title: Use of smoking cessation applications in China: a realist evaluation
title: The use of smoking cessation applications in China: a realist evaluation
titleType: AlternativeTitle
Creators: name: Zhang, Mengying
Publisher: name: The University of Edinburgh
Year: 2025
Subjects: subject: Smoking cessation
subject: Mobile applications
subject: Realist evaluation
subject: China
subject: User engagement

description: BACKGROUND: The epidemic of tobacco use has posed huge challenges to global public health. Consequently, tobacco control is crucial in achieving the United Nations Sustainable Development Goal 3 (good health and well-being). Smoking, as one of the most prevalent forms of tobacco use, is a leading cause of preventable morbidity and mortality worldwide. One measure of tobacco control is launching smoking cessation programmes, which have been recognised as an effective method to support individuals in quitting smoking. Smoking cessation programmes can be delivered through various approaches, including mobile applications (apps). According to the most updated data of the World Health Organization in 2024, China is the world's largest producer and consumer of tobacco, with over 30% of worldwide smokers coming from China. Given the high penetration rate of mobile phones in China, smoking cessation apps have great potential to assist Chinese smokers to stop smoking. Although the effectiveness of mobile health interventions in smoking cessation has been established by previous research, there is still a lack of research exploring how smoking cessation apps work. AIM: This study aims to examine what aspects of smoking cessation apps work for Chinese smokers, under what circumstances, and how. METHODS: The study employs the realist evaluation methodology and is composed of three stages. In stage one, two separate systematic reviews and six semi-structured interviews with Chinese health workers working in the field of smoking cessation were conducted to formulate initial programme theories (IPTs) in both the forms of ‘if...then...because...’ statements and Context-Mechanism-Outcome Configurations (CMOCs). In stage two, 24 semi-structured interviews were conducted with Chinese smokers who have experience using smoking cessation apps to test the IPTs. Stage three involved realist refinement of the IPTs leading to the development of refined programme theories, which proceeded by comparing the data with initial CMOCs deductively and identifying new constructs of programme theories inductively. The refined programme theories were presented in the form of CMOCs. Across this study, all semi-structured interview data were analysed using the thematic analysis approach. Ethics approval for the study was obtained from the University of Edinburgh. FINDINGS: In the context of being motivated to stop smoking and perceiving smoking cessation apps as a useful tool, smokers reported that engaging with the app features that tracked quitting achievements and health gains and showed the risks of smoking boosted their motivation and self-efficacy in smoking cessation, therefore supporting long-term abstinence. Social features within apps provided crucial informational and emotional support, proving particularly beneficial for smokers seeking social support. Engaging with the social features enhanced their motivation, confidence, and self-esteem, although poor management and regulation of these social platforms within apps can lead to reduced engagement and affect the support necessary to quit smoking. Although the withdrawal symptoms management features were intended to increase smokers’ skills to cope with withdrawal symptoms and clarify their craving patterns, the engagement level of these features was low. For those smokers who need the skills to prevent relapse and seek support within apps, the low intensity of intervention that lacks further guidance and personalisation may deter continuous use. This evaluation also found that good usability and user experience could boost user engagement levels, therefore improving smoking cessation outcomes. CONCLUSION: This evaluation has generated explanations of the use of smoking cessation apps among Chinese smokers. The programme theories can be useful resources for app developers to design apps that better meet user needs to help them recover from addictive behaviours.