Between June and July of 2023, we conducted 8 focus groups with 40 Black adults who use tobacco products. Participants were recruited using the social media platform Instagram. After completing a brief screener and obtaining consent during a brief screening call, eligible participants were purposively invited to participate in focus groups. Focus groups were stratified by age groups (21‐34, 35‐54, and ≥55 years old) to optimize representation.

Eligible participants included Black adults who were 21 years old or older, who reported current use of one or more tobacco products in the past 30 days, spoke English, and were current US residents at the time of recruitment. Exclusion criteria included lack of access to the internet and lack of interest in the use of technology for smoking cessation.

To identify which features to discuss during focus groups, we developed a comprehensive list of features of mHealth apps for tobacco cessation using previous research and a review of existing mHealth literature [23-31]. The mHealth apps involved were designed based on behavior change techniques and theories, such as the principles of acceptance and commitment therapy [24,26], persuasive technology for behavior change [27], or followed the US clinical practice guidelines [28,31]. One of the apps was developed by the National Cancer Institute [28], and another was developed to target young adults who are motivated to quit [27]. We then divided this list into different domains to explore with participants. Initial mHealth app feature domains included content, user experience, personalization, tracking, privacy and security, connections or support, and inclusivity. Within each domain, several features were included to discuss with participants, with the primary focus being whether these features were inclusive and preferred by Black adults who use tobacco products. Using guidance from experts, the resulting domains and features were organized and distilled. The list and resulting domains were further refined through focus groups using the focus group guide.

Using the list of domains and features of mHealth apps, the research team developed the focus group guide to address the research question: What features in mHealth apps for tobacco cessation are preferred by Black adults? The interview guide included questions and probes about participants’ experience with tobacco use and cessation, and experience with mHealth apps. Next, the guide listed each of the domains and features with a corresponding question about what features they preferred and a final question to get feedback about other design features or advice participants had. The semistructured focus groups were conducted using Zoom videoconferencing software to allow for participation from different locations within the United States, and each focus group lasted an hour [32].

The resulting focus group recordings were professionally transcribed, and transcripts were uploaded into Atlas.ti, a qualitative data analysis software (version 23). Using the focus group guide, an initial codebook was developed. The qualitative analysis team comprised 3 researchers (CE, SAC, and RP), who each had prior experience with qualitative coding and received formal qualitative and mixed methods training at the University of North Carolina at Chapel Hill. After familiarizing themselves with the codebook, 2 researchers (SAC and RP) independently coded a randomly selected transcript with the guidance of the senior researcher (CE). To establish the rigor of the analysis, we applied multiple methods to strengthen the credibility, dependability, and confirmability. First, we documented codebook revisions and applied analytic triangulation with multiple coders who reviewed transcripts independently and participated in consensus meetings to review discrepancies, add new codes, and refine definitions as needed. To assess interrater reliability, Krippendorff α was used, and the initial interrater reliability was calculated to be 0.769, indicating substantial agreement. After resolving coding conflicts, a different transcript was then coded, and “near perfect” agreement, 0.9, was reached. Upon reaching this threshold of high agreement, the team recoded the initial transcript and coded the remaining transcripts with the finalized codebook.

Furthermore, the focus groups were conducted with cultural sensitivity. For instance, the main facilitator of the focus groups was a member of the research team and is also a part of the Black community, as well as familiar with participants’ cultural values [32]. We did not conduct member check-in to reduce the burden on participants and concerns for confidentiality. However, the data were presented to the larger research team, and findings were discussed in detail [33].

Using thematic content analysis, the research team discussed and identified recurring themes and concepts across the transcripts [34]. The team determined that thematic saturation was achieved after the completion of 8 focus groups [35].

This study was approved by the institutional review board at the University of North Carolina at Chapel Hill (24‐0798). All study participants were informed about the study aims and significance, as well as the methods. Participants gave their informed consent, retained the rights to withdraw from the study at any time, and were informed of the confidentiality and anonymity of the data and the goal to publish findings from the study. All participants received a US $50 gift card for their participation in the study.

Forty adults aged 21-69 years, with an average age of 43 (SD 13.6) years, participated in 8 focus groups (Table 1). Most participants were female, and the majority were non-Hispanic. Many participants endorsed current cigarette use. Fifty-five percent (n=22) reported use of electronic cigarettes or other vaping devices, while 40% (n=16) endorsed use of cigars.

Four central themes emerged about what mHealth app features were desirable by Black adults who use tobacco products. Each theme had 2‐3 subthemes that represented different domains of mHealth app features. See Table 2.

As more mHealth apps for tobacco cessation are introduced each year, it is critical that these apps are built to serve everyone, including priority populations. Increasingly, apps tailored for Black adults have been introduced to confront health inequities, with an emphasis on iterative design using formative work from members of the target population [37]. Themes and subthemes from the focus groups revealed a strong preference for certain features, including the type and presentation of content in the app, inclusivity, user experience, tracking capability, professional and social support, gamification, and rewards. Preferred features also aligned with components of the self-determination theory, thereby enhancing the significant role that these features may play in the usage of an mHealth app. These findings provide insight into what app features deter or promote app receptivity, and how to attract Black adults who use tobacco products to use an mHealth app for smoking cessation.

In our study, we found that participants desired an app with features that highlight representation and promote inclusivity. To do this, participants recommended that an mHealth app should include testimonials, images, and videos featuring Black adults. Prior studies examining preferred features of mHealth apps for Black women have found that participants desire an app to include a directory of nearby Black female health care providers within their community [38,39]. Having racial concordance with a health care provider can help participants feel they have someone with whom they can relate [39]. One way that representation can be achieved in an mHealth app for tobacco cessation is to have a video testimonial by a Black former tobacco user included in the app, with the person sharing their experience with quitting as well as the health benefits experienced after quitting.

We also found participants desired in-app personalization of content and user experience based on their attributes, such as race, gender, and tobacco use habits and experience. Our findings suggest that to improve the user experience, mHealth apps should allow for personalization based on several factors, not just race. This may lead to a more robust experience for the app user. Further, several participants emphasized how the hypothetical mHealth app should feature a diverse range of people with different perspectives, experiences, and identities. This is consistent with findings in one study on app development where participants desired a diversity of people within an app, specifically wanting “everyone” to be included [40].

Similar to our study, previous research has shown that people are interested in an app with relevant health information and statistics [28]. This finding suggests that when health risks and statistics are personalized, the data are more relatable. Providing personalized content and feedback is associated with increased engagement with mobile app interventions [41]. For example, in an mHealth app for tobacco cessation, including statistics about the rate of cardiovascular disease or cancer for Black tobacco users compared with nontobacco users may increase engagement.

Another important finding in this study is that while participants were in favor of representation within the app, they were understandably hesitant or resistant to an app that focused solely on their racial identity. A previous study on mHealth apps for smoking cessation noted similar concern [28]. This perspective may stem from the justified mistrust of the health community and historical mistreatment of Black people in health care and research [42-44]. In a study that examined mHealth research receptivity among Black men, over a quarter (27%) of men and nearly a third of Black women (30%) identified “mistrust of researchers” as a barrier to participation [45,46].

While a more inclusive but nontargeted app is preferred, outreach strategies to reach the Black community were suggested, including marketing at events for the Black community, marketing by Black influential figures or celebrities on social media, and promotion by Black influencers. This finding suggests that having a known source may engender feelings of trust [47]. Furthermore, in recent years, health campaigns have begun working with influential figures such as pastors or influencers to promote health interventions, including vaccine campaigns [47] and physical activity and healthy eating [48,49]. Influencers can leverage their social influence and reach their audiences directly to promote health interventions [50,51], which could be used to increase app receptivity within the Black community.

In addition, with the high rate of social media use by Black adults [25] and the inclusion of social media as a tool for health promotion and intervention dissemination due to wider reach, scalability, and cost-effectiveness [52], targeted social media campaigns can be beneficial. In tobacco cessation studies, the use of social media platforms for recruitment has shown success, especially for minority populations that are typically hard to reach [49]. In one study by Bricker et al [52], tailoring of a social media campaign to disseminate an mHealth app in a way that focused on self-control and health values was found to be cost-effective and associated with high reach based on the number of clicks and conversion to app installation. The use of social media platforms to disseminate an mHealth app for tobacco cessation targeted for Black adults can increase the likelihood of awareness of the mHealth app, which may convert into more interest and greater use.

Furthermore, prior research to investigate smokers’ reactions on social media platforms revealed that comments and the type of reaction such as “love” or “haha” were a reflection of the level of motivation with regard to readiness to quit [53]. This suggests that although social media can be used to enhance the visibility of mHealth apps for tobacco cessation, it can also stimulate motivational processes by serving as a space for cessation-related posts that contain culturally representative narratives, prompting users to share their own motivations and goals for quitting or positively respond to comments that are reflective of their own experiences. This way, social media is not only a tool to promote the mHealth app but can also help to assess qualitative measures such as levels of engagement and motivation to quit.

Our findings also revealed the importance of an in-app community that offers accountability through supportive connections (eg, through health care providers and quit buddy programs). Previous research on mHealth apps has found that many people desire the ability to connect with health care providers within apps [39]. One study examining supportive accountability through counselor monitoring and supportive advice found that having a trusted expert within an mHealth app intervention for smoking cessation led to increased app engagement [54]. In another intervention that used peer-to-peer exchanges between participants seeking smoking cessation resources and communications from experts with treatment-related questions for participants to discuss, doubled sustained abstinence was observed compared to those who only used nicotine patches and had access to a cessation website [55]. Further, the effectiveness of mHealth interventions can be enhanced by human and social support [56,57].

Although open to connections, participants were hesitant and less receptive to having family or social media integrated within the app due to privacy concerns. Other studies examining receptivity to social media on mHealth apps have similarly found that most participants did not want social media integration, citing privacy concerns [39]. Although privacy is a major concern, social media play a significant role by serving as a platform through which health-related behavior change interventions can be delivered and health-related connections or support groups developed in a meaningful way [58,59]. For Black adults who use tobacco products, addressing the privacy concern in a transparent way may improve receptivity to the integration of elements of social media into the intervention.

In contrast, some people prefer having emotional support, such as encouragement, from friends and family [60,61]. Studies have found that stigma against individuals who smoke can prevent them from seeking care [62]. One study found that negative comments from one’s social network about their smoking habits can even lead to a decrease in quitting progress [61]. To combat this concern, any external connections to the app should be optional.

App tracking capability was also an important feature for accountability and has been identified as a desirable feature and method to promote accountability in other studies [39,54]. Several mHealth interventions use the tracking feature to help monitor chronic health conditions and medication intake [63,64]. One qualitative study that explored experiences of Black adults who use tobacco products with a specific mHealth app for smoking cessation identified that the tracking feature was highly preferred [28]. With mHealth apps for tobacco cessation, tracking of the rate of use of tobacco products, cravings, or money saved over a period of time from less use can lead to sustained motivation and cessation-related behavior.

Lastly, we found that while some participants said that financial incentives could attract some people to use the app, many participants did not think financial incentives were necessary to attract users to the app. Prior research suggests that financial incentives can modify or increase adherence to desired behavior changes, like exercise [65], dietary changes [66], or engagement with a state Quitline [67]. However, the sustained provision of financial incentives may not be feasible for mHealth apps long term, nor are they always necessary. In one study examining motivations and barriers to participating in mHealth research among Black males, approximately 40% indicated that offering financial incentives would motivate participation, while only 16% indicated that a lack of financial incentives was a barrier to participation [45]. Similar rates were also seen among Black women, 39% and 15%, respectively [46]. Continued engagement with an app is further augmented by other considerations, like the content shared [68]. Therefore, while financial incentives are desirable, their absence may not significantly deter participation with mHealth interventions. This finding aligns with existing research that the gamification (eg, inclusion of game elements and rewards) of mobile apps can reward and motivate app users [69,70] and promote behavior change [71].

To enhance the translation and application of our findings to an mHealth app development, we mapped out each subtheme and domain feature into examples of concrete mHealth app features with pertinent processes from the self-determination theory. We also included examples of ethical and privacy considerations, as well as potential metrics to consider during implementation. The map, as outlined in Table 3, shows how representation and inclusivity, personalization, content, accountability, tracking and user experience, social and professional support, and nonmonetary incentives can be operationalized into actual, concrete features within an mHealth app for tobacco cessation.

A limitation in this study is that findings may not be generalizable. First, we used a convenience sample online and recruited from one social media platform. This may have limited the sample size as well as the diversity of participants in terms of gender, age, educational level, and income. Conducting the focus groups online, as well as the requirement of a history of app usage or willingness to use an mHealth app in the future for participation in this study, further limits the diversity of perspectives about features of mHealth apps for tobacco cessation. Furthermore, findings may also not be generalizable to Black adults outside of the United States due to cultural differences and other factors that may exist across countries. Obtaining the perception of Black adult tobacco users who are not receptive to the idea of mHealth apps for tobacco cessation may provide additional insight into how best to develop and market these apps in a more inclusive way.

Our findings confirm the need to design mHealth apps for tobacco cessation with features that are reflective of cultural relevance, inclusivity, and diversity of experiences without excessive targeting and support motivation as stated in the self-determination theory [19-21]. Consistent with Perski and colleagues [72], engagement with mHealth apps increases when design features support personal relevance, motivation to quit, and credibility. Our findings provide insight into the improvement of existing apps and future development of an mHealth app that can appeal to Black adults who use tobacco products, potentially increasing app use, engagement, and successful cessation. Findings from this research can also serve as a groundwork for future research to explore the effectiveness of an mHealth app culturally tailored with preferred features optimized to enhance engagement by Black adults who use tobacco products and to identify other factors that may improve usage and lead to better outcomes for the target population.