Objective Serious health games might have the potential to prevent tobacco smoking and its health consequences, depending on the inclusion of specific game elements. This review aimed to assess the composition of serious games and their effects on smoking initiation prevention and cessation and behavioral determinants. Materials and Methods We systematically searched MEDLINE, Embase, PsycINFO, and Web of Science for publications that evaluated serious games aimed at changing smoking behavior or behavioral determinants. A taxonomy by King et al was used to classify game elements. Results We identified 15 studies, evaluating 14 unique serious games. All games combined multiple game elements (mean 5.5; range, 3-10). Most frequently used were general and intermittent rewards, theme and genre features, and punishments. Six studies on smoking prevention together assessed 20 determinants and found statistically significant positive effects for 8 determinants (eg, attitude, knowledge, intention). Of 7 studies on smoking cessation, 5 found positive, statistically significant effects on smoking cessation or status. These studies found statistically significant positive effects for 6 of 12 determinants (eg, self-efficacy, attitude, intention). The majority of included studies had poor or fair methodological quality, lacked follow-up measures, and had fixed (as opposed to free, on-demand) play sessions. Conclusions Serious games included multiple types of game elements. The evidence from a number of studies suggests that games may have positive effects on smoking-related outcomes, particularly smoking cessation. However, as most studies had important methodological limitations, stronger designs are needed to demonstrate, quantify, and understand the effects of serious games.

Background Smoking prevalence during and after pregnancy remains high among socioeconomically disadvantaged women. Mobile health (mHealth) apps with game and social support elements seem promising to support smoking cessation. Objective This study aims to describe the user-centered design and usability evaluation of Kindle, an mHealth app with game and social support elements, to support disadvantaged young women during and after pregnancy through the first stages of smoking cessation. Methods Disadvantaged women (n=9), members of their social networks (n=4), and nurses supporting these women (n=51) were informants throughout the iterative prototype development of Kindle according to the International Organization for Standardization 9241-11:2018. Specific phases included understanding the context of use through secondary analysis of qualitative interview data (phase 1), establishing the user and organizational requirements (phase 2), production of design solutions (phase 3), and usability inspection of the prototype through a heuristic evaluation (3 experts) along with user testing by a think aloud method (5 disadvantaged women and 5 nurses; phase 4). Usability problems were categorized according to the principles of the Healthcare Information and Management Systems Society. Results Phase 1 resulted in an understanding of the VoorZorg program and the needs of VoorZorg nurses and clients (eg, focus on early stages of change and building new supportive networks to aid clients in smoking cessation). In phase 2, we established requirements (n=22; eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring at early stages of change in smoking cessation). Phase 3 resulted in a prototype of Kindle, combining the interface for nurses and clients, including the following functionalities: personal goal setting with earning points; secured chat function between nurses and other clients; and tips, diary, and profile creation. The heuristic evaluation and thinking aloud method in phase 4 revealed 78 usability problems in the interfaces. Most usability problems concerned simplicity (eg, unclear clickable button) and naturalness (eg, unclear icon). Conclusions The user-centered design and usability testing of the mHealth app Kindle yielded useful insights. The involvement of end users, specifically socioeconomically disadvantaged women during and after their pregnancy, resulted in a prototype that met their needs and requirements (eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring to the early stages of change in smoking cessation) to achieve readiness for smoking cessation. Moreover, the usability evaluation by end users and experts revealed unique usability problems for this population. These insights allow for further optimization of Kindle and encourage future studies to engage disadvantaged populations in all phases of mHealth intervention design and usability testing.

BACKGROUND Smoking prevalence during and after pregnancy remains high among socioeconomically disadvantaged women. Mobile health (mHealth) apps with game and social support elements seem promising to support smoking cessation. OBJECTIVE This study aims to describe the user-centered design and usability evaluation of Kindle, an mHealth app with game and social support elements, to support disadvantaged young women during and after pregnancy through the first stages of smoking cessation. METHODS Disadvantaged women (n=9), members of their social networks (n=4), and nurses supporting these women (n=51) were informants throughout the iterative prototype development of Kindle according to the International Organization for Standardization 9241-11:2018. Specific phases included understanding the context of use through secondary analysis of qualitative interview data (phase 1), establishing the user and organizational requirements (phase 2), production of design solutions (phase 3), and usability inspection of the prototype through a heuristic evaluation (3 experts) along with user testing by a think aloud method (5 disadvantaged women and 5 nurses; phase 4). Usability problems were categorized according to the principles of the Healthcare Information and Management Systems Society. RESULTS Phase 1 resulted in an understanding of the VoorZorg program and the needs of VoorZorg nurses and clients (eg, focus on early stages of change and building new supportive networks to aid clients in smoking cessation). In phase 2, we established requirements (n=22; eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring at early stages of change in smoking cessation). Phase 3 resulted in a prototype of Kindle, combining the interface for nurses and clients, including the following functionalities: personal goal setting with earning points; secured chat function between nurses and other clients; and tips, diary, and profile creation. The heuristic evaluation and thinking aloud method in phase 4 revealed 78 usability problems in the interfaces. Most usability problems concerned <i>simplicity</i> (eg, unclear clickable button) and <i>naturalness</i> (eg, unclear icon). CONCLUSIONS The user-centered design and usability testing of the mHealth app Kindle yielded useful insights. The involvement of end users, specifically socioeconomically disadvantaged women during and after their pregnancy, resulted in a prototype that met their needs and requirements (eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring to the early stages of change in smoking cessation) to achieve readiness for smoking cessation. Moreover, the usability evaluation by end users and experts revealed unique usability problems for this population. These insights allow for further optimization of Kindle and encourage future studies to engage disadvantaged populations in all phases of mHealth intervention design and usability testing.