YOUNG ADULT SMOKING CESSATION AND MOBILE HEALTH: A QUALITATIVE INVESTIGATION OF THE CRUSH THE CRAVE APP by Laura Louise Struik B.S.N., Laurentian University, 2008 M.S.N., The University of British Columbia, 2012 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in The College of Graduate Studies (Interdisciplinary Studies) THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan) July 2017 © Laura Louise Struik, 2017 The following individuals certify that they have read, and recommend to the College of Graduate Studies for acceptance, a thesis/dissertation entitled: Young adult smoking cessation and mobile health: a qualitative investigation of the Crush the Crave app submitted by Laura Louise Struik in partial fulfillment of the requirements of the degree of Doctor of Philosophy Dr. Joan Bottorff, School of Nursing Supervisor Dr. Bruce Baskerville, School of Public Health and Health Systems, University of Waterloo Supervisory Committee Member Dr. John Oliffe, School of Nursing, University of British Columbia’s Vancouver campus Supervisory Committee Member Dr. Kathleen Martin Ginis, School of Health and Exercise Sciences University Examiner Dr. Harvey Skinner, University of Toronto External Examiner Additional Committee Members include: Dr. Susan Crichton, Faculty of Education Supervisory Committee Member ii Abstract Smoking remains a major public health issue, particularly among young adults because smoking rates are highest in this demographic. With young adults’ low uptake of the various smoking cessation interventions available, innovative ways to support young adult smoking cessation are needed, and there is much enthusiasm about the use of mobile phones, especially apps, to reach this population. How these tools influence smoking cessation, however, remains largely unknown. Therefore, the purpose of this qualitative case study was to understand the design and use of the mobile app, Crush the Crave (CTC), for helping young adults quit smoking. Data included document analysis, fieldwork, and semi-structured interviews with 15 key informants (those involved in the development of CTC) and 31 young adult CTC users. Guided by sociomateriality theory and an affordances approach, as well as a gender-based analysis, data were inductively analyzed to derive thematic findings in relation to the influence of CTC on young adult’s quit smoking efforts. Findings were grouped per the overall strengths and limitations of the app, and the affordances of the app. Affordances were grouped according to each design component of the app: credibility, task support, social support, and dialogue support. Data from key informants revealed the expectations of CTC for helping young adults quit smoking, which were juxtaposed to young adults’ actual experiences with the app. While key informants’ expectations often aligned with young adults’ experiences, there were also some noteworthy differences and additional experiences that the key informants did not anticipate. The credibility, task support, and dialogue support functions lent to largely positive experiences and practices, including trust in the app, encouragement and motivation for quitting, and enhanced awareness of smoking behaviour. The social support component lent to negative user experiences (vulnerability) and practices (low engagement) that rendered this aspect as the iii weakest component in supporting efforts to quit. There were also some notable gender differences and similarities in relation to the preferences and experiences of young women and men. This study highlights both productive and unproductive approaches to the development of smoking cessation apps, and offers new directions for future improvements and app development. iv Preface This dissertation is the original work of the author, Laura Struik. The research study was conducted under the supervision of committee members: Dr. Joan L. Bottorff (supervisor, Chair in Health Promotion and Cancer Prevention, Director of the Institute for Healthy Living and Chronic Disease Prevention, Professor at the School of Nursing, University of British Columbia’s Okanagan Campus), Dr. N. Bruce Baskerville (Senior Scientist at the Propel Centre for Population Health Impact, Research Associate Professor in the Faculty of Applied Health Sciences, University of Waterloo), Dr. Susan Crichton (Director of the Innovative Learning Centre, Director of the Faculty of Education, Associate Professor in the Faculty of Education, UBC’s Okanagan Campus), and Dr. John Oliffe (Professor at the School of Nursing, UBC). Ethics approval for this study was obtained from the University of British Columbia (Okanagan campus) Behavioural Research Ethics Board prior to commencement of data collection (Certificate No. H15-00466) v Table of contents Abstract ........................................................................................................................................................ iii Preface .......................................................................................................................................................... v Table of contents .......................................................................................................................................... vi List of tables ................................................................................................................................................. xi List of figures .............................................................................................................................................. xii List of definitions ....................................................................................................................................... xiii List of abbreviations .................................................................................................................................. xiv Acknowledgements ..................................................................................................................................... xv Dedication ................................................................................................................................................. xvii CHAPTER 1 – INTRODUCTION ............................................................................................................... 1 Background and context .............................................................................................................. 1 Problem statement ....................................................................................................................... 5 Statement of purpose and research questions .............................................................................. 5 Theoretical framework: Sociomateriality .................................................................................... 6 Presentation of the dissertation ................................................................................................. 11 CHAPTER 2 – LITERATURE REVIEW .................................................................................................. 13 Tobacco use and young adults................................................................................................... 13 Smoking prevalence among young adults........................................................................................... 13 Smoking initiation among young adults ............................................................................................. 14 Smoking cessation among young adults ............................................................................................. 15 Implications of young adult tobacco use ............................................................................................. 16 Benefits of early quitting..................................................................................................................... 17 Smoking cessation interventions and young adults ................................................................... 18 Young adults and mobile phone technologies ........................................................................... 19 Smartphone apps and smoking cessation .................................................................................. 21 Smartphone apps for smoking cessation among young adults .................................................. 22 Evaluative evidence in relation to mobile-based smoking cessation interventions .................. 24 Evaluative evidence in relation to smoking cessation apps ...................................................... 28 Methods............................................................................................................................................... 29 Results ................................................................................................................................................. 29 vi Content of smoking cessation apps ..................................................................................................... 51 Summary of included studies .............................................................................................................. 61 Gender and tobacco use ............................................................................................................. 66 Summary ..................................................................................................................................