Quitting smoking is one of the most challenging addictions to break. Early in my career, I worked with many longtime smokers who had successfully quit drugs like heroin and cocaine. Time after time, they would note the ways that quitting cigarettes was different—and much harder.
Decades of research have led to powerful cessation interventions, yet most smokers still try to quit on their own and only 4-7% are successful each year. On top of how addictive cigarettes are, the tobacco industry is constantly developing new products and deploying new marketing tactics to entice new customers and keep their existing ones.
What this means is that innovation in cessation interventions is critical to help tobacco users of all kinds break free from addiction. This innovation needs to focus both on making sure available treatments are used by more tobacco users and continuing to optimize treatment effectiveness.
The challenge for you as an HR benefits leader or wellness buyer is how to evaluate cessation programs that are marketed as “innovative.” You’ll want to ask questions about how appealing and engaging they are, but you’ll also want to dig into the science behind them.
As a non-profit public health organization dedicated to ending tobacco use, we support all evidence-based approaches that help people quit all forms of tobacco and nicotine.
Here are key considerations to keep in mind as you’re assessing the evidence behind new tobacco cessation programs for your people.
What we know works to help people quit
To evaluate innovation, you first need to understand the current evidence.
Since the Surgeon General’s first report on Smoking and Health came out in 1964, more than 8,700 scientific publications have addressed smoking cessation.
The 2020 Surgeon General’s Report on Smoking Cessation summarized the evidence regarding proven strategies to help smokers quit. Here’s a thumbnail sketch:
In addition to these strategies, the Community Preventive Services Task Force recently issued a statement that recommends text messaging interventions based on strong evidence of effectiveness in increasing tobacco cessation among adults interested in quitting. A systematic review showed meaningful improvements in smoking cessation outcomes measured at 6 or more months following a text messaging intervention. The task force found effective text messaging interventions provided tailored content, interactive features, or both.
Novel approaches in tobacco cessation
In the past few years, numerous companies have entered the health and wellness market with smoking cessation programs anchored around the use of a personal, handheld carbon monoxide monitor. Carbon monoxide (CO) is a colorless, odorless, and deadly gas that is produced with the burning of carbon-containing fuels. It’s found in things like vehicle exhaust, furnaces—and cigarette smoke.
Carbon monoxide can be measured from the exhaled air of smokers using a CO monitor, which has long been part of smoking cessation research. Smokers participating in a quit-smoking study who said that they had quit would be asked to use a CO monitor as a means of verifying their smoking status. CO levels below a certain level (usually 10 parts per million) would signal that someone was, in fact, smoke-free.
Several new commercial quit-smoking programs provide a personal device to participants, which they connect via Bluetooth to their smartphone for real-time feedback about the level of CO in their body. The rationale behind this approach is that these readings may make the health impact of smoking more salient and, thus, encourage cutting down and quitting.
But what does the science say?
- A few studies have shown that physiological monitoring and biological marker feedback can motivate quit attempts and a recent trial in Japan yielded promising quitting outcomes. But overall, there is little evidence to support the effectiveness of CO feedback in promoting cessation.
- A small study from the U.K. of the views and preferences among smokers regarding a CO smartphone system found that some smokers (including those who are motivated to quit) may interpret CO feedback as demotivating or permissive of smoking, as long as they are not scoring in the top range of CO values. There were also concerns about being embarrassed to use the device in public.
Mobile apps are another relatively new entrant to the commercial quit smoking market. Roughly 8 in 10 U.S. adults own a smartphone and roughly 90% of mobile time is spent using apps, making mobile apps an appealing channel to reach and engage smokers with treatment.
Indeed, there are hundreds of quit-smoking apps available for both iPhone and Android devices. Mobile apps are often quite simplistic, providing simple tools like calculators to track money saved and health benefits accrued, calendars to track days until/since a quit attempt, and trackers to help structure the process of cutting back.
But do they work?
- The Surgeon General’s report concluded that “the evidence is inadequate to infer that smartphone apps for smoking cessation are independently effective in increasing smoking cessation.”
- A number of studies have reviewed the content of mobile apps and found that in general, they do not incorporate evidence-based practices and they are not very “smart” in that they commonly fall short of providing tailored feedback despite users’ preference for it. Unfortunately, these limitations have been noted for over 5 years, reflecting little progress in apps for smoking cessation.
That’s not to say that there hasn’t been any progress. A randomized trial showed the effectiveness of a mobile app grounded in Acceptance and Commitment Therapy, and several other academic groups have shown promising early results from mobile apps that incorporate proven behavior change techniques and show promise among socioeconomically disadvantaged adults and cancer patients. Given the ubiquity of mobile apps, this is an area of innovation to watch.
3 things to look for in innovative tobacco cessation programs
- High-quality scientific evidence. As a buyer, you’re obviously looking for a program that works. The gold standard for demonstrating effectiveness is the randomized trial, where smokers are randomly assigned either to the program being studied or to a comparison program. The process of randomization allows program designers to say, “all things being equal, our program outperformed this other kind of program.”
You’ll also want to pay attention to what that “other” program is. The most rigorous comparison program is an active intervention that is considered standard-of-care rather than a no-treatment control. It’s easy to outperform no treatment.
It’s also important that a randomized trial have enough participants to show that the impact of a program is robust. Qualitative research, online surveys, and single group cohort studies do not meet these standards.
Finally, a strong track record of peer-reviewed publications is another level of rigor to look for and demonstrates a commitment to advancing the science, not just to selling a product.
- Relevant scientific evidence. Next, you’ll want to evaluate the extent to which the effectiveness of a specific program is likely to apply to your population.
Studies that involve a complicated enrollment process may be testing an intervention among a highly motivated group of smokers. Monetary incentives can also influence the type of smoker that joins a study.
Program effectiveness among highly motivated or financially incentivized smokers may not reflect the potential impact it would yield when implemented under real world conditions.
- Transparency of evidence. Lastly, it’s important to gauge the extent to which commercial interests may be influencing the presentation of scientific evidence. Look for programs that make their study protocols publicly available through national registries like ClinicalTrials.gov or the International Committee of Medical Journal Editors.
Registering a study protocol requires investigators to state their hypotheses before the study starts, specify the primary outcomes, and describe how they will be measured. In other words, it minimizes potential biases.
With more than 50 million people in the U.S. still using tobacco, getting proven treatments into the hands of all tobacco users is a top public health priority. As an employer, you have a unique opportunity to support your employees and their dependents who smoke with proven interventions that they actually want to use.
Want more insights on what to look for when buying a tobacco cessation program for your population? Download The Buyer’s Guide for Workplace Smoking Cessation Programs.