Background Several stand-alone smartphone apps have used serious games to provide an engaging approach to quitting smoking. So far, the uptake of these games has been modest, and the evidence base for their efficacy in promoting smoking cessation is still evolving. The feasibility of integrating a game into a popular smoking cessation app is unclear. Objective The aim of this paper was to describe the design and iterative development of the Inner Dragon game within Smoke Free, a smartphone app with proven efficacy, and the results of a single-arm feasibility trial as part of a broad program that seeks to assess the effectiveness of the gamified app for smoking cessation. Methods In phase 1, the study team undertook a multistep process to design and develop the game, including web-based focus group discussions with end users (n=15). In phase 2, a single-arm study of Smoke Free users who were trying to quit (n=30) was conducted to assess the feasibility and acceptability of the integrated game and to establish the feasibility of the planned procedures for a randomized pilot trial. Results Phase 1 led to the final design of Inner Dragon, informed by principles from psychology and behavioral economics and incorporating several game mechanics designed to increase user engagement and retention. Inner Dragon users maintain an evolving pet dragon that serves as a virtual avatar for the users’ progress in quitting. The phase-2 study established the feasibility of the study methods. The mean number of app sessions completed per user was 13.8 (SD 13.1; median 8; range 1-46), with a mean duration per session of 5.8 (median 1.1; range 0-81.1) minutes. Overall, three-fourths (18/24, 75%) of the participants entered the Inner Dragon game at least once and had a mean of 2.4 (SD 2.4) sessions of game use. The use of Inner Dragon was positively associated with the total number of app sessions (correlation 0.57). The mean satisfaction score of participants who provided ratings (11/24, 46%) was 4.2 (SD 0.6) on a 5-point scale; however, satisfaction ratings for Inner Dragon were only completed by 13% (3/24) of the participants. Conclusions Findings supported further development and evaluation of Inner Dragon as a beneficial feature of Smoke Free. The next step of this study is to conduct a randomized pilot trial to determine whether the gamified version of the app increases user engagement over a standard version of the app.

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BACKGROUND Several stand-alone smartphone apps have used serious games to provide an engaging approach to quitting smoking. To date, the uptake of these games has been modest, and the evidence base for their efficacy in promoting smoking cessation is still evolving. The feasibility of integrating a game into a popular smoking cessation app is unclear. OBJECTIVE The aim of this paper is to describe the design and iterative development of the Inner Dragon game within Smoke Free, a smartphone app with proven efficacy, and the results of a single-arm feasibility trial as part of a broader program that seeks to assess the effectiveness of the gamified app for smoking cessation. METHODS In Phase 1, the study team undertook an multi-step process to design and develop the game, including virtual focus group discussions with end users (N=15). In Phase 2, a single-arm study of Smoke Free users who were trying to quit (N=30) was conducted to assess the feasibility and acceptability of the integrated game and to establish the feasibility of the planned procedures for a randomized pilot trial. RESULTS Phase 1 led to the final design of Inner Dragon, informed by principles from psychology and behavioral economics and incorporating several game mechanics designed to increase user engagement and retention. Inner Dragon users maintain an evolving pet dragon that serves as a virtual avatar for the users’ progress in quitting. The Phase 2 study established the feasibility of the study methods. The mean number of app sessions completed per user was 13.8 (median 8.0, range 1.0 to 46.0), with a mean duration per session of 5.8 minutes (median 1.1, range 0.0 to 81.1). Three-quarters of participants entered the Inner Dragon game at least once, and had a mean of 2.2 ± 2.2 sessions of game use. Use of Inner Dragon was positively associated with total number of app sessions (correlation 0.57). The mean satisfaction score of participants who provided ratings (n=11) was 4.2 on a 5-point scale, although satisfaction ratings for Inner Dragon were only completed by 3 participants. CONCLUSIONS Evidence supported further development and evaluation of Inner Dragon as a beneficial feature of Smoke Free. The next step of this research is to conduct a randomized pilot trial to determine whether the gamified version of the app increases user engagement over a standard version of the app.

Background While the prevalence of undernutrition in children has decreased in many low- and middle-income countries since the 1990s,  overweight and obesity have increased. Frequent consumption of sugar-sweetened food might have contributed to this change, although very little is known about sugar-sweetened food consumption in early life. Objective The objective of this study was to explore the association between individual, household and maternal factors, and the primary outcome, prevalence of sugar-sweetened food consumption in 6–24-month-old children in Bangladesh. Methods Multistage sampling was used to select households with children 6–24 months in rural Chatmohar, sub-district of Bangladesh (n = 1635). Research assistants conducted a 24-hour qualitative dietary recall questionnaire with the enrolled child's primary caregiver to measure maternal and child dietary patterns. We examined factors associated with the prevalence of child sugar-sweetened food consumption with multivariate logistic regression models. We conducted tests of heterogeneity to explore differential associations between child sugar-sweetened food consumption prevalence and household income by maternal nutrition knowledge and wealth. Results Primary caregivers reported that 62% of toddlers had consumed sugar-sweetened food in the past 24 hours. Higher prevalence of child sugar-sweetened food consumption was associated both with a higher dietary diversity score (OR: 1.19, 95% CI: 1.09, 1.29) and with a higher prevalence of maternal sugar-sweetened food consumption (OR: 2.54, 95% CI: 1.97, 3.28). At higher levels of maternal nutrition knowledge and wealth, more household income was associated with lower prevalence of child sugar-sweetened food consumption. Conclusions Almost two-thirds of 6–24-month-old children in rural Chatmohar, Bangladesh had consumed sugar-sweetened food in the last day. This is a high and concerning prevalence and the associated factors identified in this study should be investigated further to identify potential areas of intervention to decrease the prevalence of child sugar consumption in Bangladesh.