Last updated: October 2016
Suggested citation: Greenhalgh, EM., Stillman, S., & Ford, C. 7.4 What finally prompts smokers to attempt to quit? 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/7-8-external-factors-associated-with-quitting
When asked about the factors that motivate them to consider quitting, smokers frequently mention the effect of smoking on their health and fitness, and the cost of cigarettes. Results from the 2013 National Drug Strategy Household Survey showed that almost half (47%) of smokers aged 14 years and over who had changed their smoking behaviour in the past year cited “it was costing too much” as a key reason. Health concerns (43%), wanting to get fit (34%), and friends or family asking them to quit (26%) were also common responses.1 Among younger smokers, illness, concern about future health, concern about fitness and physical appearance, the suffering or death of a loved one, image, the smell of cigarettes, cost, and a request from a boyfriend or girlfriend are all factors that can prompt a quit attempt.2-4 In 2013, health reasons were by far the most commonly reported motivator for changing smoking behaviour among 18–24 year-old Australian smokers, with the high cost of cigarettes ranking second.1
Population-level studies from a number of countries show that intentions to quit, past quit attempts, longer duration of past attempts, motivation to and confidence in quitting, less nicotine dependence, younger age, and receiving advice to quit from a health professional can predict quit attempts.5-9 Perceiving smoking or quitting to be an important part of one’s self-identity may also affect intention to quit and actual attempts to quit.10
Negative opinions about smoking and concerns about its health effects are strong predictors of cessation attempts,9,11 which provides a strong rationale for interventions such as restrictions on the promotion of tobacco products (which attempt to create positive connotations around smoking) and for anti-smoking mass media campaigns and explicit health warnings.
While tobacco-control policy and social norms shape people’s attitudes and beliefs about smoking over time, a more immediate prompt to quit is often something specific and personal,12 such as concern about one’s own health or the health of a loved one, or becoming pregnant. Quit attempts are commonly triggered by seeing an anti-smoking TV advertisement, many of which highlight health risks, or experiencing an increase in the price of cigarettes.
Health concerns, either for oneself or for a friend or family member, are a major motivator for smoking cessation.13-15 Many smokers hospitalised with cardiovascular disease report being prepared and attempting to quit.16,17 Attending an emergency department has been found to encourage a quit attempt in adult smokers, particularly among those who attributed their visit to a smoking-related problem and who were admitted to hospital.18 A new diagnosis of heart or lung disease is associated with increased rates of quitting, and similarly, being diagnosed with cancer can greatly increase motivation and interest in smoking cessation,19,20 and can lead to sustained quitting well after diagnosis.21 A study in the US found that about half of patients diagnosed with head or neck cancer were interested in taking part in a smoking cessation program.22 Receiving abnormal results following lung cancer screening is associated with smoking cessation up to five years later.23 On the other hand, limited evidence suggests that those with stroke/transient ischaemic attack do not necessarily associate their illness with smoking and it does not necessarily prompt a quit attempt.24 The detection of disease may be more motivating for men than women; a large longitudinal US study found that men (but not women) newly diagnosed with hyperlipidemia (a precursor to atherosclerosis) were more likely to stop smoking and less likely to start smoking compared to those with no such diagnosis.25
In a 2013 national survey, 16% of smokers responded that receiving advice from their doctor to quit was one of the factors that motivated them to change their smoking behaviour.1 Interventions within healthcare systems have been shown to promote smoking cessation. Even brief advice from a health professional increases quit rates among patients compared to those not receiving such advice.26,27 (See Section 7.10 for further information.)
Women are more likely to quit smoking during pregnancy than at any other time of life. They also experience higher levels of social and family support for quitting and have greater contact with the healthcare system.28,29 In 2012, 21.1% of Australian women who reported smoking during the first 20 weeks of pregnancy reported not smoking during the second 20 weeks of pregnancy.30 (See Section 7.11 for further information on smoking and pregnancy.) Expectant and new fathers have also been shown to change their smoking behaviours in order to protect their partners and infants from harm;31 thus, the perinatal period represents an important time for promoting quitting among both men and women.
Concern about the impact of smoking on children can motivate parents to quit. Discussion of smoking by paediatricians with mothers can be effective in encouraging quit attempts,32 as can parents’ beliefs that their child has higher health risks due to their smoking, or that their child’s health would improve if they quit.33 Apart from concerns about the effects of secondhand smoke, ‘setting an example’ for children can be an important reason for quitting.34
Both local35-38 and international 39,40 evidence supports the positive effect of anti-smoking mass media advertising on encouraging smoking cessation and helping ex-smokers remain abstinent. (See Chapter 14, Section 14.4 for further information.) A 2013 Cochrane review concluded that mass media campaigns likely contribute to a reduction in smoking when they form part of a comprehensive tobacco control program, but highlighted that more high quality evidence is needed to ascertain their unique role in behaviour change.41 (See Chapter 9, Section 9.8.1 for further information.) Anti-smoking commercials help to shape behaviour in a number of direct and indirect ways. Over the long term they increase awareness and understanding of the health effects of smoking and help to create the negative attitudes toward smoking within the community and individual that contribute to a person’s decision to quit.42 In the short term, seeing an anti-smoking commercial—particularly one that effectively conveys the health effects of smoking at a visceral level,43 evokes a strong emotional response and empathy with a character suffering from a smoking-related disease,44,45 and/or is perceived as personally relevant and effective46 —can increase motivation to quit and/or prompt behaviour change. For example, such advertisements can prompt individuals to take immediate action such as calling a quitline47 or purchasing cessation medication, both of which may help to convert what may have been a passing impulse into a serious quit attempt. At the population level, increasing exposure to such advertising significantly reduces the prevalence of smoking,35 and conversely, suspending mass media campaigns can lead to reduced quitting activity.48
Extensive research has shown that tobacco price increases prompt quitting attempts among adults.49,50 This effect appears to be consistent across all socio-economic status groups, with a significantly greater effect among those on low incomes.51 (See Chapter 13, Section 13.1.5 and Chapter 9, Section 9.8.2 for further information.) An analysis of a range of tobacco control policies in Australia found price increases (along with sufficient exposure to mass media campaigns) to be a crucial strategy in reducing population smoking prevalence.35 (See Chapter 13, Section 13.5 for further information.)
While the primary purpose of placing health warnings on cigarette packs is to inform users about the health risks of smoking, a robust body of research now shows that they also serve to prompt behaviour changes.52 Exposure to health warnings invokes thoughts about quitting, increases quit attempts, and promotes greater use of cessation aids, such as the Quitline. For a comprehensive overview of health warnings and their effects, see Chapter 12, Section A12.
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