title: Crave-Out: A Distraction/Motivation Mobile Game to Assist in Smoking Cessation.
abstract: BACKGROUND
  Smoking is still the number one preventable cause of death. Cravings-an intense desire or longing for a cigarette-are a major contributor to quit attempt failure. New tools to help smokers' manage their cravings are needed.
  
  
  OBJECTIVE
  To present a case study of the development process and testing of a distraction/motivation game (Crave-Out) to help manage cravings.
  
  
  METHODS
  We used a phased approach: in Phase 1 (alpha testing), we tested and refined the game concept, using a Web-based prototype. In Phase 2 (beta testing), we evaluated the distraction/motivation potential of the mobile game prototype, using a prepost design. After varying duration of abstinence, smokers completed the Questionnaire of Smoking Urge-Brief (QSU-Brief) measurement before and after playing Crave-Out. Paired t tests were used to compare pregame and postgame QSU-Brief levels. To test dissemination potential, we released the game on the Apple iTunes App Store and tracked downloads between December 22, 2011, and May 5, 2014.
  
  
  RESULTS
  Our concept refinement resulted in a multilevel, pattern memory challenge game, with each level increasing in difficulty. Smokers could play the game as long as they wanted. At the end of each level, smokers were provided clear goals for the next level and rewards (positive reinforcement using motivational tokens that represented a benefit of quitting smoking). Negative reinforcement was removed in alpha testing as smokers felt it reminded them of smoking. Measurement of QSU-Brief (N=30) resulted in a pregame mean of 3.24 (SD 1.65) and postgame mean of 2.99 (SD 1.40) with an overall decrease of 0.25 in cravings (not statistically significant). In a subset analysis, the QSU-Brief decrease was significant for smokers abstinent for more than 48 hours (N=5) with a pregame mean of 2.84 (SD 1.16) and a postgame mean of 2.0 (SD 0.94; change=0.84; P =.03). Between December 22, 2011, and May 29, 2014, the game was downloaded 3372 times from the App-Store, with 1526 smokers visiting the online resource www.decide2quit.org linked to the game.
  
  
  CONCLUSIONS
  Overall, playing the game resulted in small, but nonsignificant decreases in cravings, with changes greater for those had already quit for more than 48 hours. Lessons learned can inform further development. Future research could incorporate mHealth games in multicomponent cessation interventions.
  
  
  BACKGROUND
  Clinicaltrials.gov NCT00797628; https://clinicaltrials.gov/ct2/show/NCT00797628 (Archived by WebCite at http://www.webcitation.org/6hbJr6LWG).
authors.affiliation: University of Massachusetts Medical School, Worcester, MA, United States. kathryn.delaughter@va.gov.
authors.forename: Kathryn L
authors.initials: KL
authors.lastname: DeLaughter
authors.forename: Rajani S
authors.identifier: http://orcid.org/0000-0001-8406-6207
authors.initials: RS
authors.lastname: Sadasivam
authors.forename: Ariana
authors.identifier: http://orcid.org/0000-0001-5363-825X
authors.initials: A
authors.lastname: Kamberi
authors.forename: Thomas M
authors.identifier: http://orcid.org/0000-0002-3924-8391
authors.initials: TM
authors.lastname: English
authors.forename: Greg L
authors.identifier: http://orcid.org/0000-0002-2094-0441
authors.initials: GL
authors.lastname: Seward
authors.forename: S Wayne
authors.identifier: http://orcid.org/0000-0002-5193-7560
authors.initials: SW
authors.lastname: Chan
authors.forename: Julie E
authors.initials: JE
authors.lastname: Volkman
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Amante
authors.forename: Thomas K
authors.initials: TK
authors.lastname: Houston
keywords: Internet; health behavior; secondary prevention; smoking cessation