7.2 Quitting activity

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7.0 Introduction

7.1 Health and other benefits of quitting

7.2 Quitting activity

7.3 Theories about smoking and quitting

7.4 What finally prompts smokers to attempt to quit?

7.5 What we know about smokers who are persuaded to attempt to quit

7.6 How smokers go about quitting

7.7 Factors that predict success or failure in quit attempts

7.8 How can relapse be prevented?

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

7.10 Role of health professional practices

7.11 Smoking cessation and pregnancy

7.12 Smoking and mental health

7.13 Cessation assistance: self-help

7.14 Cessation assistance: high reach, tailored or interactive

7.15 Cessation assistance: low reach, intensive

7.16 Pharmacotherapies

7.17 Financial incentives

7.18 Unproven remedies

7.19 Interventions for particular groups

7.20 National policy and progress in encouraging and supporting cessation

7.2.1 Population prevalence of ex-smokers, quit proportions

In the 2010 National Drug Strategy Household Survey of Australians aged 14 years and over, just under one-quarter (24.1%) of the population were estimated to be ex-smokers and well over half (57.8%) had never smoked. The number of people smoking daily decreased from 2.9 million in 2007 to 2.8 million in 2010.¹

Table 7.2.1 shows a small decline in the percentage of ex-smokers since 2001, suggesting that increases in the percentage of 'never' smokers rather than increases in the number of 'ex-smokers' might have been most important in reducing the proportion of current smokers. 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 one-third higher in 2010 than it was in 1991 two decades earlier and it still increasing though perhaps at not quite as great a rate as between 2001 and 2004.

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.⁹ Data from 2005 indicated that 54% of Victorian smokers were intending to quit within the next six months.¹⁰ 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.¹¹

As smoking rates decline, some people have argued that a greater proportion of the remaining smokers are likely to be 'hardcore' and that 'hardcore' smokers are less able to quit because they are highly dependent and/or they are unwilling to quit.¹² 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 2007.¹³ Australia-wide statistics show that the mean number of cigarettes smoked per week similarly declined between 1998 and 2007,^5–8 though did slightly increase in 2010.¹ (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.¹⁴ 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.¹⁵

A review of the US smoking population reported a similar finding. Authors concluded that there was 'little evidence that the population of smokers 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.¹²

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.¹⁶

Different strategies exist for measuring quit attempts; each has its own limitations and current estimates of the amount of quitting activity vary considerably.¹⁷ One study has raised an issue around 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.¹⁸

In a 2010 national survey of smokers aged 14 years or older, 77% 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. Twenty-nine per cent reported they had tried to quit without success, 19% had given up smoking for more than one month and 38% tried to reduce the amount smoked per day.¹

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.¹⁹ Low socio-economic smokers were less likely to be interested in quitting and less likely to make a quit attempt.¹⁹

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 2010²⁰ and a similar proportion in 2005.²¹ 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 2010.²⁰ 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.²⁰

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.¹⁷ 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 around 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.¹⁷ 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.¹⁷

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.²²

References

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

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

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15. 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: www.healthpromotion.org.au/members/journals/apr06/HPJA_2006_1_WALSH.pdf

16. Hyland A, Borland R, Li Q, Yong HH, McNeill A, Fong GT, 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

17. 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 2012;107(3):673-82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21992709

18. 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

19. 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

20. 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.

21. 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, Australia: Centre for Behavioural Research in Cancer, 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

22. Hill D, Borland R, Carrol T, Donovan R and Taylor J. Perspectives of the Australian National Tobacco Campaign. In Hassard K, edn. Australia's National Tobacco Campaign, Evaluation Volume Two. Canberra: Commonwealth Department of Health and Aged Care, 2000 1-9. Available from: http://www.quitnow.gov.au/internet/quitnow/publishing.nsf/Content/national-tobacco-campaign-lp