7.7 Personal factors associated with quitting

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While factors associated with quitting vary somewhat from one study to the next, there are some reasonably consistent findings. The focus of most studies has been on a range of individual psychological and demographic factors associated with success or failure in quitting. Some of these are summarised below.

7.7.1 Knowledge and risk perception of harm caused by smoking

Responses to surveys on smokers' knowledge of the health effects of smoking, presented in Chapter 3, Section 3.34.2, demonstrate that most smokers believe there are illnesses or damage caused by smoking. However their knowledge of particular illnesses caused by smoking appears to be somewhat lower, particularly in surveys testing unprompted awareness.70–72 In the National Tobacco Campaign survey, lung cancer was recalled (unprompted) by about two-thirds of respondents, followed by emphysema, heart disease and cancer (unspecified), which were each recalled only by about one-third.71 Responses to these types of surveys vary over time and may be influenced by concurrent events such as mass media campaigns.

Several studies have examined the accuracy of smokers' risk perceptions, and have generally found that many smokers are unrealistically optimistic about their personal health risks.73 It has been difficult to assess risk perception data, as answers often reflect level of concern rather than probability, and apparent underestimations or overestimations of risk depend on the way in which risk judgements are assessed.73–75 Nevertheless, smokers show a clear tendency to believe that they are not as much at risk as other smokers of becoming addicted or suffering health effects.73, 74, 76 Those who judged that their own risk of developing lung cancer was less than the objective risk were more likely to accept myths associated with smoking, overestimate the number of lung cancers that are cured, and be less likely to quit.77 Smokers consistently acknowledge that smoking increases health risks, but they judge the size of these increases to be smaller and less well-established than do non-smokers.73, 74

Although some level of knowledge about the harm from smoking can be assumed to be necessary to motivate smokers to quit based on health concerns, education only forms part of successful smoking cessation policy.

7.7.2 Smoking history

Several overseas studies indicate a trend for smokers who start smoking at a later age to be more likely to quit.78–83 Following this finding, it has been proposed that interventions that at least delay the onset of smoking by adolescents may increase the likelihood of quitting,80 however there is no longitudinal evidence to show that such an approach is effective. Also, contrary to these studies, an Australian survey found that smokers who started smoking before the age of 15 were twice as likely to have quit than those who had their first cigarette at 15 years or older.84

While younger smokers are more likely to make a quit attempt,11 people of older ages may be more likely to succeed.11, 82, 85

7.7.3 Level of dependence

Smokers with a higher level of nicotine dependence are less likely to make an attempt to quit and also find it harder to quit.11, 82 This may reflect more severe withdrawal symptoms, more pronounced neuro-adaptation (changes to the brain from nicotine exposure), a greater constitutional need for nicotine, a more highly learned and deeply ingrained habit, or possibly a physical or social environment that discourages staying stopped (i.e. one with more cues and opportunities to smoke).11, 84, 86, 87 Recent research suggests dependent smokers often require numerous attempts to quit, and therefore those who are unsuccessful on any one attempt should be encouraged to try again as soon as is practical.88

Addiction to tobacco and measures of nicotine dependence are discussed in Chapter 6 .

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.89 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 2007.10 Australia-wide statistics show that the mean number of cigarettes per week was similar between 1998 and 2007.7, 12, 90 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.91 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.92

A review of the US smoking population reported a similar finding. Reviewers concluded that there was 'little evidence that the population of smokers as a whole is hardening', but subgroups 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 were susceptible to quitting.89

7.7.4 Quitting history

Research indicates that previous attempts at quitting, and the recency and duration of quit attempts predicts making another quit attempt.11, 79 Smokers who have made recent attempts to quit are more likely to try again, and those whose previous attempts have lasted longer are more likely to successfully stop.11, 49, 93, 94

7.7.5 Motivation

Motivation seems an obvious factor in successful quitting. Smokers themselves often see their own strength of motivation or willpower as being the key to successful quitting, with the implication that they are inadequate if they seek help from others or fail.95, 96 From an observer's point of view, successful quitters are often seen as better motivated, while those who relapse are less motivated. However such an analysis does not help understand what motivation to quit is all about. There is no one simple concept of motivation: it is a multidimensional concept.

Different theories have been applied to smoking cessation that together have a number of elements that can be used to describe motivation.97 In simple terms motivation is directed action. Motivation requires goals that are pursued and energy, wanting, drive or activity in order to overcome obstacles to achieving these goals. Motivation to quit and stay quit is characterised by ambivalence and conflict, which ebbs and flows as negative thoughts about smoking compete with urges to smoke. Working to resolve this ambivalence may be helped by intrinsic and extrinsic sources of input: intrapersonal inputs or rewards such as self-efficacy (belief that one can quit), self-competence, better health, and being a better role model, or environmental inputs or rewards such as money and social approval. In the self-regulation model, motivation refers to maintaining an optimal state or system balance; if people feel good or neutral then they will maintain their behaviour. Smoking cessation usually results in temporary unpleasant moods, so it is necessary to use coping resources to avoid returning to smoking. Feedback loops on how behaviour affects mood is an important motivational mechanism: negative effect (unpleasant moods) predicts relapse, but effective coping to decrease negative effect helps maintain cessation.97

There is considerable evidence that some self-report measures of motivational factors are predictive of making quit attempts, but at least when assessed before the person quits, are not predictive of the success of attempts.11 It seems likely that this is because the determinants of motivation differ from before to after a quit attempt. Before an attempt, thinking about the pros and cons of quitting and making estimates of the outcome of the attempt does influence decision making and thus stimulates trying.95 However, once the person has actually quit, the main determinants of motivation are the experiences they are having, something people are poor at estimating in advance.97, 98

The key difficulty of motivation in the context of overcoming addiction is that there are counteracting urges and motivations to keep smoking. One framework is to view quitting as a triumph of rationality over transient desires that are distorted by conditioning associated with dependence. For most smokers, getting to the point of really wanting to quit presents a formidable challenge, and there is a strong argument for encouraging and assisting smokers to quit even though they may not have resolved all doubts before making a decision to quit.95

Motivational interviewing is a set of counselling techniques that aim to help motivate smokers to quit, sometimes organised around the stages of change of the Transtheoretical Model, but applicable to any theory of behaviour change that posits a motivational component. The strategies used in motivational interviewing involve asking questions of the smokers to get them to review relevant personal facts about the negative consequences of smoking, weigh the pros and cons of quitting, and think about strategies for overcoming obstacles to quitting. It aims to enhance smokers' sense of self-efficacy, commitment to quitting and problem-solving skills while acknowledging the challenges inherent in quitting. Motivation for change vacillates over time, and addressing this vacillation is crucial for enabling behavioural change. The process helps smokers clarify the need and process for change and supports them in achieving their goal.95, 97 There is as yet little systematic evidence of the effectiveness of these techniques in smoking cessation, although some work suggests that motivational interviewing may be effective for increasing behaviour change related to smoking, such as reducing cigarette consumption, reducing exposure of children to second-hand smoke and adopting household smoking bans.99

When asked about the factors that motivate them to consider quitting, smokers most frequently mention health and fitness (51%), followed by cost (44%), and improving fitness (28%). Pressure from family/friends was also frequently mentioned (26%) as was worry about smoking affecting the health of others (21%) and anti-smoking advertisements (21%).12

Self-efficacy

Self-efficacy is the belief or confidence that one has the capacity to perform a behaviour, and that the action will achieve its desired outcome. Self-efficacy theory proposes that it underpins motivation and is a requirement for behaviour change, along with having actual skills, knowledge and opportunity.100, 101

According to theory, behaviour change has a number of phases, each affected by efficacy beliefs.101 In the context of smoking cessation, these would include considering quitting, motivating oneself to stop smoking, persevering with the change, being vulnerable to relapse, recovering after a setback, and adjusting to and maintaining a non-smoker lifestyle.

In general, high self-efficacy is a modest predictor of success at smoking cessation in the short to medium term.52, 102 The predictive power of a person's self-efficacy beliefs may be limited by their understanding of the challenges facing them, or influenced by the phase of change they are involved in at the time of measuring self-efficacy. For example, if a person bases their self-efficacy beliefs on their confidence at resisting temptations to smoke immediately after quitting, but does not take into account the need to adjust to a non-smoking lifestyle in the longer term, then their self-efficacy may not have as much value for predicting long-term success.52, 55, 103, 104 Also, self-efficacy beliefs based on past quitting experience may be better informed than pre-quitting expectations.102

Self-efficacy is reinforced by success,100 but tends to go down following a lapse after quitting.105 In one study, self-efficacy for quitting tended to be lower in people from low SES background.106 For some smokers, focusing on their inability to change is a barrier to quitting. Strategies aimed at helping these smokers include encouraging openness to the possibility of change, breaking down quitting into manageable steps, reframing past failures as learning experiences, subsidising and encouraging the use of quitting aids without overstating their benefit, and encouraging personal responsibility for change.55

7.7.6 Planned vs spontaneous quitting

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.46, 49, 99, 107, 108 However, according to two recent studies, spontaneous quit attempts are common and are more successful than those that are planned.46, 107 The reasons for this are not clear. The authors point out that these findings do not necessarily imply that planned quit attempts are counterproductive. After all, use of behavioural support and quitting medications are known to increase the chances of success and generally require planning ahead. However, there are implications for theories on the process of quitting and the nature of the advice and support offered by health professionals.46 These findings suggest that the stages of change approach needs rethinking, with more focus on the changeable nature of motivation.107

7.7.7 Barriers

Barriers to smoking cessation may differ from one person to another, and can be sufficient to prevent or delay quit attempts, or to lead to relapse.85, 87, 99, 109, 110

Barriers to smoking cessation may take several forms, including:85, 99

• Physical or social, e.g. living or working with smokers, friends' smoking
• Psychological or emotional /affective, e.g. stress, depression, anxiety, fear of weight gain, psychiatric disorders
• Cognitive, e.g. knowledge, self-exempting beliefs, perceived disadvantages, motivation, self-efficacy
• Physiological, e.g. level of nicotine dependence, withdrawal symptoms, weight gain
• Behavioural, e.g. slip-ups, pattern of smoking
• Barriers to access e.g. to health promotion campaigns, to quitting medications or to treatment programs
• Social contextual or life circumstances barriers that may result in the smoker giving quitting a low priority, e.g. poverty, social isolation, lack of perceived safety, social norms.

Some of these barriers are examined in more detail below.

7.7.7.1 Withdrawal symptoms

One of the main motives for continued smoking appears to be the relief of the nicotine withdrawal syndrome.87 Withdrawal symptoms are discussed in Chapter 6 .

The average pattern for withdrawal symptoms is described as being most intense in the first week and lasting two to four weeks after quitting.111 However, withdrawal symptoms can be highly variable, both across persons and over time. In some people symptoms can be chaotic; they may fall and rise, or they may not decline for a number of weeks.38, 86, 111 Although withdrawal is not short-lived, prolonged withdrawal states over six months do not appear to occur with cigarette withdrawal.111 Relapse is related to greater severity of symptoms, greater day-to-day symptom volatility, increases in symptoms over time, and a greater degree of symptom relief associated with lapses to smoking.38, 112 While nicotine replacement products and non-nicotine prescribed medications (discussed later in this chapter) reduce the severity of cravings and other withdrawal symptoms, they do not appear to affect whether symptoms get better or worse over time, day-to-day variability in symptoms or size of acute changes in symptoms associated with lapses to smoking.38, 86

Urges to smoke or cravings are the most powerful predictor of relapse.87 They are clearly related to nicotine dependence, because they are typically most intense within the first two days after quitting and their severity is reduced by nicotine replacement products.86, 87, 113 However, urges to smoke can also be triggered by cues associated with smoking, even, in some cases, months or years after quitting.21 In a study tracking withdrawal symptoms in real-time, reports of recent smoking, exposure to someone smoking and stress were all associated with worse cravings and greater withdrawal symptoms and negative affect (unpleasant moods) in the weeks after quitting, although individual responses varied greatly.114 Evidence supports better outcomes among people who use more active coping strategies to deal with urges to smoke.115, 116

7.7.7.2  Self-exempting beliefs

Smokers widely accept that smoking is bad for them, yet continue to do it. A high proportion of smokers hold various rationalisations that seem to act as a shield against facing the reality of the harms caused by smoking and allow them to avoid engaging in the task of quitting.117, 118 Four categories of these beliefs have been identified:117

• Sceptic beliefs: 'Lots of doctors and nurses, smoke, so it cannot be all that harmful', 'More lung cancer is caused by such things as air pollution, petrol, and diesel fumes than smoking'.
• Bulletproof beliefs: 'You can overcome the harms of smoking by doing things like eating healthy food and exercising regularly', 'I think I would have to smoke a lot more than I do to put my health at risk'.
• 'Worth it' beliefs: 'You have got to die of something, so why not enjoy yourself and smoke', 'I would rather live a shorter life and enjoy it than a longer one where I would be deprived of the pleasure of smoking'.
• Jungle beliefs: 'Everything causes cancer these days', 'It is dangerous to walk across the street'.

Acceptance of each of the four sets of beliefs was found to relate to less progress towards quitting, however some are more important than others. 'Worth it' beliefs in particular were more prevalent among smokers not planning to quit. Attributes that favour fewer tendencies to hold self-exempting beliefs include higher knowledge of the hazards of smoking and being able to recall at least one anti-smoking commercial.117, 118

7.7.7.3 Stress

Smokers frequently see smoking as a way of managing stress. However, they have different opinions on how smoking relates to stress.96 Smoking is commonly perceived to affect mood such as promoting relaxation, calmness, or ease.87, 96 It may be used as a distraction from problems, or as a public demonstration that the smoker is under stress.96

Reviews of research have tried to determine whether nicotine genuinely improves mood or merely relieves withdrawal symptoms. In this research, often a distinction is made between stress from an external source that tests coping ability, and negative affect that describes unpleasant moods such as sadness, irritability, anxiety, frustration, anger, contempt, disgust, guilt, fear, and nervousness.38, 119 The findings on the relationship between negative affect, stress and smoking have been mixed and suggest a complex association.119, 120

Smokers report more stress and negative effect relative to non-smokers.119, 121 A national study in Australia found that daily smokers reported higher levels of psychological stress than non-daily smokers, who in turn reported higher stress than non-smokers.12 It is possible that smoking itself, withdrawal symptoms or a combination of the two creates a higher level of stress. However, smokers also smoke in response to negative life events and laboratory stressors so the idea that 'smoking causes stress' may not entirely explain the relationship between the two.119

The strongest evidence for an effect of stress and negative effect on smoking is for withdrawal escape, although a number of other mechanisms are being investigated.119 Withdrawal symptoms include urges to smoke and worsened mood states such as irritability, anger, frustration, anxiety and depressive symptoms.111 These may appear within two hours of last smoking, depending on the individual.3, 114, 120 The daily mood patterns of smokers show a normal pattern during smoking, but a worsening mood pattern between cigarettes.87, 122 A further variant on the withdrawal escape theory posits that after repeated experiences of alleviating these withdrawal mood symptoms with smoking, negative effect may become a cue for smoking even when it occurs independently of nicotine withdrawal.119

Despite smokers commonly citing relief from negative effect as a motive for smoking, real-time studies have found little correlation between effect and smoking behaviour during regular smoking.38 However, during smoking cessation there appears a strong connection between stress, negative affect and lapses to smoking, particularly first lapses.38, 119 Furthermore, lapses appear to mostly result in increases in negative affect, particularly guilt and discouragement and a decrease in self-efficacy.119

Quitting generally results in lower stress and negative effect over time. Although smokers usually experience an increase in stress and negative affect in the weeks after they quit, these symptoms diminish over time to levels lower than when they smoked.87, 119

7.7.7.4 Weight gain

Smokers' average weight is about 3 to 4 kg less than non-smokers.87, 123 Smoking appears to attenuate weight gain over time, in part due to increasing metabolic rate.28, 123 The difference in weight between smokers and non-smokers is more marked in older long-term smokers while the average weight of younger smokers is similar.28, 124–126 The weight difference, however, is further complicated by the finding that despite their lower weight and Body Mass Index (BMI), smokers have a greater waist/hip ratio than non-smokers. Increased waist circumference is a stronger predictor of cardiovascular disease than BMI.127

When smokers quit, the majority experience some weight gain.3 Estimates of weight gain associated with cessation vary depending on the sample, study design and follow-up period.128 Most excess weight gain occurs in the first year after cessation, after which the rate of weight gain slows.110, 123, 124, 129–132 Estimates of the mean weight gain in people continuously abstinent for a year are about 5 to 6 kilograms.129, 130, 133, 134 Individual experience of weight change after quitting is quite broad, ranging from weight loss to a minority gaining more than 10 kgs.124, 130, 133, 135–138 Increase in waist circumference per kilogram gained is smaller in people who quit than in continuing smokers, indicating that recent ex-smokers gain less visceral fat.136, 139

Limited research suggests that some of the weight gained during the first few years after quitting may be lost with continued abstinence,140, 141 however more research is needed to resolve this issue.142 Large cross-sectional studies show that long-term former smokers have a mean waist-to-hip ratio and a mean BMI similar to or approaching that of people who have never smoked. 127, 135, 138 The health benefits of smoking cessation far outweigh the health risk from extra body weight, unless the weight gain is extraordinarily large.3 Despite this, fear of weight gain is a significant factor in discouraging quitting and provoking relapse in smokers.108, 143–151

Weight gain after smoking cessation is largely due to a transient increase in food intake and to changes in metabolic rate. Nicotine replacement products and bupropion appear to postpone a portion of weight gain until their use stops.44, 108 Nicotine gum may have the potential to reduce weight gain in the long-term if higher doses are used properly, more often.152 Advice to attenuate weight gain includes engaging in physical activity, having a healthy diet and limiting alcohol consumption.108, 136, 137, 142, 144, 153, 154 Studies on simultaneous quitting and dieting to prevent weight gain have produced mixed results: some found that it undermined the attempt to quit smoking, while others reported similar or higher rates of success for smoking cessation in specific populations.144 In a different approach, cognitive behavioural therapy to reduce weight concern among weight-concerned women improved smoking cessation outcomes.144, 155, 156

For readers interested in keeping up to date on this subject, the Cochrane Library is expected to publish a review entitled 'Interventions for preventing weight gain after smoking cessation'.143 

7.7.7.5 Depression

Smoking and depression often co-occur. Compared to non-smokers, smokers report more depressive symptoms, more frequent and severe episodes of depression and higher rates of suicidal ideation and suicide.157

Many smokers appear to have an increase in depressed mood and associated negative affect as part of nicotine withdrawal, but for the majority of people who quit it is temporary.87, 111 Smokers with a history of depression tend to report higher levels of nicotine dependence and experience more severe and prolonged withdrawal episodes, including greater negative mood.158–161 Among smokers with a history of depression, about 30% who stop smoking will develop a new episode of major depression. The risk remains high for at least six months.162, 163 Having a history of depression, in itself, does not seem to substantially jeopardise successful quitting.164–166 However, one study suggests that among smokers with a history of depression, those who have an increase in depressive symptoms after quitting are more likely to relapse to smoking.167 Recommendations for co-management of depression and nicotine dependence include integrated cognitive-behavioural treatments and use of antidepressant medication while quitting to help control depressive symptoms and reduce the risk of recurrence of depression.168, 169 Chemicals in cigarettes can affect the metabolism of certain antidepressant medications, and dose levels may need adjusting after quitting.170 

7.7.7.6 Genetic factors

As research on human genetics has progressed, it is now clear that smoking is under some degree of genetic influence.171 Beginning with the observation that concordance rates are higher in monozygotic compared to dizygotic twins for both persistent smoking and for successful quitting, research has identified several genes associated with nicotine metabolism and neurotransmitter pathways. This is a new and underdeveloped field, and further research is needed to clarify the contribution of individual genes and their combined effect in interaction with environmental influences.172–174 Some research has investigated the response of smokers with specific genotypes to various pharmacotherapies. The area of pharmagenetics research is still in its initial stages. It may have the potential to yield genetic markers to help match individual smokers to the most likely effective treatment, however nicotine dependence is a complex trait with multiple genetic and environmental components. It would require extensive further research with uncertain practical outcomes. 175, 176

7.7.8 Relapse prevention

The 2005 Cochrane review of relapse prevention interventions indicates that at the moment there is insufficient evidence to support the use of any specific intervention for smokers who have successfully quit for a short time to avoid relapse.177 The verdict is strongest for interventions focusing on identifying and resolving tempting situations, as most studies were concerned with these. There is very little research available regarding other approaches. The authors conclude that until more evidence becomes available it may be more efficient to focus resources on supporting the initial cessation attempt rather than on additional relapse prevention efforts.177

There is also evidence of value in shifting the focus from the 'quality' of smokers' quit attempts to the 'quantity' of those attempts. With fewer than 10% of smokers who make an attempt in a given year succeeding, research has demonstrated that increasing the frequency of quit attempts in the general population leads to a quicker drop in smoking prevalence than increasing the use of cessation aids.88 In California, 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 constant since data collection began in the early 1990s, even though the availability of cessation aids has increased. The implication is that quitting aids reduce the overall number of attempts that are needed but smokers still have to make multiple attempts, with or without these aids. The research concludes that, while ideally all quit attempts would involve a cessation aid, counselling, or some other form of assistance, the real key to speeding up the process is to encourage smokers to keep on trying.178, 179

In observing patterns of smoking that occur after quitting, some studies distinguish between a lapse (or slip, or slip up) and full relapse. A lapse has been variously defined as at least a puff, or one, or more cigarettes, which may be followed by renewed abstinence or evolve into a relapse. A relapse refers to a return to regular daily smoking, and generally means that a quit attempt has failed.38 Most lapses lead to relapses;38, 85 one study found that 88% of those who lapsed went on to relapse.180 This provides strong grounds for advising that ex-smokers should not take even one puff after they stop. It is common for there to be a period of intermittent smoking before full relapse occurs.181

Most lapses and relapses occur in the days or weeks just after stopping,182 so that most intervention that does occur needs to be during these early days or part of the process of preparation to quit. To date, most work has focused on skills-based approaches to identify situations where relapse risk is highest (e.g. socialising with smokers while consuming alcohol) then to develop and rehearse strategies to deal with them in advance. Such situations vary from person to person, but represent an 'Achilles heel' for that individual.183 Extended telephone contact or booster sessions with Quitline counsellors, GPs or other support sources have been used extensively and these have been found to have some modest effect on increasing long-term cessation.85

One way to conceptualise the challenge of relapse prevention is to see it as three distinct tasks in becoming a non-smoker:

• To stop smoking (i.e. make a quit attempt).
• To learn to deal with cravings and other withdrawal symptoms without relapsing.
• To learn to enjoy and value a smokefree lifestyle, which involves facing old smoking situations without cigarettes, finding new behaviours to substitute for the benefits of smoking, realising that many previously perceived benefits of smoking were illusory, and adopting a new non-smoker self-image.184

This 3Ts approach serves to focus more attention on the third task, which typically comes to the fore a month or so after the quit date, when cravings occur less often than daily, and the person's vigilance and need for coping start to decline. The challenge then is for the person to integrate a new non-smoking way of being in the world into their daily functioning.

There is no escaping the fact that relapse is common, especially in the immediate post-quitting period, but also over the longer term. An important conclusion that follows is that smoking is best seen as a chronic relapsing disorder, and that many smokers may need repeated interventions over the course of their lifetime.56