The Interplay of Behavioral Science and Communications Technology in Tobacco Cessation: Dr. Amanda Graham, Chief Health Officer at Truth Initiative

Lindsey Smith

Hi, I'm Lindsey Smith, welcoming you to Raise the Line from Elsevier, an ongoing exploration about how to improve health and health care. Most adults who smoke want to quit, and about half try to quit in any given year. Yet fewer than one in ten actually succeed. That persistent gap between intention and outcome is one of the central challenges in public health, and it's exactly the kind of problem that calls for new thinking about how to communicate with people to support behavior change. That persistent gap between intention and outcome is one of the central challenges in public health, and it's exactly the kind of problem that calls for new thinking about how to communicate with people to support behavior change.

That's why we're happy to welcome Dr. Amanda Graham to Raise the Line today because she has been a national force in bringing new communication approaches to the cessation field. In her current role as chief health officer at Truth Initiative, she leads the organization's tobacco cessation efforts, bringing a strong emphasis on digital health innovation. Tobacco cessation is something I care deeply about, and I actually interned with a Truth Initiative years ago while I was in college, so it's incredibly meaningful to reconnect with an organization that does such important work.

Dr. Graham is a behavioral scientist by training and has spent twenty-five years conducting NIH-funded research on web and mobile quit smoking interventions. This work and her more than 130 peer-reviewed manuscripts have earned her international recognition as a thought leader in the space. Dr. Graham also holds adjunct professorships at Mayo Clinic College of Medicine and Science and Georgetown University Medical School. Today we'll explore how behavioral science and digital technology are being brought together to transform tobacco cessation and where the field is heading.

Thank you so much for joining us today, Dr. Graham.

Amanda

Thanks so much for having me. I love hearing about your time at Truth Initiative. That makes this conversation even more fun for me.

Lindsey Smith

Absolutely. So let's start with learning more about you and what first got you interested in behavioral science.

Amanda

So I trained as a clinical health psychologist in the late nineties. I was working with all kinds of patients with very different health concerns, and the thing that kept emerging was how people's physical health was so deeply connected to their emotional well-being and to their behavior. But what I was seeing was that the healthcare system really prioritized medical problems and medical treatment over those other areas. And what drew me to tobacco specifically was honestly the scale of the problem and the opportunity to make a difference, both at the population level and on a very personal level. 

Your audience may or may not know this, tobacco is still the leading cause of preventable death. Half of all people who smoke will die from a tobacco related disease, which is close to half a million people a year, and that's actually year after year in this country alone. And when you zoom in to understand what that means for any individual person, what you see is a picture that more often than not is someone who's dealing with an enormous amount of shame and stigma and frustration, feeling really demoralized because it's so hard to quit. 

So the question that really captivated me was how do we engage people who we know want to quit? They try to quit. They know all the reasons that they should quit. We have very effective proven treatments and yet what we see is so many people who don't benefit from all of what we know about how to treat tobacco dependence.

Lindsey Smith

That's a great story about how you got involved here, and tobacco cessation work is so important. So your work today kind of sits at that intersection of behavioral science and technology. Did that combination appeal to you right away or did it kind of evolve over time?

Amanda

I was starting my career right as the internet was becoming a household word -- this feels like a trip down memory lane -- but really, before most households had internet connections, and fewer than half of all American adults were online. Broadband was not yet a thing. Smartphones hadn't been invented yet. Text messaging was just starting to take off. And even though adoption of those technologies was pretty incremental year over year, the early signals really just felt like technology could be a powerful solution to some of the frustration that I had felt working in those clinical settings. 

The quit smoking groups that I was running, you know, maybe had five or six people come to them week after week. For many of them, attendance was sort of intermittent, and supporting patients once a week for an hour just really felt kind of like a mismatch. People would describe the lack of support that they had from friends and family who just didn't understand the nature of this addiction. Many of them only had insurance coverage for one quit attempt, which we know isn't how quitting works. 

So it felt like the tools that I had, the approach that I had at the time, was kind of a mismatch for the need. So the opportunity to use the power of computers at the time to tailor an intervention, to engage thousands of people at a time that was convenient for them when they wanted to engage for as long as they needed to engage across multiple quit attempts, that really felt exciting to me. 

The early iterations of online communities -- they were bulletin boards or forums at the time -- were showing that we could bring people together from across the quitting continuum, across the age spectrum, across the country, across income levels, and allow people to engage anonymously and privately. It really felt like a game changer in terms of delivering that kind of support that I was wanting to do more of for a longer period of time. 

So, you know, technology at the time really represented a way to provide more support more often for longer periods of time and ultimately to more people, and that's really what I wanted to achieve in my career.

Lindsey Smith
That makes a lot of sense, especially given how much science and technology have both changed so much over the years. I really liked what you said there, though, about engaging people and meeting them where they're at to kind of help build that community. For listeners who might not be as familiar as me, can you give us an overview of the Truth Initiative and how your work supports its mission?

Amanda

Sure. Truth Initiative is a non-profit public health organization focused on preventing addiction among young people and helping people of all ages to quit tobacco. Most people, you included, probably know us best for the Truth Campaign. That's been one of the most successful public health campaigns in history. We are super proud to be part of the success story. When the foundation was created in 1999, more than one in three high school students were smoking, and today that's under two percent, which is really an exciting achievement. 

Our work today spans a number of different areas that are really interrelated. We continue to run national public education campaigns. The Schroeder Institute is our policy research group. They conduct the science that informs our tobacco control advocacy work. We develop school-based education programs, and I lead the Innovation Center, which builds and runs our digital cessation programs, and we conduct the clinical research that's behind them. All of those pieces are interconnected. Our campaigns drive people to our cessation programs, our research informs our policy positions, and so really it's kind of an ecosystem that's designed to attack the tobacco problem from multiple angles.

Lindsey Smith

It really is such an important organization that I have really had the pleasure of having a front row seat to and then continuing to follow along over the years. I read a stat that stood out...that the Truth Initiative has helped over 3.25 million middle school and high school students from using e-cigarettes between 2019 and 2023, which is absolutely incredible.

Amanda

That's the really powerful reach that we can drive when we have the right messaging that's delivered through the right channels to reach the right audiences in a really persuasive and compelling way...to show up with messaging that resonates with their struggles, their motivations, and then to present a solution that really fits how young people want to engage.

Lindsey Smith

Coming back to one of those channels, you've developed text message based cessation programs. What is it about that SMS format that makes it so effective for behavior change?

Amanda
Yeah, there's this really great paper that came out a couple of years ago from colleagues in New Zealand and Australia, and they picked a really apt title for the paper that was called "Don't Forget the Humble Text Message." And I love that framing because text messaging can seem simple, almost quaint compared to newer technologies, but what the data tell us is that it's an extraordinarily powerful modality, not just for tobacco, but across many areas of healthcare. I get asked, like, why is that? To me, I think there are really three reasons. 

The first is, it's what we call a push technology rather than a pull technology. Pull technology requires that users actively seek out support, they open an app, they visit a website. Push technologies are delivered to them. The text message arrives whether they were thinking about quitting or not, and can be timed very deliberately during the day. For behavior change, that's critical. A well-timed message can really be powerful in interrupting what for many people is kind of an automatic behavior, and it's a reminder of commitment that they made at the time that they signed up for that program. 

Obviously, text messaging is native to every mobile phone ever made, and so the barrier to entry is really as low as it gets, and that's really important for equity. And the last thing we know, people read their texts. There's pretty consistent data from industry sources that something like ninety-five to ninety-nine percent of all text messages are opened and read within three minutes. So it’s all of that combined with the scientific evidence. We have many, many randomized trials that have shown the effectiveness of text messaging for smoking cessation in adults. Research that I've led has demonstrated its impact for vaping cessation among young people. It works across demographic groups, income levels, geographies -- and that's often rare in digital health. So I agree that it's humble, but in this case, we know that humble works.

Lindsey Smith

It's amazing how something that simple and accessible can make such a big difference. So you mentioned earlier that most people who want to quit try multiple times before they succeed. What does behavioral science tell us about why cessation is so difficult even for individuals that are highly motivated?

Amanda

The answer is nicotine, nicotine, nicotine. Nicotine is remarkably effective at creating dependence. When it's smoked or inhaled, it reaches the brain within seconds. It releases a powerful surge of dopamine, that's the feel-good chemical, and it creates a reinforcement loop that gets tied to hundreds of daily cues. There's the obvious ones like a morning coffee or finishing a meal or being stressed out -- those are the things that many people know as triggers -- but there are tricky, subtle ones that are often what derail people weeks, months, even years after they've been quit. It can be a distinct smell, a memory, a particular part of a song. 

Over time, all of the things that get associated with that feel-good rush of dopamine are then what reinforce the desire for nicotine. So when someone tries to quit, they're not just fighting that chemical craving, the biological addiction, they're fighting years of that learned behavior, the environmental triggers, and really a brain that has been rewired to associate nicotine with reward and relief. So, motivation is necessary, but it's certainly not sufficient.

Lindsey Smith

I think that's a really important point that you touched on with the rewiring point specifically, and it really changes how I think we should think about success and failure in quitting. I know you guys have a lot of great programs in place. Can you mention some of those where listeners can go to get more information?

Amanda

So the program that we have run since 2008 in partnership with Mayo Clinic is called EX Program. It is a multi-modal digital program, which means people can engage through our text messaging platform, through the website. We have the longest running online community specifically for tobacco users. It's available free of charge to anyone across the country who is age thirteen or older and to support people regardless of the specific tobacco product they're using. 

For many, many years, this program mostly supported older adult established smokers. But more recently, we have incorporated a quit vaping program that's been wildly successful with young people. I talked about the two randomized trials that we've run. We've expanded to address the use of oral nicotine pouches. We've expanded to address hookah. So it really is a program that cuts across the tobacco product landscape. There will be new products that emerge. We will keep pace with them. But most importantly is that it's available free of charge.

Lindsey Smith

We will be sure to put that information in the show notes for our listeners to check out. Let's talk about those other tobacco products, e-cigarettes and vaping. They have complicated the tobacco landscape, especially for young people. How has that shift changed your work?

Amanda

Yeah, for sure. The tobacco landscape has become more complicated, and I would say that may be an understatement. So as I mentioned, when I started in this field, the focus was almost exclusively on cigarettes. We had a handful of known adversaries in the tobacco industry peddling known deadly products, and now what we're dealing with are e-cigarettes, oral nicotine pouches, heated tobacco products, dual use and poly use have become much more common. And now it's this complex mix of global companies, many of whom are sending pretty confusing messages about the relative risk of those products and who should be using what. 

We're also seeing pretty concerning trends specifically in young adults. It used to be that most smokers started in their adolescent years and what we've seen is that the proportion of individuals who start smoking after age eighteen has more than doubled over the past few decades and e-cigarette use, obviously among young adults, has grown substantially. 

There's also a lot of misinformation about this mix of products on the market. It makes it challenging from a public health standpoint to message in a way that is clear and understandable to a young adult who should not be using any form of nicotine, and also to an older adult smoker who may be using less harmful products to try and quit smoking. 

So, that's been a challenge in the field and certainly informs our thinking and our approaches as we step in to serve that full age spectrum.

Lindsey Smith

The trend that you mentioned for the younger audience is very concerning, and misinformation is a really hot topic on this podcast and across healthcare in general that we've seen this year. I want to look forward a little bit with you and ask how you see AI fitting into the future of cessation support.

Amanda

I would say I'm both genuinely excited and at the same time have some genuine concerns. The things that excite me are the potential to really supercharge our ability to personalize at scale the interventions that we deliver. So I talked about the ability to tailor, you know, back in the late 1990s early 2000s, with computing power. And AI, obviously, takes that and multiplies it to a certain factorial. We can tailor our interventions more precisely across a greater number of dimensions and deliver support that really adapts in real time. The consumer demand is obviously there for this technology, and so harnessing that specifically for public health could really, really be a game changer. 

On the flip side, what concerns me is that we're already seeing AI deployed in health contexts without adequate evidence or safeguards. There have been studies that have shown that something like eighty percent of digital health products have little or no published clinical evidence. That's not a new problem. But I think AI then accelerates it because the tools become more capable and the excitement around this technology becomes more intense. 

I think just taking a step back, the pattern that I've seen over twenty-five years is that technology moves very fast, but at the same time behavior change is hard. And so the winners in digital health aren't necessarily the ones with the latest flashiest technology, but the ones who make sure to integrate evidence-based tools into real workflows to reach people at the right moment and prove that they actually improve outcomes.

Lindsey Smith

Yeah, agree entirely. I think there's a lot of promise that we see with AI functionality, but so much to think through in how it's used effectively. And I know at Elsevier, we have a couple of AI tools that deliver trusted, walled-in content, and we're thinking a lot about using AI responsibly in all of our products that we deploy. I want to ask you a question about a knowledge gap, because at Elsevier, we are an educational company, and we like to think about knowledge gaps and see if there's a topic that you think deserves more attention.

Amanda

I'm going to give you a very selfish answer. I would love to see something that brings tobacco back into the national conversation. A lot of people think that smoking has been solved because they don't see it in their immediate environment, and these are often people who influence policy decisions, employee benefits, clinical care. And so the lack of visibility, the lack of priority around tobacco use in all of its forms, I think has real consequences. 

The death toll from the COVID pandemic in 2022 was still less than the death toll from smoking in that year. We had COVID all over the headlines, and we just don't see that with tobacco. There are still more than twenty-five million people who smoke in this country. Millions more are living with tobacco-related disease, and the financial burden that comes with it. It's a major driver of healthcare costs in our country. It hasn't gone away. It's just become more concentrated in populations that are already marginalized, and it's no longer sort of top of mind or making front page news. So that would be my selfish request.

Lindsey Smith

That's a helpful perspective, and it's a good reminder that the smoking addiction requires an ongoing effort. It's a continued challenge, and it needs to be prioritized. So in our audience, we have many students and early career health professionals listening in. What advice would you give them as they build their careers and take on today's challenges in health care?

Amanda

That's such a great question. I would say this is a defining moment for tobacco control. You know, the federal tobacco control capacity has contracted significantly over the past year. And combined with new nicotine and tobacco products that are literally engineered for dependence -- they have games on them, they have trackers on them, they have an extraordinary amount of nicotine in them -- all of that means that the need is greater and the opportunity for individual clinicians and researchers to make a meaningful impact is real. 

I would say that impact doesn't mean you have to be an addiction specialist. I think regardless of what field you choose, you will encounter people struggling with addiction, and the important thing is to approach them with the same rigor, the same compassion that you'd bring to any other medical condition. 

You know, a lot of people feel daunted...”this isn't a conversation somebody wants to have; I don't know what to say; It wasn't part of my training.” Ultimately it comes down to having a short statement about the importance of quitting that feels comfortable. Make it clear that you're there to support them and know how to connect them with an evidence-based program. 

The analogy that I use is healthcare providers don't ask people with diabetes if they'd like help managing their diabetes, right? We dive in with treatment. We deliver treatment. And we should do the same thing for people who are using tobacco products and who are addicted to tobacco and nicotine.

Lindsey Smith
That's great advice. Approach anyone with addiction with compassion. Before we wrap up today's episode, is there anything that we didn't cover that we should have?

Amanda

I've talked a little bit about EX Program and how it works. I guess the one thing that I would add is that for clinicians, for hospital administrators, really anyone looking to help tobacco users, we have free promotional materials that you can use to help get your patients connected with this program. The easy way is to reach out to us at Truth Initiative and we can get you connected with those promotional materials to hang in a waiting room, in a bathroom, in the clinic. 

A lot of times somebody may not disclose that they're using tobacco when they're meeting with you. Visits get busy. There may not be time. But having that information available really makes it easy for somebody to make that decision at the time that they're meeting with you to make a change as it relates to their tobacco use.

Lindsey Smith

That is a really meaningful note to end on. Thank you so much for sharing so many great nuggets with us about the Truth Initiative, the EX Program, and how to get promotional materials to showcase. Dr. Graham, thank you for joining us today. It's been a great conversation.

Amanda

Thanks for having me. Great to be talking with you.

Lindsey Smith
And that does it for today's episode. Dr. Graham, thank you for sharing your insights and for the work you're doing to bridge the gap between intention and lasting change. It's clear that combining behavioral science with digital innovation has the power to transform how we support people on their quit journeys. 

I'm Lindsey Smith. Thanks for checking out today's show. Remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.