Cigarette smoking is the leading cause of preventable death in the United States, with more than 490,000 smoking-related deaths each year [1]. Smoking is associated with detrimental effects to the cardiovascular system, respiratory system, and other health risk outcomes [1]. While overall smoking prevalence has declined in the United States, disparities persist across racial and ethnic groups, particularly among those with low socioeconomic status [2]. For instance, smoking rates are lowest among Asian (5%) and Latino (8%) adults [2] and highest among American Indian Alaska Native (AIAN; 19.3%) adults [2]. However, aggregate rates for Latino adults mark variations. For example, Cuban and Puerto Rican adults report some of the highest rates among Latinos (up to 30%) [3]. African American [4] and Latino adults are heavily targeted in the sale of menthol cigarettes, with a higher density of smoke shops that sell menthol cigarettes in African American or Black and Latino neighborhoods [5,6]. For Latinos, the stress of acculturation to US culture [7] and experiencing discrimination increases the risk of smoking [8,9]. These intersecting factors contribute to tobacco-related disparities across racial or ethnic groups.

While California is recognized as a national leader in tobacco control, with some of the most comprehensive policies and lowest smoking rates in the United States, rural regions maintain disproportionately higher smoking rates [10]. California’s San Joaquin Valley (SJV), a predominantly rural and agricultural region, exemplifies this disparity, with a tobacco use prevalence of 15.6% in 2019 [11], exceeding the state average of 11.4% in 2022 [1]. Home to more than 4 million people across 8 counties (Stanislaus, San Joaquin, Merced, Madera, Fresno, Kings, Tulare, and Kern) [12], SJV includes many structurally marginalized and under-resourced communities. Nearly 45% of SJV residents identify as Latino [12], and 70% of immigrant residents originate from Central America and Mexico [13]. Latinos in California experience a disproportionate burden from tobacco use, with 1.2 million Latinos reporting current use of tobacco, second to Whites at 1.4 million, followed by 0.3 million African Americans and less than 0.1 million AIANs [11].

The SJV region is considered a medical desert, with severe shortages of health care providers, limiting access to health care, specialty services, and tobacco cessation resources. Low literacy skills and limited English proficiency [13] also make it more challenging to navigate health care systems and access cessation support. The SJV also has one of the highest poverty rates in California, with 20% of residents in most counties living below the federal poverty level, compared with 12% statewide [12].

Although Latinos in California attempt to quit smoking at higher rates than the general population (56.5% vs 55.1%), they are less likely to use evidence-based cessation treatment such as nicotine replacement therapy (NRT) and receive cessation advice from health care providers [14]. In 2023, of the 21,500 people who used the free cessation program known as Kick It California, which includes the state Quitline, text, web, and chat support, only 21.1% identified as Latino, while 37.7% identified as non-Hispanic White [10]. Latinos face disparities in access to health care and health insurance [14], and 46.7% of Latino adults who smoked were advised to quit versus 49.9% of all California adults [10], which may contribute to underutilization of cessation supports. Other reasons for not using cessation supports include misperceptions about the addictiveness of NRT [15], hesitation to use support because of the cultural belief that using willpower is a way to take personal responsibility for quitting [16], or using both cigarettes and e-cigarettes (8.1% of Latinos use both vs 8.8% non-Hispanic White) [17], which might make it more challenging to quit [18]. Given these disparities, there is an urgent need for culturally responsive and affirming smoking cessation interventions for Latinos in the SJV. Expanding cessation resources beyond traditional clinical settings—particularly through digital health solutions—may help address gaps in cessation services for Latinos who smoke and face significant barriers to treatment.

While expanding access to health care is critical for increasing cessation treatment utilization, many Latino adults who smoke face persistent barriers such as lack of insurance, limited access to health care providers, and language barriers. These challenges are exacerbated in rural regions such as California’s SJV, where access to health care and cessation services is highly limited. Racial and ethnic minorities in rural areas have limited resources to use health care services [19]. Compared with non-Hispanic Whites (15%), 23.1% of Latinos, 24.5% of non-Hispanic Blacks, and 19.1% of AIANs [1,2] could not see a physician due to elevated cost [19]. Digital cessation tools offer a promising and cost-effective alternative, providing a scalable approach to reaching those who may otherwise lack access to cessation support.

Latinos in the United States have among the highest rates of smartphone adoption (93%) [20]—often using smartphone devices as their primary means of web-based access—compared with 91% of non-Latino Whites. In addition, 95% of Latinos use the web [21] and 84% [22] engage with social media platforms, making digital health interventions a viable strategy for smoking cessation [23-25]. A systematic review of 60 studies found that digital interventions, including mobile apps, text messaging, and web-based programs, significantly increased smoking abstinence compared with printed materials for adult smokers (risk ratios=1.32 for prolonged abstinence and 1.14 for point prevalence abstinence) [26]. These findings highlight the potential of leveraging mobile and social media–based interventions to improve cessation support among Latinos, particularly in hard-to-reach, rural communities such as the SJV.

Social media interventions may also enhance engagement by leveraging existing social networks. For example, the Tobacco Status Project, a 90-day Facebook smoking cessation intervention, delivered evidence-based counseling to young adults in group meetings on Facebook [27]. Social media interventions have been studied in national samples of young adults [27-30] and can be adapted to users’ preferences. Social media–based interventions, whether delivered through existing platforms such as Facebook, Instagram, and WhatsApp, or through specialized platforms, have been shown to be efficacious in increasing abstinence compared with control conditions [31].

Smoking cessation smartphone apps when used in combination with pharmacotherapy may also be an effective aid [32]. A 2023 meta-analysis of randomized controlled trials compared continuous smoking abstinence rates between young adults receiving smartphone text cessation support messages and those receiving only self-help materials or referrals to the Quitline (ie, controls) and found an overall increase in abstinence among those receiving SMS text messaging interventions [33]. The subgroup analysis (k=5) showed that continuous abstinence rates were higher in the SMS text messaging interventions than in control groups at 1-month, 3-month, and 6-month follow-ups (relative risks=1.90, 1.64, and 1.35; P<.05; respectively); only 2 apps reported continuous abstinence outcomes [33]. Since most apps have not been evaluated in clinical trials or published in scientific literature, it makes determining the efficacy of cessation apps largely inconclusive [33-35]. A 2021 search in the iOS App Store and Android App Store generated 228 apps for smoking cessation, and evaluations of each app revealed that very few apps are evidence-based, and 53% were inaccessible due to the financial costs of using the app after downloading [34]. However, 25% of the apps were available in Spanish, signaling potential interest in Spanish language apps [34]; however, we are not aware of any apps developed specifically for lower-income Latino adults.

The high prevalence of tobacco use, health care shortages, economic hardship, and linguistic barriers creates significant obstacles to smoking cessation in the SJV, particularly for Latino residents. Without accessible, culturally tailored cessation interventions, Latinos in the region remain at heightened risk for tobacco-related illnesses [36]. Although the adoption of digital technology is growing and digital cessation interventions may address these health disparities, little is known whether SJV residents would be interested in using digital cessation interventions to assist with smoking cessation. This study aimed to explore tobacco use behaviors, cessation experiences, and views about digital cessation tools for tobacco cessation among SJV residents.

To guide this study, we applied a widely used framework for identifying behavioral determinants across individual, social, and environmental contexts, the Capability, Opportunity, Motivation–Behavior (COM-B) model [37]. The COM-B model posits that behavior is the result of interactions between individual capability (psychological and physical), opportunity (social and environmental), and motivation [37]. The model’s 3 components interact to either enable or constrain behavior and can serve to inform intervention design and health communications [37]. In this study, the COM-B model was used to identify barriers to and facilitators of quitting smoking and engaging with mobile health platforms.

We also drew from constructs from behavioral change theories to contextualize our secondary objective, evaluating the acceptability and usability of 2 digital cessation tools. For example, the Health Belief Model informed our prompts about perceived risks of smoking and benefits of quitting [38]. In addition, 2 smoking cessation tools were presented to participants—1 mobile app and 1 social media–based cessation intervention—both developed from a combination of these behavioral models and evidence-based cessation strategies. For example, Social Cognitive Theory, we considered constructs relevant to digital interventions when presenting app features (eg, self-regulation, self-efficacy, and model learning) [39]. Both digital tools incorporated social support that can help people model behaviors to avoid smoking and teaching self-regulation. The secondary aim of our study was to explore people’s perceptions of these digital tools, particularly their appeal, usability, and suggested adaptations.

In partnership with the California Health Collaborative (CHC), a leading, nonprofit community-based organization in the SJV, we recruited 29 adults from the SJV to participate in the focus group sessions. Coauthor EH, CHC’s senior director of programs for the past 22 years, played a key role in conducting the study. He led participant recruitment across the different counties in the SJV by leveraging his connections with community organizations, which helped identify interested participants. Participants also used word of mouth to let people they know about the study. These strategies allowed us to fulfill our recruitment goals. Eligible participants were aged 18 years or older who reported cigarette smoking in the past 30 days. Participants did not know the researchers prior to the study. We developed focus groups and semistructured interview guides with input from CHC, the study investigators, and undergraduate students proficient in Spanish.

Audio files were transcribed verbatim and translated from Spanish to English and uploaded to ATLAS.ti (version 24; Scientific Software Development GmbH). Spanish-speaking researchers (AD and KDL) read the Spanish-transcribed and translated files to identify errors in the transcription process. Two coders (KDL and SS) read each transcript, coded them, and identified themes. We used thematic analysis (inductive approach) to identify individuals’ needs for smoking cessation digital tools to facilitate their quitting process [43,44]. The codebook was refined as new themes were identified during the coding process. Discrepancies in coding were discussed and resolved by consensus, including discussion with a third coder (AD), if necessary.

We paid particular attention to ensure that participants fully understood the nature of the research and their rights, given potential language barriers and vulnerabilities. We began each focus group with icebreakers and an introduction of ourselves as researchers, along with an explanation of the study’s purpose. We also acknowledge our own positionalities as researchers and how they may have influenced the research process. AD is a health communication researcher and is a second-generation Mexican American Californian who grew up with Spanish as his first language, and KDL is a bilingual (ie, first language was Spanish), Latina public health postdoctoral scholar with roots in the Southwest. Our shared cultural and linguistic backgrounds contributed to trust-building with participants, particularly in communications requiring sensitivity to language access and cessation support experiences among racial or ethnic minority and Spanish-speaking individuals. The bilingual team conducting the focus groups and interviews ensured that information was not lost in translation because participants freely expressed themselves in their preferred language. We reviewed the focus group and interview guides with research interns who brought lived experience as SJV residents. In addition, to ensure cultural and linguistic appropriateness, our community partner and coauthor, EH, who grew up in the region, reviewed and provided feedback on the Spanish translations of the consent form, survey, and focus group guide. This partnership helped ensure that research materials were accessible and culturally relevant for SJV residents.

This study was reviewed and approved by the University of California, San Francisco (IRB 22‐37978) and University of California, Merced (IRB UCM2022-119) institutional review boards. All participants read and provided informed consent on Zoom or in person. Researchers reassured participants of confidentiality. Participants were also offered a printed or electronic copy of the informed consent form. The researchers deidentified surveys, focus groups, and interviews by using a self-generated ID number for each participant. We used the COREQ (Consolidated Criteria for Reporting Qualitative Research) to describe and present the research findings to fit standard qualitative reporting. We attest that we did not use generative AI to write any portion of the manuscript or for data analyses. Participants each received a US $50 gift card for participating in the focus group and an additional US $50 gift card for participating in an in-depth interview.

Although 29 participants participated in the focus groups, not all completed all survey items. Participants were permitted to skip questions they did not want to answer. The majority of participants were Latino (24/27, 88.9%), 51.9% (14/27) self-identified as female, and mean average age was 41 years (SD 14.04, range 21‐77). Most (14/26, 53.8%) preferred Spanish language, 38.4% (10/26) reported limited English proficiency, and 63% (17/27) reported that they were unable to save money each month (Table 1). Those who preferred Spanish were predominantly from Madera County, older, preferred smoking cigarettes, and were less comfortable with technology. Focus group participants from Fresno County were younger, English-speaking, primarily used e-cigarettes, and were comfortable with technology. Participants from Merced County were older, preferred English language, most smoked cigarettes, and the focus group was conducted in person. Overall, 82.1% (23/28) had made a quit attempt in the past year, and most intended to quit smoking in a month to 6 months, with 11.1% (3/27) never expecting to quit.

Many in the older Spanish-speaking group were parents, and their motivation to quit was their children or family. For the younger English-speaking group, having children was a reason to quit in the future but not currently. Participants described being concerned about their health. Illnesses made them more aware of their overall health and motivated them to quit or reduce smoking. One participant got COVID-19 disease, another had asthma, and a third was worried about developing cancer.

Tobacco regulation efforts such as flavor bans or price increases motivated some individuals to quit smoking or vaping. Flavors enticed many younger participants to initiate vaping, and a participant reported that she smoked less because of the flavor ban.

Participants tried different methods to quit smoking and vaping. Only a few participants had used NRT, some when hospitalized, which had helped them to temporarily quit. Most had tried to quit on their own (ie, cold turkey), and one participant interpreted ongoing use of NRT as a reason not to use it.

A few participants used cannabis to cope with nicotine withdrawal symptoms.

Participants described that tobacco and other substance use was common, where some participants substituted other substances (eg, cannabis) for smoking. One participant found that decreasing the use of other substances decreased their cigarette consumption.

Another individual switched from combustible cigarettes to e-cigarettes to quit smoking but found that he instead increased nicotine use.

Many of the Spanish-speaking participants in the focus groups felt that what was available did not meet the specific needs, challenges, or preferences of other members in their community. Participants discussed that smoking cessation tools should be not only linguistically appropriate but also include the lived experience of someone who understands their culture. Offering services in Spanish alone was not sufficient to be culturally appropriate.

In addition to information on quitting, participants felt that instructional materials to increase awareness of the dangers of secondhand smoke should be incorporated.

When asked for general recommendations for digital cessation tools, participants expressed interest in social connections.

Younger participants from Fresno also expressed interest in “more real-life examples instead of just a big X on a vape pen” [36-year-old, female, Fresno] and something easy to navigate.

Some individuals expressed interest in daily digital posts that they could relate to.

Participants liked the interactive engaging content and opportunity for social and peer support with people with shared experience:

Other appealing features of Quit The Hit were the availability and accessibility of a peer counselor, similar to other in-person models of substance use treatment such as Alcoholics Anonymous or Narcotics Anonymous.

Participants liked the idea of interacting with other members of their group when they needed it as social support and to hold themselves accountable.

Participants also liked that the program was structured over 5 weeks, perceiving that the time allotted allowed substantial progress in behavior change at their own pace.

A few participants expressed dissatisfaction with both interventions, describing practical inconveniences in their daily routines. For instance, a participant highlighted difficulties engaging with interventions while at work.

Some participants reported technology-related concerns with an app such as a need for extra storage space on their device, or the need for a web-based connection or a charged battery. Other participants were uninterested in social media interventions, preferring “person to person contact” [57-year-old, female, Madera]. Others expressed concerns about privacy.

Some participants felt that the support should be anonymous to avoid stigma.

Other participants who did not currently use social media reported not wanting to join social media simply to access a support group.

Participants expressed interest in several features that could apply broadly to digital cessation tools. For example, participants expressed interest in a chance to earn prizes, money, or other tangible compensation as opposed to points.

Participants expressed a need for digital tools to be visually appealing and attention-grabbing. They also suggested materials to discuss tobacco use and vaping within the context of other life stressors and other addictions, including substance use.

Participants reported that linking treatment for tobacco use with other substance use could help prioritize the issue of tobacco use, particularly in SJV counties where counseling and support services are scarce.

They expressed interest in linkages to other related interventions such as acupuncture or games to keep busy and cope with stressors.

Our research highlights the need for tobacco cessation tools for people living in economically challenged rural areas, such as the SJV. Our study indicated that both older and younger predominantly Latino adults who smoked or vaped nicotine were amenable to digital cessation tools, particularly when these interventions were delivered in a culturally affirming way that included not only language concordance but also relevant lived experiences. Consistent with past studies [14,45], participants smoked or vaped as a coping response to stressors [46], many did not use pharmacotherapy to quit, and most attempted to quit on their own. Latinos who smoke may hold misperceptions about the addictiveness of NRT [15]. In this study, SJV residents were skeptical of the use of NRT and believed that NRT may be as addictive as other nicotine products. This suggests a need for tailored programs to support evidence-based counseling and education about pharmacotherapy to improve cessation outcomes [47].

Older Spanish-speaking participants preferred culturally tailored tobacco cessation services. Participants emphasized the need for counselors or messages to express empathy toward their particular circumstances, as well as needs for relatable peer support and personalized approaches such as individualized text messaging in Spanish to increase engagement among Latino adults [48].

To overcome these barriers, evidence-based solutions can be integrated into the design and delivery of digital cessation tools. First, digital health interventions delivered or introduced by trained community health workers (CHWs) or promotoras/es (Spanish-speaking CHWs) from the SJV might increase buy-in among older, Spanish-speaking adults [49]. CHWs and promotoras/es, as trusted members of the community who speak the same language and understand cultural practices, can be trained to deliver tobacco cessation interventions supported by digital tools [49]. In prior work, lay health worker cessation interventions had superior abstinence rates compared with referrals to a Spanish language Quitline (20.5% vs 8.7%, respectively) [50]. Second, providing culturally tailored, accessible cessation materials (eg, mailed written material) to adults who prefer Spanish educational material improves quit rates [51]. A pilot study evaluating a culturally and linguistically tailored text message intervention combined with NRT found moderate to high levels of acceptability, good engagement measured by the number of text messages participants sent during the 12 weeks of program, and improvements in self-efficacy; this intervention reported a 30% biochemically verified abstinence rate [52].

While older participants expressed openness to using digital interventions, some lacked the familiarity and comfort with social media to engage with these platforms. According to the COM-B model, having the necessary skills (ie, the psychological capability) and the opportunity to use social media if a social media platform is adopted may increase the chance of smoking cessation [37]. Participants’ willingness to use digital interventions suggests that the CHWs and promotoras/es model may be beneficial in increasing comfort with technology. These trusted members of the community could support participants by providing guidance on how to use the digital tools prior to the delivery of intervention content [37]. Alternatively, other social media communications platforms such as WhatsApp may be better suited for residents of the SJV than a downloadable app or Instagram interventions. To address concerns about technology issues, participants who are less familiar with apps or social media platforms must receive training to help them navigate the technology with access to offline resources.

In contrast, younger participants were more receptive to social media–based interventions but emphasized the need for attention-grabbing, user-friendly, and easy-to-navigate tools. Younger participants did not emphasize culturally affirming support as much as older participants but expressed interest in peer supports and the importance of integrating lived experience of quitting. A meta-analysis of 16 randomized controlled trials found that peer support interventions were more effective for smoking cessation (mean RR 1.34, 95% CI 1.11‐1.62) and more effective when peer support had quitting experience (k=5 studies) (mean RR1.43, 95% CI 1.17‐1.74) [53]. To increase the use of digital cessation tools, it is important to account for digital literacy, technological issues (eg, internet connectivity or memory or battery life), peer support, and age-appropriate messaging [54,55].

Another key COM-B construct that affects the adoption of cessation tools is opportunity to engage with intervention content [37]. A few participants noted that job constraints would make it difficult to meet the demands of engaging with the cessation intervention content particularly during work hours. The limited availability highlights the need for digital cessation content that offers flexibility, whether delivered via smartphone app or social media platforms.

The motivation construct of COM-B will also affect the adoption of cessation tools [37]. Participants also expressed interest in tangible rewards such as money incentives and reminders. Contingency management is an intervention based on operant conditioning, which delivers contingent monetary rewards based on behavior change (eg, smoking cessation) [56]. A 2019 meta-analysis (k=7) found that mobile phone–delivered contingency management was efficacious for tobacco cessation [56]. Overall, we found that smartphone apps [57] and social media interventions [58] are acceptable digital health tools that could help Latinos quit smoking if tailored to enhance engagement [58]. Incorporating digital tools and health interventions is appealing because health information can reach audiences and messages can be tailored to meet individuals’ personal needs or risks.

Participants reported polyuse of tobacco with other substances, including cannabis and crystal methamphetamine, but neither digital intervention offered treatment for polyuse. Treatment for tobacco and substance use can be integrated to improve substance use outcomes and should be investigated further in this population [59]. Smoking cessation interventions among people with substance use disorders can increase long-term abstinence from all substances by 25% [60]. Participants expressed that there was a dearth of substance use treatment supports in the SJV and suggested tobacco cessation to be integrated with mental health and substance use treatment resources.

Although inclusive of Spanish-speaking Latino participants, these findings are from a small sample (29 participants) from 3 counties (Madera, Kings, and Fresno), recruited through community-based organizations, which might not generalize to other California populations, including the remaining 5 SJV counties. Only 9 participants were presented with videos of 2 prototypes of digital smoking cessation tools via interview rather than directly testing them, and recommendations may differ if the cessation tools were used in real-world settings. User testing among users and nonusers of the app could provide valuable feedback for improving the digital tools. Digital interventions that address stress as a trigger and that integrate pharmacotherapy may be beneficial.

While our study included participants from 3 of the 8 counties that comprise SJV, these counties are broadly reflective of the region’s structural and demographic characteristics. All 3 counties are also considered medically underserved, with persistent health care provider shortages and limited access to smoking cessation services [61]. Our study captured the unique voices from people who are often underrepresented in cessation research, particularly Spanish-speaking Latino individuals in the United States and rural settings. Additional strengths of this study are its successful engagement with Latino residents in underserved, rural communities, leveraging trusted community partners and Spanish-speaking researchers to ensure participants’ comfort and authenticity in responses.

This study provides insights into digital smoking cessation tool preferences among predominantly low-income and Latino residents of the SJV, a region with urgent need of cessation services. Using a community-engaged approach, we found that participants expressed interest in linguistically appropriate and culturally tailored digital cessation tools featuring empathy toward their circumstances, relatable peer supports, engaging content, easy access to information and support, and social or material rewards. Our findings underscore the need for customizable, culturally affirming digital health interventions for tobacco cessation in the SJV, with a focus on social support and user engagement strategies.