The tobacco epidemic and burden from overweight/obesity are major causes of health loss in New Zealand.1 Changes to the obesogenic environment and the use of various price signals are probably the most critical interventions required (eg, tobacco tax increases2,3). But there is potentially a place for the promotion of individual-level interventions, including the use of innovative internet and smartphone technologies.
In New Zealand, smartphone access has been increasing, and a survey in 2013 found 59% smartphone ownership or access by New Zealand adults.4 It was even higher, at 71%, for those aged 18 to 54 years, and also for Māori or Pacific peoples compared to New Zealand European (70% vs 55% respectively).
There is some New Zealand randomised control trial (RCT) evidence for the effectiveness of mobile phone text messaging for smoking cessation,5 with this being equally effective for Māori as non-Māori.6 Work has also been done in New Zealand on smartphone-mediated cardiovascular management7 (eg, as per a New Zealand trial on ‘Text4Heart’8). Internationally, there is evidence detailed in a systematic review that computer-based and other electronic aids can assist with smoking cessation, and are “highly likely to be cost-effective”.9 Another systematic review of five RCTs has reported that mobile phone interventions are effective for smoking cessation.10 But the evidence from RCTs of ‘smartphone apps’ for smoking cessation is fairly limited (eg, we only identified two trials11,12).
For smartphone apps for weight loss, one review reported on 10 RCTs which used text messaging or app interventions to support weight loss in women, with significant improvements being observed in eight studies.13 Another review of 17 studies14 that utilised smartphone applications, text messaging and web resources, reported overall weight loss of 0.43 kg (95% CI 0.25–0.61, p-value≤0.01). But not included in this review were some other smartphone app specific studies which did not report statistically significant weight loss15-18 (albeit some of these being small pilot studies).
Given this background of some promising evidence, we aimed to assess the quality of existing apps for weight loss and smoking cessation available for downloading to smartphones by New Zealanders.
We screened potential weight loss and smoking cessation apps to identify a final list of 120 Android and Apple apps (four groups of 30 apps each) based on their focus on the topic, price (all under $4), being in English language and download popularity as estimated by a relevant website (xyo.net). Each app was examined by two assessors and was rated against a published “Mobile App Rating Scale” (MARS),19 (45% of the total score); in terms of weight loss/smoking cessation as appropriate (45% of the total score); and cultural appropriateness criteria (10% of the total score). We designed these other criteria (in addition to the MARS) based on relevant New Zealand literature: eg, weight loss/smoking cessation criteria were based on New Zealand weight management guidelines20 and New Zealand smoking cessation guidelines.21,22 We also collected 48 hours of experiential data on 10 of the weight loss apps. The full details of the methods are detailed in an online report.23
Overall, these 120 apps did not perform particularly well against the various criteria (eg, mean scores by group for the MARS: 51%, 52%, 60%, 62%; for weight loss: 29%, 32%; for smoking cessation: 18%, 20%; and for cultural appropriateness overall: 17%. See Table 1). The poor scores for the cultural appropriateness criterion reflected the lack of specific designs for the New Zealand market. Nevertheless, there were still some high-scoring individual apps, with the top five in each category shown in Table 1. The top weight loss app was “Noom Coach: Weight Loss Plan” (score: 70%), and the highest-scoring smoking cessation app was “Quit Now: My QuitBuddy” (77%). The latter was produced by an Australian Government agency.
In 48 hours of experiential use, we found that some of the top 10 weight loss apps (5 Android, 5 Apple), had additional desirable features of note: low battery usage, provision of feedback, provision of motivation/encouragement, memory functions retaining previously logged meals, and offline functionality. But most did not have a food barcode scanning capacity that was relevant to the New Zealand market. Additional details on the top five apps in each category are given in an online seven minute video (http://vimeo.com/133304804). Other more detailed results and discussion of study limitations are in an online report.23
Table 1: Scores and final ranking for smartphone apps in each of the four groupings (weight loss, smoking cessation, Android and Apple) for the top five apps and mean results for the 30 per category
This study found that these 120 apps were generally of limited quality—but the top scoring apps did have some reasonable high quality aspects. As such, these particular high scoring apps could be subject to further research, including head-to-head comparisons with text-messaging interventions (eg, the Txt2Quit service provided by the NZ Quitline). There may also be a case for New Zealand health authorities (eg, the Ministry of Health, the Health Promotion Agency, and DHBs) to systematically evaluate such apps and list the top ones on their official websites (eg, the National Health Service in the UK has a website that includes “approved” apps: http://www.nhs.uk/Conditions/online-mental-health-services/Pages/introduction.aspx).
Health professionals could consider suggesting the highest quality apps to interested patients. But given the uncertainties with the evidence-base for app effectiveness, they could do this in conjunction with recommending more well-established evidence-based measures (eg, Quitline support and pharmacotherapy for smoking cessation) and referral to a dietician for dietary counselling for weight management.