7.6 How smokers go about quitting

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In simple terms, quitting smoking has two major components: making an attempt and maintaining cessation once quit. These two tasks do not necessarily have the same predictors. For example, nicotine dependence is the most important predictor of smoking cessation, whereas motivational factors are much more important in prompting an attempt to quit.¹

7.6.1 Planned versus spontaneous

Tobacco dependence guidelines for health professionals promote the idea of planning quit attempts in advance, and such planning is widely thought to be important for success.^2-6 Reported planning may be more likely among those who think they are more addicted, and those who plan may be more likely to use a quit aid, particularly pharmacotherapy.⁷ However, unplanned or spontaneous quit attempts are common and they can be a successful route to cessation.^2,4,8,7 Some findings suggest that spontaneous attempts may have a greater chance of long-term success than those that are planned.⁹ Discussion about planned versus unplanned attempts is further complicated by the difficulty in clearly distinguishing between the two approaches. Reported unplanned attempts may often involve elements of planning and delay by quitters in order to access cessation support.¹⁰

There are implications for theories on the process of quitting and the nature of the advice and support offered by health professionals.² These findings suggest the need for a greater focus on the changeable nature of motivation⁴ and highlight the need for smoking cessation services to offer flexible and adaptable support that can be used readily by potential quitters.¹⁰

7.6.1.1 Stages of change

For most people, changing from being a smoker to a non-smoker is a complex and difficult journey rather than single event. There are several stage-based theories of behaviour. One widely used way of describing this process is the 'stages of change' or transtheoretical model (TTM) of Prochaska and DiClemente.¹¹ It proposes that smokers move through a discrete series of motivational stages before they quit successfully. In brief, the core stage definitions used are:

1. Precontemplation, during which a smoker is not thinking about quitting in the next six months.
2. Contemplation, when a smoker begins to think seriously about quitting in the next six months.
3. Preparation, when a quit attempt is planned within the next 30 days.
4. Action, when a quit attempt is made lasting for at least 24 hours.
5. Maintenance, when the person becomes a non-smoker for at least six months.

Inherent in the TTM and related conceptualisations is that a smoker may go back to earlier stages or cycle through a number of times before permanently quitting.^{2, 12, 13} According to this model, interventions to help people stop smoking should be tailored to their stage of readiness to quit and designed to move them forward through subsequent stages to eventual success.¹⁴ The TTM, or modifications of it, has been used in structuring or evaluating cessation programs and media campaigns. For example, the Smoking Cessation Guidelines for Australian General Practice instruct GPs to identify a patient's stage of readiness to change in order to tailor information.^{15, 16}

7.6.1.2 Criticisms of stages of change and other conceptualisations

This model, as applied to smoking cessation, has many critics. Criticisms include that it does not satisfy the criteria required of a valid stage model.¹⁷ Nevertheless it remains widely used to understand cessation^{3, 18-21} because it draws attention to the challenges in getting smokers interested in quitting, not just in implementing attempts. A major problem with the model is that the definitions of the stages are arbitrary,²² based either on timeframes of intention or length of time quit. The exception is the transition between preparation and action, which occurs at an important milestone–when a quit attempt is made.²³ The other stage classifications are unlikely to be optimal, and alternatives have been proposed.^{18, 19} For example, pre-quitting, it may be more useful to just use simplified categories of not interested, open to the possibility and actively planning. Post-quitting, there is no consensus on what categories, if any, should be considered, but there is some evidence that smokers experience the first month or so, when strong cravings to smoke occur at least daily, differently from the subsequent period when cravings are less common.²⁰

In terms of the application of the stages of change approach to cessation interventions, one review found that stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling are neither more nor less effective than their non-staged-based equivalents. However, providing these forms of practical support to those trying to quit appears to be more productive than not intervening at all. The evidence is not clear for other types of staged intervention, including telephone counselling, interactive computer programs and training of health professionals or other supporters. The evidence does not support the restriction of quitting advice and encouragement only to those smokers perceived to be in the preparation and action stages.¹⁴

7.6.2 Abrupt versus gradual

Two methods of quitting involve either abruptly stopping smoking ('cold turkey') or gradually reducing the number of cigarettes smoked per day before stopping completely ('cutting down'). When cutting down, the number of cigarettes per day may be reduced in a scheduled or unscheduled way, or the first cigarette of the day is delayed for longer and longer. Both cutting down and cold turkey methods can be done with or without medication. Evidence suggests that cold turkey is more common than cutting down.^24,25

Studies comparing the efficacy of abrupt versus gradual stopping have found overall that both methods produce comparable quit rates at six months whether or not pharmacotherapy, behavioural support or self-help therapy are used.²⁶ One large study of smokers quitting on their own found that those who used the cold turkey method were almost twice as likely to stop for at least a month than those who used a cutting down method. However, because the findings are based on personal choice in a naturalistic setting, it is not possible to conclude that the results were due to quitting methods. The authors suggest, with caution, that the cold turkey method may be the better method for smokers intending to quit on their own, but that this advice does not apply to structured programs involving cutting down strategies.²⁴ Other evidence suggests that for smokers who have no strong preference for either method, abrupt and gradual produce similar results. However those who prefer and use the abrupt method are more likely to quit than those preferring and using the gradual method, in particular when they have low motivation and confidence.²⁷ There is evidence that among smokers who want to stop gradually in the near future, gradual cessation with nicotine pre-treatment does not produce higher quit rates than abrupt cessation. One liability of gradual reduction may be that it allows smokers to delay their quit date.²⁸ Other research suggests that delaying a quit date once a quit attempt is underway or quitting after a planned quit date may predict less success in quitting.²⁹

Smoking reduction may be a viable treatment approach if proven to increase the rates of long-term abstinence from smoking. There is some evidence that smoking reduction approaches using pharmacotherapy alone or combined with behavioural interventions significantly increases long-term smoking abstinence for smokers not ready to make a quit attempt.³⁰ Further research investigating which method of reduction before quitting is the most effective and which categories of smokers benefit most from each method is warranted.²⁶ Limited evidence suggests that smoking reduction in current smokers is associated with reduced levels of nicotine dependence but further study would be needed to determine the implications of this for future smoking cessation.³¹

7.6.3 Unassisted versus mediated

Behavioural and pharmacological treatments have been shown to improve smoking cessation rates, but treatments are under-utilised.³² Most people who have quit do so without quitting aids and professional support even when pharmacotherapy is available.^33,34 The role of cessation assistance in helping form a desire to quit appears to be poorly understood by most smokers.³⁵ Long-term success rates (six to 12 months) of people attempting to quit on their own are around 3–5%.³⁶ (See sections 7.13, 7.14, 7.15 and 7.16 for further information on quitting assistance.)

Smokers who perceive that quitting aids are helpful are more likely to try to quit and to use assistance.³⁷ There is some international evidence that being older, female, more nicotine dependent, more educated and wealthier is related to use of assistance to quit.^32,38 Survey data from New South Wales shows that (prior to subsidisation of nicotine replacement therapy on the Pharmaceutical Benefits Scheme) use of nicotine replacement therapy, health professional advice, natural therapy and prescribed medication were higher among older smokers and those from low socio-economic groups, while quitline use was higher among the middle age group.²⁵

Use of quitting medications and support services has become more common over the past decade.^{33, 39, 40} There appears to be an increase in use of support, especially among more dependent smokers. A survey of Australian smokers from 2002 to 2009 found that use of prescription medication to quit smoking increased with the addition of varenicline to the Pharmaceutical Benefits Scheme in 2008. Among smokers who tried to quit, use of help rose gradually from 37% in 2002 to almost 59% in 2009 (including 52% using pharmacotherapy and 15% using behavioural forms of support).⁴¹ In 2007 and 2008 in Australia more than 44% of smokers reported using quit smoking medications in the last year and more than 10% of smokers reported using a quitline.⁴²

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