Developing a Game (Inner Dragon) Within a Leading Smartphone App for Smoking Cessation: Design and Feasibility Evaluation Study

Justin S White, Marie K Salem, Séverine Toussaert, J Lee Westmaas, Bethany R Raiff, David Crane, Edward Warrender, Courtney Lyles, Lorien Abroms, Johannes Thrul, Justin S White, Marie K Salem, Séverine Toussaert, J Lee Westmaas, Bethany R Raiff, David Crane, Edward Warrender, Courtney Lyles, Lorien Abroms, Johannes Thrul

Abstract

Background: Several stand-alone smartphone apps have used serious games to provide an engaging approach to quitting smoking. So far, the uptake of these games has been modest, and the evidence base for their efficacy in promoting smoking cessation is still evolving. The feasibility of integrating a game into a popular smoking cessation app is unclear.

Objective: The aim of this paper was to describe the design and iterative development of the Inner Dragon game within Smoke Free, a smartphone app with proven efficacy, and the results of a single-arm feasibility trial as part of a broad program that seeks to assess the effectiveness of the gamified app for smoking cessation.

Methods: In phase 1, the study team undertook a multistep process to design and develop the game, including web-based focus group discussions with end users (n=15). In phase 2, a single-arm study of Smoke Free users who were trying to quit (n=30) was conducted to assess the feasibility and acceptability of the integrated game and to establish the feasibility of the planned procedures for a randomized pilot trial.

Results: Phase 1 led to the final design of Inner Dragon, informed by principles from psychology and behavioral economics and incorporating several game mechanics designed to increase user engagement and retention. Inner Dragon users maintain an evolving pet dragon that serves as a virtual avatar for the users' progress in quitting. The phase-2 study established the feasibility of the study methods. The mean number of app sessions completed per user was 13.8 (SD 13.1; median 8; range 1-46), with a mean duration per session of 5.8 (median 1.1; range 0-81.1) minutes. Overall, three-fourths (18/24, 75%) of the participants entered the Inner Dragon game at least once and had a mean of 2.4 (SD 2.4) sessions of game use. The use of Inner Dragon was positively associated with the total number of app sessions (correlation 0.57). The mean satisfaction score of participants who provided ratings (11/24, 46%) was 4.2 (SD 0.6) on a 5-point scale; however, satisfaction ratings for Inner Dragon were only completed by 13% (3/24) of the participants.

Conclusions: Findings supported further development and evaluation of Inner Dragon as a beneficial feature of Smoke Free. The next step of this study is to conduct a randomized pilot trial to determine whether the gamified version of the app increases user engagement over a standard version of the app.

Keywords: feasibility; games for health; gamification; mobile app; mobile phone; smoking cessation; software design.

Conflict of interest statement

Conflicts of Interest: DC is the Founder and chief executive officer at 23 Limited, the software development company that owns and operates Smoke Free. EW is the chief technical officer at 23 Limited. CL was a Visiting Researcher at Google during the publication of this study. LA receives royalties for the sale of Text2Quit, a quit smoking program. JT reports membership on the scientific advisory board of MindCotine, Inc, which offers a smoking cessation program. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflicts of interest policies. All other authors declare no other conflicts of interest.

©Justin S White, Marie K Salem, Séverine Toussaert, J Lee Westmaas, Bethany R Raiff, David Crane, Edward Warrender, Courtney Lyles, Lorien Abroms, Johannes Thrul. Originally published in JMIR Serious Games (https://games.jmir.org), 11.08.2023.

Figures

Figure 1
Figure 1
Conceptual model.
Figure 2
Figure 2
Overview of study approach.
Figure 3
Figure 3
Dragon evolution. (A) Egg hatches into full dragon. (B) Evolves every 7d, gains new “abilities.”.
Figure 4
Figure 4
Dragon care. (A) Feeding dragon (fun). (B) Memory mini-game (distraction). (C) Breathing exercise (manage cravings). (D) Dragon park (social feedback and support).
Figure 5
Figure 5
Participant flow diagram. *Individuals may be ineligible because of >1 factor.
Figure 6
Figure 6
Total number of sessions. (A) Percentage of users with a session by day. (B) Number of sessions by users.
Figure 7
Figure 7
Association between number of sessions with and those without the use of Inner Dragon. (A) Number of sessions with game use. (B) Average minutes per session versus number of sessions.
Figure 8
Figure 8
Pet care events by user.

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