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7.7 Factors that predict success or failure in quit attempts

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Factors that influence the success or failure of quit attempts differ from one person to another, and can be sufficient to prevent or delay quit attempts, or to lead to relapse.1-5

These may take several forms, including:1, 2

  • physiological (e.g. level of nicotine dependence, withdrawal symptoms, weight gain)
  • behavioural (e.g. slip-ups, pattern of smoking)
  • physical or social (e.g. living or working with smokers, having smoking friends, home or workplace subject to smokefree policies or seeing tobacco products displayed)
  • 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)
  • barriers to access to interventions (e.g. affordable quitting medications, treatment programs)
  • social context or life circumstances that may result in the smoker giving quitting a low priority (e.g. poverty, social isolation, lack of perceived safety, social norms).

Adult population level studies from a number of countries suggest that, of all these, nicotine dependence (quantified through measures such as numbers of cigarettes smoked per day) is the factor most consistently predictive of success or failure in quitting.6,7 Social smoking cues and a recently failed quit attempt are also important predictors.8 There appears to be little association between gender, marital status, age, evaluations of smoking and quitting and success in quit attempts. The evidence is inconsistent regarding the relationship between successful quitting and income, education level, smoking restrictions at home, quitting history, desire to quit, and confidence.7

For young women, there is evidence that lifestyle and life-stage factors are determinants of smoking behaviour. For this group, recent illicit drug use and high-risk drinking appear to be related to relapse, while marriage or being in a successful relationship and moderate and high physical activity levels are associated with successful quitting.9 Some of the factors mentioned are examined in more detail below.9

7.7.1 Personal characteristics that predict failure in quit attempts

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. There is evidence of a relationship between people's cessation-related experiences and satisfaction with stopping smoking at different points during the process.10 Evidence shows that post-quitting beliefs, experiences and expectations change at different rates dependent on duration of abstinence.11 Lower abstinence self-efficacy and higher frequency of urges to smoke appear to predict subsequent relapse,12,13 as do deficits in impulse control.14 The role of menstrual cycle phase and quit date has also been examined.15,16 Limited research suggests that the personality trait of sensation seeking influences the effective use of NRT and smoking cessation strategies, with higher sensation seeking predicting lower likelihood of successful quitting.17

Some particular characteristics are outlined below.

7.7.1.1 Duration of smoking

Several overseas studies indicate a trend for smokers who start smoking at a later age to be more likely to quit.18–23 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,20 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.24

While younger smokers may be more likely to make a quit attempt,6 people of older ages may be more likely to succeed. However the evidence is inconsistent.1,6,7,22

7.7.1.2 Level of dependence (heaviness, time to first cigarette)

Smokers with a higher level of nicotine dependence are less likely to make an attempt to quit and also find it harder to quit.6–8,22,25–28 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).3,6,24,29 There is also evidence that more dependent smokers experience greater negative affect and craving pre- and post-quit regardless of their cessation status and that these factors are associated with relapse.30,31 Getting up to smoke during the night is an indicator of nicotine dependence. There is some evidence that night smokers who report significant sleep disturbance are at particular risk of relapse when they try to quit,32,33 but more research is needed to substantiate this relationship.34 Experience from the Californian Quitline 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.35

See Chapter 6 for further information on addiction to tobacco and measures of nicotine dependence.

7.7.1.3 Severity of withdrawal symptoms

One of the main motives for continued smoking appears to be the relief of the nicotine withdrawal syndrome.3 Withdrawal symptoms are discussed more fully 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.36 However, withdrawal symptoms can be highly variable, both across persons and over time.37 In some people symptoms can be chaotic; they may fall and rise, or they may not decline for a number of weeks.29,36,38 In one 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.39 Although withdrawal is not short-lived, prolonged withdrawal states over six months do not appear to occur with cigarette cessation.36 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.38,40

Urges to smoke or cravings are core components of withdrawal and powerful predictors of relapse.3,12,22,31,41 They are clearly related to nicotine dependence, as they are typically most intense within the first two days after quitting and nicotine replacement products reduce their severity.3, 29, 42 Cravings appear to be related to negative affect.30 However, urges to smoke can also be triggered by cues associated with smoking, even, in some cases, months or years after quitting.43-45

7.7.1.4 Genetics?

As research on human genetics has progressed, it is now clear that smoking is under some degree of genetic influence.46 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. Limited research has found that those able to change smoking behaviour in a general practice setting are likely to have a similar genetic profile to those able to change this behaviour in clinical trials.47 However, the evidence is inconsistent, with some results suggesting that the establishment of regular heavy smoking might abolish associations between genetic determinants of nicotine dependence and the probability of successful smoking cessation.48 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.49-51

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.52,53

There is some evidence that attributing smoking to genetic factors is associated with lower levels of perceived control over smoking but not lower quit rates, but further research would be needed to determine if personalised genetic feedback has the same outcome.54

7.7.1.5 History of previous failed quit attempts?

Research indicates that previous attempts at quitting, and the recency and duration of quit attempts predicts making another quit attempt.6, 19 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.6, 55–57 Smokers who relapse are more likely to reduce consumption compared to those not making a quit attempt.58

7.7.1.6 Low confidence, poor 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.59,60

According to theory developed by social psychologist Albert Bandura, behaviour change has a number of phases, each affected by efficacy beliefs.60 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. Self-efficacy judgements and expectations appear to be influenced by the different tasks involved in smoking cessation.61

In general, high self-efficacy is a predictor of success at smoking cessation in the short to medium term.12,62,63 There is some evidence however that self-efficacy may be less influential than expected, and that many studies may have overestimated the relationship by failing to appropriately control for smoking behaviour at the time of self-efficacy assessment.64 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.62, 65–67 Also, self-efficacy beliefs based on past quitting experience may be better informed than pre-quitting expectations.63

Self-efficacy is reinforced by success,59 but tends to go down following a lapse after quitting.68 Some researchers have suggested that further investigation is warranted into the notion of self-efficacy as a reflection of recent smoking behaviour change rather than just as a cause.69 Evidence suggests that drops in self-efficacy are associated with progression from one lapse to the next.70

In one study, self-efficacy for quitting tended to be lower in people from low socio-economic background.71

7.7.1.7 Concern about weight gain

Fear of weight gain is a significant factor in discouraging quitting and provoking relapse in smokers.5, 72-80 Some evidence suggests that weight gain is a more significant concern for younger women.81 Concerns about weight when trying to quit appear to be associated with higher body mass index, intention to quit, more previous quit attempts and less support for quitting.82 One measure that has been developed specifically for smoking-related weight concerns is the smoking-related weight and eating episodes test (SWEET).83

(See Section 7.1.2 for further information on the effects of cessation on weight. See Chapter 3, Section 3.29 for information on the health effects of smoking in conjunction with and compared with the health effects of obesity.)

7.7.1.8 Disturbances of mood

Negative affect is a core component of withdrawal and a predictor of urge to smoke and relapse,84,85,31 Negative affect appears to be associated with craving,30,86 with limited evidence of gender differences in the relationship between negative affect and smoking behaviour.87 Compared to sustained quitters, those who relapse are more likely to report symptoms of emotional distress25 and negative mood.13 There is evidence that smoking may decrease happiness and stopping may increase it.88 Research also suggests that anhedonia (an affective dimension related to the inability to experience pleasure) is associated with poor smoking cessation outcomes.89 For those who have quit smoking, perception of an improvement in post-quitting experiences–such as the capacity to enjoy life's simple pleasures, ability to calm down when stressed or upset and ability to control negative emotions–increase over time but at different rates.14

Stress and negative affect

Smokers frequently see smoking as a way of managing stress. However, they have different opinions on how smoking relates to stress.90 Smoking is commonly perceived to affect mood such as promoting relaxation, calmness or ease.3, 90 It may be used as a distraction from problems, or as a public demonstration that the smoker is under stress.90

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, which tests coping ability, and negative affect, which describes unpleasant moods such as sadness, irritability, anxiety, frustration, anger, contempt, disgust, guilt, fear and nervousness.38,91 The findings on the relationship between negative affect, stress and smoking have been mixed and suggest a complex association.91,92

Smokers report more stress and negative affect relative to non-smokers.91, 93,94 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.95 It is possible that smoking itself, withdrawal symptoms or a combination of the two create 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.91

The strongest evidence for an effect of stress and negative affect on smoking is for withdrawal escape, although a number of other mechanisms are being investigated.91 Withdrawal symptoms include urges to smoke and worsened mood states such as irritability, anger, frustration, anxiety and depressive symptoms.36,96 These may appear within two hours of last smoking, depending on the individual.39,92,97 The daily mood patterns of smokers show a normal pattern during smoking, but a worsening mood pattern between cigarettes.3,98 A further variant on the withdrawal escape theory posits that after repeated experiences of alleviating these withdrawal mood symptoms with smoking, negative affect may become a cue for smoking even when it occurs independently of nicotine withdrawal.91

Despite smokers commonly citing relief from negative affect as a motive for smoking, real-time studies have found little correlation between affect 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.14,38,91 Furthermore, lapses appear to mostly result in increases in negative affect, particularly guilt and discouragement and a decrease in self-efficacy.91, 94 Evidence also suggests that smokers with more financial stress are more likely to relapse.99,100

Quitting generally results in lower stress and negative affect 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.3, 91,101

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.102

Having a history of depression, in itself, does not seem to substantially jeopardise successful quitting.103–105 However, one study suggests that 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.106 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.107,108 Chemicals in cigarettes can affect the metabolism of certain antidepressant medications, and dose levels may need adjusting after quitting.109

(See Section 7.12 for further information on how best to encourage and support smoking cessation among those suffering from depression.)

Anxiety

Evidence suggests that anxiety sensitivity is associated with nicotine withdrawal symptom severity110 and increased risk of early smoking lapse, but is not associated with smoking relapse during the first two weeks of quitting.111 (See Section 7.12 for further information.)

7.7.2 External factors that predict failure in quit attempts

External factors that increase the difficulty of staying stopped include 'cues' to smoke in a smoker's environment. Cue reactivity is increasingly being studied.112–116 Point-of-purchase cigarette displays act as cues to smoke, even among those not explicitly intending to buy cigarettes and those trying to avoid smoking.117 Research shows that smokers respond to smoking stimuli with increased craving but that they also respond to environmental contexts where cigarette cues are normally present but are not.118 Social temptation situations appear to affect cessation outcomes but further research would increase understanding of the effect of situational temptations.119

7.7.2.1 Social factors

Factors related to smoking in the social environment influence abstinence from smoking.120 There is a positive association between social support and cessation and some research findings suggest that the perception of social support (negative or positive) provided to smokers trying to quit is an important factor in success and is influenced by the relationship with the supporter.121 Partner influence on smoking persistence and behaviour change is significant.122,123 Evidence shows that quitting is made more difficult if a smoker's social environment is filled with smokers24 and alcohol use is also related to relapse.9,25,124 Limited evidence suggests that the temptation to smoke caused by the smell of other people's smoke is only related to relapse as part of a general urge to smoke.125

7.7.2.2 Depictions of smoking in popular culture

Incidental promotions of tobacco, such as in movies, continue to influence the normalisation of smoking and act as cues to smoke.126,127 (See Chapter 11 for further information on tobacco advertising and promotion.)

7.7.2.3 Remaining tobacco marketing

Exposure to tobacco advertising can reduce current smokers' motivation to quit and bring attention to tobacco products, which may result in former smokers resuming smoking. (See Chapter 11, Section 11.1.) Tobacco advertising may remain in a community's collective memory for many years after it has been severely restricted with many individual smokers reporting that they have recently seen such advertising even though it had been banned for some years in their jurisdiction.128

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