This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.
Cannabis misuse in young adults is a major public health concern. An important predictor of continued use is cannabis craving. Due to the time-varying nature of cravings, brief momentary interventions delivered while cravings are elevated may improve the use of strategies to cope with cravings and reduce cannabis use.
The goal of this manuscript is to describe a formative study to develop coping strategy messages for use in a subsequent intervention.
Young adults (aged 19-25 years; n=20) who reported using cannabis >10 of the past 30 days recruited via social media participated in this formative study. Participants rated an initial set of 15 mindfulness and 15 distraction coping strategies on a scale from 1 to 4 (very low degree to very high degree) for clarity, usefulness, and tone. They also provided comments about the content.
Participants found the initial distraction messages slightly clearer than mindfulness (mean 3.5, SD 0.4 and mean 3.4, SD 0.4, respectively), both were comparable in tone (mean 3.2, SD 0.5 and mean 3.2, SD 0.4, respectively), and mindfulness messages were more useful than distraction (mean 3.0, SD 0.5 and mean 2.8, SD 0.6, respectively). Of the 30 messages, 29 received a rating of very low or low (<2) on any domain by >3 participants or received a comment suggesting a change. We revised all these messages based on this feedback, and the participants rated the revised messages approximately 2 weeks later. Participants earned US $10 for completing the first and US $20 for the second survey. The ratings improved on usefulness (especially the distraction items) with very little change in clarity and tone. The top 10 messages of each coping type (mindfulness and distraction) were identified by overall average rating (collapsed across all 3 dimensions: all rated >3.0). The final items were comparable in clarity (distraction mean 3.6, SD 0.4; mindfulness mean 3.6, SD 0.4), tone (distraction mean 3.4, SD 0.4; mindfulness mean 3.4, SD 0.4), and usefulness (distraction mean 3.1, SD 0.5; mindfulness mean 3.2, SD 0.5).
The inclusion of end users in the formative process of developing these messages was valuable and resulted in improvements to the content of the messages. The majority of the messages were changed in some way including the removal of potentially triggering language. These messages were subsequently used in an ecological momentary intervention.
Young adults between the ages of 19 and 25 years are in a time of major life changes during which they are developing new social relationships, experiencing increased independence, and developing the skills necessary to regularly make healthy choices [
Craving is one predictor of subsequent cannabis use and may be an important target for intervention when attempting to reduce or quit use [
Mindfulness and distraction are two strategies to reduce cravings [
Direct comparisons of mindfulness and distraction coping strategies have largely been limited to controlled laboratory settings, limiting the generalizability of these findings. The extent to which mindfulness or distraction are effective as coping mechanisms likely depends on the environmental context at a given moment [
Several app-based interventions have shown success in helping people who use cannabis reduce their use [
An ongoing concern with digital interventions is the promotion of engagement with the intervention [
Participants included 20 young adults (19-25 years; mean 21.65, SD 1.79 years; n=9, 45% male; n=9, 40% non-White or Hispanic; see
Demographic characteristics of participants.
Participant characteristics | Values, n (%) | |
|
||
|
Female | 9 (45) |
|
Male | 9 (45) |
|
Nonbinary | 2 (10) |
|
||
|
White | 14 (70) |
|
Black or African American | 1 (5) |
|
Asian | 2 (10) |
|
American Indian or Alaska Native | 1 (5) |
|
Other (not specified) | 2 (10) |
|
||
|
Hispanic or Latino | 3 (15) |
|
Not Hispanic or Latino | 17 (85) |
All procedures were reviewed and approved by the institutional review board at Dartmouth College (#32248). Participants clicked on a link in a Facebook ad and were brought to an online survey where they received general information about the study and were asked if they consented to be screened for eligibility to participate. All consent procedures were embedded in questions within the survey. Prospective participants who affirmatively consented to be screened were asked questions to determine their eligibility for participation. Those who met the inclusion criteria were presented with more detailed information about the study and asked if they consented to participate in the study. Affirmative consent was required before progressing to participate in the study survey.
After completing the eligibility screening and providing informed consent, the participants completed a survey to evaluate a bank of 30 messages consisting of mindfulness-based or distraction-based suggestions for how to cope with cannabis cravings. The initial message items are in
The goal of this study was to select a final bank of 20 total messages (10 mindfulness and 10 distraction) for use in an ecological momentary intervention that would present 1 randomly selected message from the bank of 20 messages when participants reported an urge to use cannabis ≥4 on a scale of 0-10. The number of messages was selected to prevent habituation and boredom by ensuring that a variety of coping strategies are delivered to the participants across a 4-week intervention. All participants in this study were given the same 30 messages at the same time to provide their ratings. Beginning with a bank of 30 possible messages allowed for the 10 lowest-rated messages to be removed from the final message bank.
We implemented a rating scale used in other formative research that aimed to develop a text-based intervention to reduce alcohol use among college students [
Initial participant ratings (n=20) of the distraction and mindfulness messages. Each data point shows one participant’s average rating of the 15 distraction or 15 mindfulness messages on each of the three domains (clarity, tone, and usefulness). Horizontal bars show average ratings and error bars are 95% CIs.
Mean (SD) and range of message ratings.
Timepoint | Distraction | Mindfulness | |||||
|
Clear | Tone | Useful | Clear | Tone | Useful | |
|
|||||||
|
Mean (SD) | 3.53 (0.39) | 3.21 (0.46) | 2.83 (0.56) | 3.39 (0.42) | 3.19 (0.41) | 3.03 (0.49) |
|
Range | 2.67-4.00 | 2.33-3.93 | 1.67-3.73 | 2.73-4.00 | 2.67-4.00 | 2.00-3.73 |
|
|||||||
|
Mean (SD) | 3.50 (0.44) | 3.27 (0.51) | 2.96 (0.48) | 3.49 (0.44) | 3.32 (0.46) | 3.07 (0.54) |
|
Range | 2.67-4.00 | 2.47-4.00 | 2.20-4.00 | 2.67-4.00 | 2.20-3.93 | 2.00-3.93 |
Major feedback themes for the mindfulness messages included concerns about the clarity of the messages, suggestions for rewording the message content, concerns about the suggestion being too difficult to implement at the time cravings were high, and positive responses to the nonjudgmental nature of the messages. Major feedback themes for the distraction messages included confusion about the rationale of the message and how it relates to coping with cannabis cravings, indications that the strategy would not be helpful to them, and concerns that the strategy could be triggering (eg, use of social media as a distraction technique could bring up images that are related to cannabis use).
Last sentence could reverse: “you don't need to act on any urges you may feel to use cannabis”
Had to read over a second time to understand the message
This may be true, but it's very hard to implement in real life. Message doesn't provide a good strategy to use this method IMO
This perspective feels empathic and helpful
But why? What's the benefit
As I said before, music tends to be more enjoyable when high. I think it is still effective, but it also may make the person want to use cannabis before zeroing in on his or her favorite song.
Vague and not particularly helpful.
Focus on something new by doing something hard. Try counting backward from 100 by sevens.
This feels silly and I wouldn’t do it.
Reduce your urge to use by focusing on something new and challenging.
Try saying the alphabet backwards. Or, try coming up with as many words as you can that rhyme with “think.”
We were unable to reach 2 participants to complete the second round of revisions. Therefore, 18 participants completed the second round of message evaluations. The 2 participants whom we could not reach were excluded from these analyses.
Participant ratings (n=18) of the distraction and mindfulness messages after the first round of message revisions. Each data point shows one participant’s average rating of the 15 distraction or 15 mindfulness messages on each of the three domains (clarity, tone, and usefulness). Horizontal bars show average ratings and error bars are 95% CIs.
A number of themes emerged from the second round of feedback. For the mindfulness messages, the remaining concerns were primarily about some messages not being helpful (eg, 4 comments with concerns about the strategy not working or not being relatable), and there were some suggestions about how to reword messages to improve their clarity and usefulness (4 comments). For the distraction messages, the remaining concerns were primarily about the strategies not being helpful or practical (12 comments). We made final revisions to the messages based on the participants’ comments.
The top 10 messages of each coping type (mindfulness and distraction) were identified by overall (collapsed across all 3 dimensions) average rating.
Participant ratings (n=18) of the final distraction and mindfulness messages after removing the unused messages. Each data point shows one participant’s average rating of the final 10 distraction or 10 mindfulness messages on each of the three domains (clarity, tone, and usefulness). Horizontal bars show average ratings and error bars are 95% CIs.
We set out to develop messages to be used in a pilot digital intervention to help young adults cope with cannabis cravings, including young adults who use cannabis in the message development process. This formative process resulted in changes to the original messages, and the selection of the highest-rated messages to be used in the subsequent intervention. Items improved significantly in terms of usefulness (distraction messages) and tone (mindfulness messages) following the first round of revisions. Although there were no significant improvements on the other domains following revisions, this was likely due to a ceiling effect, given the high initial ratings (mean >3.0 out of the maximum 4.0) on these domains. Initially, the participants found the distraction items to be clearer than the mindfulness messages, and the mindfulness messages to be more useful than the distraction messages. Following the revisions and final selection of 10 messages each from the mindfulness and distraction categories, the ratings of each message type were high and comparable across all domains.
Prior work on SMS text message intervention development has highlighted the importance of including end user populations in the development and design of the intervention [
Unlike other preliminary studies focused on text-based interventions, we did not conduct focus groups. Instead, we developed our initial messages based on existing evidence-based interventions, sought input from users on the content we developed, and modified our content based on participants’ feedback. Future research could implement a more comprehensive participatory approach in developing the various components of the intervention such as the timing and frequency of message delivery. One major finding of previous studies has been the importance of message tone on user engagement. The tone of the messages we developed is one domain on which our messages improved as a result of participant feedback, again highlighting the importance and benefits of including end users in the development of interventions.
The findings of this study should be considered in the context of a few limitations. We limited the involvement of our target population in developing the intervention to providing feedback on messages adapted from established interventions. This limitation is partially due to the constraints of the platform we used for our intervention delivery. The platform used allowed for flexible and diverse experimental designs and made the intervention possible at a low cost without the need for outsourcing programming but was limited in terms of app customization. After appropriate efficacy testing, it may be appropriate to distribute the app using a self-pay subscription model or by making the app freely available to consumers similar to other apps designed for those who are seeking assistance to moderate or abstain from substance use such as SoberTool developed by Blitzen, LLC. The costs of such apps can be sustained using in-app advertisements or possibly reimbursement through medical insurance [
A second limitation is regarding our sampling strategy. We limited our recruitment to social media in an attempt to reach a diverse population and allow users across the country to participate in the development of our intervention messages. This strategy allowed us to recruit nationwide and is the same planned strategy for recruiting our intervention participants. However, this method of recruitment may have resulted in bias due to self-selection. Additionally, due to time and monetary constraints, we solicited feedback from the participants using an asynchronous survey instead of more involved focus groups.
One additional limitation is that the user-rated usefulness of messages when craving levels are not currently elevated may be a poor proxy for clinical utility in the context of high craving; however, the usefulness of the messages will be evaluated in the subsequent intervention. We also did not distinguish between craving as a desire to use cannabis and urge as the intent to use cannabis. Although this is beyond the scope of this study, future studies may make this distinction and test whether 1 strategy (mindfulness or distraction) is better suited for managing the desire for the effects (ie, cravings) versus managing intent to use cannabis (ie, urges).
The findings of this study support the importance and highlight the value of including the target intervention population in the formative process of intervention development. The content of the messages was significantly improved over the course of this formative process.
Additionally, the community identified possible triggers embedded in the messages that may have been counterproductive to our intervention—triggers that would not have been identified without their lived experience and inclusion in the message development. Focus groups may be more useful in developing and revising messages, allowing for additional conversation between the participants and the researchers, thus giving space for clarification and conversation. Sometimes, open-ended participant feedback comments were somewhat unclear, and having the opportunity to have an ongoing discourse could help develop messages further. The final messages developed in this study were subsequently used in a pilot intervention aiming to provide young adults who use cannabis with support for coping with their cannabis cravings as they attempt to reduce their use.
Initial bank of mindfulness messages.
Initial bank of distraction messages.
Final mindfulness messages.
Final distraction messages.
ecological momentary assessment
This research was supported by National Institute on Drug Abuse grants P30 DA029926 and T32 DA037202. In addition, National Institute on Drug Abuse grants P50 DA054039 and R01 DA039901 supported the effort of IN-S.
AJB is a Science Advisor at Canopy Growth Inc.