A simple, low-cost, automated text-messaging program can nearly triple the odds of quitting smoking for patients with tuberculosis (TB), according to findings from a trial published in JAMA. The encouraging results have experts to debate whether such a program could be adapted by US healthcare providers to help patients who smoke and have comorbidities such as diabetes, cardiovascular disease, and cancer to cease smoking.

While the US has long utilized population-level tools like SmokefreeTXT, these resources exist mainly as broad outreach or small research projects, Maureen George, PhD, a pulmonary clinical nurse and a professor of nursing at Columbia University Irving Medical Center, New York City, told Medscape Medical News. There are currently no large-scale federal effort to integrate cessation texting directly into clinical treatment plans.

Study Leverages ‘Teachable Moment’

The multicenter cluster randomized clinical trial involved 1080 daily smokers age 15 or older across 27 clinics in Bangladesh and Pakistan. Participants were randomly assigned to either a mobile health intervention called mHealth or a usual care group. The intervention leveraged the critical period following TB diagnosis, which Kamran Siddiqi, PhD, a professor in Public Health at the University of York, York, England, described as a “teachable moment” when patients are highly receptive to health advice.

Patients in the intervention group received daily text messages for the first 2 months of TB treatment, followed by monthly messages for another 4 months. Usual care consisted of written cessation materials. Continuous abstinence was confirmed using a carbon monoxide breath test.

The researchers found that 41.7% of participants in the mHealth group achieved biochemically-verified continuous abstinence at 6 months. By comparison, only 15.3% of those receiving usual care successfully quit.

Regular Texts Offered Alternatives to Smoking

The messages were designed to provide both behavioral strategies and disease management support. A patient might receive a prompt at 12:00 PM asking: Did you think about situations that might trigger your desire to use tobacco? Start planning for how you will manage your urges. This might be followed at 2:00 PM by a practical tip: To avoid the urges to use tobacco, think of alternative things you could do instead, like using gum, clove, or cardamom to keep your mouth busy.

The program also integrated TB treatment adherence into the cessation curriculum. Patients were frequently reminded of the stakes: If you stop taking TB medicines, you can pass TB germs to others! Keep taking your medicine to help you recover and protect others from TB!

While the research team had seen similarly high quit rates (32%-40%) in earlier face-to-face trials, those interventions were rarely implemented in the real world. Face-to-face education requires resources and staff time that most “overstretched clinics simply don’t have,” according to Siddiqi.

“Even asking health workers to spend 10 minutes on structured counseling was tough,” Siddiqi explained. “In busy TB clinics, proven interventions often fail not on effectiveness but on time.” The automation bypasses common barriers in resource-limited settings, he said.

The trial showed that even very cheap, one‑way text messages, if delivered at the right moment to the right high‑risk group, can be surprisingly powerful at helping people quit smoking, said George. “A result that challenges many of our assumptions about how complex public‑health interventions need to be,” she said.

A Solution for Other Comorbidities?

The success of the mHealth intervention relies on shifting the perception of smoking from a “someday” risk to a “right now” one, said Siddiqi. “TB creates a powerful ‘teachable moment’ for smokers,” he said. “Patients are faced with a frightening, potentially fatal disease, they suddenly see smoking not as a distant risk but as something actively worsening their chances of recovery. Once that immediate link is clear, their motivation to quit is far stronger than in the general smoking population.”

George expressed skepticism about whether such a program would trigger the same response in a population that may not feel the same level of immediate vulnerability.

“I’m not certain we can create enough level of susceptibility in the US population that something like this would work,” George said. She said her research on US veterans showed that they remained skeptical of the link between their heavy smoking history and lung cancer risk even after diagnosis. “If there is such a level of skepticism of the connection between cigarette smoking and lung cancer, even in lung‑cancer patients, then I’m not certain that we’re going to get people who have heart disease to receive text messages saying, ‘You’re more at risk of a heart attack if you continue to smoke.’”

There are also significant technical and socioeconomic barriers. In low-income US communities, many patients rely on intermittent pay-as-you-go phone plans. “The discontinuous use of text messaging and cell phones is a thing,” George said. “If they run out of money, they are out of service for a couple of weeks, potentially breaking the momentum of a 6-month intervention.”

Accessibility Through At-Home Messages

However, Katrina Roux-Bernstein, MSN, CRNP, a smoking cessation specialist at the University of Maryland, Baltimore, said that such programs can address accessibility issues for patients in urban centers like Baltimore. “I have bed-bound patients and homebound patients who smoke,” Roux-Bernstein said. “When you have a patient who can’t get out of their home or has no one to drive them to appointments, this technology can be a vital assistance.”

She also highlighted the public health benefits of remote tools for infectious diseases. “A TB patient could use text messaging or an online class and stay safe without worrying about transmitting the disease to someone else,” she explained. Roux-Bernstein also said the model can be highly adaptable to incarcerated settings and other chronic conditions such as diabetes or cardiovascular disease, where the knowledge piece of how smoking worsens the specific disease can be delivered directly to the patient’s pocket.

“It’s nice to be surprised that low-cost interventions, when delivered at the right time to the right population, can be as highly efficacious as this trial,” George said. “It would be good for us to go back to our presumptions and rethink our public health messaging here in the US.”

Siddiqi, George, and Roux-Bernstein reported having no relevant financial relationships.

Manuela Callari is a freelance science journalist specializing in human and planetary health. Her work has been published in The Medical Republic, Rare Disease Advisor, New Scientist, The Guardian, MIT Technology Review, and others.