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A touching app voice Thinking about ethics of persuasive technology through an

analysis of mobile smoking-cessation apps

Cosima Rughiniş

Răzvan Rughiniş Ştefania Matei

University of Bucharest cosima.rughinis@sas.unibuc.ro

University Politehnica of Bucharest razvan.rughinis@cs.pub.ro

University of Bucharest stefania.matei@sas.unibuc.ro

The article in published in: Ethics and Information Technology, 2015, 17:4, pp. 295-309 The final version is available at http://link.springer.com/article/10.1007%2Fs10676-016-9385-1

Abstract

We study smoking-cessation apps in order to formulate a framework for ethical evaluation, analyzing apps as ‘medium’, ‘market’, and ‘genre’. We center on the value of user autonomy through truthfulness and self-understanding. Smoking-cessation apps usually communicate in an anonymous ‘app voice’, with little presence of professional or other identified voices. Because of the fast-and-frugal communication, truthfulness is problematic. Messages in the ‘quantification’ modules may be read as deceitfully accurate. The app voice frames smoking as a useless, damaging habit indicative of weakness of will, in a ‘cold-turkey’ frame of individual mind-over-body heroism. Thus apps contribute to a stigmatization of smokers and culpabilization of relapses. The potential to support user autonomy through diverse meaningful voices and personalized communication remains yet unused. Keywords Persuasive technology, ethics, mobile apps, smoking-cessation, app voice, autonomy

1 Introduction: technology and ethical inquiry

In this paper we aim to highlight ethical issues in order to guide design and use of smoking cessation apps, starting from a review of current Android solutions.

Smoking cessation apps are an instance of persuasive technology (B. Fogg, 1998) developed in the growing field of mobile health solutions, aiming to support users in their decision of quitting. Digital persuasive technology refers to “digital products designed to change what we think and do” (B. J. Fogg, 2009, p. 1). Persuasive technology may be designed in pursuit of specific beliefs or actions, or may aim to support users’ decision making at a broader level, by enhancing awareness, motivation, self-efficacy, memory etc.

Unlike other monitoring and tracking apps (Lupton, 2013), especially those part of the Quantified Self movement (Nafus & Sherman, 2014), smoking cessation programs put less emphasis on generating data on user behaviors, and more on issuing eloquent voices to guide users in this difficult stage of life. These voices sometimes speak in numbers, through what we have called the ‘quantification modules’ – but these numbers are largely

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projections, rather than measurements. They may also speak in pieces or advice, as well as through visual means. Mobile smoking cessation apps literally talk to their users, and thus raise the question on how are we to evaluate this conversation from an ethical perspective.

We use the concept of voice following its career in the social sciences after the original formulation of M. Bakhtin (1984). A voice refers to “a speaking subject's perspective, conceptual horizon, intention, and world view” (Wertsch, 1993, p. 51) – for any given utterance, in any medium - aural or written. Subjects often speak with multiple voices, referring to and addressing others’ speeches. Their voices are shaped by what Bakhtin termed social languages: “social dialects, characteristic group behavior, professional jargons, generic languages, languages of generations and age groups, tendentious languages, languages of the authorities of various circles and of passing fashions, languages that serve the specific sociopolitical purposes of the day" (M. M. Bakhtin, 1981, p. 262, apud Wertsch, 1993, p. 58). Individual subjects speak through social languages, appropriating their vocabularies and styles into distinctive voices. Research in medical humanities has relied on the concept of voice to identify multiple ways of interpreting and speaking about one’s condition, grounded in different experiences, concerns and vocabularies – see for example Puustinen’s analysis of shifting physician’s voices (Puustinen, 2000), Engestrom classification of voices in medical encounters (Engestrom, 1995), or Lewis’ discussion of the multiplicity of voices interpreting depression in Chekhov (Lewis, 2006). With the rise of persuasive software, artificial voices become increasingly common – ventriloquizing medical and other expert languages to fuel users’ decision making processes with discursive resources. We pay attention to apps’ voices in order to identify ethical issues relevant for design.

Researchers in engineering ethics have gradually enlarged the scope of ethical inquiry beyond safety concerns, for example in the Value Sensitive Design (VDS) movement (Friedman, Kahn, & Borning, 2008; Friedman, 1996). VDS rests on the theoretical insight that technology is not a morally neutral instrument: ‘values emerge from the tools that we build and how we choose to use them’ (Friedman, 1996). Lessig’s controversial assertion that ‘code is law’ (Lessig, 2000) has furthered discussions on the moral valence of technology.

While the morality of tools is often implicit in designers’ projects, the Persuasive Technology (PT) movement (B. Fogg, 1998) or Design with Intent (DwI) (Lockton, Harrinson, & Stanton, 2008) have brought technologically-enabled (or disabled) moral action to the forefront of design.

1.1 Framing reality through technological lenses

Technologies shape the choice situations in which people find themselves, re-creating them as moral subjects. Designers are taking on the job of a choice architect (Thaler, Sunstein, & Balz, 2010) – influencing ways in which users define their situations and act upon them, aiming to routinize some actions and take them out of decisional spotlight, and proposing forms of feedback to keep actions in line with desired goals. This is

At the same time, technological framing reverberates through multiple aspects of a person’s life, beyond stated objectives. Verbeek relies on Don Ihde’s post-phenomenological philosophy of technology to argue for the mediating role of technology in the reciprocal constitution of the acting subjects and their world (Verbeek, 2008), thus writing about the ‘technological mediation of morality’. Verbeek examines how technology makes possible interpretations of the world (hermeneutic mediation) and ways of action (pragmatic

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mediation) (Verbeek, 2006: 3) that influence our engagement with the world at large. To illustrate:

“The FoodPhone, to stick to the example, may persuade its users to develop more healthy eating habits.(…) Beside having the desired effect of stimulating a more healthy eating pattern, the FoodPhone can e.g. make eating something stressful; it can stimulate humans to interpret their health exclusively in terms of their eating pattern while neglecting the importance of other factors like having enough exercise; and taking pictures of all food consumed will definitely organize social relations at the table.” (Verbeek, 2008: 4)

These observations bring into question the moral acceptability and risks of framing actions through the lenses of such technologies. Observing oneself and acting through technologies that privilege a focus on the value of health, and measurement of health-defining indicators may lead to medicalization (Conrad, 1992) or healthism (Lupton, 2013). When these technologies create a sharp, moralized distinction between the healthy and the ill, one may also witness stigmatization of the ‘unhealthy’ selves or others (Courtwright, 2013; Guttman & Salmon, 2004) .

1.2 Truthfulness of technological voices

Technologies frame situations of choice through multiple forms of communication – including signals, reminders, notes to self, but also messages initiated within the technological product or conversations with others enabled by the product. This raises the issue of truthfulness in communication.

Some values, such as safety and privacy, are shared by many types of technologies, be they explicitly persuasive or not. Enhancing user autonomy through truthfulness and honesty in communicated messages are distinctively central values in PT discussions – deriving from an ambivalent understanding of persuasion, between ‘manipulation’ and ‘convincing’.

As Spahn observes, truthfulness refers both to messages that are formulated to the user, and to the feedback that the application gives about the user (Spahn, 2012: 639-640). Still, some bias may considered contextually acceptable. Users judge truthfulness in the context of a specific genre that may allow various forms of reasonable re-elaborations of what would count as ‘factual truth’. For example, accuracy of self-presentation in the context of online dating profiles may be better judged as the truthfulness of a promise (Ellison, Hancock, & Toma, 2011), than that of a medical or judicial record. Apps may also offer clues to guide a specific interpretation of truthfulness, through a gamified appearance, inviting a playful relativity, or through appeals to scientific objectivity, leading to expectations of rigor.

Still, assessing autonomy through transparency of intent and truthfulness leaves open the issue of unforeseen consequences (Atkinson, 2006), or the ‘not reasonably predictable’ (Berdichevsky & Neuenschwander, 1999) outcomes.

Various authors discuss the morality of PT also by inquiring whether the intentions of the persuader are transparent, and whether they are shared by users (Atkinson, 2006; Berdichevsky & Neuenschwander, 1999) – in other words, whether PT is an instance of self-persuasion or other-persuasion:

“With regard to autonomy, it is furthermore important to distinguish whether the user persuades himself with the PT, or whether the PT is used to persuade him by someone else. Cases of self-persuasion are most likely cases, in which the user already shares the value in question and uses the PT only to overcome a ‘weakness of the will’” (Spahn, 2012: 645).

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2 Mobile apps for health persuasion

Smartphones have become an increasingly common device for health persuasion (Klasnja & Pratt, 2012; Mosa, Yoo, & Sheets, 2012). Mobile phones have been already used in smoking-cessation programs, in a wide range of SMS-based interventions (Meier, Tackett, & Wagener, 2013). Smoking-cessation applications (apps) for smartphones are now available in ever larger varieties on software markets for various operating systems (Abroms et al., 2011; Abroms et al., 2013).

Apps have also become an instrument for large scale public health interventions: the European Commission has initiated the ExSmokers campaign, developed by Saatchi & Saatchi, that uses two mobile apps - the ExSmokers iCoach and the FCB iCoach - besides visual messages, public events, and social media communication. The campaign received two Euro Effie awards, as well as an EACA Care award (2013) and the European Lung Foundation Award (2013).

Randomized studies offer some indication of effectiveness for SMS-based interventions in smoking cessation (Meier et al., 2013). As regards smoking cessation apps, a content-analysis review of features for 47 iPhone apps (L. Abroms et al., 2011) and a follow up analysis for 47 iPhone and 51 Android apps (L. C. Abroms et al., 2013) concluded that, as a rule, they do not adhere to established clinical guidelines for smoking cessation; for example, they did not recommend approved medication or counseling. Similar results obtain in a content analysis of content analysis of 225 Android smoking cessation apps (Hoeppner et al., 2015): apps cover on average only 2-3 of the 5 recommended clinical practice steps and provide few opportunities for tailoring. A study looking at smoking cessation apps in light of motivation theory concluded that, as a rule, apps are limited in complexity and are mostly focused on extrinsic motivators (Choi, Noh, & Park, 2014). There is very little information, to date, concerning effectiveness for smoking-cessation apps. On study of a specific app concluded that it might be helpful for at least some of its users, as almost 19% of them recorded abstinence periods of 28 days or longer (Ubhi, Michie, Kotz, Wong, & West, 2015). It is beyond our scope to assess effectiveness for individual apps or specific collections, but we notice that this absence of information is also an ethical concern.

Smoking-cessation apps purport to guide users through a difficult personal transformation, which has both short- and long-term implications for self and others. Attempting to renounce smoking involves a transformation in one’s lifestyle, and, whether successful or unsuccessful, it impacts the individual’s health and emotional wellbeing. Moreover, attempts to quit influence relationships with significant others, who may welcome or disapprove of the attempt: ex-smokers lose some opportunities of cigarette-focused sociability, and gradually acquire an interest in smoking cessation or abstinence for those around them. Therefore, given the increasing acceptance of mobile apps for health communication among the general public, and their use in public health campaigns, it is important to highlight specific ethical issues.

2.1 Typical app modules

We analyze 27 free smoking-cessation apps for Android available in the Google Play market, ranging from the most popular (more than 4.000 user reviews at the time of app selection) to the more recent or less popular. As of October 15, 2013, when we started our analysis, a total of 6 apps had more than 1000 user reviews, and another 7 had more than 300 user reviews (Figure 1). In what follows, we refer to specific apps by means of their rank in the

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top of user reviews, as presented in Figure 1. We do not aim to quantify the relative frequency of features, but to present a repertoire of ethical considerations that can inform users’ choice, engineering education, design work, public health interventions, and counselors’ recommendations. Starting from ethical analyses of ubiquitous healthcare (Brown & Adams, 2007) and public health communications (Guttman & Salmon, 2004), we evaluate the relevance of typical ethical concerns and we identify additional, specific moral risks.

Figure 1. Smoking-cessation applications included in analysis

Source: Authors’ analysis of data on Google Play, 15 October 2013.

Apps include one or several typical modules for supporting smokers in giving up or diminishing smoking. Most applications are dedicated to persons who have just given up smoking, and confront the initial, difficult cigarette-free hours and days. Some apps also address people who aim to control their smoking and decrease it gradually, or people who contemplate giving up smoking but they have not made any decision yet.

The most common module for supporting recent ex-smokers consists in a ‘calculator’ – that is, a device that estimates various parameters of users’ health state and risks, as well as savings through not smoking, and displays them as a function of time. Users are required to input initial information such as: the number of cigarettes smoked per day, duration of smoking, number of cigarettes per pack, price per pack. This data is used to customize app messages concerning the benefits of cessation: immediate improvements in one’s physical condition, decreased risks, saved money, and saved time through not smoking. Figure 2 illustrates three different calculator displays for ‘Quit Smoking – Quit Now!’ (app 3): statistics, progress bars for health improvements, and ‘achievements’.

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Figure 2. Quit Smoking – Quit Now! Calculator module: statistics, health improvements, achievements

(a) Quit Smoking – Quit Now! (b) Quit Smoking – Quit Now! (c) Quit Smoking – Quit Now! Source: Screenshots published on Google Play.

Photo courtesy of Fewlaps [http://fewlaps.com]

Calculator modules require users to report their ‘relapses’ (cigarettes smoked after the quit date), with several types of reactions. Most calculators reset all progress indicators, considering that a ‘relapse’ cigarette turns back the user to the status of ‘smoker’, with its associated risks (Figure 3a, app 1). Less frequently, apps count the number of ‘relapse cigarettes’ as a distinct indicator, without any modification in the gradual improvement of health indicators associated with the status of ex-smoker. Apps can also attempt to alleviate the urge to smoke through temporization, asking users to push a button whenever they want to smoke, then asking whether they can wait, and advising abstinence (Figure 3b, app 1, and c, app 3).

Figure 3. Reactions to reported cigarettes

(a) Quit Smoking - Azati (b) Quit Smoking - Azati (c) Quit Smoking - Azati

Source: Screenshots from authors’ phones. Photo courtesy of Azati [www.azati.com]

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A second typical app device consists in ‘coach’ modules dedicated to the management of cravings and relapses. Apps may offer textual tips for such difficult moments. A typical collection includes circa 30 pieces of written advice, expressed in the app anonymous voice, of one to several sentences in length, that may be presented on users’ request (upon pushing a ‘panic’ button, for example), as random messages, or on a dedicated static page. Some apps also include internal forums, in which users share experiences and advice. Apps also encourage users to tell about their efforts on social media – for example, by publishing their medals on Facebook.

The most popular apps focus on the calculator module; some do not offer any tips for situations of cravings, while others have a rather limited collection of tips. Other apps focus on advice with little display of statistics, including the European Council solutions (apps 9 and 14).

2.2 Apps as situations of choice

Apps shape situations of choice for designers and users, thus mediating moral action and moral subjectivity. We propose to study these situations at four levels of generality: (1) the app medium, (2) the market, (3) the genre, and (4) the individual piece of software. For each type we discuss specific ethical issues, while examining how apps are currently working, and also how they could work, given the potentialities of the medium.

Smartphone apps represent, first and foremost, a medium of communication, enabling the formulation and dissemination of multiple messages – relying on different sensorial modalities, various degrees of gamification, more or less interactivity and personalization, individual or community relationships etc. Individual apps can vary greatly; still, it is possible to examine the ethical specificities of the medium itself.

Secondly, users do not typically encounter a single app, but a multitude of apps available at the same time and in similar access conditions. Therefore, it is important to take into account the variability of the solutions on offer, and the interactional features of the platform that mediates users’ contact with apps – that is, the app market. In this paper we examine free Android apps available on the Google Play platform.

Thirdly, app components can be classified in genres according to their communication and interaction patterns. In this study we focus on two smoking-cessation genres: the ‘calculator’, which presents users with quantitative indicators of health and finance, and the ‘coach’, which offers advice for difficult moments of craving a cigarette. Any individual app may combine several genres; most smoking-cessation apps that we have analyzed combine calculators, coaches, and some elements of visual persuasion through anti-smoking posters.

There are other genres as well in smoking-cessation apps, based on hypnosis, subliminal messages, smoking simulation, presentation of scary images, audio and video coaching. They appear in dedicated products rather than integrated with calculators and coaches, and we did not include them in this analysis because they rely on different theoretical assumptions and communication strategies; also, they are significantly less popular (as indicated by the number of user reviews).

Last but not least, the most specific objects of ethical evaluation are individual apps as pieces of software which interact directly with users, shaping their daily situations of choice.

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2.3 App voices

Apps introduce in users’ life new voices, communicating through various social languages (M. M. Bakhtin, 1981, apud Wertsch, 1993, p. 58). Calculator modules communicate in a voice that relies heavily on quantification and on scientific legitimation from medical research, employing a vocabulary of health risks and benefits. This voice is also present in textual advice in the coach module – combined with much more colloquial and moralizing injunctions (see examples in section 3.3.5). Still, as previous research has pointed out (L. C. Abroms et al., 2013; L. Abroms et al., 2011), this quasi-medical voice stops short of including clinical guidelines for smoking cessation – it appears rather as a distinctive ‘app voice’ that ventriloquizes numbers from research as a resource to deliver quantitative encouragement.

Apps may also bring forward peers’ voices, typically in pseudonymous form, in the internal app forums. Other than that, the apps communicate in their own anonymous voice – it is the app speaking to the user, throughout its operation.

Other voices that could tell about their experiences or share advice are notably missing – such as known peers, writers, doctors, humorists, psychologists, or any other person communicating from within a personal standpoint. The EC app FCB iCoach is an exception, including FCB players’ and members’ voices as personally assumed advice.

App voices are also confined to textual messages, usually ‘fast and frugal’ – with little reliance on actual human voices or other aural means of persuasion, such as music (‘hypnosis’ is the app genre which relies on images and sound). Visual communication employs mostly poster-type images - either inspirational or scary.

3 Ethical issues for smoking-cessation apps

We propose a frame of reference for ethical assessment of apps inquiring into all four situations of choice: medium, market, genre and piece of software.

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Table 1 presents an overview.

Besides moral issues such as privacy, truthfulness, autonomy and equity, we have also included effectiveness (impact) as an ethical concern at the market, genre and individual level, given that smoking-cessation apps operate under the explicit promise to support users in a difficult transformation with important consequences for their and significant others’ wellbeing. Whether or not apps actually deliver this support is of clear ethical import. We can define effectiveness most clearly for individual apps: at this level, it could be evaluated through various research designs, experimental or experiential. At the level of app genre, it would be possible to estimate the aggregated or typical impact, through designs such as meta-analyses of experimental evaluations, or other styles of review.

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Table 1. A framework for ethical assessment of smoking-cessation apps

Apps as… Ethical concerns

1. Medium Privacy: o Use of personal information o Security vulnerabilities

Truthfulness: communication based on ‘fast and frugal’ messages in ‘app voice’

Equity and social gaps

2. Market Effectiveness (reliance on medical knowledge and expertise, medical authorization)

Free choice: costs

Informed choice: o Visible credentialing or authorization information o Transparency of commercial interests o Quality of labeling information o Quality of feed-back from users

Equity and social gaps

3. Communication genre

Encouraging autonomy: o Users’ control and app interactivity o Self-persuasion through personalization o Qualities of information: diversity and reach of hosted

voices, truthfulness, depth of understanding, moral values

o Risk of stigmatization

Effectiveness o Adherence to medical guidelines o Theory-informed design o Evidence from evaluation of aggregated or typical

impact (review, meta-analysis)

4. Piece of software All concerns listed above

Effectiveness o Adherence to medical guidelines o Theory-informed design o Evidence from case-study evaluation of impact

(experimental, experiential)

At the market level, the relevant considerations for effectiveness is whether any process of medical authorization is in place, whether scientific knowledge and expertise (medical, psychological, sociological) are present in the diversity of solutions, and the extent to which informed choice concerning expected effectiveness is possible (that is, whether evidence about app usefulness to past and present users, and its reliance on scientific knowledge and professional expertise is easily available for would-be users).

In what follows we illustrate discussions of ethical issues at medium, market and genre levels, for smoking cessation apps. We do not analyze in detail individual apps, given that higher-level issues are shared with individual app level issues, and the in-depth case study of specific apps is beyond our scope of inquiry.

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3.1 Medium-specific ethical issues

The most common concerns regarding the medium of mobile apps refer to privacy and the use of personal information. In order to install and use an app, users consent to various levels of access to their information and smartphone services. This opens to a more or less extent the possibility of misuse of personal information, by companies or persons who manage app users’ data or by mobile communication carriers, as well as the possibility of hackers’ acquiring unwanted access through security breaches (Meier et al., 2013).

Mobile apps are a medium that favors ubiquitous access to short, ‘fast and frugal’ messages – usually formulated in an anonymous ‘app voice’, or in pseudonymous peer voices on forums (see section 2.3). This raises potential concerns for truthfulness versus deceitfulness, and reasonable versus manipulative approximation: there is often no time and space for qualifications of certainty and the details needed in medical communication.

3.2 Market-specific ethical issues

As observable in its name, the Google Play app market does not claim any medical authority whatsoever. While it hosts many apps purporting to address health issues, it also hosts apps for entertainment, lifestyle, office work, social networking etc. People search and find smoking-cessation apps as elements of this heterogeneous collection, and it is likely that they are not entrusting them with the legitimacy typical for professional medical settings. It is also likely that health-related apps are used for a variety of tasks, including entertainment, self-presentation on social networks, or tech experimentation. The social situation in which apps become available is relevant for contextualizing the weight of ethical considerations in relation to other issues (of technical, aesthetical, social, or entertainment value).

3.2.1 Effectiveness: medical presence and authorization

There is, to date, no process of authorization for health-related apps according to proven impact, adherence to medical procedures or other criteria. Conditions for their public release are similar with those for entertainment, office, or social networking apps. A question rises, then, whether medical expertise is represented in the variety of apps on the market. Are users able to choose a medically-informed intervention, if they want one?

Our analysis corroborates conclusions in previous research (L. C. Abroms et al., 2013; L. Abroms et al., 2011): there is a general low compliance with clinical guidelines for smoking cessation. Similar conclusions apply to apps for panic disorders (Van Singer, Chatton, & Khazaal, 2015), alcohol-control (Cohn, Hunter-Reel, Hagman, & Mitchell, 2011), diabetes self-management (Breland, Yeh, & Yu, 2013), weight loss and fitness (Cowan et al., 2013; Pagoto, Schneider, Jojic, DeBiasse, & Mann, 2013). The European Council apps are the only ones in our collection that recommend use of approved medication, appeal to counseling, and offer to connect the user with a Helpline. ‘Cold turkey’ is the dominant approach of other apps, either explicitly (‘Nicotine replacement therapy might not be your best option… Cold turkey is the most logical option!’- app 12) or implicitly - see the qualitative analysis of app messages in Rughiniș, Matei, & Rughiniș, 2014 and Matei, Rughiniș, & Rughiniș, 2014. Also, we found little psychological insight in most instances of textual advice – with the notable exception of the European Council apps.

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3.2.2 Free and informed choice

An important ethical feature of markets is freedom of choice. This depends on costs, information, and access, among others.

As a rule, most apps offer a free version, and costs per individual apps are relatively low (in the range of USD 1-7). A second dimension of free choice consists in access to information about available options.

Before installing an app from Google Play market, users have access to several types of information:

a) Name of the producer, date of publication, and producers’ description that usually lists: the main features, a series of several screenshots illustrating functionalities and aesthetics, and, occasionally, a video presentation;

b) Price; c) Users’ comments and ratings; users are, as a rule, anonymous or writing under

pseudonyms; therefore, credibility is at stake; d) Quantitative indicators of popularity: user reviews (illustrated in Figure 1); ratings

on Google Plus; a range for the number of installs (eg: 100,000 – 500,000 for app 8).

As mentioned before, smoking-cessation apps have not been comprehensively evaluated as regards their effectiveness. Still, apps do occasionally present themselves with reference to medical criteria of performance or credibility. For example, app 8 mentions that it is ‘Featured at Healthline.com in their list of top quit smoking apps of 2013!’. While this is accurate, Healthline.com also includes a note specifying that ‘Healthline Networks does not endorse or warrant for fitness of purpose any of these applications. These apps have not been evaluated for medical accuracy by Healthline Networks and unless otherwise indicated, haven’t been approved by the Federal Drug Administration (FDA)’. App 3 mentions that ‘Also, QuitNow! will provide you with W.H.O.-based (UN's World Health Organization) indicators on your health improvement process (…)’. A question rises, then, to the appropriateness of reference to medical authority in app claims of effectiveness.

Another issue regards the transparency of commercial interests. Many of the free apps include advertisements, a practice that is expected by users. Still, app 11 offers ‘E-cig coupons’ as part of smoking cessation strategy, without marking this as a commercial interest. The offer includes the following encouragement: ‘Having an electronic cigarette can help you during those tough times when you really want to smoke. (…) Just take a few pulls from the electronic cigarette to hold yourself off until the next scheduled smoke time!’ Users are thus exposed to unmarked advertisement.

A content analysis of Android smoking cessation apps (Hoeppner et al., 2015) concludes that user reviews and the number of downloads correlate positively with the degree of customization and the number of clinically recommended steps covered within the app; thus, it follows that users can rely with some predictive success on common market indicators in their selection of individual apps. This is important especially given the results of a study on users of a smoking cessation app, stating that about three quarters of those who have used other health related apps did not check the credibility of the app publishers before downloading it (BinDhim, McGeechan, & Trevena, 2014). Thus market metrics such as the number of user-awarded stars and the number of downloads remain important criteria of choice.

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3.2.3 Social gaps

By selectively targeting sections of the population, public health interventions risk increasing social gaps (Brown & Adams, 2007; Guttman & Salmon, 2004). This can become a vicious circle dynamic if the intervention relies on stigmatization and imputation of individual responsibility, while at the same time failing to reach social categories that are already lacking in financial, human and social capital: in such a situation, the intervention may leave them even more disempowered in confronting their health vulnerabilities.

There is a case to be made that the current market for calculator and coach apps targets mostly smokers with higher human capital. For example, a study of the users of one specific smoking-cessation app concludes that “compared with smokers trying to quit in England, they had higher consumption, and were younger, more likely to be female, and had a non-manual rather than manual occupation” (Ubhi et al., 2015). This is, on the one hand, a property of the medium: while mobile phones are virtually universally accessible, smartphones have not yet reached the same degree of penetration. Moreover, calculator modules do require a certain degree of statistical literacy and medical vocabulary, while coach modules rely heavily on written text communication; in particular, the European Commission’s solution ExSmokers iCoach delivers relatively lengthy pieces of written information (covering one or more full screens). This may account for its relatively low popularity, despite being part of a massive intervention program (ranking 9 in Figure 1).

While the market is dominantly English speaking, the most popular apps offer versions in other languages (such as apps 1, 2, 3 in Figure 1); also, the ExSmokers iCoach (app 9) is available in a variety of languages. Therefore, language is becoming less and less a barrier, at least in theory. In practice, users still need to search for apps on Google play in English, install apps in English, and then select other language from the Settings menu. Apps that offer multiple languages cannot be actually found on the market by searching with keywords in French (‘fumer’), Romanian (‘fumat’), German (‘rauchen’), etc. This is a clear access barrier for people with less formal education, in non-English speaking countries.

3.3 Genre-specific ethical issues for ‘calculator’ and ‘coach’ apps

One of the key moral considerations in persuasive technology and in health interventions refers to personal autonomy: to what extent the intervention is enabling the person to make free and informed decisions, to gain understanding of and control over her life, to improve her wellbeing according to her own moral worldview? Typical moral risks consist in: a) paternalism, when individual preferences and decisions are ignored or overridden in the name of wellbeing; b) dependence, when individuals are kept in a subordinate position by not receiving the knowledge, information, decision-making power, or other resources required to make their own choices; c) problematic agency – when individuals experience a change in their personalities through intervention, and it becomes unclear for them who is the source of agency in their own actions (Brown & Adams, 2007); d) culpability – when individuals are held responsible for success or failure of actions which are only partly under their control, without being offered the required support; culpability may lead to e) stigmatization, a negative moral portrayal of persons that decreases their possibility to engage in social interaction and to legitimately sustain their points of view (Guttman & Salmon, 2004).

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3.3.1 Dimensions of autonomy

We can examine apps in relation to several dimensions of autonomy (Figure 4). The most concrete sign refers to the actual involvement of individuals in the app-intervention: what degree of control do they have? The second layer refers to personalization - the extent to which users can communicate their circumstances and preferences in order to customize treatment, allowing them to direct their own behavior change as a form of self-persuasion (Spahn, 2012). The third layer points to the degree that apps enhance the information base on which individuals ground their decisions. The fourth and the fifth layers refer to enhanced self-understanding and self-direction; this distinction is analytical rather than psychological. Self-understanding refers to the messages that users receive concerning their agency, the forces that shape their actions, the imputation of responsibility for various outcomes. At the highest level, moral deliberation refers to the moral values highlighted by the app, and instantiated in the actions and lifestyle that it recommends.

Figure 4. Layers of app-supported autonomy

Source: Authors’ analysis.

3.3.2 Involvement and personalization

Apps have a high potential for interactivity and user control of interaction. In most cases, users choose when they want to see app-related information and advice.

Interactivity is a resource for personalization: apps can rely on specific information provided by individual users in order to tailor communication to their situation. Calculator modules employ data about users’ smoking patters, although, as we discuss in section 3.3.3 dedesubt, their level of individualization as regards health is make-believe rather than substantive. Apps may also position users on an evolution trajectory, passing through various stages depending on their smoking behavior and willingness to quit; European Council apps customize advice to users’ self-declared stage. As regards the content of tips and advice, as a rule, they are not customized to users’ preferences. Although it would be possible to enable people to rate advice and adjust content to their preferences, such features have not yet been implemented. Customization would also require a much larger

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collection of advice and motivational messages, in order to enable meaningful personalization on a variety of dimensions (such as positive versus fear-based motivators, humorous vs. inspirational, text vs. audio or video, short vs. long, focused on the body, mind or socio-material surroundings, etc).

Personalization is rarely pursued, even in forms of addressing the users: apps do not employ their name, and often formulate tips as general rather than specific advice. A more recent review also concludes that tailoring is used “sparingly” - on average for only about one of the five As (“ask”, “advise”, “assess”, “assist” and “arrange follow-up”) recommended by clinical practice guidelines (Hoeppner et al., 2015).

While users can customize to some extent their app-based smoking-cessation program at the market level, when selecting a genre and a particular solution, there is little space for personalization and increasing self-persuasion in interactions with individual apps.

3.3.3 Information and truthfulness

Apps offer a wide array of information concerning smoking risks and their evolution after cessation, as well as information concerning nicotine addiction, withdrawal symptoms, and strategies for managing cravings. While smoking-cessation app users have considerable opportunities to broaden their knowledge basis as regards nicotine dependence, truthfulness remains problematic.

Calculator modules require users to input summary information on their smoking patterns and offer, in exchange, quasi-personalized estimates of health improvement and risk reduction. These indicators are offered with high numerical precision: for example, users are informed about the exact number of days, hours, minutes and seconds in which their risk of heart disease will be reduced by half (Figure 2). Given that apps have no access to individual level information about health status, this is at best an estimate at a highly aggregate level, and the decimals and seconds on display are of aesthetic rather than medical relevance. Users are offered personalized health information of high numerical precision that bear little actual relation to their current individual situation. This raises the moral issue of truthfulness and its reverse, deceitful persuasion (Guttman & Salmon, 2004). On the one hand, it may be argued that users understand that app communication relies on a rhetorical convention of personalization, while its content is essentially impersonal. Still, such an assumption cannot hold for all possible users. Thus, even if only a small proportion of users start to believe that those risks actually describe their individual health condition, persuasion turns into deceit. Several specific recommendations can be formulated here, for designers interested in enhancing app truthfulness. Firstly, apps should inform users about the nature and sources of the information that is presented as being ‘about them’. Secondly, apps should not translate aggregated estimates of average individual chances and risks into a numerically precise formulation – rather, they should consistently communicate that numbers include a degree of approximation. Thirdly, users should be reminded that app messages refer not to “you” but, rather, to “people like you” – where this likeness is determined on the basis of input information. Users may also be invited to create avatars, for example, in order to create a slight distance between their real, flesh-and-blood persons and the targets of app communication; they would thus become guides and observers of their half-fictive-half-real avatars influenced by aggregate risks of smoking and various probabilities of withdrawal symptoms.

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Apps also engage in other types of persuasive manipulation. For example, app 1 offers to assess users’ level of nicotine dependence through a questionnaire. After answering questions in all possible combinations, it becomes clear that the app only offers two diagnostics: ‘low’ dependence, and ‘moderate’ dependence. There is no inbuilt possibility to be diagnosed with ‘high’ dependence. The ‘low’ diagnosis brings the following clarification: ‘Mild nicotine dependence. It is mostly psychological. You can handle it. Stay firm and do not give up’. The ‘moderate’ diagnosis explains: ‘Moderate nicotine dependence. You should make an effort to overcome both psychological and nicotine dependence’. The absence of a ‘high’ level may be deemed encouraging, but at the same time it is deceitful for those persons that are strongly addicted; the ‘moderate’ message puts the burden of resistance on the individual (‘you should make an effort…’), ignoring the availability of counseling and of pharmacotherapy, including nicotine replacement, that can alleviate withdrawal symptoms. This strategy of persuasion may thus lead to the recrimination of users for an eventual failure to quit, and to a misunderstanding of their condition – in effect undermining their scope of action.

It is also noteworthy that apps do not use established psychological scales which are available online to describe nicotine dependence (Etter, Le Houezec, & Perneger, 2003; Wellman et al., 2011), motives for smoking (Smith et al., 2010) or withdrawal symptoms (Bolt et al., 2009; Welsch et al., 1999). Apps could make better use of available scientific tools for identifying and measuring smoking dependence and withdrawal experiences. This brings us back to the abovementioned absence of psychological voices, be it of quantitative or experiential persuasion.

Last but not least, our discussion of truthfulness risks to omit the fact that some users may actually prefer to be scared rather than accurately informed – that is, they may prefer to be a little pushed into believing whatever it takes so that they can quit. People often engage in self-deception, and they may also deliberately choose a scaring app over a scientifically sound app. Designers are left to arbitrate the conflicting requirements of truthfulness, playfulness, and persuasive (self-)deception, in a rhetorical situation that is under-specified. There is no explicit promise for scientific soundness on Google Play – other than avoiding malware and fraud, and apps’ occasional, explicit or implicit claims of evidence-based advice. The clearest recommendation that one may derive from this rhetorical situation is that, whatever balance designers choose for their app between conflicting communication styles (factual, playful, threatening or another), they should communicate it effectively to users.

3.3.4 Self-understanding: ‘mind over body’ and culpability

Smoking cessation engages people in a process of self-understanding, as they are confronted with issues of physical dependence on nicotine and of psychological dependence on smoking as a coping strategy and a social habit. The ethical issue is, then, what ‘theory of self’ do smoking apps promote?

The dominant model of most calculator and coach apps relies on a ‘cold turkey’ strategy, ignoring pharmacotherapy and medical counseling and advocating individual self-control as the central resource for quitting . The implicit model of human action is that of ‘mind over body’, glorifying individual control over bodily reactions, with little if any external support. This view is often shared by app users and it is consolidated through app forum talk (Figure 5 c).

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Peer support is the only social resource commonly enrolled, since users are encouraged to take part in dedicated forums and to share their challenges and victories on Facebook, Twitter etc. This stress on the importance of community support counterbalances to some extent the individualistic bent of the app voice.

A consequence of the individualist and mentalist representation of action is that relapses are often framed as a personal failure, as a reset of the smoking-cessation process that should be imputed to the individual. There is variability in the treatment of relapses, with some apps allowing for occasional cigarettes as part of cessation (‘Have you tried so many times already? Your chance of succeeding the next time is greater. You’re more aware of the pitfalls’, app 9), and micromanaging cravings by encouraging users to report relapses and to keep on going. The relevant ethical issue concerns the definition of failure and the imputation of responsibility: how can individuals be supported by encouraging self-efficacy and avoiding moral recrimination for instances of relapse?

3.3.5 Self-understanding and stigmatization

A widely discussed issue in relation to anti-smoking public health campaign refers to whether the negative moral, cognitive, and aesthetic portrayal of smoking results in a stigmatization of smokers – and, if yes, whether this stigmatization is morally acceptable. From a contractualist perspective, acceptability of stigmatization as an incentive for behavior change revolves on the extent to which it leads to cross-situational social isolation of the targeted persons, preventing their participation in decisions that shape their lives (Courtwright, 2013). It becomes an empirical task for ethical assessment to determine whether the redefinition of smoking in a specific social setting has led to a trans-situational stigmatization of smokers, diminishing their social standing, or has constrained strictly their smoking behaviors, without affecting their voice in various relationships and communities. For example, in authors’ social surroundings smoking does not seem to function as a stigma, at least in our interpretation – but this may well be different in other parts of the social world.

If smoking turns into a ‘morally defective’ behavior in a social group, this may also affect ex-smokers, in at least two ways:

a) If they view smoking as morally flawed, they may end up devaluing their own past self;

b) Ex-smokers may gradually devalue and / or avoid interaction with some of their significant others (colleagues, friends, family) who are still smoking.

Apps rely occasionally on the resource of stigmatizing discourses to uphold ex-smokers through the cessation period. There is considerable variability: some apps do not include such negative messages, or very rarely. Some examples are:

a) Defining smokers as wrongdoers: ‘Quitting smoking means: You will no longer hurt yourself and others’ (app 4); ‘Young women who are pregnant and who smoke put their fetuses at increased risk for decreased birth weight, premature birth, and perinatal mortality’ (app 12);

b) The aesthetization of smoking as disgusting: ‘You’ve taken the first steps towards busting this disgusting habit’ (app 11); ‘Smoking is a disgusting and stinking habit’ (app 4); the olfactory sense plays a powerful role in the process of Othering smokers (Gavriluță, 2002);

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c) A focus on bodily disfigurement: ‘Are you worried about your sex appeal? Studies have shown a clear link between smoking and impotence and reduced sexual pleasure. Fancy a cigarette?’ (app 9); ‘Your teeth, your breath and your skin thanks you. Smoking leads to tooth loss, gives you bad breath and a sallow complexion’ (app 22);

d) An evaluation of smoking as stupid (‘When you haven’t smoked for a month or more you will realize how stupid it was to spend all that money on an addiction that was literally killing you! Never again!’, app 22), and of smokers as foolish (‘Smokers are comparable to alcoholics and heroin addicts. You fool yourself, and tell yourself it’s not that bad an addiction to have. Treat yourself like an alcoholic and never touch another cigarette again!’, app 12).

As part of their persuasive approach, most apps rely on framing smoking as a useless behavior, driven by biological addiction, which incurs massive losses with no gain, and is to be understood as a sign of lack of will, irrationality, or disease. This understanding stands in contrast to the multiple psychological and social uses that smoking can have – as attested in social research as well as biographical accounts. Smoking is used as a powerful resource for sociability, self-presentation and identity work (Bottorff, Oliffe, Kalaw, Carey, & Mroz, 2006; Desantis, 2003; Fry, Grogan, Gough, & Conner, 2008; Macnaughton, Carro-Ripalda, & Russell, 2012). The value of smoking may be even higher for socially marginal groups (Lawn, Pols, & Barber, 2002). While smoking cessation may not be the best stage of life to extol cigarettes as tools for friendship, creativity, and self-control, the ethical issue remains as to the limitations in self-understanding, understanding of other smokers, and appreciation of difficulties in giving up smoking, induced by a simplistic discourse on the nature of ‘psychological dependence’ (that remains largely undefined in the app body of knowledge).

The two European Council apps differ from the other couch-type modules insofar the body of advice reflects a broader understanding of the resorts of action. They include more tips on emotional work, guiding users to a more attentive observation of their thoughts and feelings, encouraging introspection and even introducing some concepts: ‘When you crave a cigarette, you're more susceptible to 'rationalisation': justifying a bad habit. Don't cling to it, seek a temporary distraction!’, ‘It's normal to feel panic from time to time. Are you afraid you'll lose part of your identity? Rest assured, you won't!’; ‘Stay calm! Is that anger you're feeling? Or is it fear? Don't walk away from your feelings. Observe them. Then they're easier to let go’; ‘A little resistance is normal. Put that feeling under a microscope. Why do you smoke? Is this a rational or more of an emotional choice?’; ‘You might sometimes glorify the past and miss smoking. This is nothing more than the 'rose-tinted spectacles’ phenomenon!’ (app 9). These examples are an illustration of the potential of apps to promote a sharper self-understanding - a potential that, for now, remains largely unrealized.

3.3.6 Moral deliberation and medicalization

At the higher level of moral deliberation, the question is: what values are promoted, explicitly or implicitly, by smoking-cessation app-based interventions? One of the relevant risks derives from medicalization (Conrad, 1992): promoting health and lack of disease as the dominant vocabulary of wellbeing, rendering other sources of value in life less visible.

Calculator modules are heavily dependent on health and also on financial indicators, adding consumerism to medicalization as an implicit moral orientation; smokers are continuously encouraged to consider the state of their body, in the present and in the

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future, and the state of their savings. Coach modules also focus on health and finance, but add encouragements concerning beauty and interpersonal relationships (‘Without smoking you will stay attractive much longer’, app 4; ‘When a craving comes, call a friend and take a few minutes to connect with him. Your spirits will be lifted and chances are you’ll perk them too’, app 22). The dominant virtue of smoking-cessation apps is strength of will, to which tips and pieces of advice refer as a resource to overcome cravings.

App 2 (‘Get Rich or Die Smoking’) is an interesting attempt to overcome a money-focused view of cessation benefits, encouraging users to convert their savings in a list of products (Figure 5 a). While the application title and the product list encourage a consumerist view of wellbeing, the app forum highlights users’ plans for their savings that often include travel, spending time with their significant others, or helping their family and friends, and other diverse projects – thus enlarging the view of what smoking cessation can contribute to the value of life (Figure 5 b).

Figure 5. Communication devices: product lists and forums in smoking-cessation apps

(a) Get Rich or Die Smoking (b) Get Rich or Die Smoking

Source: Screenshots published on Google Play. Photo courtesy of Tobias Gruber [grubsen@gmail.com]

As a consequence of their medicalizing perspective, most apps are also focused on the individual smoker, with little representation of the adverse effects that second-hand smoke has on others – humans but also non-humans, such as pet cats or dogs. Smoking is framed, implicitly, as an individual action that primarily affects the individual – and quitting, likewise, is framed as an individual’s decision about her or his own life. There is significant scope for improving apps representation of the effects of smoking and smoking cessation on other beings other than the individual smoker (C. Rughiniș & Rughiniș, 2014).

4 Conclusions

We examine how smoking-cessation apps mediate moral action for designers and users by shaping situations of choice as medium, market, and genre. We highlight specific moral

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issues, taking into account both the current state of app-based smoking-cessation persuasion, and the potential of the app medium.

In dialogue with previous assessments of ethics in persuasive technology and in public health interventions, we focus on the core value of autonomy for people who interpret the world and act with smoking-cessation apps. Apps communicate mostly in an anonymous ‘app voice’, complemented with pseudonymous peer voices in forums. Messages are fast and frugal as a property of the medium, thus raising issues of truthfulness. Moreover, smoking cessation apps open an ambivalent situation, in which game elements combine with scientific rhetoric, complicating users’ expectations of reasonable verity. Outside numerical messages, there is little presence of professional voices in the app environment, be it medical, psychological, sociological, literary or otherwise. There is also a virtual absence of personal voices of people speaking from experience under a personal name, either through text or audio or otherwise.

The app voice in the couch modules has relatively little to contribute to smokers’ self-understanding qua smokers, outside health-related trivia. The app voice relies more frequently than not on messages that stigmatize smoking and smokers, thus limiting the potential for understanding self and others as smokers. The dominant moral frame relies on the ‘cold-turkey’ lay medical theory, framing the ex-smoker as an individual hero who overcomes addiction through strength of will. App incentives often promote medicalization and commercialization of personal wellbeing.

The app medium offers substantial potential for assembling knowledge and advice about smoking and smoking cessation, for expressing diverse voices, including peer experiences and professional insights, and for encouraging users to personalize app messages shaping them into self-persuasion. Still, to date much of this potential remains unused.

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