7.6 How smokers go about quitting

Last updated: January 2018     

Suggested citation: Greenhalgh, EM., Stillman, S., & Ford, C. 7.6 How smokers go about quitting. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2018. Available from http://www.tobaccoinaustralia.org.au/7-3-the-process-of-quitting

In simple terms, quitting smoking has two major components: making an attempt to quit, and maintaining abstinence. These two tasks do not necessarily have the same predictors.1 For example, motivational factors are very important in prompting an attempt to quit, whereas a person’s level of nicotine dependence is the most important predictor of his or her ability to maintain abstinence.2

7.6.1 Planned versus spontaneous

Tobacco dependence guidelines for health professionals traditionally promoted the idea of planning quit attempts in advance;3, 4 however more recent guidelines acknowledge that quit attempts made with minimal planning can be successful.5 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.6 Among those who do set a quit date, choosing a date sooner rather than later appears to lead to greater long-term success.7, 8 However, unplanned or spontaneous quit attempts are common and they can also be a successful route to cessation.69-11 Some findings suggest that spontaneous attempts may have a greater chance of long-term success than those that are planned.12 The International Tobacco Control Four Country Survey (ITC-4) found no evidence of a benefit of planning either before or after the initiation of a quit attempt on short-term success.13

However, discussion about planned versus unplanned attempts is further complicated by the difficulty in clearly distinguishing between the two approaches. Reported unplanned attempts can often involve elements of planning, such as first accessing cessation support.14 In the ITC-4 study, more than half of those who reported a spontaneous quit attempt (i.e., those who stopped smoking immediately upon deciding to quit) also reported some pre-quit planning.13 These findings suggest the need for a greater focus on the changeable nature of motivation, and the importance of theories about quitting recognising that it is often opportunistic or abrupt.9 (See Section 7.3 for theories about smoking and quitting). Smoking cessation services might offer flexible and adaptable support that can be used readily by potential quitters.14

7.6.2 Abrupt versus gradual

Common methods of quitting involve either abruptly stopping smoking (‘going cold turkey’) or gradually reducing the number of cigarettes smoked per day before stopping completely (‘cutting down to quit’). 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. Cold turkey is a more commonly used strategy than cutting down among smokers trying to quit.15, 16

Surveys carried out in the general population have found that going cold turkey is more effective than cutting down,15,17  and the results of randomised controlled trials have been mixed but generally more supportive of abrupt cessation. A randomised trial published in 2011 found that, for smokers who had no strong preference for abrupt or gradual cessation, either method produced similar outcomes. However, those who preferred and used the abrupt method were more successful than those preferring and using the gradual method.18 Possible explanations for why those who prefer cutting down are less successful are that such smokers may have less motivation and confidence to quit, and that the remaining cigarettes may be perceived as increasingly rewarding and valued.15, 18

A 2012 Cochrane review of randomised controlled trials comparing the efficacy of abrupt versus gradual cessation concluded that both methods produce comparable quit rates at six months regardless of whether or not they are combined with pharmacotherapy, behavioural support, or self-help therapy. In all of the included studies, gradual quitting methods included a definite quit day.19

Another more recent randomised controlled trial compared the success of quitting smoking by gradual compared with abrupt quitting, with both groups receiving behavioural support and NRT. Findings showed that quitting abruptly was more likely to lead to lasting abstinence than cutting down first, even for smokers who initially preferred to quit by gradual reduction. The authors suggest that gradual cessation was probably less successful because fewer participants made a quit attempt when reducing smoking; that is, cutting down appeared to deter later quit attempts. They also note that, in line with earlier studies, motivation may have affected outcomes. Participants who favoured gradual cessation were less likely to quit than those who favoured going cold turkey, regardless of allocation.20

While it may be less effective and less preferred among smokers than going cold turkey, encouraging some smokers in their efforts in cutting down prior to a future quit attempt may still be a worthwhile strategy for increasing population-level cessation rates.20 Some smokers prefer cutting down, particularly if their attempts to abruptly quit have previously failed.18 For smokers unwilling to quit, or for those unwilling to quit abruptly, smoking reduction approaches using pharmacotherapy alone or combined with behavioural interventions may significantly increase eventual successful cessation from tobacco products.21-23 NRT-assisted reduction appears to be an effective intervention for achieving sustained smoking abstinence for smokers unwilling or unable to quit,22, 24 and is effective and cost effective compared to no quit attempt.25 (Note that the addition of NRT also increases the success of abrupt quit attempts).25

A secondary analysis of data from the recent randomised controlled trial above20 examined whether smoking reduction while using cessation medication prior to quit date predicted abstinence. Results showed an association between purposeful reduction and subsequent cessation, but not between inadvertent reduction (in response to the medication) and quitting. The authors suggest that it may be conscious, effortful reduction, rather than response to medication, that predicts subsequent cessation.26 A 2015 review concluded that smoking reduction itself may make cessation more likely, with a greater reduction in cigarettes per day predicting a greater probability of cessation (i.e., there appears to be a dose–response relationship between cutting down and cessation success).27 Another recent review of studies exploring the usefulness of cutting down to quit has found that smokers who have no immediate intention of quitting, who reduce the number of daily cigarettes smoked, are more likely to attempt and actually achieve smoking cessation, particularly when combined with NRT. The authors conclude that smoking reduction is a promising intervention; however, the benefits are only observed when it leads to permanent cessation.28

7.6.3 Unassisted versus mediated

Behavioural and pharmacological treatments can improve smoking cessation rates, but treatments are under-utilised.29 Most people who quit do so without quitting aids and professional support even when such support is available.30-32 The role of cessation assistance in promoting a desire to quit appears to be poorly understood by most smokers.33 Long-term success rates (six to 12 months) of people attempting to quit on their own are about 3–5%.34 While the success rates are low, the large numbers of smokers who have quit using this method means that unassisted quitting has been a major contributor to the reduction in smoking prevalence.35 (See sections 7.137.147.15  and 7.16 for further information on quitting assistance.)

Smokers who perceive quitting aids as helpful are more likely to try to quit and to use assistance.36 There is some international evidence that being older, female, more nicotine dependent, more educated, and wealthier is related to use of assistance to quit.29, 37,38 Survey data from New South Wales shows that (prior to subsidisation of nicotine replacement therapy on the Pharmaceutical Benefits Scheme) receiving health professional advice and use of nicotine replacement therapy, 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.16 Conversely, a Danish study found that quitting unaided was more likely among men, younger age groups, those with a shorter history of smoking and those who were light smokers.39 Research in the EU found that smokers living in countries with comprehensive tobacco cessation programmes that offered cost-covered national quit lines, medication, and other cessation services were more likely to use effective cessation aids, highlighting the importance of access to cessation assistance as part of a comprehensive tobacco control program.40

A 2015 review of the qualitative literature on smokers who quit unassisted explored the views and experiences of such smokers. Three key concepts were identified—motivation, willpower, and commitment—as important to smokers and ex-smokers who quit without formal assistance. The authors conclude that having a better understanding of this strategy, which is employed by the vast majority of smokers who quit, can inform more nuanced and effective communication and cessation support.41  Australian community research has found that smokers’ reasons for quitting unassisted are complex and go beyond issues relating to misperceptions or treatment barriers. Smokers reported prioritising lay knowledge; evaluating the costs and benefits of quitting options; believing quitting is their personal responsibility; and perceiving quitting unassisted to be the right or better option.42 Another Australian study similarly found that smokers often described unassisted quitting as the best method, and expressed negative attitudes toward pharmacotherapies, particularly concerns about side effects from prescription medications.43 These results may also help shape effective guidance by health professionals, who could validate unassisted quitting when it is preferred by smokers and modify brief interventions as appropriate.42

Use of quitting medications and support services has become more common over the past decade,30, 40, 44, 45 especially among more dependent smokers. A survey of Australian smokers from 2002 to 2009 found that use of prescription medication to quit smoking increased over time, particularly after 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).46

The 2016 National Drug Strategy Household Survey asked smokers about any cessation strategies they might have used, and respondents were able to choose multiple responses. Among adult smokers who had tried to quit in the previous year (successfully or unsuccessfully), 3% had contacted the Quitline, 14% had asked their doctor for help to quit, and 22% had used nicotine gum, patches, or inhalers. Seven per cent reported using a smoking cessation pill. Other responses included using some other type of product (9%), reading cessation literature (11%), using the internet (6%), or using a mobile phone app (7%). Going cold turkey was by far the most popular method, with about two in five quit attempters (39%) adopting this strategy.47

Recent news and research

For recent news items and research on this topic, click here (Last updated June 2018)  

References

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