Tobacco smoking contributes substantial global health burden through disability-adjusted life years (1), poor health-related quality of life (2), and preventable morbidity and premature mortality (3). In some settings, smoking causes more disease and death than alcohol and illicit drugs combined (4). Whilst overall smoking prevalence has declined in most Organization for Economic Co-operation and Development nations in the past decade (5), morbidity and mortality related to tobacco smoking continues to rise with global population growth (6). Whilst smoking cessation programs such as Quitline have been established as an effective, and cost-effective means of reducing tobacco smoking internationally (7–16), evidence-based interventions and practices may not achieve their full or desired effect if poorly implemented (17, 18).

Implementation science bridges the gap between knowledge and practice by evaluating how interventions that have been shown to be effective at small scale, within the controlled research environment, can be embedded on a large-scale into routine service structure and delivery (19–22). Implementation strategies describe the methods used to implement evidence-based practices into routine service provision, and are essential to ensuring successful implementation (23). However, implementation strategies are infrequently used and reported, or may lack an implementation theory, model, and/or framework (TMF) to support their use (23). Whilst there are a number of implementation TMFs reported in the literature (for example (24–28)), they are rarely applied to prospectively guide the study design, development and conduct, or to support interpretation of results from research projects or implementation studies (29). Limited use of implementation TMFs may be due to lack of provider familiarity or experience, or uncertainty about how to apply TMFs to an implementation effort (30). Reporting implementation strategies alongside TMFs supports the evaluation of how interventions, treatments, and services can be implemented successfully into routine care, at scale (31, 32). Furthermore, prospective use of TMFs can guide the design of implementation strategies (33). Reasons for inconsistent use and reporting of implementation strategies are not well understood, however may be due to confusing definitions, inconsistent application of terminology, and poorly described strategies (23). Proctor (23) argues that the degree of implementation success cannot be evaluated, nor can the implementation effort be replicated, without clear, accurate, and complete reporting of the implementation strategies used.

The implementation of smoking cessation programs has been evaluated previously in a number of systematic and scoping reviews (34–40). Existing reviews have focused on specific contexts, for example, within oncology clinics (34), or in hospitals (35, 36). Other reviews have focused on service provider outcomes (36, 39, 40), implementation outcomes (35, 37, 38), or barriers and facilitators of implementation (36, 40). Based on preliminary searches as part of our study, no reviews of the implementation of smoking cessation programs with a focus on the use of TMFs alongside implementation strategies were identified internationally. Therefore, this review focusses on the use of implementation strategies, guided by TMFs or principles where relevant, in the implementation of smoking cessation programs.

The aim of this scoping review was to map evidence regarding the real-world implementation of smoking cessation programs for adults in community contexts. The study objectives were to evaluate the following:

A scoping review was selected to map the current literature and enable synthesis of key concepts across a broad range of study designs and topics (41). Scoping reviews are particularly relevant when the area of research is nascent, unclear, or complex (42, 43). Nicotine addiction is particularly complex due to the physiological, psychological, and behavioral drivers of addiction contributing to high prevalence of tobacco use in groups experiencing socioeconomic disadvantage (44, 45). The study protocol provides a full description of the methods, and is available as a pre-print (46). Minor deviations from the protocol included: (1) changes to the research questions in the study objectives to provide greater clarity for the reader; (2) updates to the inclusion and exclusion criteria to ensure potentially relevant papers were included in this review (Tables 1, 2; Figure 1; 46).

The initial database search returned 3,947 unique records after deduplication. Of these, 3,734 (95%) were excluded during title and abstract screening. Full-text publications of the remaining 213 papers were retrieved and assessed for eligibility. Of the 213 articles, 21 (10%) were included in the review. An additional 10 papers were identified from grey literature and citation searching, resulting in 31 papers included in this review.

To our knowledge, this is the first scoping review to evaluate the implementation of smoking cessation interventions alongside implementation theories, models, and frameworks, concurrently mapping implementation strategies to ERIC (53). We identified relevant studies across a range of designs and methods, participant groups, clinical and community settings, and geographic locations. Studies included a broad range of intervention types, delivery modes, providers, and theoretical evidence bases to inform intervention development. Evidence bases most commonly included motivational interviewing (55), and clinical guidelines or standards. There was substantial heterogeneity in TMFs reported across studies. Implementation strategies identified covered all nine ERIC domains, most of which were individual-level strategies (53). Our finding that no strategies fell outside of ERIC is somewhat surprising considering ERIC was compiled and refined in clinical, and mental health, rather than the community-based contexts that were the focus of this review (102).

This review summarized interventions used during the implementation of smoking cessation programs. Our results highlight the numerous intervention types, methods of delivery, providers, and theoretical foundations for implementing smoking cessation interventions in the community. We identified multicomponent interventions tailored to the intended populations, and/or individuals reported in most studies (n = 27/31). Multicomponent, tailored interventions have been shown to be more effective than single, less complex interventions for smoking cessation, particularly for vulnerable, at-risk, and culturally diverse groups (103–105). Furthermore, we identified peer counsellors and community supporters among intervention providers, in addition to peer support as an intervention component. Our findings corroborate with previous research emphasizing the importance of social support alongside intensive, multicomponent interventions (103), However, we did not evaluate the duration of interventions in included studies, which has been identified as an important element of cessation support (103).

We evaluated implementation theories, models and frameworks, limiting the inclusion criteria to studies using an implementation TMF, or other identifiable implementation components (23). Thus, most (n = 26/31) of the included studies used at least one TMF. In two studies that did not use a TMF (59, 61), and one study that did use a TMF (78), community participation and engagement was a strong component of implementation (58). Whilst there are numerous community participatory frameworks for implementation (106–110), a number of studies using community participation to guide the implementation without specifying TMF use have been reported previously in a review (111). There is current debate in the literature suggesting that “common sense” in the form of local knowledge, which could be garnered through community participation, could replace TMFs to guide implementation (32). Whereas others contend that conscientious use of TMFs can support the ability to plan, guide, conduct, and evaluate implementation (29). Furthermore, that TMFs can improve the generalizability and translation of findings through shared terminology and knowledge (29). This suggests that whilst community participation may be considered an effective standalone approach to implementation, judicious application of TMFs may support successful implementation, and translation of theory to practice. Translation to practice is particularly important in countries such as Australia, Canada, and New Zealand, where the First Nations people have considerably higher smoking prevalence due to the ongoing effects of colonization (112). As such, TMF selection should take into consideration the strengths and diversity, in addition to the needs and preferences of these populations for future implementation (113). Furthermore, Australia covers an expansive geographic area, with diverse communities spanning from urban, to very remote and varying access to health services (114). Such contextual factors should be considered when selecting a TMF, to ensure that implementation extends to populations that historically may have been excluded from implementation projects (115, 116).

We excluded studies that did not use a TMF, or other identifiable elements of implementation. Consequently, 129 studies reporting on implementation of smoking cessation programs, including “real-world” studies, were excluded from this review (Figure 2). Reasons for underutilization of TMFs may be due to a number of factors, including difficulty selecting from the overwhelming number of TMFs available, hesitancy in applying a TMF due to lack of knowledge or experience, or confusion due to inaccurate and inconsistent definitions related to implementation terminology (30, 117, 118). Whilst a TMF is not prerequisite for implementation, as demonstrated in a number of included studies (58, 61, 62, 70, 84), there are a number of possible implications to not applying TMFs to an implementation effort. For example, potential benefits for planning, delivery, evaluation, and reporting the implementation of smoking cessation programs may not be realised where a TMF is not applied (29, 119). When conducting full-text screening, we encountered a challenge in differentiating between implementation strategies and intervention components in some studies lacking a TMF, due to unclear terminology and definitions (23), and a lack of clear and methodical structure for implementation processes (120). Whilst smoking cessation interventions have been extensively researched (121), implementing effective interventions into routine practice is vital to combat the rising trajectory of morbidity and mortality related to tobacco smoking (6). Following the advice of others, we suggest taking a purposeful approach, applying the appropriate knowledge and tools that align with the studies purpose and goals to guide and support implementation (117, 119). The process of selecting appropriate TMFs for the target population, study purpose, or context, could be supported by use of checklists and tools (122). Deliberate and appropriate use of TMFs may support the transferability of implementation to other interventions and contexts (29).

We mapped implementation strategies in included studies across the strategy clusters detailed in ERIC, and did not identify any implementation strategies that could not be mapped to ERIC (53). Whilst strategies that fall outside of ERIC have been identified in other studies (123, 124), our findings suggest that ERIC (53) could be an appropriate framework for implementing smoking cessation interventions. We identified diverse approaches to implementation within the ERIC strategy domains in included studies. Individual-level strategies, within the domains of ‘use evaluative and iterative strategies’, ‘adapt and tailor to context’, ‘development of stakeholder interrelationships’, ‘train and educate stakeholders’, and ‘engage consumers’ were commonly applied across included studies. Whereas we noted less common application of service-level strategies within the domains of ‘provide interactive assistance’, ‘utilize financial strategies’, and ‘change infrastructure’. This finding may be due to use of TMFs other than ERIC to guide implementation in all but one study (85), or approaches to implementation without use of a TMF. Alternatively, these systems-level strategies may have been considered incompatible with the aims or scope of the included studies, nevertheless these strategies are vital to translating evidence to practice (125). We suggest that future studies implementing smoking cessation interventions should consider incorporating strategies across ERIC domains to support tailoring of implementation efforts, and translation to practice (126).

A novel finding in this review was the cultural tailoring applied to the process of implementation in three studies (59, 61, 78). Cultural tailoring includes modifications to study procedures and interventions in response to the cultural needs of the population (127), and has been established as an important component of smoking cessation and health services (104, 128, 129). Cultural tailoring is not limited to race and ethnicity, and refers to the shared characteristics that shape the attitudes and behaviors of a population through their interactions with their environment (130). In the three studies (59, 61, 78) that developed culturally tailored interventions, we identified further evidence that the implementation was culturally tailored through purposefully embedding Treaty principles (94), First Nations Ethics and Guidelines (97), and culturally guided application of a community engagement framework (101) to the implementation process. The collaboration between the researchers and communities, development of partnerships, shared decision making, and culturally guided, community-driven intervention and implementation planning, development, delivery, and evaluation aligns with a culture-centered approach (131). Community participation and ownership of the projects was emphasized throughout the implementation of the aforementioned studies (59, 61, 78). These approaches have been previously described using a co-creation lens, which encompasses principles of equity, reflexivity, reciprocity and mutuality, transformation and personalization, and relationship facilitation (132). Emphasis on health equity through genuine community engagement and partnership, shared goals and power, centered on the needs and culture of the community has been identified as critical to progressing the field of implementation science (133). Whilst the culture-centered approach and co-creation have been previously described (131, 134), employing and identifying such strategies in research may be hampered due to confusing terminology, a lack of guidance for design and implementation, and a need for more research on applying frameworks to planning and implementation (134–136). Given the effectiveness of culturally tailoring smoking cessation interventions (104, 137–139), we believe that tailoring the implementation process according to culturally specific guidelines and principles (94, 97) (hereafter referred to as cultural TMFs) has the potential to improve the implementation of smoking cessation programs for intended populations. This could be achieved firstly through advancing terminology and knowledge surrounding the culture-centered approach and the co-creation lens (131, 132). Secondly, by harmonizing approaches described in the aforementioned models, and finally, through improved understanding of how to select and apply appropriate cultural TMFs to implementation projects.

To the best of our knowledge, there are currently no comprehensive reviews mapping smoking cessation interventions, implementation theories, models and frameworks, and implementation strategies. This review contributes substantial knowledge to further the future implementation of smoking cessation interventions in community settings. Nevertheless, there are a number of limitations to this review. Five papers were excluded during full-text screening due to being non-English, additionally we did not include abstracts for which there was no full-text available. We limited the study setting to the community, therefore studies taking place exclusively in inpatient hospital settings were excluded thus limiting the generalizability of the results to non-community based contexts and providers. Whilst we provided a comprehensive report of smoking cessation interventions, TMFs, and implementation strategies, we did not evaluate the intensity and duration of interventions, their effectiveness for smoking cessation outcomes, nor implementation success. Furthermore, we did not evaluate the quality of implementation TMFs for smoking cessation interventions within included studies. Future systematic reviews could build on the findings of this review to evaluate the comparative effectiveness of theory-and non-theory-based implementation strategies for smoking cessation interventions. We mapped implementation strategies to ERIC, however, we acknowledge other taxonomies for implementation strategies exist and could be considered for mapping implementation strategies for smoking cessation programs. Finally, this review did not evaluate de-implementation, which is often required alongside implementation efforts and should be considered in future reviews.

This scoping review identified interventions, TMFs and other approaches, and implementation strategies for smoking cessation programs. We identified broad use of numerous, multi-component, and tailored interventions, by diverse providers, for smoking cessation programs, emphasizing the strategies by which cessation may be supported. These strategies included non-TMF approaches including co-design and community engagement. Culturally tailored implementation emerged as a distinct implementation strategy in three studies. Harmonizing strategies using a culture-centered approach and co-creation lens alongside relevant cultural TMFs could be considered as a means to improve implementation for intended populations, and thus public health.