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Tobacco use continues to be the leading preventable cause of death, disease, and disability in the United States. Since 2000, Washington state has offered free tobacco “quitline” services to help its residents stop using tobacco. In 2015, the state began offering free access to a tobacco cessation smartphone app to absorb excess quitline demand. Since most publicly funded tobacco cessation programs are designed to provide access to populations disproportionately impacted by tobacco use, it is important to consider who these public health interventions reach.
The aim of this study is to understand who used a free cessation app and the extent to which users represented populations disproportionately impacted by tobacco use.
This is an observational study of 1280 adult Washington state residents who registered for and activated the cessation app. Demographic data were collected as part of the sign-up process, examined using standard descriptive measures, and assessed against state-level surveillance data for representativeness.
Participants were primarily non-Hispanic White (978/1218, 80.3%), identified as female (780/1236, 63.1%), were between ages 25-54 years (903/1186, 76.1%), had at least some college education (836/1222, 68.4%), and reported a household income under US $50,000 (742/1055, 70.3%). Fewer respondents were from rural counties (359/1220, 29.4%); identified as lesbian, gay, bisexual, pansexual, queer, questioning, or asexual (LGBQA; 153/1222, 12.5%); were uninsured (147/1206, 12.2%); or were currently pregnant, planning pregnancy, or breastfeeding (42/624, 6.7%). However, relative to available state data for tobacco users, there was high representation of women, 35- to 54-year-olds, college graduates, and LGBQA individuals, as well as individuals with low household income, poor mental health, Medicaid insurance, and those residing in rural counties.
A diverse population of tobacco users will use a free cessation app, including some demographic groups disproportionately impacted by tobacco use. With high reach and high efficacy, it is possible to address health disparities associated with tobacco use and dependence treatment among certain underserved and at-risk groups.
Smoking and secondhand smoke exposure in the United States lead to approximately 480,000 deaths each year [
Among US adults in 2019, cigarette smoking (14%) was the most common form of tobacco use, followed by electronic cigarettes (e-cigarettes; 4.5%), cigars (3.6%), smokeless tobacco (2.4%), and pipes (1%) [
Over the last several decades, the rate of smoking has declined largely due to tobacco control policies such as tobacco taxes, smoke-free workplaces and spaces, public awareness campaigns, and the availability of effective cessation treatments [
In 2000, the WA Department of Health (DOH) started one of the first state quitlines in the United States [
The present study is a real-world observational study based on data from 1280 WA residents who registered for and activated the 2Morrow Health Smoking & Tobacco app (2Morrow Inc) between October 1, 2018, when the DOH last updated its sign-up process and questions, through December 31, 2020. Demographic data were collected as part of the sign-up process (described below), examined using standard descriptive measures, and compared to the overall WA tobacco user population. The Washington State Institutional Review Board determined that this study did not constitute human subject research and was deemed exempt from the associated ethical requirements (2021-044).
The 2Morrow Health Smoking & Tobacco app (
2Morrow Health Smoking & Tobacco app. NRT: nicotine replacement therapy.
Promotional efforts varied throughout the 27 months for which sign-up data were examined, but generally relied upon the DOH website and business card–sized promotional materials distributed to the public through DOH tobacco prevention contractors. All promotional messaging directed prospective users to the DOH website using a short URL. This webpage linked them to the sign-up survey hosted on the 2Morrow website (
Excerpts from app sign-up page.
Demographic data were collected during sign-up. In addition to a question that requires prospective users to confirm that they live in WA, the sign-up survey includes as many as 16 optional demographic questions. Demographic data collected includes the following: age group, sex and gender, sexual orientation, race and ethnicity, education level, county, household income level, source of health care coverage (if any), mental health status, and type(s) of tobacco used. Prospective users who indicated a female sex assignment at birth were also asked if they are currently pregnant, planning pregnancy within the next 3 months, and/or breastfeeding.
Many questions were based on those used in the state’s Behavioral Risk Factor Surveillance System (BRFSS) surveys [
Counties with a population of less than 100 persons per square mile and counties smaller than 225 square miles were categorized as rural [
Characteristics of October 2018 to December 2020 tobacco cessation app users and 2020 Washington state (WA) tobacco users.
Characteristic | App users, N=1280 | WA tobacco users | |||||
Value, n (%) | 95% CI | Value (%)a | 95% CI |
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Female | 780 (63.1) | 60.3-65.8 | 42.4 | 39.5-45.4 | <.001 | |
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Male | 441 (35.7) | 33-38.4 | 57.4 | 54.4-60.3 | <.001 | |
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Nonbinary/other | 15 (1.2) | 0.7-2 | N/Ab, c | N/A | N/A | |
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Not reportedd | 44 | N/A | N/A | N/A | N/A | |
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18-24 | 77 (6.5) | 5.2-8 | 11.1 | 9.2-13.2 | <.001 | |
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25-34 | 256 (21.6) | 19.3-24 | 22.8 | 20.2-25.6 | .50 | |
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35-44 | 349 (29.4) | 26.8-32.1 | 19.7 | 17.4-22.2 | <.001 | |
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45-54 | 298 (25.1) | 22.7-27.7 | 16.8 | 14.8-18.9 | <.001 | |
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55-64 | 173 (14.6) | 12.6-16.7 | 16.9 | 14.9-19 | .12 | |
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65 and up | 33 (2.8) | 1.9-3.9 | 12.7 | 10.9-14.6 | <.001 | |
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Not reported | 94 | N/A | N/A | N/A | N/A | |
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Less than high school | 77 (6.3) | 5-7.8 | 12.4 | 10.3-14.8 | <.001 | |
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High school graduate or GEDe | 309 (25.3) | 22.9-27.8 | 32.2 | 29.4-35 | <.001 | |
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Some college | 485 (39.7) | 36.9-42.5 | 40.7 | 37.8-43.7 | .62 | |
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College graduate | 351 (28.7) | 26.2-31.4 | 14.8 | 13-16.6 | <.001 | |
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Not reported | 58 | N/A | N/A | N/A | N/A | |
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Less than 15,000 | 270 (25.6) | 23-28.3 | 10.2 | 8.6-12.1 | <.001 | |
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15,000-24,999 | 189 (17.9) | 15.6-20.4 | 17.6 | 15.3-20.1 | .86 | |
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25,000-34,999 | 154 (14.6) | 12.5-16.9 | 11.6 | 9.6-13.9 | .05 | |
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35,000-49,999 | 129 (12.2) | 10.3-14.4 | 14.8 | 12.7-17.1 | .09 | |
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50,000-74,999 | 139 (13.2) | 11.2-15.4 | 15.5 | 13.2-18 | .14 | |
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75,000 or more | 174 (16.5) | 14.3-18.9 | 30.3 | 27.4-33.3 | <.001 | |
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Not reported | 225 | N/A | N/A |
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Hispanic (all races) | 78 (6.4) | 5.1-7.9 | 7.2 | 5.7-9 | .43 | |
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American Indian/Alaska Native (NHf) | 21 (1.7) | 1.1-2.6 | 3.3 | 2.3-4.5 | .02 | |
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Asian (NH) | 35 (2.9) | 2-4 | 5.4 | 3.7-7.4 | .02 | |
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Black (NH) | 35 (2.9) | 2-4 | 5.3 | 3.9-7 | .01 | |
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Multiracial (NH) | 60 (4.9) | 3.8-6.3 | 3.2 | 2.4-4.2 | .02 | |
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Native Hawaiian/Pacific Islander (NH) | 11 (0.9) | 0.5-1.6 | 1.3 | 0.7-2.1 | .37 | |
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White (NH) | 978 (80.3) | 77.9-82.5 | 73.7 | 70.8-76.4 | <.001 | |
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Not reported | 62 | N/A | N/A | N/A | N/A | |
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Heterosexual | 1069 (87.5) | 85.5-89.3 | 90.8 | 89-92.5 | .01 | |
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LGBQAg | 153 (12.5) | 10.7-14.5 | 9.2 | 7.5-11 | .01 | |
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Not reported | 58 | N/A | N/A | N/A | N/A | |
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Less than 14 days of poor MH in the past month | 715 (64.4) | 61.5-67.2 | 74.4 | 71.6-77 | <.001 | |
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14 or more days of poor MH in the past month | 395 (35.6) | 32.8-38.5 | 25.6 | 23-28.4 | <.001 | |
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Not reported | 170 | N/A | N/A | N/A | N/A | |
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Currently pregnant, planning pregnancy, or breastfeeding | 42 (6.7) | 4.9-9 | N/A | N/A | N/A | |
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Not currently pregnant, planning pregnancy, or breastfeeding | 582 (93.3) | 91-95.1 | N/A | N/A | N/A | |
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Not reported | 169 | N/A | N/A | N/A | N/A | |
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Employer or union health plan | 412 (34.2) | 31.5-36.9 | 41.6 | 38.6-44.7 | <.001 | |
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Individual or family health plan | 86 (7.1) | 5.7-8.7 | 6.2 | 4.8-7.9 | .41 | |
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Medicaid | 356 (29.5) | 27-32.2 | 18.8 | 16.5-21.3 | <.001 | |
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Medicare | 140 (11.6) | 9.9-13.6 | 15 | 13-17.1 | .01 | |
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None (uninsured) | 147 (12.2) | 10.4-14.2 | 12.5 | 10.5-14.8 | .82 | |
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Other | 31 (2.6) | 1.8-3.6 | 2.6 | 1.8-3.5 | >.99 | |
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TRICARE, Veteran’s Affairs, or military | 34 (2.8) | 2-3.9 | 3.3 | 2.2-4.7 | .58 | |
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Not reported | 74 | N/A | N/A | N/A | N/A | |
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Nonrural counties | 861 (70.6) | 67.9-73.1 | 75.1 | 72.7-77.3 | .01 | |
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Rural counties | 359 (29.4) | 26.9-32.1 | 24.9 | 22.7-27.3 | .01 | |
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Not reported | 60 | N/A | N/A | N/A | N/A | |
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Cigarettes | 1133 (90.9) | 89.1-92.4 | 70.3 | 67.5-73 | <.001 | |
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E-cigarettej or vapor product | 172 (13.8) | 11.9-15.8 | 31.3 | 28.5-34.2 | <.001 | |
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Smokeless tobacco | 64 (5.1) | 4-6.5 | 16.0 | 13.9-18.2 | <.001 | |
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Multiple (2 or more of cigarettes, e-cigarettes, and smokeless tobacco) | 155 (12.4) | 10.6-14.4 | 15.6 | 13.4-18 | .03 | |
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Multiple (2 or more of any product) | 202 (16.2) | 14.2-18.4 | N/A | N/A | N/A | |
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Cigars, cigarillos, and little cigars | 74 (5.9) | 4.7-7.4 | N/A | N/A | N/A | |
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Pipe | 20 (1.6) | 1-2.5 | N/A | N/A | N/A | |
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Other | 32 (2.6) | 1.8-3.6 | N/A | N/A | N/A | |
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None selected/not reported | 33 | N/A | N/A | N/A | N/A |
aData in this column are from Washington state’s Behavioral Risk Factor Surveillance System (BRFSS) surveys. Absolute values are not provided.
bN/A: Not available.
cA nonbinary response option for this category was not provided by the BRFSS surveys.
dAll percentages are calculated based on the number of participants who reported data for each category.
eGED: General Educational Development.
fNH: non-Hispanic.
gLGBQA: lesbian, gay, bisexual, pansexual, queer, questioning, or asexual.
hThis question was only asked of the 793 participants who reported a female sex assignment at birth (not displayed).
iParticipants were asked which type(s) of tobacco and/or nicotine products they use, and they could select multiple options; hookah tobacco is not displayed due to low response frequency.
je-cigarette: electronic cigarette.
App data examined included individuals who signed up for the app between October 1, 2018, and December 31, 2020, and met program eligibility (verified living in WA). The analysis excluded individuals who did not activate the app by January 28, 2021, (n=1177), and 11 additional individuals who reported being less than 18 years old.
R software, version 4.0.4 (R Foundation for Statistical Computing) was used for data analysis, the R tidyverse package was used to generate frequencies and proportions for all variables, and exact confidence intervals for binomial proportions were estimated using the epitools package.
The WA 2020 BRFSS was used to generate prevalence estimates representative of the WA adult population of tobacco users. The total BRFSS sample size was 12,902. The R survey package was used to calculate weighted prevalence estimates and asymmetric 95% confidence intervals of demographic and risk factor distributions among current tobacco users. To compare BRFSS and app proportions, z-scores for two-sample means and two-sided
For both app user and BRFSS percentages, missing data were excluded from the analysis. Frequencies of missing values for optional demographic questions asked of app users at sign-up are presented as “Not reported” in
The analysis included 1280 participants. Participants were primarily non-Hispanic White, identified as female, were between ages 25-54 years, had at least some college education, and reported a household income under US $50,000 (
Compared to BRFSS estimates of WA tobacco users, app users were significantly more likely to be female, age 35-54 years, non-Hispanic White or multiracial, LGBQA; they were also more likely to report poor mental health and live in a rural county (
Overall, this study shows that a mobile tobacco cessation app reached a diverse population, including relatively large proportions of some groups disproportionately impacted by tobacco use; there was high representation of LGBQA individuals as well as individuals with low household income, on Medicaid insurance, with poor mental health, and residing in rural counties.
Research shows that 68% of smokers are interested in quitting [
Lack of access to smartphone technology can serve as an obstacle to digital or app-based treatments. This is of concern for low-income populations who are less likely to own smartphones [
Digital health cessation studies have shown that younger tobacco users are more likely to use web-based programs [
This study benefited from large sample sizes, which allowed for the detection of frequent significant differences between the app user group and the BRFSS tobacco user population. In addition to individuals with low household income and 35-54-year-olds, the BRFSS comparisons revealed that LGBQA individuals, college graduates, those with poor mental health, those on Medicaid insurance, and those who reside in rural counties all activated the app in greater proportions than otherwise expected among the state’s population of tobacco users. As in comparable digital health cessation interventions and state quitline studies, there were also disproportionately high rates of use among tobacco users who identify as female and/or non-Hispanic White [
Of note, 1 in 15 women who used the app were pregnant, breastfeeding, or planning pregnancy, which inspired the DOH and 2Morrow to codevelop a tailored module of the app for this high-risk population [
Offering a free cessation app may help state funders and other program sponsors reach these and potentially other priority populations who are known to have disproportionately high rates of tobacco use and tobacco-related disease. By offering cessation programs through different modalities, a telephonic quitline and a mobile app, the DOH can achieve broader demographic reach.
The generalizability of these results may be limited by a few factors. First, participants were not required to complete the demographic survey items to download and use the mobile app, which resulted in some missing data that could affect the interpretation of findings. Second, it is possible that participants could have registered and activated the app more than once across the study period, so some counts may be inflated. Third, the app was only promoted to WA residents, so the results may not generalize to other states or national populations. The DOH did not have any significant paid promotions for the app, which limits the conclusions about who might use the app, when robustly and continuously promoted. Additionally, 12 months into the app user data collection period for this study, the DOH and 2Morrow launched a vaping cessation program [
The results from this study indicate that a diverse population of tobacco users, varying in terms of race, ethnicity, mental health status, sexual orientation, and other demographic characteristics, will use a free cessation app. Individuals who used the app in this study largely represent the demographic groups most at risk for cigarette smoking and associated premature disease and death. This may have implications for health equity. Understanding who uses cessation apps is important for developers and funders alike; this information can be used to address gaps in use, such as by developing marketing and outreach strategies or examining new product features that may be needed to appeal to different users. The extent to which users engage with the app should be explored and continuously improved upon to maximize effectiveness and, therefore, public health impact.
Behavioral Risk Factor Surveillance System
US Centers for Disease Control and Prevention
Washington State Department of Health
electronic cigarettes
General Educational Development
US Department of Health and Human Services
lesbian, gay, bisexual, pansexual, queer, questioning, or asexual
non-Hispanic
Washington state
This project was supported by the US Centers for Disease Control and Prevention (CDC) of the US Department of Health and Human Services (HHS) and Washington state (WA). The contents are those of the authors and do not necessarily represent the official views of, or an endorsement by, the CDC or HHS, the US government, or WA. Wording of select sign-up questions was provided by Gay City: Seattle's LGBTQ Center.
SMZ is a paid consultant working for 2Morrow, Inc.