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7.2 Quitting activity

Last updated: July 2017

Suggested citation: Greenhalgh EM, Stillman S, & Ford C. 7.2 Quitting activity. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-1-quitting-activity

7.2.1 Population prevalence of ex-smokers, quit proportions

In the 2016 National Drug Strategy Household Survey (NDSHS) of Australians aged 14 years and over, just under one-quarter (24%) of the population were estimated to be ex-smokers and well over half (62%) had never smoked.1

Table 7.2.1
Proportion of never smokers, ex-smokers and current smokers, Australians aged 14+ years, 1991 to 2016 (%)

Sources: National Drug Strategy Household Surveys 1991,2 1993,3 1995,4 1998,5 2001,6 2004,7 20078, 20109, 201310 and 201611

* From 2001 the definition of ex-smoker was 'ever smoked more than 100 cigarettes but now no longer smoke'. This includes people who have only ever smoked less than daily.

Table 7.2.1 shows a small decline in the percentage of ex-smokers since 2001, suggesting that increases in the percentage of people not taking up smoking in the first place (‘never’ smokers) rather than increases in the number of people quitting (‘ex-smokers’) might have been most important in reducing the prevalence of current smoking. However it should be noted that the proportion of ex-smokers would also be declining due to mortality among the generation born prior to 1930, many of whom were smokers as young adults but who quit over subsequent decades.

The final column of Table 7.2.1 also sets out the proportion of ever smokers who have quit. A change in definition of ex-smokers in 2001 makes it difficult to be certain, but it appears that the proportion of ever smokers who have quit was more than fifty percent higher in 2016 than it was in 1991. Figure 7.2.1 shows this trend since 2001.

Figure 7.2.1
Proportion of never smokers and proportion of ever smokers who have quit, Australians aged 14+ years, 2001 to 2016 (%)

Sources: Australian Institute of Health and Welfare, National Drug Strategy Household Surveys 2001,6 2004,7 20078, 20109, 201310 and 2016.11  

7.2.2 Population trends in intention to quit

Another index of quitting potential is obtained by asking smokers about their intention to make a quit attempt in the future. In 1983–84 approximately 25% of Victorian smokers said that they were very likely to quit within the next three months.12 Data from 2005 indicated that 54% of Victorian smokers were intending to quit within the next six months.13 This is consistent with international data that also suggest that many smokers are in some form of transition. Most smokers who plan to reduce their smoking see it as a step towards quitting completely.14

As smoking rates decline, some people have argued that a greater proportion of the remaining smokers are likely to be ‘hardcore’ smokers who are unwilling or able to quit (also known as the ‘hardening hypothesis’);15 however, measures of physical dependence in the Australian population do not appear to uphold this theory. In Victoria, the mean number of cigarettes smoked per day (a proxy measure of nicotine dependence) among daily smokers and the percentage of heavy smokers in the Victorian smoking population (defined as smoking at least 25 cigarettes per day) significantly declined between 1998 and 2007.16 Australia-wide statistics show that the average number of cigarettes smoked per week by current smokers aged eighteen years and over similarly declined between 1998 and 2007.5-8 A slight increase was seen in 2010,9 before significantly decreasing again in 201310 and did not significantly change in 2016.11 (See Chapter 2, Section 2.3  for further details.) Australian studies indicate that the proportion of smokers with hardcore attributes (unable or unwilling to quit) is small. A 2001 Australian survey found that only 8% of smokers reported being happy to continue smoking with no intention of ever quitting.17  A 2006 New South Wales survey, using a restricted definition of hardcore incorporating measures of nicotine dependence, age, and lack of quitting intent and activity, classified 6% of smokers as hardcore.18  Analysis of NDSHS data from 2001 to 2010 found that the overall rate of hardcore smoking (defined as the number of smokers who smoked more than 15 cigarettes a day, had not made an attempt to quit in the last 12 months, and did not plan to quit) remained stable over the 10 years, but varied by SES. The proportion of high-SES hardcore smokers decreased over time, but the proportion of low-SES hardcore smokers increased.19

A number of international studies have reported similar findings.15, 20 Authors of a 2003 paper concluded that there was ‘little evidence that the population of smokers [in the US] as a whole is hardening’, but sub-groups who have more difficulty quitting may be becoming a larger fraction of the remaining smoking population. However, cessation rates have not decreased and most smokers are susceptible to quitting.15 More recent examination of the US smoking population also concluded that the evidence does not support hardening, except among sub-groups who were more nicotine dependent (women and low-income smokers).20 A 2015 study examining the smoking populations in the US and EU concluded that the populations are softening as prevalence declines, rather than hardening.21 Similarly, New Zealand researchers found that from 2008 to 2014, quit rates remained steady, and there were no significant changes in indicators of hardening.22

7.2.3 Population trends in quit attempts and success in quitting

Overall quit rates in the population are a function of the percentage of smokers who make an attempt to quit, and the success rate among those who tried to quit.23

Different strategies exist for measuring quit attempts; each has its own limitations and current estimates of the amount of quitting activity vary considerably.24 One study has queried the definition of a quit attempt, as many surveys require that the attempt lasts at least 24 hours. The authors suggest this may underestimate the prevalence of attempts in studies that are measuring the effects of tobacco-control interventions.25

In a 2013 national survey of smokers aged 14 years or older, 86% of the respondents who had reported smoking in the previous 12 months said they had tried to change their smoking behaviour in the past year. Thirty per cent reported they had tried to quit without success, 20% had given up smoking for more than one month and 36% reduced the amount smoked per day.10

One Australian study of smokers between 2002 and 2009 found that 40% had tried to quit and, of these, about 23% remained abstinent for at least a month.26 Low socio-economic smokers were less likely to be interested in quitting and less likely to make a quit attempt.26

The Victorian annual surveys on smoking status have monitored attempts of current smokers to quit in the previous 12 months, and proportions that have ever made a quit attempt. The percentage of regular smokers who have ever made a quit attempt was 81% in 201027 and a similar proportion in 2005.28 The proportion of regular smokers who had made multiple (three or more) attempts to quit increased from 36% of regular smokers in 1998 to 49% in 2010.27 While these statistics show a very high level of quitting activity among smokers, the rate of successful quitting is low because of the high relapse rate. In 2010, approximately 77% of current smokers reported having previously attempted to quit and 66% of current smokers could be classified as unsuccessful quitters.27

One international study of smokers from high-income counties aimed to accurately document the amount of quitting, length of quit attempts and prevalence of plans and serious thought about quitting among smokers. It found that smokers think a great deal about stopping and make many unsuccessful quit attempts. Although most attempts end rapidly, the majority of smokers succeed in staying quit for more than one month, with about one-third stopping for more than six months. The results also found that quit attempts made in the past year and lifetime attempts appear to be under-reported and that fewer than 10% of smokers have never tried to quit.24 This evidence shows that there is a large amount of unsuccessful quitting activity and that even a small increase in the success rate would have significant effects on prevalence, highlighting the challenge of helping smokers to stay quit in the longer term.24 Another international study found that there is a subset of smokers who repeatedly attempt to quit, but fail. The authors suggest that it is important to determine why repeated quit attempts may be unhelpful in the long-term, as tailored interventions might be needed for people who want to quit, but persistently relapse.29 A longitudinal study concluded that previous research may have underestimated the average number of quit attempts it takes a person to successfully stop smoking, finding that for many smokers, it may take 30 or more quit attempts before being successful.30

Although success in quitting is clearly difficult for many, even the small percentage of smokers who quit, when seen at a population level, represents substantial progress. Evaluation of the National Tobacco Campaign showed a decline in smoking prevalence of 1.4% in the first six months of the campaign, which represented about 190,000 fewer smokers across the country.31

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References

1. Australian Institute of Health and Welfare. National Drug Strategy Household Survey (NDSHS) 2016 key findings. Canberra: AIHW, 2017. Available from: http://www.aihw.gov.au/alcohol-and-other-drugs/data-sources/ndshs-2016/key-findings/.

2. Makkai T and McAllister I, Patterns of drug use in Australian society. An analysis of national trend data, 1985-1991. Canberra: Commonwealth Department of Health, Housing, Local Government and Community Services; 1993.

3. Commonwealth Department of Health Housing and Local Government and Community Services, National Drug Strategy Household Survey. Conducted on behalf of the national drug strategy Canberra: AGPS; 1993.

4. Commonwealth of Australia. National Drug Strategy Household Survey: Survey report 1995. Canberra: AGPS, 1996.

5. Adhikari P and Summerill A. 1998 National Drug Strategy Household Survey: Detailed findings. AIHW Cat. No. PHE 27, Drug Statistics Series No. 6. Canberra: AIHW, 2000. Available from: http://www.aihw.gov.au/publications/index.cfm/title/6243 .

6. Australian Institute for Health and Welfare. 2001 National Drug Strategy Household Survey: Detailed findings. Drug statistics series no. 11, aihw cat. No. Phe 41. Canberra: AIHW, 2002. Available from: http://www.aihw.gov.au/publications/index.cfm/title/8227 .

7. Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2004: Detailed findings AIHW cat. no. PHE 66. Canberra: Australian Institute of Health and Welfare, 2005. Available from: http://www.aihw.gov.au/publications/index.cfm/title/10190 .

8. Australian Institute of Health and Welfare. 2007 National Drug Strategy Household Survey: First results. Drug Statistics Series, Number 20.Canberra: Australian Institute of Health and Welfare, 2008. Available from: http://www.aihw.gov.au/publications/phe/ndshs07-fr/ndshs07-fr-no-questionnaire.pdf .

9. Australian Institute of Health and Welfare. 2010 National Drug Strategy Household Survey: Survey report. Drug statistics series no. 25, AIHW cat. no. PHE 145.Canberra: AIHW, 2011. Available from: http://www.aihw.gov.au/publication-detail/?id=32212254712&libID=32212254712&tab=2 .

10. Australian Institute of Health and Welfare, National Drug Strategy Household Survey detailed report: 2013. Supplementary tables. Canberra: AIHW; 2014. Available from: http://www.aihw.gov.au/publication-detail/?id=60129549469&tab=3.

11. Australian Institute of Health and Welfare. National Drug Strategy Household Survey (NDSHS) 2016 key findings data tables. Canberra: AIHW, 2017. Available from: http://www.aihw.gov.au/alcohol-and-other-drugs/data-sources/ndshs-2016/data/.

12. Mullins R, Borland R, and Hill D. Smoking knowledge, attitudes and behaviour in Victoria: Results from the 1990 and 1991 household surveys. Quit Evaluation Studies No.6. 1990-1991.Melbourne: Victorian Smoking and Health Program, 1992.

13. Brennan E. Regular smokers' intention to quit smoking in the next 6 months: Changes over time. Melbourne: Centre for Behavioural Research in Cancer, 2007.

14. Cunningham JA and Selby PL. Future intentions regarding quitting and reducing cigarette use in a representative sample of Canadian daily smokers: Implications for public health initiatives. International Journal of Environmental Research and Public Health, 2010; 7(7):2896–902. Available from: http://www.mdpi.com/1660-4601/7/7/2896/pdf

15. Warner K and Burns D. Hardening and the hard-core smoker: concepts, evidence, and implications. Nicotine & Tobacco Research, 2003; 5(1):37–48. Available from: http://ntr.oxfordjournals.org/content/5/1/37.short

16. Germain D, Wakefield M, and Durkin S. Smoking prevalence and consumption in Victoria: key findings from the 1998-2007 population surveys. CBRC Research Paper Series, No. 31. Melbourne: Centre for Behavioural Research in Cancer, 2008. Available from: http://www.cancervic.org.au/downloads/08rps31_smok_prev07.pdf.

17. Borland R and Balmford J. Understanding how mass media campaigns impact on smokers. Tobacco Control, 2003; 12(90002):ii45–ii52. Available from: http://tc.bmjjournals.com/cgi/content/abstract/12/suppl_2/ii45

18. Walsh R, Paul C, Tzelepis F, and Stojanovski E. Quit smoking behaviours and intentions and hardcore smoking in New South Wales. Health Promotion Journal of Australia, 2006; 17(1):54–60. Available from: http://www.publish.csiro.au/paper/HE06054.htm

19. Clare P, Bradford D, Courtney RJ, Martire K, and Mattick RP. The relationship between socioeconomic status and 'hardcore' smoking over time - greater accumulation of hardened smokers in low-SES than high-SES smokers. Tobacco Control, 2014; 23(e2):e133–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24706085

20. Smith PH, Rose JS, Mazure CM, Giovino GA, and McKee SA. What is the evidence for hardening in the cigarette smoking population? Trends in nicotine dependence in the US, 2002-2012. Drug and Alcohol Dependence, 2014; 142:333–40. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25064023

21. Kulik MC and Glantz SA. The smoking population in the USA and EU is softening not hardening. Tobacco Control, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26108654

22. Edwards R, Tu D, Newcombe R, Holland K, and Walton D. Achieving the tobacco endgame: evidence on the hardening hypothesis from repeated cross-sectional studies in New Zealand 2008-2014. Tobacco Control, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27382047

23. Hyland A, Borland R, Li Q, Yong HH, McNeill A, et al. Individual-level predictors of cessation behaviours among participants in the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 2006; 15(suppl. 3):iii83–94. Available from: http://tc.bmjjournals.com/cgi/content/abstract/15/suppl_3/iii83  

24. Borland R, Partos TR, Yong HH, Surname KM, and Hyland A. How much unsuccessful quitting activity is going on among adult smokers? Data from the International Tobacco Control 4-Country cohort survey. Addiction, 2011; 107(3):673–82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21992709

25. Hughes J and Callas P. Definition of a quit attempt: a replication test. Nicotine & Tobacco Research, 2010; 12(11):1176–9. Available from: http://ntr.oxfordjournals.org/content/12/11/1176.long

26. Cooper J, Borland R, and Yong H. Australian smokers increasingly use help to quit, but number of attempts remains stable: findings from the International Tobacco Control Study 2002−09. Australian and New Zealand Journal of Public Health, 2011; 35(4):368–76. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1753-6405.2011.00733.x/full

27. Centre for Behavioural Research in Cancer, Current and former smokers' quitting activity and intentions: finding from the 1998-2010 Victorian Smoking and Health Surveys, unpublished data. Melbourne, Australia: CBRC; 2011.

28. Brennan E, Durkin S, Wakefield M, and Dunlop S. Victorian current and former smokers’ quitting activity and the impact of cessation aids, services and anti-smoking campaigns. CBRC Research Paper Series, No. 29. Melbourne: Centre for Behavioural Research in Cancer, The Cancer Council Victoria, 2007. Available from: http://www.cancervic.org.au/about-our-research/our-research-centres/centre_behavioural_research_cancer/research_projects_and_reports/cbrc_research_paper_series/vic_quitting_aids_campaigns_2007.html.

29. Partos TR, Borland R, Yong H-H, Hyland A, and Cummings KM. The Quitting Rollercoaster: How Recent Quitting History Affects Future Cessation Outcomes (Data From the International Tobacco Control 4-Country Cohort Study). Nicotine & Tobacco Research, 2013; 15(9):1578–87. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23493370

30. Chaiton M, Diemert L, Cohen JE, Bondy SJ, Selby P, et al. Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ Open, 2016; 6(6):e011045. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27288378

31. Hill D, Borland R, Carrol T, Donovan R, and Taylor J. Perspectives of the Australian National Tobacco Campaign, in Australia's National Tobacco Campaign, Evaluation Volume Two.  Hassard K, Editor Canberra: Commonwealth Department of  Health and Aged Care; 2000. p 1–9 Available from: http://www.quitnow.info.au/internet/quitnow/publishing.nsf/Content/evaluation-reports.

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