7.8 External factors associated with quitting
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7.8.1 Social networks
The Framingham Heart Study into the collective dynamics of smoking in a large social network demonstrates that smoking cessation by personal contacts, such as spouses, siblings, friends and co-workers in small firms decreased a person's chances of being a smoker.185 The influence of spouses and siblings remained strongly significant on smokers with any level of dependence, but the influence of friends and co-workers was not apparent on moderate to heavy smokers. The influence of friends was most marked among people with higher education and casual smokers. The study is consistent with other research showing that spouses who smoke are likely to quit at the same time, and smokers married to non-smokers or ex-smokers are more likely to quit and remain stopped.186 Conversely, being with an immediate social group of people who are smoking is highly conducive to relapse.115
The Framingham Study identified clusters of smokers and non-smokers in a large social network, and revealed that while smoking declined in the overall population, the size of social clusters of smokers remained the same over time. This suggests that whole groups of people were quitting together. The study also found that between 1971 and 2003, smokers in the network became increasingly marginalised socially, as they became more frequently found on the network periphery.185
Smokers typically state that partners and immediate family members are more in favour of them quitting than other social contacts.187 Smokers who receive support from partners and other people are more likely to successfully quit. Supportive behaviours such as talking the smoker out of smoking and praising the smoker's efforts to quit predict smoking cessation, but negative behaviours such as nagging and complaining about smoking are associated with earlier relapse.186 However, attempts to develop interventions aimed at helping smokers receive increased support for quitting from partners and other people have not improved long-term quit rates, possibly because their behaviours are not easily changed by the interventions used.186
Another type of social support intervention is the 'buddy system', where smokers are provided with someone to support them at quitting smoking, however there is no convincing evidence of better quit rates.188, 189 Reviews of the evidence recommend that counselling and behavioural therapies include providing support and encouragement as part of treatment. However evidence is limited on the effectiveness of this aspect of counselling, because it difficult to separate it from the influence of other components and treatment characteristics such as program length or type of therapist, or from the placebo effect.57, 190
7.8.2 Point-of-sale displays and popular culture
In Australia, many types of tobacco advertising, promotion and sponsorship have disappeared due to legislative restrictions. However, there remain a number of highly visible avenues for the display and marketing of tobacco products.
At the point of sale, tobacco companies promote their product through pack design, pack displays in purpose-built display cabinets or hardware, and price board signage.191–193 While some progress has been made to limit these displays, they are still widespread in supermarkets, petrol stations and convenience stores, and usually positioned near the cash register for maximum exposure.191 Such displays help promote tobacco as a 'normal' and familiar consumer product, as well as acting as cues for smokers and ex-smokers to buy and consume tobacco products when they did not intend to.191
An Australian study on the effects of retail cigarette pack displays on impulse purchases found that about a third of people trying to avoid smoking have had urges to buy cigarettes after seeing cigarette displays. Younger smokers were more likely to notice displays and tended to be more likely to buy on impulse. Almost a third of smokers thought that banning cigarette displays from stores would make it easier for them to quit.191 This raises the question as to whether the introduction of over-the-counter sale of nicotine replacement products in retail outlets may trigger thoughts about quitting and help promote quit attempts.
Popular culture is another prominent source of exposure to the promotion of smoking and tobacco products, especially in movies, but also on television, internet sites, and in print media such as magazines. Smoking in these settings usually escapes control under current legislation as it is deemed to be accidental or incidental to the movie or publication (if it has not been deliberately placed and funded by the tobacco industry).194 While there is clear evidence that smoking in movies encourages uptake by young people,195, 196 there is little research on the effect of smoking in movies on adult smoking and cessation. However, video footage of people smoking and virtual reality smoking cues are known to trigger cravings in smokers and are used in research studying nicotine cravings.197–200 Therefore, it may be plausible that exposure to smoking in popular media may encourage continued smoking and undermine cessation attempts. Proposals for controlling the portrayal of smoking in movies and restricting the other remaining avenues of tobacco promotion are discussed in Chapter 11.
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