The Systematic Development of a Mobile Phone Delivered Text-Messaging Tobacco Cessation Intervention in India

Introduction Tobacco consumption is a leading cause of mortality globally. Eighty percent of these deaths occur in low- and middle-income countries. Despite this, there is a large treatment gap due to both demand and supply-side barriers. Digital interventions are an innovative solution to bridge this gap. We describe the systematic development of ToQuit, a text-messaging intervention for tobacco cessation in India. Aims and Methods ToQuit was developed in sequential steps: (1) Identifying Behaviour Change Techniques (BCTs) from evidence-based tobacco cessation interventions; (2) Identifying additional BCTs through in-depth interviews; (3) Online expert survey to rate BCTs on feasibility, acceptability, and perceived effectiveness when delivered via text messaging; and (4) A consultation workshop with practitioners. Results Thirty BCTs were identified from steps 1 and 2. Three were excluded in step 3. The final intervention included 27 BCTs delivered over three phases: phase 1 - orientation (information about antecedents and consequences of tobacco consumption, goal setting, reattribution, pros and cons of quitting); phase 2 - skill building (self-monitoring, avoidance of cues for behavior, behavior substitution, distraction, stress management, handling urges, restructuring physical and social environments, instructions on how to perform a behavior, prompts and cues, problem-solving, social support, and referrals among others); and phase 3 - relapse prevention (psychoeducation about lapse and relapse, review goals, action planning, and feedback on behavior). The intervention is delivered via text messages over 8 weeks with 2-3 messages a day, 2-3 days a week. Conclusions ToQuit is a contextually relevant and potentially scalable text-messaging intervention for tobacco cessation in resource-constrained settings. Implications This manuscript is an important piece in the development of contextually relevant digital interventions for the cessation of both smoked and smokeless forms of tobacco. The detailed description of the steps followed in developing the ToQuit intervention will help others replicate these procedures while developing similar interventions responsive to their contexts; particularly in low- and middle-income countries.