes. It is critical during this step to defer judgment and push for a wide range of ideas, allowing us to think beyond obvious existing solutions. The best solution is eventually determined during the prototyping and testing steps. We propose to systematically involve smokers and their health care providers in this step.
Prototype: transform ideas into physical forms so users can interact with them. Initial low-fidelity prototypes (eg, sketch drawings, storyboards) are quick and inexpensive ways for the team to learn how well a solution aligns with the user needs. Each iteration moves the team closer to a final, user-defined solution.
Test: observe and elicit feedback to learn more about the user, refine prototypes, and gain clarity on how well the solution addresses the problem statement.
We will develop iterative versions of digital interventions for smoking cessation in Spanish and English that are highly responsive to the needs and preferences of low-income and Latino smokers. Development will take place with user input from patients who are part of the SFHN. We will use the 5-step cyclic design thinking process described above to understand low-income smokers and iteratively develop and refine an effective digital smoking cessation Web app that they will use.
We will include in the ethnographic semistructured interviews questions regarding how the users found out about Web apps installed on their phones, how they use text messaging, and which digital smoking cessation tools they have used the most (if any). This information will guide the development of our recruitment and dissemination strategies both at the SFHN and at the state level.
We will develop a baseline Web app and 3 successive versions of the user-centered Web app, the last of which will be evaluated in an RCT.
We will recruit 60 low-income participants aged 18 years or older who are members of the SFHN, use smartphones, and have been advised by their care providers to quit smoking or have tried to quit smoking at least once. They will be divided into four target groups (15 English-speaking men, 15 English-speaking women, 15 Spanish-speaking men, 15 Spanish-speaking women). These 60 participants will be asked to sign consent to participate in the shadowing process and short or in-depth interviews conducted by research assistants. We will also recruit 10 health care providers from the SFHN (eg, smoking cessation counselors, nurses, physicians) to contribute to the Ideate step by taking part in a prototyping exercise (see
Flow of research study.
To ensure that our solution is based on a solid foundation, we will invest significant efforts during the initial Empathy step to understand our users. We will employ ethnographic methods to build a deep understanding of low-income English- and Spanish-speaking smokers. Research assistants will receive ethnography training (manuals and mock interviews) prior to going out into the field. We will conduct semistructured interviews pertaining to our themes of interest. Short interviews are hour-long semistructured interviews where research assistants will recruit patients from SFHN clinic waiting rooms to ask a set of questions related to their lifestyle and smoking habits. In-depth interviews will include a short interview plus a follow-up interview after a quit attempt and shadowing period of 3 hours in a natural location for the participant. Relevant themes include behaviors related to smoking, technology usage, personal lifestyle and social circles, how they get information (informing dissemination strategies), and personal values and motivations. All interviews will be audiorecorded and sent to third-party services for transcription.
Our ethnographic methods will yield a large amount of transcribed material, screenshots, and other photographs showing the use of apps. Our qualitative analysis will involve developing and refining our themes, identifying quotes from participants that support each theme, and developing a coding system that will help us identify behavior patterns and draw conclusions that will inform the next step in the design process.
SFHN patients will be recruited by research assistants at outpatient clinics. We will seek patients who own smartphones and intend to quit smoking in the next 3 months who either have been advised to quit smoking by their care provider or have tried to quit smoking at least once. Patients will be paid $25 per hour for their time for interviews as described in face-to-face studies below.
User-centered design, development, and testing will be carried out as shown on
For every field study the eligibility criteria are 18 years of age and older, current smoker (any number of cigarettes per day), and English or Spanish speaker. We plan to recruit low-income participants (ie, those who have Medicare and/or Medi-Cal, the California state equivalent, or are uninsured). Six face-to-face field studies are planned.
We will use shadowing methods (observing smokers’ actual behavior in their natural environment) plus semistructured interviews to learn how smokers think about their smoking behavior, how they attempt to quit, and how they use their smartphones (ie, how they find, download, install, and begin using apps).
We will recruit SFHN patients who have installed at least one smoking cessation app on their smartphones. We will use shadowing and semistructured interviews to study the use of smoking cessation apps participants have installed on their own. We will ask participants to install the baseline version of our Web app and use it for one week, scheduling follow-up interviews to learn about use patterns and reactions to the baseline Web app.
We will schedule two meetings, one in English and one in Spanish, with 5 SFHN smokers each, with the purpose of jointly working on the design of an ideal app to help them stop smoking. Groups will be facilitated by research staff familiar with Web apps to keep the group focused on the intended product. The result will be a paper prototype and sample screens developed on tablets to ensure that we are accurately rendering the patients’ suggestions. In addition, we will schedule two meetings, one in English and one in Spanish, with 5 SFHN providers each (smoking cessation counselors, nurses, physicians), using the same procedure. The results of the four meetings will be shared with the development team as part of the creation of version 1.0.
Once the developers begin the design process, we will engage in iterative usability testing with 4 or 5 SFHN English speakers and 4 or 5 Spanish speakers. Their input will be incorporated in version 1.0, which will be subjected to limited online testing (Online Study 2).
We will engage in iterative usability testing as version 2.0 is being developed to ensure that SFHN smokers have input into the new version, which will then be subjected to limited online testing (Online Study 3).
We will carry out iterative usability testing of the final version to ensure that SFHN smokers have input. The final version will be tested in an RCT.
A Web app will be developed to test the data-gathering infrastructure for the subsequent apps and generate baseline information on four variables: recruitment rates, utilization of the app, follow-up completion rates, and quit rates. Usual care is described in the Intervention section. We will engage in focused recruitment of smokers from the SFHN (up to 25 English speakers and 25 Spanish speakers) as well as open online recruitment with California as our main target (up to 50 English speakers and 50 Spanish speakers). We will implement follow-up interviews to examine quit rates at 1, 2, and 3 months after enrollment in the study. We will use 3 text messages (identified as coming from the Stop Smoking Study) 2 days apart. The first question will ask “Have you smoked 1 or more cigarettes in the last seven days?” A no response will be interpreted as 7-day point prevalence abstinence. Additional questions will address 30-day abstinence, number of cigarettes smoked daily if not abstinent, and use of other smoking cessation tools.
We will implement the same procedure as Online Study 1. We will obtain suggestions from our field test participants as to how to increase recruitment rates, for example, by modifying the wording in our social media announcements, the themes we touch upon in our radio and television interviews, the flavor of our public service announcements, word-of-mouth recruitment, the use of text messages to encourage enrollment, the wording of our search engine ads, and so on. We will use “tokens,” as described below, to identify how the participant heard about the Web app. We will examine which of these sources yield the greatest increases in recruitment. We will also track overall recruitment, as measured by the speed with which we meet our recruitment goals.
We will repeat the procedure as in Online Studies 1 and 2.
We will carry out an RCT comparing the final version of the San Francisco Stop Smoking Web App with the baseline Web app. The RCT will be powered to detect differences in utilization rates and 7-day point prevalence quit rates, as described in the Data Analysis section. We will carry out open online recruitment, with a target of 800 smokers (400 English speakers and 400 Spanish speakers), as well as focused SFHN recruitment, with a target of 200 smokers (100 English speakers and 100 Spanish speakers).
Open recruitment will focus on California smokers. We will target English- and Spanish-speaking smokers searching for information on smoking cessation online using social media recruitment efforts, appearances on radio and television shows (especially those likely to be watched by Latinos), and a limited amount of search engine ads. To target the latter, we will use information reported by Graham and others [
SFHN recruitment involves providing fliers for patients in waiting rooms at the San Francisco General Hospital clinics. Waiting room staff will also be given the fliers so they can inform smoking patients about the study. Primary care physicians will be provided with Post-It–like prescription pads which will have information regarding how to obtain the smoking cessation Web app. We will provide tokens (code numbers) to be entered when the Web app is installed that will indicate the source of the referral in order to determine whether physician recommendations to use the Web app result in greater utilization and higher quit rates than standard fliers. These tokens will also distinguish SFHN users from users recruited via open online recruitment.
Online Study 1 will test the data gathering aspects of the proposed Web app using a baseline usual care intervention consisting of a static smoking cessation guide,
This Web app will be developed with input from the SFHN population. Thus, we are not able to provide a concrete description of the app at this time. However, our work to date has been guided by social learning/social cognitive theory and uses cognitive behavioral principles that will guide our thinking. Based on our experience with Web-based apps, we have found a number of features are valued by users. Users want information provided in a number of ways (text, graphics, audio, video,
User-centered design and usability testing aims to determine whether people can use the tools and features (ease of use) and how they like using them (usefulness). These questions will be addressed using a mix of qualitative (semistructured interview) and quantitative (satisfaction, acceptability, and perceived usefulness ratings) methods. Furthermore, during usability testing participants will be audio- and videotaped while interacting with the tools and features. Participants will report their overall satisfaction, as well as satisfaction with the design, content, functionality, and features. Participants will report what they liked best and least about the tools and features as well as strengths and weaknesses of the tools. Participants will rate the perceived usefulness of each aspect and the acceptability of using the program in the future.
To reduce participant burden, we will use reduced versions of the baseline and follow-up questionnaires we used in our earlier website-centered studies. Being asked to respond to long surveys on a mobile device is likely to result in high dropout rates. Therefore, we propose the following:
Eligibility: age, current smoker, speak English or Spanish.
Baseline (obtained on the Web app when the smokers installs the app and gives consent to enter the study): demographics (age, sex, race, ethnicity, marital status, employment status, income, and educational level), smoking history (age first cigarette, age regular smoker, cigarettes per day, quit attempts, and methods used to quit), the Fagerström Test for Nicotine Dependence (6 items) [
Follow-ups (brief and obtained using text messaging to increase completion rates): smoking status (7-day and 30-day point prevalence abstinence rates, operationalized as a “no” response to “Have you smoked 1 or more cigarettes in the last seven days?” and, if “no” to the previous question, “Have you smoked 1 or more cigarettes in the last 30 days?”); number of cigarettes per day smoked in the last week (if still smoking); and rating of confidence that the user will remain quit (if not smoking) or be able to quit in the next 30 days (if smoking).
Mixed-methods data analysis will incorporate qualitative data from patient and therapist feedback; quantitative data from the satisfaction, acceptability, and usefulness ratings; and audio recordings from the field tests. Although quantitative ratings can highlight possible usability concerns, qualitative data provide answers to why those features might cause problems in ways that can guide development. Qualitative data will be interpreted following a grounded theory approach in which results from the semistructured interview will be analyzed using a series of codes to determine patterns in topics related to patients' and therapists' needs, concerns, and impressions of the prototype. Grounded theory was selected because it is a useful methodology for determining common topics within qualitative data to inform future practices and research. For the usability phase, we believe the users will raise unanticipated concerns and needs and thus we selected an approach that is flexible. Mean values of ratings from individual tools and features will be computed to identify those that require further refinement. Any tool or feature that is given the lowest value on a quantitative rating scale will be flagged for more intensive review in the video recordings and screen captures. Audio recordings and screen captures will address ease of use and be coded to determine three types of errors: navigation errors refer to instances when users cannot locate a function or have difficulty with aspects of the screen flow, content errors refer to instances of problems due to labeling or information presented, and usage errors refer to improper tool use or data field entry. Qualitative and quantitative data will be integrated through linking categories identified using the grounded theory approach with ratings on tools and features. Tools and features must score a mean value in the satisfactory range to be included in the next version. We will consider developing additional tools and features for other categories identified by users. Consistent with principles of constant comparative analysis, the principal investigator will make final decisions regarding tools and features.
These studies are intended to provide continuous quality improvement data as a baseline smoking cessation intervention (a static stop smoking guide) moves through two iteratively designed versions of a user-centered Web app. The final version of the Web app will be evaluated in comparison to the baseline app. We will examine successive changes in recruitment rates, utilization of the app, follow-up rates, and quit rates. We will use observed changes or lack thereof to pinpoint areas that need improvement; this will help prioritize changes in recruitment media and messages, Web app functionality, text messaging issues, and elements of the Web app likely to increase quit rates.
Participants will be randomly assigned to use either the baseline app or the final version of the San Francisco Stop Smoking Web app. We will focus our analysis on quit rates and use of the app. Latency (time spent) on content pages will be compared across the two versions of the app using independent samples
We estimate needing a minimum of 800 participants to detect small effect sizes in utilization and 550 to detect clinically significant differences in quit rates. We therefore propose to recruit 800 participants via the open online recruitment process (to reach the minimum sample size estimated in our power analysis) and an additional 200 SFHN participants to increase our sample size and carry out secondary subgroup analyses to determine whether utilization and quit rates for the SFHN patients appear similar to those recruited outside the SFHN.
The project was funded in July 2015. Enrollment is currently underway and is expected to be finished by 2018. The first results are expected to be submitted for publication in 2019.
Our research team is committed to the dissemination of our research products. We disseminated the findings supported by our three earlier TRDRP grants (7RT-0057, 10RT-0326, and 13RT-0050) to the tobacco research community via 19 published articles and many additional posters and papers presented at local, national, and international venues. We plan to do the same with the research findings stemming from this project. In addition we actively sought continuous funding to extend the reach and duration of the intervention resulting from our three previous TRDRP grants. Since we were first funded in 1998, we have documented 347,000 visitors from more than 200 countries and territories and 52,268 consented participants in several online smoking cessation trials. For the participant preference trials, we made the
Timeline. Note: D=Development, R=Recruitment, F=Follow-ups
The project received approval from the institutional review board at Palo Alto University in January 2016. Many of the study materials have been widely distributed and are well validated, and we do not anticipate any negative physical, mental, emotional, legal, or social consequences stemming from this study that are beyond what an individual would encounter in daily life. The Web app is presented to potential participants as a self-help automated research intervention (similar to a self-help book) and as neither counseling nor therapy. Therefore, use of the app does not involve a therapeutic contract. Participants are not compensated for interacting with the app, but they may receive indirect benefits such as a reduction in smoking behavior. Participants may withdraw from the study at any time and may refuse to answer any questions. During the study enrollment process, participants are informed that they may refuse to have their data used for official research reports but may still use the app. Their data will still be collected and used solely for the research team's ongoing Web app development.
All participants are informed that under no circumstances will their information be shared with their doctor or anyone outside the research team without their consent and that any published data will be aggregated and deidentified. All components of the Web application are provided in English and Spanish, and the previously validated stop-smoking guide has been shortened and simplified to a sixth-grade reading level. The project aims to sample equal numbers of male and female participants as well as English and Spanish speakers.
The first year of the current protocol has been registered at ClinicalTrials.gov Protocol Registration and Results System [NCT02666482].
This study is intended to increase the range of utilization and effectiveness of a smoking cessation Web app beyond well-educated users. English- and Spanish-speaking low-income primary care patients of a public-sector health network will be asked to contribute to the development of the new Web app via ethnographic interviews and focus groups. After several iterations of the Web app, an RCT will be conducted to determine whether the final version of the Web app is superior to the baseline version in terms of acceptance, utilization, and higher abstinence rates.
individually timed educational message
National Cancer Institute
rapid, responsive, relevant
Taking Control of Your Life
Tobacco-Related Disease Research Program
randomized controlled trial
socioeconomic status
San Francisco Health Network
This project was partially supported by funds provided by The Regents of the University of California, Tobacco-Related Diseases Research Program, Grant Number No. 24RT-0027. The opinions, findings, and conclusions herein are those of the authors and not necessarily represent those of The Regents of the University of California, or any of its programs. Programming and development of the web app for this project is being carried out by the Center for Behavioral Intervention Technologies at Northwestern University Feinberg School of Medicine.
None declared.
Reviews of TRDRP grant.