7.9 Approaches to increasing the proportion of ever smokers who have quit

Last updated: October 2016 

Suggested citation: Greenhalgh, EM., Stillman, S., & Ford, C. 7.9 Approaches to increasing the proportion of ever smokers who have 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/7-9-policy-measures-associated-with-quitting

To increase the proportion of ever smokers who have quit requires a combination of increasing the number of smokers who attempt to quit, increasing the success rates among those who do make attempts and encouraging further attempts even among those who have tried and failed before.

7.9.1 Strengthening of comprehensive tobacco control policy

Expert scientific bodies have concluded that success in smoking cessation at the population level requires a comprehensive approach to tobacco control.1-4 Maintaining the high proportions of smokers attempting to quit is likely to require:

  • further real and effective price increases
  • sustained, evidence-based mass media campaigns
  • extension of smokefree public environments
  • extension of bans on tobacco advertising and promotion
  • inclusion of prominent health warnings on packs and efforts to ensure the warnings remain salient and
  • ensuring that smokers receive encouragement and appropriate support to quit in all healthcare settings and other public institutions such as prisons.

All of these interventions are likely not just to prompt quit attempts, but also to prevent relapse among quitters, and to prevent ex-smokers from resuming smoking.

Another important strategy for increasing the success of quit attempts is:

  • making evidence-based cessation support readily available and promoting its use to smokers.

Success rates among those attempting to quit are relatively low. A longitudinal study of smokers from Canada, the US, the UK, and Australia (the ITC-4 study) found that among those who reported at least one quit attempt within the past year, about half lasted a week or less on their most recent attempt, and only about one-fifth successfully abstained for more than a month.5 A key consideration among public health experts is whether it is more beneficial to focus on increasing success rates among smokers who have quit (i.e., preventing relapse) or whether it would be more useful to try and increase the number of smokers who make quit attempts.

There is some evidence that shifting the focus from the quality of smokers’ quit attempts to the quantity of those attempts produces greater overall benefits.6 Data from California indicate that smokers on average tried 12 to 14 times before quitting for good: 12 if they used cessation aids, and 14 if they did not. These figures have stayed fairly consistent since data collection began in the early 1990s, even with the increased availability of cessation aids. So while quitting aids reduce the number of attempts that are needed to achieve successful cessation, most smokers will still have to make multiple attempts. The authors concluded that—while ideally, all quit attempts would involve a cessation aid, counselling, or some other form of assistance—the key to increasing the proportion of ever-smokers who have quit is to encourage smokers to try again if they relapse.7, 8

7.9.2 Reduced barriers to use of cessation programs and pharmacotherapies

Evidence-based smoking cessation treatments are underutilised. Increasing smokers’ knowledge of and access to such treatments can in turn increase demand for them.9 Many smokers are unaware of the full range of strategies that can help them to quit, and many use non-evidence-based approaches.10 One study also found that current smokers may be less trusting than non-smokers of information from health professionals or the Internet.11 A consumer-centred approach to increasing the use of cessation aids involves understanding and addressing smokers’ needs and concerns and communicating effectively with them about the nature and value of treatments.12 For example, a study in the UK found that presenting information about the effectiveness of the National Health Service (NHS) stop smoking service improved service attendance.13 Addressing smokers’ expectations about the effectiveness and desirability of cessation medications may also increase the likelihood that they will use them.14 A 2012 Cochrane review considered ways in which more smokers might be encouraged to enter smoking cessation programs. It concluded that that increasing contact time with potential participants may be an important strategy, along with tailored and proactive strategies.15

An integrated, comprehensive systems approach to cessation treatment and policy may help improve population quit rates.16 Treatment policies suggested in the literature include:16, 17

  • expanding cessation treatment coverage and provider reimbursement
  • mandating adequate funding for the use and promotion of evidence-based, state-sponsored quitlines
  • supporting healthcare system changes to prompt and guide tobacco treatment
  • supporting and promoting evidence-based treatment via the Internet
  • improving individually tailored approaches and the long-term effectiveness of evidence-based treatments.

One study from the US that modelled the potential impact of smoking cessation treatment policies on adult quit rates estimated that implementing any policy in isolation could increase quit rates from a baseline rate of 4.3% to between 4.5% and 6%. By implementing policies in combination, the quit rate would increase to 10.9%.17

One way to increase the use of available smoking cessation treatment may be to provide greater financial support through healthcare systems to people who want treatment for their tobacco addiction, in line with treatment for other medical and behavioural disorders.18 Higher out-of-pocket expense has been associated with a lower probability of a smoker using any smoking cessation medication.19, 20 Providing access to subsidised pharmacotherapy can increase usage of quit treatments and increase the proportion of quit attempts that are successful. A 2012 Cochrane review concluded that covering smokers’ costs of cessation treatment increased the proportion of smokers attempting to quit, using smoking cessation treatments, and succeeding in quitting, when compared to providing no financial benefits.21 Evidence suggests that lower socio-economic status (SES) smokers are more addicted and may benefit from more intensive support to successfully quit, highlighting the importance of providing ready access to pharmacotherapies complemented by evidence-based behavioural support.22

7.9.2.1 Availability and price of nicotine replacement therapy (NRT)

Since February 2011, Australian smokers have been able to access a 12-week supply of nicotine patches under the Pharmaceutical Benefits Scheme (PBS) as long as they have a medical prescription.23 Data from the Australian National Drug Strategy Household Survey show that among adult regular smokers, past year use of NRT (gum, patches, or inhalers) increased significantly from 14.9% in 2010 to 16.7% in 2013 (controlling for age and sex).24 UK research found that while making pharmacotherapies for cessation reimbursable did not increase the proportion of smokers who tried to quit, the policy increased the proportion of quit attempts that were aided by medication.25 There is evidence from the US that adding free NRT to a smoking cessation program may increase numbers in the program and short-term quit rates, but not sustained abstinence.26 Research in Canada examining the effectiveness of mass distribution of nicotine patches found that odds of cessation at six months were significantly greater among groups receiving nicotine patches compared to those who did not.27

7.9.2.2 Subsidy of prescribed medicines

As with distribution of low-cost NRT, making prescribed pharmacotherapies more affordable for smokers appears to increase their use. Evidence from the UK shows that making prescription smoking cessation medicines reimbursable leads to greater use.25 Similarly, Australian research has found that reported use of prescription medication to quit smoking rose sharply with the addition of varenicline to the PBS.28

7.9.3 Building knowledge about and skills in quitting: population-wide education versus clinical and other one-to-one approaches

Most smokers attempt to quit on their own even when effective support is available. Building smokers’ knowledge about and skills in quitting may play an important role in increasing successful cessation. Smokers are often unaware of and underestimate the benefits of available cessation assistance.29 One study found that the use of a decision aid aimed to motivate smokers to use effective cessation treatments can have a positive effect on knowledge of and attitude towards the methods, confidence about being able to quit and quit attempts but does not affect actual usage.30

To increase successful cessation at a population level it is important to understand which cessation methods are most often used by smokers, and which are most helpful.31 Australian research found that going cold turkey, NRT, and gradual cigarette reduction before quitting are strategies commonly used by smokers and are perceived as being very helpful, while receiving advice from health professionals, although common, is perceived as less helpful. Although the number of prescriptions filled is very high (see Section 7.16), surveys suggest that prescribed medication has low use but high perceived helpfulness.31

7.9.3.1 Intensity of intervention

An important consideration in implementing cessation interventions is their structure or level of intensity, including the duration of each contact/session, total amount of contact time, and number of person-to-person sessions. Cessation rates tend to increase with extended contacts and with the number of treatment formats (different types of counselling and educational interventions).1, 32 Low intensity interventions typically offered in Australia include brief advice from a doctor or other health professional and the Quitline service, although these interventions have the potential to be more intense. Examples of high intensity interventions include the Quitline program of callbacks for smokers while they are in the process of quitting, group programs that have multiple sessions, and individual counselling involving multiple sessions with a doctor, nurse or psychologist. The effectiveness of all levels of interventions is improved by concurrent use of proven quitting medications.33, 34

Smokers who undergo more intense interventions generally have a greater likelihood of achieving successful cessation.33 Lower SES smokers in particular are often more addicted and may therefore be more likely to need more intensive support to quit successfully.35 However, higher intensity interventions are usually more costly (to the individual, government or other funders) and less likely to be available or attractive to all smokers. There are also interventions (such as motivational interviewing) that appear to be more effective when they are less intense.36 The relative costs and benefits of each intervention is therefore an important consideration to individuals and policy makers. (See Sections 7.14 and 7.15 for further information)

7.9.4 A middle way: population education plus system-wide minimal interventions combined with low-cost, high-reach tailored services

The National Tobacco Strategy 2012–18 outlined a comprehensive approach to tobacco control in Australia that included several priority areas specifically for prompting or assisting people to quit, including: strengthening mass media campaigns to motivate smokers to quit and recent quitters to remain quit, discourage uptake of smoking, and reshape social norms about smoking; eliminating remaining advertising, promotion and sponsorship of tobacco products; providing greater access to a range of evidence-based cessation services to support smokers to quit; continuing to reduce the affordability of tobacco products; and strengthening efforts to reduce smoking among priority populations.37

Australia’s National Preventative Health Strategy38 also named these strategies as key action areas for state and federal tobacco control policies, and additionally highlighted the importance of ensuring all smokers in contact with health services are encouraged and supported to quit, with particular efforts to reach pregnant women and those with chronic health problems.

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