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APP REVIEWS

Smoking

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Dr. Stephen Pomedli
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Quitting smoking is really tough. As physicians, we know that encouraging and supporting smoking cessation is one of the most important things we can do to impact the health of the ~18% of Canadians who smoke [1]. But as an addiction, the quitting process can be frustrating for patients and providers alike.

The accessibility, convenience, and interactivity of smartphones can be harnessed by apps to engage users and might be able to nudge more people to successfully stop smoking. It’s thought that such app engagement might extend the usually too-brief and sporadic support that we as clinicians offer at clinic visits [2] and could complement effective treatments such as nicotine-replacement therapy and medications such as varenicline and bupropion [3]. And smartphone users seem to be hopeful as well – smoking cessation-related apps have been downloaded millions of times [4].

This review looks at five of the more popular apps available for both iOS and Android.

While it isn’t fully clear which features of smoking cessation apps sustain engagement and improve cessation rates, these apps generally do well at emphasizing the health benefits of quitting, tracking and rewarding post-cessation achievements, analyzing cravings and triggers, and facilitating support via social media. Unfortunately, the apps are less consistent in evaluating and supporting motivations for quitting, linking to other resources such as established websites or cessation hotlines and encouraging support via other modalities like practical counselling and medical therapy, all of which would likely give people who smoke the best chance of leaving the pack behind.

Apps Reviewed

SmartQuit
4 stars4 stars4 stars4 stars4 stars
SmokeFree
3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars
Kwit
2.5 stars2.5 stars2.5 stars2.5 stars2.5 stars
QuitNow!
2.5 stars2.5 stars2.5 stars2.5 stars2.5 stars
Quit Pro
2 stars2 stars2 stars2 stars2 stars

Quit Pro

2 stars2 stars2 stars2 stars2 stars

QuitPro has most of the basic features that are available among the other apps reviewed here but has few differentiating features, beyond a nice interface to help track cravings. The remainder of the interactions, experience and content leave something to be desired.

Detailed Review View All

Features

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The app includes opportunities to passively unlock achievements as well as track money saved, cigarettes avoided and improvements in health. All of these are easily shareable via email, messaging or social media. Push notifications to the phone help prompt the user to interact with the app if engagement has dropped off. Additional scientific evidence to help motivate sustained quitting behaviour is available via an in-app purchase.

Effectiveness

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QuitPro cites statistics and information from reputable sources such as the British Medical Journal and uses these primarily to help keep the user motivated. The developers here missed opportunities to link to related topics for users who might want to learn more about particular facts that they find motivating. Integration of more evidence-based approaches to smoking cessation are generally lacking.

Usability

+-

This app has one of the better interfaces for tracking cravings and breaks down the situations and locations in which one is more vulnerable to cravings. The achievements layout is simple but engaging. Little thought has been put into making the statistics and data interesting or digestible; the information is presented as poorly-formatted plain text.

Privacy & Security

+-

No privacy policy is available in the app or on the website. The app does request access to location services to track common locations for cravings though this can be easily disabled. When testing the app, a disconcerting feature was the appearance of specific health ads targeted to the tester’s location, despite not having given permission to share location data.

Reliability

+-

The app has not been updated since 2015, which means it is unclear if it will gradually become incompatible with future operating systems. There were no concerns with reliability or bugginess. Of note, it is one of the few apps to direct the user to a doctor if there are any particular health concerns, though this is only accessible via a hard-to-find disclaimer.

Accessibility

+-

The app is available in English and French, for both iOS and Android. Though the core elements are free, upgrade at a cost of $8.49 provides an enhanced trigger/craving module, additional motivational tips and the removal of those pesky ads.

Kwit

2.5 stars2.5 stars2.5 stars2.5 stars2.5 stars

Overall, this app probably has the best aesthetics and overall design but still lacks key information. Some features feel unfinished, such as the lackluster achievements module. The primary differentiating features is a Willpower tracker that graphs the number of cigarettes smoked set against cravings avoided – though it can be hard to know what “Level 9 Willpower” means. Like the other apps, it has basic tracking, push notifications, options to share achievements via email or social media and rewards to unlock, but has virtually no linkages to clinical supports for smoking cessation, such as other validated resources or medical treatments. There doesn’t appear to be a privacy policy at all, though the privacy risks to using this app appear minimal.

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Features

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Kwit helps you pick a quit date and adds it directly to your calendar if desired. In addition to the willpower tracker described above, the app offers an assortment of techniques and quotations to help bolster one’s willpower, though it is unclear how effective this type of support is when working through cravings – some may feel that they oversimplify the quitting process. In-app purchases for sets of motivational quotes from ancient philosophers or contemporary sports stars may resonate with certain users.

Effectiveness

+-

There is no indication that any clinical input or evidence was used in the development of this app and there are no citations or sources for further information. Failing to mention effective therapeutics – such as nicotine replacement or other medications – does would-be nonsmokers a disservice.

Usability

+-

Kwit is one of the only apps with an “on-boarding process” upon first opening the app, which doubles as a mini in-app user guide. The clean graphics and interface lead to a pleasant experience.

Privacy & Security

+-

Though there is little personal information collected by this app, aside from general smoking behaviour, there is no available privacy policy, so it is unclear to what extent any data is stored, used or shared. There is no direct login to access the app.

Reliability

+-

The app was generally free of glitches and is updated regularly. The development team can be easily emailed via the app for feedback.

Accessibility

+-

The app is available for both iOS and Android, as well as in multiple languages. Interestingly the app includes a setting to make the interface more accessible for colourblind users. In addition to removing the ads, purchasing the full version for $6.99 grants full access to the Willpower tracker and adds other motivational quotes, enhancing the main features of this app.

QuitNow!

2.5 stars2.5 stars2.5 stars2.5 stars2.5 stars

One of the most popular apps across platforms, this app is built around its surprisingly active chat-like messaging, with hundreds of users active at any given time of the day. The chatrooms allows users to connect and interact based on language or location. There isn’t a Canada-specific chatroom. A nice feature is that you can create an anonymous profile to chat with other users and you can also block other users if they aren’t following appropriate “netiquette.” Achievements can be easily shared with others in this community and others often shout out their support. However, the app is very light on other features and thus might be best suited for users who enjoy instant messaging or feel they would most benefit from a “live community” of like-minded individuals. Unfortunately there are significant concerns with user privacy that should be strongly considered before recommending this app.

Detailed Review View All

Features

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Aside from the strong chat community, the app includes basic tracking for the number of days since quitting, money saved and improvements in health based on World Health Organization data. Achievements can be unlocked, though these are mostly attained passively at certain milestones after the quit-date.

Effectiveness

+-

The app was not clearly developed with particular smoking cessation evidence in mind or with clinical input. There isn’t any mention of medical therapies that would enhance cessation efforts. Aside from citing World Health Organization data, there are no links to supports or other sources. The chatrooms are also not moderated, so the app cannot guarantee that the recommendations that come from users in the community forum are helpful or valid.

Usability

+-

The app is generally simple, straightforward and intuitive. Though the interface and elements feel somewhat dated, the comic-like graphics for the achievements are fresh and engaging.

Privacy & Security

+-

The privacy policy is difficult to find on the app’s website. The Apple App Store directs the user to a dead link and the privacy policy is not accessible directly from the app. Further, the privacy policy does not explicitly mention that information is not shared with or sold to third parties, which is a concern if users login with their Facebook credentials. It is unclear why the app requests permission for location information or accesses a user’s phone contacts.

Reliability

+-

Creating an account to access the chat community was a bit buggy but the app was otherwise smooth and reliable. The app has been updated frequently over the past year and offers ways to provide feedback to the developers.

Accessibility

+-

This app is available in more than 30 languages, including French and English on both Apple iOS and Android. The majority of the app’s features, including the chat forum, are available for free. A modest fee ($5.49) removes ads and allows for real-time notifications.

SmokeFree

3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars

This app takes a neat approach to figuring out how to effectively take on smoking cessation via an app: the developer, who is a PhD student in the UK, selectively releases certain features to different users and follows up – after asking the user’s permission— one month and three months after the user’s quit date to see if the user has successfully quit. This then helps determine which features are more successful than others and should be included in future releases. This design lets the app claim to be the “stop smoking app that science built” although the details of the underlying science isn’t readily available. A generally friendly interface packed with features make this an engaging app, though some areas are a bit dense and difficult to navigate. One drawback is that the option to opt-out of the research study isn’t as prominent as it should be.

Detailed Review View All

Features

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This app, in addition to many of the standard bells and whistles for smoking cessation apps – craving tracker, unlockable achievements, social media sharing, push notifications – has some unique features including a daily diary to track the progress from that day. It includes a nice list of very practical techniques to battle cravings and lets users create their own tips or “favourite” the best tips from the long, categorized list. The daily missions are also very practical and specific, displaying amusing video clips and gifs as a reward for completion. Bill Murray fans will enjoy these!

Effectiveness

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The app was developed with an advisory team of out of London, UK, with expertise in health psychology and behaviour change, though no clinicians seem to have been involved in its development. It is one of the few apps that mentions nicotine-replacement therapy – even if the information isn’t very prominent – but it doesn’t mention other medications that are helpful with smoking cessation. Curiously, the app mentions specific brands of e-cigarettes and the app links to an online retailer, though the nature of the relationship between the app and these commercial groups is unclear. There are some links to great resources, such as the Mayo Clinic and smokefree.gov, and active online communities, but some dubious sources as well.

Usability

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The layout is mostly clean and inviting, but some sections get rather cluttered and key information can be hard to find. For example, the text on nicotine replacement therapy is buried in the “Help” menu. The information-rich portions rely heavily on large blocks of text in small fonts. Some missions suggest “searching online” to get further information, which isn’t a recommended strategy to get the best health information.

Privacy & Security

+-

The app doesn’t initially disclose that the user information is, by default, included as part of the data collected for the underlying research study or that there is potential for the data to be shared with other research groups. While opting out is simple, it is a bit misleading that this isn’t addressed up-front. However, the app only collects age and details of smoking, though allowing for the collection of location information could “deanonymize” the data. No specific login is required, which does make the information generally accessible to any user of the device.

Reliability

+-

The app was generally stable and has been updated regularly over the past year. The app provides opportunities for direct feedback to the developers. The app mentions and supports the use of e-cigarettes – which don’t have a clear safety profile and are still somewhat controversial in the medical community.

Accessibility

+-

Available in English and French on both Android and iOS. The majority of features are free, though additional features are included for $9.99. Small dense text may be challenging to read for some users.

SmartQuit

4 stars4 stars4 stars4 stars4 stars

This is the most complete app of the group, embracing the nuances and complexity of quitting smoking. Engaging with the app requires upfront work – it takes a few minutes to create a complete “quit plan” by delving into one’s motivations for quitting, examining commitment level. Personalized touches such as motivating photographs of family members or direct connections with friends or allies to help you stick to the plan can be included. While this initial work may turn off some users from interacting, it may have longer-term effectiveness for those who persevere. Beside the higher effort required to engage with Smart Quit, the other major barrier is the $69.99 cost for a full subscription to the app which, while less than the cost of five or six packs of cigarettes, may present a very real obstacle for users. Privacy is a concern with this app given the deeper information it collects from the user’s device and an incomplete privacy policy, warranting a discussion before recommending this app to patients.

Detailed Review View All

Features

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The excellent quit plan also helps guide how to use the app by indicating “next steps” and encourages engaging in a number of activities before the quit date. The app also encourages deeper engagement and learning by providing “Anytime Coaching” and suggesting exercises to help with cessation, such as gaining awareness of, accepting and dealing with cravings. Anytime a craving is logged, it prompts the user with a simple activity or reflection to prompt awareness.

Effectiveness

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SmartQuit relies on Acceptance and Commitment Therapy, which targets awareness and acceptance of urges and has evidence for effectiveness in other contexts. It has the real possibility of effecting behavioural change via apps such as this one: a small head-to-head study of this app showed a trend toward both increased user engagement and increased cessation in comparison to another app [5]. Of note, SmartQuit is one of the few apps to mention both nicotine replacement therapy and medications as part of the complete quit plan and appropriately directs the user to discuss these options with a medical professional.

Usability

+-

The look and graphic-rich layout is attractive and engaging. Instead of making the user read through long instructions for exercises and approaches to smoking cessation, SmartQuit gives the option of listening to these instructions as audio clips, which makes the learning much easier. The app provides easy access to the nicely laid out quit plan so it can be frequently referenced. The calendar feature is a bit awkward and not intuitive.

Privacy & Security

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A privacy policy is accessible via the app and discloses that de-identified information is collected and may be shared for research purposes. While personal information is generally not directly collected, the policy discloses that IP addresses may be collected. Unfortunately, the policy does not explicitly note that the data is not shared or sold to other third parties and the app requests more information from your phone than the other apps reviewed here, including detailed information about your specific phone — the reason for this is not clear. A login is not required for general use of the app.

Reliability

+-

There were occasional issues with the app freezing or spontaneously closing, but use was otherwise smooth and crisp. There are built-in options to provide direct feedback. The app has been recently updated over the previous year.

Accessibility

+-

Available on both Android and iOS, but only in English. Most features are free, but the six-month subscription cost of $69.99 is likely to be an obstacle for many users.

What Experts Say

Watch our interview with leading smoking cessation specialist Dr. Andrew Pipe.

Patient Experiences

There are about 1.2 billion websites. Eleven million of them are about how to quit smoking.

According to a report by the U.S.-based Centres for Disease Control and Prevention, most adults who smoke wish they could quit and more than half have tried within the past year. The report says 48.3 percent of smokers who saw a health professional in the past year recalled getting advice to quit. It estimates that smokers who try to quit can double or triple their chances by getting counseling, medicine or both.

According to one “quit smoking” website, people want to stop smoking for health, financial and even social reasons. “Joel” on WhyQuit.com says “Smoking is now viewed as smelly, offensive and disgusting by non-smokers as well as by many … ex-smokers in our country. While smoking was once thought to be sophisticated, people who smoke today are scorned by many of their peers.”

People also have reasons for not quitting. A 2012 qualitative study published in the journal Tobacco Induced Diseases https://tobaccoinduceddiseases.biomedcentral.com/ looked at the reasons COPD patients are unable to quit smoking. The researchers found that half of the participants described cigarettes as a companion and dear friend, even best friend, and a part of their community.

Participants also identified the fact that it never seemed the right time to quit and that even when they made plans to quit, the plans came to nothing because they lacked real motivation.

The participants said they wanted help and support, but they did not want to be patronized. The participants experienced demands about smoking cessation, in some cases daily, from spouses, family, friends, employers and physicians. Nagging from people in their environment could lead to continued smoking or get them started again after smoking cessation. “I think to myself … this is none of your business … it’s my own choice.”

References

  1. Statistics Canada. Tables on Smoking. Ottawa: Government of Canada; 2016 [cited 2016 Nov 23] Available from: http://www.statcan.gc.ca/eng/help/bb/info/smoking
  2. McClure J, Hartzler A, Catz S. Design considerations for Smoking Cessation Apps: feedback from nicotine dependence treatment providers and smokers. JMIR Mhealth Uhealth. 2016;4(1):e17.
  3. CAN-ADAPTT. Canadian Smoking Cessation Clinical Practice Guideline. Toronto: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health; 2012 [cited 2016 Nov 23]. Available from: https://www.nicotinedependenceclinic.com/English/CANADAPTT/Guideline/Introduction.aspx
  4. Abroms L, Lee Westmaas J, Bontemps-Jones J, Ramani R, Mellerson J. A content analysis of popular smartphone apps for smoking cessation. Am J Prev Med. 2013;45(6):732-6.
  5. Bricker et al. Randomized, controlled pilot trial of a smartphone app for smoking cessation using acceptance and commitment therapy. Drug Alcohol Depend. 2014;143:87-94.
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