JMIR Publications

ABSTRACT

Background:

Due to the colonization of tobacco plants by European settlers and the subsequent intensive marketing of commercial tobacco products to American Indian and Alaska Native (AI/AN) communities in the U.S., commercial cigarette smoking accounts for half of all deaths among AI/AN people. Lack of awareness, access to treatment, and the absence of culturally relevant, effective smoking cessation interventions contribute to these high death rates.

Objective:

To culturally adapt iCanQuit, a smartphone smoking cessation application (“app”) proven efficacious for the general population, for AI/AN people.

Methods:

A user-centered and community-based participatory research (CBPR) mixed-methods approach was applied to culturally adapt iCanQuit for AI/AN people in collaboration with a community advisory board (CAB) of AI/AN individuals using a three-step process between June/2024 and August/2025. Step 1 identified ways to culturally adapt the iCanQuit for AI/AN people through one-on-one qualitative interviews with eight prior iCanQuit AI/AN participants. Step 2 involved developing prototypes of cultural refinements identified in Step 1 through regular bi-weekly meetings of the CAB, research and app development teams. The prototypes were then evaluated with a separate group of four prior iCanQuit AI/AN participants through one-on-one qualitative interviews. Step 3 involved beta testing the app through a six-day diary study followed by one-on-one qualitative interviews with a nationally recruited group of seven AI/AN adults who smoke commercial cigarettes. The development work associated with Step 3 was further informed by the CAB and the research and app development teams.

Results:

Step 1 yielded five suggested cultural refinements to iCanQuit that were subsequently developed and tested in Steps 2 and 3: (1) modify the app’s stories to feature AI/AN adults and elders who quit smoking, emphasizing the values of culture, spirituality, family, and community as motivators; (2) add the value of honoring the Earth as a motivator to quit smoking; (3) make the appearance of the app’s “guide” character more representative of AI/AN people; (4) add information distinguishing ceremonial vs. commercial tobacco use; and (5) use earth tones in the app’s colors. In Step 3, 100% of diary study participants rated the beta version of the app as excellent or good/meets expectations (69% and 31%, respectively) and that it felt made for them. They suggested six modifications which were incorporated into the final version of the app: (1) include a vaping FAQ, (2) feature motivation icons more prominently, (3) increase notification frequency, (4) track today’s cigarettes rather than yesterday’s, (5) allow users to update how much they spend per pack of cigarettes; and (6) rename the medications tool to reflect the inclusion of AI/AN traditional healing modalities.

Conclusions:

A user-centered and CBPR development process yielded IndigeQuit—one of the first known apps developed specifically to help AI/AN adults quit commercial cigarette smoking. Clinical Trial: ClinicalTrials.gov Identifier, NCT06145763