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. 2024 Nov 9;48:102925. doi: 10.1016/j.pmedr.2024.102925

Can a smoking cessation app benefit individuals in disadvantaged areas? A qualitative study on motivation, barriers, and perceptions of a digital app

Nina Åsbring a,⁎, Samira Dini a, Stephanie Madsen a, Joanna Stjernschantz Forsberg a,b
PMCID: PMC11615897  PMID: 39634283

Abstract

Objective

In Sweden, the prevalence of daily smoking has decreased substantially over the past few decades. However, a socioeconomic divide is evident, contributing to health inequities. The current study focuses on the needs, facilitators, and barriers in relation to quitting smoking among individuals in disadvantaged areas and explores their perception of digital tools for smoking cessation.

Method

Semi-structured interviews were conducted with 30 participants in Stockholm County between 2022 and 2023. Participants were recruited through health care centres, dental clinics, and civil society actors. A thematic analysis was performed.

Results

Two cross-cutting main themes were identified; 1) Motivational factors and barriers in smoking cessation, including the subthemes “health, concern for loved ones and economic aspects” and “emotional, environmental, and cultural barriers” and 2) Benefits and limitations of a digital tool for smoking cessation, including the subthemes”important/relevant features in a digital app” and “limitations of digital support”.

Conclusions

The results reveal that most participants want to quit smoking but perceive it as difficult. The study highlights the importance of addressing social disparities in smoking and the need for accessible smoking cessation support. While mobile apps are viewed as promising for smoking cessation by some of the participants, scepticism exists among others. Moving forward, personalized approaches that integrate digital tools with traditional methods for smoking cessation can be important to reduce smoking prevalence. Ensuring accessibility of effective smoking cessation support for all is a key public health interest.

Keywords: Qualitative, Interviews, Smoking cessation, Digital tool, Mobile app, Low SES areas

1. Introduction

In 2020, the number of people who smoked cigarettes was 991 million globally (World Health Organization, 2021). Smoking is estimated to result in eight million deaths annually (World Health Organization, 2023a), including 1.3 million due to passive smoking (World Health Organization, 2023b). However, notable differences exist among countries, with 80 % of people who smoke living in low- and middle-income countries (World Health Organization, 2023a). Previous research consistently links smoking to socioeconomic status across regions, ages, and genders (Casetta et al., 2017, World Health Organization, 2014). In Sweden, the prevalence of daily smoking among adults has shown a significant decline, from approximately 20 percent in 2000 to six percent in 2021. Despite this promising trend, smoking remains a leading cause of preventable deaths (The National Board of Health and Welfare, 2014). Moreover, a pronounced socioeconomic divide is evident (The Public Health Agency of Sweden, 2023a). A striking 12 % of individuals with low level of education smoke, contrasting with 2 % among individuals with high education. Smoking is also more common among people with low income, as well as among people who are unemployed or foreign-born (The Public Health Agency of Sweden, 2019, Zetterqvist, 2023). This contributes to health inequities (U.S. Department of Health and Human Services, 2014, Gallo et al., 2012). The prevalence of smoking in Stockholm is similar to Sweden as a whole, with the same socioeconomic stratification (The Public Health Agency of Sweden, 2023b). In 2021, around 11 percent of men and women aged 16 to 64 smoked daily in Rinkeby-Kista, an area characterized by low socioeconomic status. In contrast, less than two percent smoked in Danderyd, an affluent area within the county (Centre for Epidemiology and Community Medicine, 2024).

A study by Kotz and West (2009) demonstrated lower quit rates among individuals with low socioeconomic status (low-SES), but that this is not a result of fewer attempts to quit but of poorer success rates. Factors that have been identified to impede cessation in low SES-groups include higher levels of nicotine dependence, lower motivation, lack of support, smoking being normalized, lower adherence to treatment, stressful living conditions and using smoking as a coping mechanism (Hiscock et al., 2012).

Smoking cessation at any time in life improves health and decreases mortality caused by smoking (U.S. Department of Health and Human Services, 2020, Doll et al., 2004). Securing accessibility of effective smoking cessation support is therefore a major public health interest. Interventions incorporating modern technologies such as web-based programs, m-health (mobile communications technologies and mobile phones to support health care) have been developed during the last decade(s) (Whittaker et al., 2019, Guo et al., 2023, Mersha et al., 2021). Such interventions have the benefit of being easily accessible to large numbers of people who may not otherwise seek cessation support. Using mobile apps can also contribute to more flexible support, that can be tailored to individual needs. However, systematic reviews and meta-analyses have not provided clear evidence of effectiveness of stand-alone smoking cessation apps (Whittaker et al., 2019, Guo et al., 2023, Mersha et al., 2021).

The objective of the current study is to explore the specific needs of individuals in low SES groups in Stockholm County to quit smoking. It explores their history of smoking, personal facilitators, and barriers. Furthermore, it explores their perception of a digital tool and how it could function as semi-individualized smoking cessation support. The study is part of a project that aims to develop and evaluate a digital tool for smoking cessation through a collaborative, co-creative approach involving experts, healthcare providers, and representatives from the target group in disadvantaged areas. The interviews contribute with valuable insights that can be used in the development of the digital tool.

2. Methods

2.1. Study design

A qualitative explorative design was used.

2.2. Context

The study was conducted in Stockholm County in Sweden. Socioeconomically disadvantaged areas with high prevalence of adults who smoke daily were selected (Centre for Epidemiology and Community Medicine, 2024). A Care Need Index (CNI) was used to identify primary healthcare centres that enlisted a high proportion of patients with low socio-economic status to assist in participant recruitment (Sundquist et al., 2003). CNI is a tool that uses socioeconomic conditions to identify risk of ill health and is used for healthcare reimbursements.

2.3. Data collection

Ethical approval was obtained for this study (see Ethics statement).

An interview guide was developed, and a reference group consisting of tobacco cessation specialists and representatives from relevant organizations working in the communities was invited to provide feedback on themes and questions. This was done to ensure trustworthiness of the study, alignment of interview questions in relation to research objectives, and appropriateness in the study context. The interview guide included background variables (age, gender, social situation, education, daily activities, smoking history, and habits etc.), general situation in relation to smoking, environmental factors affecting the person's smoking, previous attempts to quit smoking, perceptions of support needed, how digital support (an app) might be of help.

Initially healthcare practitioners at six primary healthcare centres with high CNI-index were asked to consecutively approach patients that were current tobacco smokers, 18 years or older and had no severe psychiatric disease. One member of the staff at each test site was asked to initiate the recruitment by screening for tobacco smoking in consecutive patients. Then, the researchers contacted the persons that were interested in participating to arrange time and place for an interview. Due to high workload following the covid pandemic, three of the centres were not able to prioritize recruitment of patients, and the remaining three had difficulties recruiting participants. The strategy was therefore broadened to also include participants recruited by dental clinics, municipal, and non-profit organizations, civil society actors and the Swedish national tobacco quit line. Also, the possibility of snowball sampling was used. This is a method where participants are asked to recruit additional people they know (Kvale, 2007). However, only one person, was recruited through this method.

Semi-structured individual interviews were conducted with 30 participants by five interviewers, between June 2022 and June 2023. The researchers and research assistants that conducted the interviews had training in qualitative methods, public health, and tobacco cessation counselling. One of the interviewers was Arabic speaking. Written informed consent was obtained from all participants. The interviews were conducted face-to-face at a location convenient for the participant (e.g. healthcare centres, libraries, other local facilities), and lasted between 20 and 45 min, in average 30 min. Data was collected until saturation was reached. Participants received a voucher worth 200 Swedish crowns (approximately 17,5 Euros). In connection with the interviews the participants were offered smoking cessation support by the Swedish national tobacco quit line.

2.4. Data analysis

The interviews were audio-recorded and transcribed verbatim. Thematic analysis was performed (Braun and Clarke, 2006). Thematic analysis is a useful approach when examining people’s views, opinions, knowledge, and experiences. The phases of thematic analysis are 1) familiarizing yourself with your data, 2) generating initial codes, 3) searching for themes, 4) reviewing themes, 5) defining and naming themes and 6) producing a report (Braun and Clarke, 2006). Transcripts were, thus, independently, and repeatedly read by three of the authors familiarizing themselves with the data. Initial codes were discovered and noted down. Data relevant to each code was then collected. After joint discussion the codes were sorted into preliminary themes and data relevant to the themes was gathered. A thematic map with overarching themes and sub-themes was compiled. The material was re-examined, and the themes were reviewed after the authors had read each other's data analysis to ensure validity. Thereafter, the data analysis was discussed until consensus was reached and themes were perceived as concisely describing the content and clearly defined and distinct from one another. Finally, citations representing the themes and sub-themes were selected and sorted under the relevant themes.

3. Results

30 participants in total were interviewed, 21 men and nine women. Four were Arabic, two English and one Turkish speaking (this interview was conducted with an interpreter). The ages of the participants varied between 20–79 years, with a mean age of 50 years. Six of the interviewees had basic elementary school education while the majority (n = 16) had secondary education. Five had tertiary education. The educational level of three participants was not documented. Five persons were recruited through health care centres, four through dental practices and 21 persons via the Swedish national tobacco quit line visiting organizations in the local community.

Two cross-cutting main themes were identified in the analysis:

  • 1.

    Motivational factors and barriers for smoking cessation

  • 2.

    Benefits and limitations of a digital tool for smoking cessation

Within these overarching themes, four sub-themes were identified. Theme 1: (a) Health, concern for loved ones, and economic aspects, (b) Emotional, environmental, and cultural barriers. Theme 2: (c) Important/relevant features in a digital app, (d) Limitations of digital support.

3.1. Motivational factors and barriers in smoking cessation

The first two sub-themes highlight motivational factors that inspire individuals to embark on the journey of smoking cessation, as well as the barriers they encounter along the way.

3.1.1. Theme: Health, concern for loved ones and economic aspects

The interviews shed light on different motivations for smoking cessation. Many participants were motivated by health issues, expressing a desire to maintain or improve overall health.

“When I was 20–30 years old, I didn't notice any difference, but now that I'm 40, I can't run or be active as much. I feel like it's affecting my health very negatively… I want to quit smoking. There's a chance I'll end up damaging my lungs”. (Man, 40).

Furthermore, participants were motivated by the impact of their smoking on other people. A desire to quit for the sake of family, friends, and colleagues was often described. The aspiration to set a positive example, could be a powerful motivator.

“… For my daughter's sake. I don't want her to start smoking either. So, I have to show her that one does not smoke, you know what I mean. Children do as one does, not as one says.” (Man, 44).

Participants also brought up economic factors playing a role. A nuanced relationship between addiction and economic considerations surfaced, revealing that the cost of cigarettes was compared with the cost of basic supplies.

“That's a lot of money for cigarettes, that's why I want to quit. It's not cheap. It's food money”. (Man, 54).

Support from other people, such as a friend or health professional could, according to some participants, facilitate smoking cessation. All things considered, the true motivation within oneself, was seen as a crucial aspect in smoking cessation.

” For me, nothing will help me as my will can. If I make up my mind, I think I'll succeed”. (Man, 43).

3.1.2. Theme: Emotional, environmental and cultural barriers

Participants discussed how stress and a challenging life situation influence their smoking habits, using cigarettes to cope with various emotional states.

“I'm just waiting for better times. If I'll feel better, I maybe won't even think about these cigarettes. It [the cigarette] shouldn't be stronger than me. But now, I need it”. (Woman, 55).

Furthermore, participants expressed a desire for daily activities, such as a job, suggesting that it could positively influence their efforts to quit smoking.

“The motivation for me is right there, I have to have something to do, a job or something”. (Man, 45).

Participants also discussed the significant impact of their immediate environments on their attempts to quit smoking. Many of them recognized that there are a lot of people who smoke in the area they live in, and some of them stated that they only socialize with those people. These circumstances can create more challenges to stop smoking.

“All my friends smoke, and at home my dad smokes, these are factors that hinder me”. (Woman, 43).

According to some participants, there seems to be a difference in smoking behaviour between socially deprived areas and more affluent ones.

“Where I live, every day someone comes to ask about cigarettes, a lot of young people and also older people … if you compare to the city, there are not so many people who smoke, but it's in the suburbs […] So I think it's very difficult in these deprived areas”. (Man, 72).

Participants also notes smoking attributes in socially disadvantaged areas.

“All our properties they have an ashtray in each gate. When I go out and on my way into the local center and if I feel like smoking, I usually sit down on a rock right next to the parking lot. Then I see everywhere, the floor, trash can, full of cigarette butts”. (Man, 75).

Some participants shared cultural norms of smoking in their community. These norms could pose specific challenges, further complicating attempts to quit smoking.

“In Alby, Fittja, Norsborg [three socioeconomically disadvantaged areas in Stockholm County], there is a lot of smoking. I believe that unemployment and “old culture” [plays a role]. That older people, they have smoked in their countries, and they come here and continue to smoke, and it becomes like a vicious circle”. (Man, 45).

3.2. Benefits and limitations of a digital tool for smoking cessation

The final two sub-themes focus on features of a digital tool for smoking cessation, exploring both potential benefits and limitations.

3.2.1. Theme: Important/relevant features in a digital app

Some participants highlighted the value of mobile apps in overcoming barriers to accessing smoking cessation counselling. They expressed convenience of having an app on their mobile phones close at hand, with emphasis on time efficiency and easing of burdens, particularly beneficial for individuals with a challenging or busy life.

“I think it's good that you always have your mobile phone with you. You can read information and gain a lot of knowledge. That's a good idea… If you're stressed and don't have much time in your everyday life, it's easier to use an app than to go to different places and talk to people.” (Man, 40).

Participants also stressed potential benefits of a smoking cessation app, including features that track financial savings and health improvements. These features could possibly motivate them further.

“I think if there is an app, if it tells us how much money we are saving because of not smoking and the health benefits. Like.. if you have not smoked in 20 min your blood pressure is normalized […] Now you have regained your sense of smell, which is great, continue like that. Such small notifications or reminders will help me to stay on the path”. (Man, 38).

Participants expressed a preference for app-content being short in text, as opposed to lengthy information. Visuals and illustrations were emphasized as valuable, enhancing clarity and accessibility of the information provided. A digital tool was also thought to be in line with ways to communicate today.

“I believe that a general trend today, is using more of audios and visuals, as we have entered a bit into a multimedia society. Reading is not the thing anymore. I think people, in general, are getting tired of it. […] I believe videos are most helpful.” (Man, 53).

The idea of creating a forum where people who want to quit smoking can connect, share their cessation experiences, and offer mutual advice and motivation was considered valuable by some of the participants. Also, some believed that learning about others' journeys could offer valuable insights, motivation, and practical advice for their cessation efforts.

“So, in the app, if you can read about other smokers, their habits, what they have done, can be good to have. People who have smoked longer than me, and people who have tried hard to quit smoking.” (Man, 34).

Participants also emphasized the importance of support from a tobacco cessation counsellor accessible through the app when needed. Additionally, anxiety management and advice via messages within the app was perceived to be helpful.

“When I am in a stressful situation, I go to the app and hear like calm music or somebody saying something very calmly and explaining to me, maybe a recorded message, I do not know, then I may feel okay”. (Man, 38).

3.2.2. Theme: Limitations of digital support

Some of the participants were sceptical about using digital tools for quitting smoking. They expressed a preference for face-to-face communication and support. The need for real-time, tangible support from a person, rather than virtual assistance, was highlighted as a crucial factor.

“I want to have personal contact. […] It's the important contact. That you can talk with someone and agree on this and that. I believe in that rather than you are doing this digital thing. I don't think it will be the same”. (Man, 72).

Also, there was thought to be a difference regarding this aspect in different age-groups.

There might be generational differences concerning the interest using an app […] Maybe older people, for them maybe it is better to just call somebody and talk with them”. (Man, 38).

Furthermore, some participants had doubts about how helpful apps could be when they really craved a cigarette. Some believed that in those tough moments, for example using nicotine replacement products, would bring quicker relief compared to relying on a mobile app.

“If you're a smoker… Then it's not the phone you're thinking about, oh, I'll go to an app, but it's a cigarette. In such cases to talk about it I personally don't think will help to stop smoking. Then it's better to take a [nicotine] chewing gum.” (Woman, 57).

4. Discussion

Smoking prevalence is generally higher among socioeconomically disadvantaged groups and therefore they face higher exposure to tobacco’s harms. Additionally, quit attempts in these groups have been shown to be less successful (Kotz and West, 2009, Hiscock et al., 2012). However, the findings from the interviews in this study show that despite these challenges, most of the participants express a desire to quit smoking at some time, mainly for health reasons but also for concern for others, particularly family members. These findings align with previous research (Jiang et al., 2022). Economic factors also play a significant role in the desire to quit, due to the high cost of cigarettes (cf. Widome et al., 2015). However, participants report, that when facing challenging life circumstances motivation for smoking cessation tends to decrease and is perceived to be more difficult (cf. Santiago-Torres et al., 2022). Many people who smoke in the immediate environment as well as cultural norms are also believed to influence smoking behaviours. Socially disadvantaged areas often have a high proportion of people who smoke (Centre for Epidemiology and Community Medicine, 2024) and some participants believed that individuals from countries where smoking is prevalent may carry these habits to their new environment (cf. Peiris et al., 2019).

According to participants, factors that could make it easier to quit smoking include high motivation, a stable life situation, and engagement in daily activities, such as having employment. Some participants believed that digital tools such as mobile apps could be helpful. The convenience of having support close at hand and the potential of an app to assist individuals at their own pace were highlighted as advantages (cf. Jiang et al., 2022). However, a few participants also expressed scepticism about the effectiveness of an app as a stand-alone solution and emphasized the significance of having access to a tobacco cessation counsellor. Studies have shown that a combination of eHealth and face-to-face support is a promising method (Meijer et al., 2021, Lepore et al., 2021). Nevertheless, several participants preferred interpersonal communication and opposed the idea of digital support for smoking cessation altogether, notably middle-aged, and older people. When it comes to preferable functions of an app for smoking cessation the participants stated that it should be easy to use and include many pictures, audio files, and videos. Such features were desirable as opposed to much text. Studies reveal that simplicity and user-friendliness are highly valued features in apps (Coughlin et al., 2016, Stanczyk et al., 2013). Coping strategies, stress management, and motivational feedback are other examples of preferable functions mentioned by participants (cf. Businelle et al., 2016).

4.1. Considerations

As the prevalence of daily smoking decreases, smoking has become an increasingly segregated behaviour, with a significant divide between affluent and disadvantaged groups. Ensuring access to effective smoking cessation support for all is a major public health interest. Mobile phone-based cessation support seems to be desirable by some participants in this study (cf. Brown et al., 2014). However, scepticism about using an app for smoking cessation was expressed by several participants, although some acknowledged the value of an app that also could facilitate contact with a tobacco counsellor (cf. Meijer et al., 2021, Vidrine et al., 2019). An app for smoking cessation should not, therefore, be viewed as a stand-alone solution, but as a complement to traditional tobacco cessation counselling that involves personal contact, to meet different needs.

Furthermore, tailored smoking cessation interventions may be beneficial for individuals in low SES areas, addressing specific challenges that might exist such as coping with stressful living conditions or lacking time or energy. An app that is easy to use and navigate, without demanding tasks to perform, that contains audio files, images, and videos easily accessible in real-time might be helpful (cf. Boland et al., 2018).

4.2. Limitations

First, many participants were not familiar with digital tools for smoking cessation. Therefore, it was difficult for them to imagine how an app would function. Interviewers often initiated discussions with questions such as “What do you think about an app for smoking cessation? And “What kind of functions do you think could be helpful in such an app?” However, if the participants were unable to provide answers interviewers often asked about specific functions and how they would appeal to the participant. Hence, leading questions may have been used. This is sometimes seen in research exploring issues that are not yet fully formulated (Peng et al., 2016). Participant́s responses might have been influenced by social desirability bias, leading them to provide answers they believed were expected or favourable, rather than reflecting their true attitudes or behaviours.

Additionally, while most of the participants lived in low SES-areas within Stockholm County, not all of them had low socioeconomic status. For example, a few of the participants had higher education which is, according to regional statistics (Centre for Epidemiology and Community Medicine, 2024), not so common in these areas. Hence, this study mainly focused on low SES-areas, not low SES on the individual level.

Focusing recruitment efforts on individuals in areas with low SES was a deliberate choice in this study. While this approach aligns with the study’s objectives, it also poses limitations in terms of sample size and diversity. There are, for example, many foreign-born people living in the recruitment areas, and in these groups, it is more common that men smoke than women. Therefore, the selection is somewhat skewed with more men than women.

Also, small sample size and homogenous recruitment areas limit the external generalizability of the results, as is often the case in qualitative explorative studies (Patton, 2014). However, the results of the study are in line with previous research regarding motivational factors and barriers experienced by individuals in low SES groups who smoke (Kotz and West, 2009) and can offer valuable insights in the development of a digital tool for smoking cessation.

5. Conclusion

The results of this study reveal that many participants would like to quit smoking at some time but perceive it as challenging, partly due to difficult life situations. The study highlights the importance of addressing social disparities in smoking behaviour and the need for accessible smoking cessation support. Moving forward, personalized approaches that integrate digital tools with traditional methods for smoking cessation can be important for reducing smoking prevalence across diverse populations, increasing treatment exposure, and reducing tobacco-related health disparities. Further research is needed, particularly focusing on individuals living in socioeconomically disadvantaged areas. By acknowledging challenges that exist and using technology effectively, smoking cessation support can become more inclusive and effective for all. This is a key public health interest.

6. Ethics statement

Approval for the study was obtained from the Swedish Ethical Review Authority [Dnr. 2022–00856-01 and 2022–05830-02].

CRediT authorship contribution statement

NinaÅsbring: Writing – review & editing, Writing – original draft, Project administration, Methodology, Investigation, Formal analysis. Samira Dini: Writing – review & editing, Writing – original draft, Project administration, Methodology, Investigation, Formal analysis. Stephanie Madsen: Writing – review & editing, Writing – original draft, Investigation, Formal analysis. Joanna Stjernschantz Forsberg: Writing – review & editing, Supervision, Project administration, Funding acquisition, Conceptualization.

Funding

This work was funded by FORTE: Swedish Research Council for Health, Working Life and Welfare [grant number: STY-2021/0005, date: 2021–09-30].

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

This work was funded by FORTE: Swedish Research Council for Health, Working Life and Welfare. The authors would also like to express their gratitude to the following persons that have contributed to the research project: Mariam Al-Qurashi, Rosaria Galanti, Henna Hasson, Sebastian Nykvist, and Markus Saarijärvi. We are also grateful for all the participants that agreed to be interviewed.

Data availability

The data that has been used is confidential.

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