This study showed that Pick-Klop, a board game for smokers, is an acceptable, feasible, and potentially helpful intervention for smokers who wish to quit smoking or for those who do not. At inclusion, 35% of smokers were in the precontemplation stage (had no intention to quit smoking in the next 6 months). The game therefore seems also to be acceptable for smokers in the precontemplation stage.
Furthermore, the study assessed participants for psychiatric and substance abuse disorders, which are common comorbidities among smokers [15–17], showing the acceptability of the game and the study process among participants with comorbid psychiatric or substance use disorders.
The dropout rate was relatively low (22.1%), indicating a good acceptability of the study process and the study treatment procedures. Smokers who dropped out of the study were more likely to be in the preparation stage than in the precontemplation stage. One possible hypothesis is that for people who are in precontemplation, the tools and the game are acceptable, whereas a part of the smokers in preparation may ask for more intensive treatment tools. There is higher dropout among people who scored high on the psychoactive benefits of smoking, probably linked to more difficulty in engaging in a smoking-cessation process. Furthermore, people with a lower level of education dropped out more frequently, possibly due to difficulties regarding several aspects of the game questions or of psychoeducation. Overall, it appears, however, that the smokers reported good satisfaction related to the game.
A favorable time effect was observed for most of the variables under scrutiny. A number of important between group differences were observed.
Across time, between T1 and T2, scores on internal self-efficacy increased for smokers allocated to Pick-Klop more than for the participants allocated to psychoeducation or to the waiting list. The game includes an important number of cards linked to smoking facing internal stimuli. This may explain the more important impact on internal self efficacy than on external self-efficacy.
In addition, smokers in the Pick-Klop and the psychoeducation groups increased their knowledge related to NRT (decrease of “I don’t know” answers). Psychoeductaion seems to have a more important effect between T0 and T1 whereas the effect of Pick-klop seems to be more important between T1 and T2. Furthermore the perceived advantages of NRT increased in pick–klop and psychoeducation groups more than it did among the participants allocated to the waiting-list group.
These observed changes were of high interest in consideration of previous studies showing that a positive attitude towards NRT and an increase in self-efficacy may enhance quitting in smokers, reduce the number of smoked cigarettes, and increase the use of NRT during smoking-cessation attempts [8, 10, 11].
During the study, a decrease of the scores related to the perception of the pleasure of smoking was observed. This decrease was more important for the participants allocated to Pick Klop and psychoeducation than to the waiting list between T0 and T1 and between T1 and T2.
The study did not find any treatment group effect on the perception of psychoactive benefits of smoking. The mean scores related to the perception of the adverse effects of smoking increased however between T0 and T1 for Pick Klop and waiting list group (at a trend level) more than for the other groups.
Lack of clear treatment group effects on these last two measures is possibly due to the sample size. Furthermore, participants have already a relatively good awareness related to the adverse effects of smoking among participants at inclusion. So it is probably more difficult to increase more this aspect. Psychoactive benefits of smoking were discussed during the Pick Klop game sessions as well as during psychoeducation as possible reinforcement mechanisms involved in smoking addiction and were acknowledged by this way. So the interventions may have an impact on the awareness of the links between these effects and the addictive aspects of the behavior rather than on the strict perception of the effects.
The decrease of the scores related to the perception of the pleasure of smoking may have an impact on further smoking cessation attempts by a modification of the perception of the advantages related to smoking.
Because of the relatively small sample size, stages of change were regrouped into stage 1 (precontemplation) and stage 2 (contemplation, preparation and action). It appears that smokers allocated to the Pick-Klop and psychoeducation groups were more likely to progress towards stage 2 than were participants in the waiting-list group.
Positive group effects on the behavioral measures were also found. For instance, a greater decrease in the number of cigarettes smoked per day was observed for the participants of the Pick-Klop group than for the other groups mainly between T1 and T2.
The observed finding is possibly of interest regarding the previously reported link between the reduction of the number of smoked cigarettes and the observation of further smoking cessation .
Furthermore, compared with participants at T1, those at T2 were more likely to be non-smokers. This effect is more important among participants in the Pick-Klop group than among participants in the waiting-list group. There was no significant difference between the psychoeducation and the waiting-list groups.
Thus, the participants allocated to the Pick-Klop group or to the psychoeducation group showed rapid improvement (since T1) in the main non-behavioral outcomes (attitudes towards NRT, self-efficacy, attitudes towards smoking). For some of these outcomes, Pick-Klop seems to have some advantages, particularly on internal self-efficacy and to a lesser extent on the perception of the adverse effects of smoking.
The effect of Pick-Klop on several of these non-behavioral measures appears more clearly between T1 and T2, particularly for internal self-efficacy and knowledge related to NRT. One can hypothesize that the game may enhance change by some connections automatically made by the participants when facing, at distance from the game sessions, situations similar to those encountered during the game sessions (i.e. similarities with situations encountered by the game characters…).
The behavioral effects (reduction of the number of cigarettes smoked per day and smoking cessation) appeared later at T2. One could thus hypothesize that the first non-behavioral modification will lead to later behavioral change. For example, it was previously found that an increase in self-efficacy is associated with further smoking cessation . The participants in Pick-Klop showed greater changes towards smoking cessation than the waiting-list group did. The differences on smoking cessation was however not significant between psychoeducation and the waiting list. The small sample size may contribute to this finding. The game may offer some advantages for the enhancement of behavioral change, possibly by some identification with the game characters.
None of the demographic, psychological, or psychiatric variables studied in the present study were strongly associated with further smoking cessation. This finding is possibly due to the sample size, or to the contribution of other factors to the change process, such as environmental support . Treatment group allocation was however found to predict smoking cessation at T2. Compared to the waiting list group, Pick-Klop group was less likely to be smoker at T2.
The Pick-Klop group performed better than the waiting-list group and as well as or better than the psychoeducation group for the main outcomes. Thus, psychoeducation and the Pick-Klop game may have some advantage on non behavioral (i.e. internal self-efficacy) and behavioral outcome (smoking cessation at T2). The game seems to be a good option, possibly eliciting behavioral change in a wide range of smokers, including smokers in precontemplation or smokers with psychiatric or substance use disorders, as previously suggested by preliminary studies .
Despite the randomized controlled design of the present study, some limitations have to be considered, including the open-label design, the absence of long-term follow-up, the absence of biochemical variation in smoking abstinence, and the relatively small sample size. In addition, the particular circumstances of the premature closure of the study because of recruitment difficulties led to an underpowered study. Indeed, with the formula given by Diggle et al., the study could achieve only 70% of power. As power remains a useful statistical measure that acts as a magnifying glass in the detection of an effect size, the research may have sometimes failed to point to a true between-groups difference due to lack of power. The modification of the study objectives (in terms of the number of included participants) was discussed with an independent referral extern to the study group (study founding contributor) and was considered as an acceptable option.
The difficulties related to the recruitment process were probably due to the characteristics of the study which was may be too much demanding in time for smokers who were not asking for help. The game in itself seems to be appreciated by the participants. One of the possible advantages of a game such as Pick-Klop is to offer smokers an alternative way to learn about information and treatment. Further studies may specify the factors associated with smokers’ learning preferences. A further question is related to the impact of the game on smokers’ later use of other proposed tools and aids for smoking cessation. It may also be helpful to study and develop other varieties of the game, as differences in game format, content, or purpose may change its clinical impact and attractiveness. A further study, in preparation, will assess an electronic version of the game, which may be more appealing in general, especially for younger smokers.