Lessons learned from unsuccessful use of personal carbon monoxide monitors to remotely assess abstinence in a pragmatic trial of a smartphone stop smoking app – A secondary analysis()

INTRODUCTION: Verifying abstinence remotely in trials of digital cessation interventions remains a major challenge. This study reports on using personal carbon monoxide (CO) monitors to assess abstinence in a pragmatic trial of a standalone cessation app involving automated recruitment with no researcher contact. METHODS: The study involved secondary data analysis of remote CO testing in a randomized trial (ISRCTN10548241) comparing two versions of a cessation app (BupaQuit). Trial participants were adult UK-based smokers interested in quitting, who were recruited online (02/2015–03/2016). Participants were followed-up through the app, email or phone at 4 weeks. Fifty-nine participants reporting not smoking were posted a personal CO monitor with instructions, and emailed two reminders. The monitors required installing software on a Windows PC. Participants were not reimbursed but retained the device. We recorded the proportion of CO tests returned, test results, self-reported ease of use, correct use, acceptability, and reasons for missing results. RESULTS: Fifteen (25.4%) CO results were returned, of which 86.6% were <10 ppm and 53.3% were <5 ppm, indicating abstinence (corresponding to 20.9% and 12.9% of all trial participants self-reporting abstinence, respectively). These 15 participants found the test easy, acceptable and believed they conducted it correctly. Eight (18.2%) of the missing results were accounted for, including no access to a Windows PC, barriers to receiving packages, and unwillingness to share results. CONCLUSION: Remote validation using personal CO monitors may not yet be feasible in pragmatic studies of cessation apps in which participants are recruited with no reimbursement or direct contact with researchers.