Abstract
Objectives:
Remote biochemical verification of smoking abstinence is limited by low adherence rates and technical problems with test completion. Qualitative data from study participants about their experiences completing these remote tests is lacking. The objectives were to interview participants who provided biochemical verification in a randomized trial of a smoking cessation intervention to (1) learn about participants’ actual experiences with cotinine saliva testing; (2) examine willingness to conduct smartphone app-based carbon monoxide (CO) breathalyzer testing; and (3) gather recommendations to minimize barriers and improve adherence.
Methods:
Participants who completed biochemical verification were invited to participate in semi-structured interviews that included watching an instructional video about the breathalyzer test. Audio recordings were professionally transcribed, and 2 independent coders applied an interactive inductive thematic analysis approach.
Results:
Ten participants, ages 38.7 (9.5) years (30% male) completed interviews. Barriers to successful saliva cotinine testing included: technical issues submitting results (56%), issues following written instructions (44%), saliva collection sponge discomfort (33%), confusion about invalid results (33%), and concerns with device safety/data usage (22%). While more participants said they would, in concept, prefer the CO test or had no preference, they reported more problems with completing the CO test, including potential inaccessibility for people with respiratory illness. Key recommendations for improving compliance included: increasing monetary incentives, diversifying reminders, amplifying reciprocity messaging, managing expectations, and embedding clear, concise in-app guidance.
Conclusion:
Results suggest that compliance with remote biochemical verification can be improved through a comprehensive approach that includes increasing incentives, managing expectations, streamlining visual instructions, and diversifying reminders.
Keywords
Introduction
Effective remotely delivered digital and telehealth (eg, quitlines) smoking cessation interventions have the potential for high reach, and thereby high population-level impact. However, remotely-delivered smoking cessation interventions are usually limited by self-reported outcomes that can be biased by missing data and misreporting associated with social desirability to report quitting success.1-3 While not essential for non-clinical population-based trials, biochemical verification has the potential to improve the validity and reliability of self-reported outcomes.4-7
Biochemical verification is used to confirm smoking status based on biomarkers in the body.5,8 Cotinine, a metabolite of nicotine, is one such biomarker and can be found in blood, saliva, and urine of individuals who smoke cigarettes.9,10 It can typically be detected for up to 3 to 4 days after the last cigarette. However, the use of nicotine replacement therapy, electronic cigarettes, or exposure to secondhand smoke can lead to false positives. Another common biomarker is carbon monoxide (CO) in exhaled breath, with levels elevated in individuals who smoke tobacco products (eg, cigarettes, cigars).11,12 In contrast to saliva testing, CO is rapidly eliminated from the body and can be detected within 8 to 12 hours after the last cigarette. CO readings can be influenced by environmental CO exposure, which may lead to false positives. Technological advancements have contributed to portable devices that are widely used for assessing both cotinine and CO for biochemical confirmation of smoking status.13-16
While biochemical verification increases the rigor of self-reported smoking status, limitations include the inability to confirm long-term abstinence, costs, poor compliance, and technical issues that invalidate results.5,7 In a recent meta-analysis of 82 studies implementing remote biochemical verification of smoking status, only 47% of individuals who self-reported abstinence were confirmed as abstinent. 3 The authors did not report data on why participants could not verify their smoking status.
A subsequent narrative review summarized potential reasons for low return rates to remote biochemical verification. 17 These included: usability and procedural causes (eg, participant burden, low digital literacy); device-related causes (eg, invalid results, device malfunction); digital divide or psychosocial factors (eg, low internet bandwidth, depression); and motivational factors (eg, inadequate incentives). However, these reasons were provided by the researchers conducting the trials, rather than by study participants themselves. Qualitative research data directly reported by study participants on specific barriers to successful testing is critical for improving the process and, ultimately, addressing low compliance. Indeed, the authors of the narrative review observed that “the field has generated little knowledge about the underlying human factors affecting low sample return rates of biomarkers of tobacco use” and recommended qualitative research to identify the causes of low compliance rates. 17
To address the limitations of prior research and improve biochemical verification completion rates in our future smoking cessation studies, this study conducted qualitative interviews with 10 adults who provided biochemical verification testing in a randomized trial of a digitally delivered smoking cessation intervention. The aims were to learn about our participants’ experiences and barriers to cotinine saliva testing; examine willingness to conduct CO breathalyzer testing; and gather recommendations to minimize barriers and improve compliance. Findings from this study will provide, for the first time, in-depth insights into some of the barriers participants experienced and their recommendations for improving the process—thereby adding to the literature much-needed context and participant-centered perspectives.
Materials and Methods
Overview
Ten one-on-one semi-structured interviews were conducted via a Health Insurance Portability and Accountability Act (HIPAA)-compliant video call with participants who had been randomly assigned to complete biochemical verification testing for the QuitBot (chatbot) parent randomized trial (ClinicalTrials.gov NCT04308759).18-20 The Fred Hutchinson Cancer Center Institutional Review Board approved the study procedures. Verbal consent was obtained from each participant at the beginning of the interview and recorded via IRB-approved written documentation. Participants were compensated $35 for their time.
Eligibility Criteria
Inclusion criteria included participation in the QuitBot parent trial. The inclusion criteria of the QuitBot parent trial have previously been published. 20 Briefly, eligible participants included adults who smoked at least 1 cigarette daily for the past 12 months and wanted to quit smoking within the next 30 days. Exclusion criteria included currently using other smoking cessation interventions and previous participation in our research trials. For this qualitative study, additional eligibility criteria included: (1) random assignment at baseline to complete biochemical verification testing at each follow-up timepoint (3, 6, and 12 months); (2) completed participation in the trial; (3) agreed to be recontacted, and (4) willing and able to participate in a 25-minute video call. Of note, the survey question asking participants whether they would agree to be recontacted occurred after completion of 12-month biochemical verification. Thus, participants we contacted must have completed the 12-month verification.
Recruitment
A total of 77 participants met the eligibility criteria in January 2025, of which 34 were selected for contact based on biochemical test completion. We prioritized those who did not complete at least 1 test and those who received at least 1 reminder call or new image request because these response patterns were assessed to be most likely to provide useful feedback about the biochemical verification procedure. The 34 participants who met this criterion were sent an email invitation. If there was no response after 7 days, 3 telephone attempts were made, 3 days apart with voicemails and email follow-up. If a participant expressed interest, they were asked about their availability for a 25-minute interview, access to a device for a video call, and willingness to be interviewed and recorded.
Of the 34 participants contacted, 20 expressed interest during the recruitment period. Of these, 16 completed the screening questions and 10 completed the interviews. Four of the 16 were unable to be contacted and 2 completed screening after the sample size of 10 was reached. Thematic saturation was not used as a stopping criterion. Rather, the number of interviews was capped at a sample size of 10 due to logistical constraints (eg, time, budget, personnel) and our limited goal of producing actionable improvements to our lab’s biochemical verification procedures.
Parent Trial Remote Biochemical Verification Procedures
In the QuitBot parent trial, 20 which included access to a chatbot or text messaging smoking cessation intervention via a smartphone application (app), participants self-reported smoking status via surveys at the 3-, 6-, and 12-month follow-ups. Biochemical verification was conducted at each follow-up among 10% of all participants randomly selected at baseline (ie, regardless of smoking status). 3 These participants were mailed an Alere iScreen cotinine test with written instructions.9,10 If cotinine is present, only the control line appears. If the test is negative for cotinine, 2 lines appear. If the control line does not appear, the test is considered invalid and needs to be repeated. On their survey date, participants were emailed a link to a secure web-based portal to follow instructions for completing the cotinine test, answer questions about their smoking status, and submit 2 photos—one of themselves doing the test and one of the results displayed on the testing device. Participants had 55 days in which to complete the biochemical verification survey. Test results were validated by study staff and participants were mailed $35 in cash through U.S. Postal Service mail within 1 week of test completion.
Interviews
The semi-structured interview guide included open-ended questions on participants’ experiences with biochemical testing in the trial, the usefulness of instructional videos, preferences for test devices, and strategies to improve response rates (Supplemental Appendix). The interview guide was collaboratively developed by investigators and study staff in an iterative process with the goal of eliciting information from participants that would improve participant experience and responsiveness in future smoking cessation trials. All one-on-one interviews were conducted by co-author A.R.K., with whom participants had only minimal prior contact.
Baseline and Follow-Up Measures
In the parent trial, participants completed questionnaires at baseline and at each follow-up time point (3, 6, and 12 months). To characterize the subset of participants who participated in the interviews, we report sociodemographic information as well as biochemically verified smoking status for each time point.
Data Analysis
Audio recordings of interviews were professionally transcribed by an online service (Rev.com), and transcribed data were analyzed using an inductive thematic analysis paradigm. Inductive thematic analysis was selected to aid in hypothesis generation about barriers participants might face when completing biochemical verification tests. It also allowed us to identify and characterize patterns across participants’ recommendations to improve procedures and testing device preferences. As such, the analytic process prioritized the identification of manifest (descriptive) themes that would aid in making actionable conclusions as opposed to focusing on latent themes that reflect participants’ embedded assumptions or underlying meanings.
Authors C.A.F. and A.R.K. conducted the analysis following the 6-phase approach for thematic analysis. 21 Both are long term members of the research group and have contributed to various smoking cessation and weight loss clinical trials including qualitative fidelity coding of hundreds of telephone-based counseling sessions. A.R.K. has coordinated multiple smoking cessation trials and has intricate knowledge of the QuitBot biochemical verification procedure. C.A.F. holds a master’s degree in experimental psychology and has led multiple qualitative research projects.
The 2 coders familiarized themselves with the transcripts through a process of iterative rereading. They then independently employed a line-by-line open coding method to identify preliminary codes. The coders then met to discuss similarities and areas of divergence in their preliminary interpretation of the data. Together, they developed, reviewed, and defined a list of themes that were then reapplied to the transcripts. There was high concordance in the themes that the coders individually identified and no interpretive drift was identified after the themes were finalized.
Results
Overview
Results are presented in 5 sections: participant characteristics, barriers experienced during the testing process, perceptions of the CO breathalyzer test, testing device preference, and recommendations for improving test completion. Participant quotes are presented throughout the results section to enable readers to assess the congruence of identified themes with the raw data and to illustrate key points. 22 The number of participants who endorsed or contributed to each theme is reported as additional context and because these counts informed how our team prioritized and implemented changes in our biochemical verification procedure for subsequent studies.
Participant Characteristics at Baseline
Participants were recruited from 6 U.S. states: California (3), Georgia (1), Ohio (2), Michigan (2), Pennsylvania (1), and Washington (1). Participants mean age (standard deviation) was 38.7 (9.5) years old, 3 were male, and 3 from racial/ethnic minority groups (ie, non-White or Hispanic). Additionally, 6 participants had a high school diploma or did not graduate from high school. Regarding smoking behaviors, at the time of enrollment in the parent trial, 2 participants smoked 11 cigarettes or more/day, 3 had high cigarette dependence (ie, Fagerström test for cigarette dependence [FTCD] score ⩾6; M [SD]: 4.2 [2.1]), 23 and all except 1 had smoked for 10 years or longer.
Regarding the baseline characteristics of those who completed the interviews (n = 10) and those who did not (n = 24), we found no differences in age, gender, education level, mobile device proficiency, number of saliva test completed, and most of the smoking behaviors expect for the number of cigarettes smoked per day reported at baseline. Non-completers smoked more cigarettes per day at baseline than completers (M [SD] 14.4 [7.8] vs 7.4 [4.2]). Of note, the number of tests completed was similar: 2.7 for those interviewed versus 2.6 for those not interviewed.
By design, all participants had completed at least 1 biochemical verification saliva test during one of the study follow-ups (3, 6, or 12 months) between September 2023 and January 2025 (Table 1). Seven participants completed all 3 tests, and the other 3 completed only 2 of the tests.
Participant Characteristics and Parent Trial Biochemical Verification Results With Cotinine Saliva Test.
Abbreviations: CA, California; GA, Georgia; GED, general education development; MI, Michigan; OH, Ohio; PA, Pennsylvania; WA, Washington.
GED or a credential that shows a person has academic skills equivalent to completing secondary (high school) education.
Age at time of interview.
Positive (+) indicates smoking detected; negative (−) indicates abstinence confirmed.
Barriers to Successful Testing
Thematic analysis identified 5 barriers to successful testing based on 9 participants’ experiences in the parent trial (1 participant’s data was excluded from this section due to their inability to distinguish their experience in the QuitBot parent trial from another smoking cessation study). Barriers to successful testing are presented from most to least common themes: (1) technical issues taking and submitting photos of test results, (2) difficulty following written instructions, (3) saliva collection sponge discomfort, (4) confusion about invalid results, and (5) safety concerns with the device. Despite experiencing these challenges, all 10 participants completed their tests and submitted results at the 12-month follow-up.
Technical Issues Submitting Results
Five participants reported trouble either taking or submitting photos during the testing process. Of these, 2 participants had difficulty taking a photo of themselves while completing the test. They described the experience as “awkward” because the size and weight of the saliva testing device made it hard to hold the test in their mouths while taking a photo. The remaining 3 participants had difficulty submitting a photo of their test results. Study records show that these 3 participants were asked to resubmit an image via email because it was missing from their original submission. One participant proposed that the photo submission process be integrated into the app: You go out [of the survey] to take the picture and then when you come back in, it makes you restart, resubmit everything from the beginning. I think that’s where the issue is. (10; 43 years old female)
Issues Following Written Instructions
Four participants described encountering issues with the written instructions during the testing process. Three of these individuals stated that they did not thoroughly read the instructions before attempting to complete the first test. This resulted in problems getting clear test results. Participants also noted that they eventually read the instructions and completed the test but experienced some confusion with the steps as described in the instructions. One participant explained: The first time, I didn’t read the directions, and I thought you were actually supposed to spit in the cap, so that was time-consuming. (2; 31 years old female)
Sponge Discomfort
Three participants described experiencing sponge discomfort with the test, although all 3 participants completed all 3 tests. Two participants reported that the sponge’s texture triggered a gag reflex, while a third strongly disliked the taste, saying: The flavor, the taste of it [is] just horrible. It makes you not want to do it. (6, 42 years old male)
Confusion About Invalid Results
Three participants reported issues getting clear, valid results on their test devices. Two participants attributed this to a combination of not reading the instructions thoroughly and possibly receiving a faulty test device. The third participant was not sure if they were doing it correctly, given uncertainty about how test results should look: It just never showed any lines or anything, so it looked like it wasn’t working to me, but I’m not real savvy on this stuff. (7; 59 years old female)
Concerns With Device Safety
One participant expressed concerns about the safety of using the testing device, saying: I don’t know what kind of chemicals are in the device that would be there to give you a positive or negative on that test. . .it’s an unknown chemical that I’m putting into my mouth. (5; 48 years old female)
Perceptions of CO Breathalyzer Testing
Our research team developed an instructional video on completing remote biochemical verification with a CO breathalyzer test (iCoQuit Smokerlyzer®; Bedfont Scientific Ltd, England) as an alternative to the cotinine saliva-based test (Alere®; Abbott, USA) used by participants in the parent trial.11,12 Participants were introduced to the breathalyzer test through this instructional video and were asked to provide feedback about which test they would be more likely to complete. All 10 participants said that an instructional video would be a good addition to the written instructions. Four concerns about the breathalyzer test emerged, and these are presented from most to least common themes: digital literacy requirement, inaccessibility for participants with breathing conditions, procedural differences compared to alcohol breathalyzers, and the use of a third party app.
Need for Digital Literacy
The first concern, raised by 5 participants, pertained to the potential for low digital literacy among older people. Specifically, they stated that while the technological component of the breathalyzer (ie, the connected app) would not be a barrier for them, they could see it being a problem for older participants or those who are less able to troubleshoot technological issues. One participant said: I think the technology aspect of it may be an issue for the older generation that may be partaking in the study just because like I know my mom, she doesn’t have a smartphone. . .and then the saliva test would probably be easier. (9; 33 years old female)
Inaccessible for Participants With Breathing Conditions
The second concern—that people with chronic obstructive pulmonary disease (COPD), emphysema, or other respiratory issues would be unable to do this test—was raised by 3 participants, 2 of whom reported having COPD themselves. One participant said: I don’t think that one would work for somebody like me. I have COPD and to put that much breath out would never happen. Just, it wouldn’t. (6; 42 years old male)
Procedural Differences Compared to Alcohol Breathalyzers
The third concern, raised by 2 participants, was that the CO breathalyzer procedure described in the video was different from how one takes a police alcohol breathalyzer and could therefore be confusing: The only breathalyzer I’m familiar with, sadly, is an alcohol PBT [Preliminary Breath Test], which is a lot like that except for the whole holding of your breath portion. . .I think my mind would’ve just not let me work through that because of my prior experience. (3; 42 years old female)
Use of a Third-Party App
The fourth concern with the breathalyzer test, raised by 1 participant, was related to the security and privacy of the third-party app: I’m kind of questioning downloading an app to my phone for a one- or two-time thing that I would need to do. I feel like that’s a lot more invasive than taking just a picture of myself with [the test device], just because I don’t know what that app is capable of accessing on my phone. (5; 48 years old female)
Biochemical Test Preference
Participants were asked whether they preferred the saliva or breathalyzer test for biochemical verification in a future study. Many acknowledged the merits of both options. Themes in the major merits of the breathalyzer test were its simplicity, speed, automatic data transfer, and avoidance of the sensory discomfort associated with the saliva test sponge: [The breathalyzer] does look a little bit easier, especially since you don’t have the foam or sponge. . .going into your mouth. (3; 42 years old female)
However, many participants acknowledged that it had more potential problems than the saliva test, as described above. Additionally, 6 participants reported that the breathalyzer device could easily be misplaced between follow-up assessments, whereas the saliva test is disposable: With the saliva test, I am guaranteed to have that because you send it to me when you want me to take it. . .There’s a slightly higher chance with the breathalyzer one that when you guys say, “OK, guess what? It’s time to take it,” that I go, “Oh, wow. Where is it?” (3; 42 years old female)
Participants noted fewer merits of the saliva test but also flagged fewer potential problems. Notably, most participants said that despite their personal test preferences, they would still complete the test sent to them: When somebody’s doing something like [a study], you kind of just do what the people ask you to do. It doesn’t really matter if you have a preference. (1; 43 years old male)
Recommendations for Improving Testing Completion
To gather recommendations to minimize barriers and improve compliance, all 10 participants were asked if there was anything we could do to increase test completion. The 5 specific recommendations generated through thematic analysis are described below: revise monetary incentives, use alternate reminders, identify a designated spot to store the testing device, emphasize reciprocity, and clarify and embed testing instructions into the app.
Revise Monetary Incentives
Seven participants cited monetary compensation as the primary motivation for completing the test. One participant strongly disliked the physical sensation of performing the saliva test but stated that they still completed it due to the incentive. Participants’ suggestions regarding monetary incentives included: (1) increasing the amount above the parent trial’s $35/test, (2) reiterating the financial incentive in the instructional video, (3) emphasizing that participants will forgo compensation by not completing each test, and (4) decreasing the time between completing the test and receiving the reward. One participant said: Maybe just italicize or promote that if you don’t participate, you don’t get paid. . .I read the fine print, but I didn’t realize, ‘Oh, man, it’s $35 every time I don’t.’ (4; 24 years old female)
Use Alternate Reminders
Four participants questioned the effectiveness of email reminders, either because people do not regularly check email or because inboxes easily become cluttered. Three participants suggested using text message reminders as a more direct communication method that provides a visual reminder, and 1 suggested embedding a digital calendar in the smoking cessation app (QuitBot parent trial) with the test dates. They also suggested reducing the time between receiving the test device and completing the test. One participant said: You get the test so far in advance before it’s time for you to take it that you just, I don’t know, put it somewhere and just forget about it. (10; 43 years old female)
Identify a Designated Spot for Testing Device
Four participants mentioned that keeping the biochemical test in a designated spot is crucial for preventing it from being lost between receiving it and the timing of the test. This recommendation could be included in the instructions sent out with the testing device to reduce the risk of misplacing it. One participant said: Typically, when I got it, I put it in my underwear drawer. And I would forget about it. I mean, I totally would forget about it. But then I would get the email saying “Hey, it’s time,” and I would be able to go back to my drawer and be like, “Oh hey, here it is.” (3; 42 years old female)
Emphasize Reciprocity
Three participants suggested emphasizing the mutually beneficial relationship between the study and the participants. For example, 1 participant explained that they completed the tests because it was required for the study and they received payment in return—they saw it as fulfilling their part of the agreement. Another said: Put that more in bold letters, like “Follow up and then we’ll do this again. You’ll help us and we’ll help you.” (1; 43 years old male)
Clarify and Embed Instructions in the App
Participants suggested clarifying and emphasizing the test instructions by: (1) including test instructions in the app used to deliver the chatbot smoking cessation intervention, (2) embedding a photo upload feature within the smoking cessation app (QuitBot parent trial), (3) noting that the test device does not contain chemicals, and (4) managing expectations early on by showing the instructional video at the beginning of the study during enrollment. Additionally, 2 participants’ comments suggested that it would be more relatable if the presenter in the instructional video had a positive outcome on the test: People with problems don’t really want saints coming and telling them how to handle their problems. It kind of seems like with somebody like me there, I might want to listen to somebody like that, maybe. (1; 43 years old male) His test was negative even, so he doesn’t even smoke, so it just kind of felt more like a[n] educational YouTube video that nobody wants to watch. (4; 24 years old female)
Discussion
This study presents the first qualitative interview data on biochemical verification testing from participants enrolled in a remote smoking cessation intervention. Barriers to successful saliva cotinine testing included: (1) technical issues submitting results online, (2) issues following written instructions, (3) saliva collection sponge discomfort, (4) confusion about invalid results, and (5) concerns with device safety. Recommendations to improve compliance included implementing a comprehensive approach that increased incentives, managed expectations early on, streamlined and embedded visual instructions, and added a variety of testing reminders.
Overall, our qualitative results both compare and contrast with the narrative review 17 of smoking cessation studies with biochemical verification regarding barriers to successful testing. Like the narrative review, the current study’s qualitative analysis identified technical issues with submitting results, confusion about invalid results, and a malfunctioning saliva test. However, we did not observe barriers associated with the digital divide or motivational factors. We posit that we did not encounter barriers associated with a digital divide because the eligibility criteria for our parent trial included ownership of a smartphone, access to the Internet, and the ability to download apps. 20 Regarding motivational factors, while participants did suggest that monetary incentives be increased, they also suggested alternative strategies such as making incentives more prominent and reminding participants that incentives would be lost if tests are not completed.
To our knowledge, only a few feasibility studies have directly assessed the preference between 2 biochemical verification tests.24,25 The first study offered 62 adults participating in a community smoking cessation trial the option to either complete an in-person CO breath test or an in-home urine test. Overwhelmingly, 77% of participants chose to take the in-home urine test and were more likely to complete it. Although participants were not explicitly asked, researchers observed scheduling and transportation barriers for the in-person CO breath test and a lack of phone or camera to capture and send results as potential barriers to completing the urine test. However, the reasons why participants preferred 1 test versus the other remain unknown. Of note, barriers related to scheduling, transportation, or mobile device requirements do not apply to our remotely delivered study.
The second study explored the feasibility of remote procedures. It provided 2 instructional videos for completing a saliva and a CO test among 15 adolescents enrolled in a contingency management smoking cessation study. 25 Participants found the CO sample collection procedure feasible, but consistently reported difficulties with the saliva cotinine procedure, as reflected by lower adherence rates with saliva (67%) versus CO (83%) testing. Indeed, 41.6% reported that providing the saliva testing results via video was difficult, compared to 0% who reported that providing the CO test results via video was difficult. In our study, after showing the instructional video for completing a CO test, most participants expressed a preference for the CO test versus the saliva test or stated they had no preference. However, participants perceived more potential problems with completing the CO than the saliva test, including potential inaccessibility for people with respiratory illness and concerns about digital literacy barriers.
Implications for Future Research
Key recommendations for improving compliance besides increasing monetary incentives included: (1) diversifying reminder strategies (eg, SMS, app-embedded calendar with automatic reminders); (2) amplifying reciprocity messaging (eg, “We support your quit journey—your feedback helps improve support for others”); (3) managing expectations early (eg, showing an instructional video of remote testing during enrollment); and (4) embedding clear, concise guidance, and a feature for photo taking and submission in the app. While no prior studies have tested such a comprehensive approach to improving compliance, a systematic review of 81 studies found no relationship between the most used strategies for improving compliance and test return rates (eg, monetary incentives, training on test completion, and reminders), suggesting that each approach in isolation might not provide satisfactory compliance rates (eg, >70%). 3 Therefore, future research is needed to explore the use of a multi-component approach aimed at improving compliance.
While there was not a strong preference for the saliva test versus the CO test, study sample characteristics and participant resources should be taken into consideration when choosing a biochemical confirmation method such as technological literacy, access to smartphones, the internet, and digital cameras. For instance, implementing the CO test requires unique considerations, including whether the population of interest has respiratory illnesses and whether participants may be psychologically triggered by the similarities between the CO and alcohol breathalyzer, which may discourage them from completing the test or contribute to procedural errors, thereby higher incidence of invalid results. The fact that all participants had experience with the saliva test and no actual experience with the CO test (having only watched an instructional video) should be kept in mind in interpreting the results on device preference.
Limitations
The study has several limitations. First, as a qualitative study, findings may not be generalizable to broader population. Nonetheless, the study offers timely qualitative insights into participants’ experiences with remote biochemical verification of smoking status. Second, we interviewed only participants who had completed at least 1 saliva test. This design choice ensured that participants could reflect on their testing experiences but may have excluded perspectives of those who encountered barriers preventing any test completion. Third, participants stated preference for CO breath testing was hypothetical, and none completed CO testing. Therefore, these findings should be interpreted as perceptions rather than direct comparisons. Fourth, observable difference between completers and non-completers of the interviews included that non-completers smoked more cigarettes per day at baseline than non-completers. However, the number of tests completed was similar: 2.7 for those interviewed versus 2.6 for those not interviewed. Fifth, there is potential for recall bias given that most participants completed the 12-month test within a year or less of the interview. Sixth, although some participants identified higher or faster compensation as a motivator for completing tests, this reflects extrinsic motivations factors such as financial incentives or immediate rewards rather than intrinsic motivational factors such as personal commitment to smoking cessation or desire to contribute to research. Finally, we conducted no power analysis for sample size as this qualitative research was exploratory in nature.
Conclusions
Qualitative results suggest that to improve compliance with remote biochemical verification, a comprehensive approach is needed, including increasing incentives, managing expectations early on, streamlining and embedding visual instructions, and providing a variety of reminders. The results extend our understanding of participants’ perceptions of testing and support future research protocols to include biochemical verification in remotely delivered cessation studies.
Supplemental Material
sj-docx-1-sat-10.1177_29768357251414464 – Supplemental material for Overcoming Challenges to Remote Biochemical Verification of Smoking Status: Insights From Participant Interviews
Supplemental material, sj-docx-1-sat-10.1177_29768357251414464 for Overcoming Challenges to Remote Biochemical Verification of Smoking Status: Insights From Participant Interviews by Margarita Santiago-Torres, Kristin E. Mull, Brianna M. Sullivan, Camille A. Fogel, Soo Bin Hwang, Alison R. Keith, Sean P. David and Jonathan B. Bricker in Substance Use: Research and Treatment
Footnotes
Acknowledgements
We appreciate the tireless contributions of the entire study staff. We are very appreciative of the study participants.
Abbreviations
App, application; CO, carbon monoxide; COPD, chronic obstructive pulmonary disease; FTCD, Fagerström Test for Cigarette Dependence; PPA, point-prevalence abstinence; RCT, randomized controlled trial; USCPG, United States Clinical Practice Guidelines; U.S., United States.
Ethical Considerations
All study procedures protocols and procedures were approved by the Fred Hutchinson Cancer Center’s Institutional Review Board (ethic approval code: FHIRB0010359).
Consent to Participate
All participants provided consent to participate.
Author Contributions
JBB, KEM, and MS-T conceptualized the study. MS-T led manuscript writing. ARK conducted all qualitative interviews. CAF led the qualitative data analyses. All authors assisted in manuscript writing and provided critical review. All authors have read and agreed to the published versions of the manuscript.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is supported by the National Institutes of Health, National Institute of Cancer (NCI) under grant R01 CA247156 awarded to Dr Jonathan B. Bricker. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The code for the data analysis underlying this article will be shared on reasonable request to Jonathan B. Bricker at
Supplemental material
Supplemental material for this article is available online.
References
Supplementary Material
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