7.4 What finally prompts smokers to attempt to quit?
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When asked about the factors that motivate them to consider quitting, smokers most frequently mention the effect of smoking on their health and fitness and the cost of cigarettes. In a national survey conducted in mid- to late-2010 44% of smokers mentioned cost.1 The desire to improve fitness (25%), pressure from family and friends (27%) and worry about smoking affecting the health of others (18%) are also frequently mentioned.1
There is much less information about what motivates young smokers to attempt to quit, with some evidence that illness, concern about future health, concern about fitness and physical appearance, the suffering or death of a loved one, image, the smell of cigarettes, cost and a request from a boyfriend or girlfriend are all factors that can prompt a quit attempt.2–4
Population-level studies from a number of countries show that intentions to quit, past quit attempts, longer duration of past attempts, more negative attitudes about smoking, motivation, less nicotine dependence, younger age and receiving advice to quit from a health professional are all predictive of attempting to quit.5–9 Higher confidence in quitting may be predictive of making a quit attempt but gender, age, marital status and education level do not appear to consistently relate to quit attempts.9 Self-identity in terms of smoking and of quitting may also play a role in explaining intention to quit and predicting actual attempts to quit.10
Having a negative opinion of smoking and having concerns about the effect of smoking on health are highly predictive of thinking about quitting and making a quit attempt.9,11 This provides a strong rationale for interventions such as restrictions on the promotion of tobacco products and for mass media campaigns and health warnings that explain the health risks of smoking as clearly and as concretely as possible.
While tobacco-control policy and cultural norms about smoking shape people's attitudes and beliefs about smoking in a general way, the more immediate prompt to quit is often something quite particular and personal.12 Developing a serious illness, the death of a person perceived to be like oneself, becoming pregnant, a child becoming ill and smoking being related to that illness, and children expressing concern about parental smoking are all common triggers. So are seeing a TV advertisement that helps one imagine such events, or experiencing an increase in the price of cigarettes.
7.4.1 Developing a serious illness
Health concerns are a major motivator for smoking cessation, whether experienced personally or through a friend or family member.13,14,15 Many smokers hospitalised with cardiovascular disease report being prepared to quit smoking and attempting to quit.16,17 Attending an emergency department has been found to encourage a quit attempt in adult smokers, particularly among those who attributed their visit to a smoking-related problem and who were admitted to hospital.18 Evidence suggests that while motivation and interest in smoking cessation greatly increase following cancer diagnosis,19,20 only around half of patients are interested in taking part in a smoking cessation program.21 Limited evidence suggests that those with stroke/transient ischaemic attack do not necessarily associate their illness with smoking and it does not necessarily prompt a quit attempt.22
7.4.2 Advice from health professional
In a national survey, 15% of smokers responded that advice from their doctor was a factor that motivated them to consider quitting.1 Interventions related to healthcare providers and systems have been shown to improve smoking cessation among people who visit them. Even brief advice from a health professional to quit smoking increases quit rates among patients compared to those not receiving such advice by one to three percentage points.23,24 (See Section 7.10 for further information.)
7.4.3 Becoming pregnant
Women are more likely to quit smoking during pregnancy than at any other time of life as they are concerned not only about their own health, but also the health of their baby. They are also likely to experience higher levels of social and family support for quitting and they have greater contact with the healthcare system.25,26 In a national survey, 5% of smokers responded that being pregnant or planning to start a family were factors that motivated them to consider quitting.1 (See Section 7.11 for further information on smoking and pregnancy.)
7.4.4 Concern for children
There is evidence that concern about the impact of smoking on their children is a reason for many parents to quit smoking. Discussion of smoking by paediatricians with mothers can be effective in encouraging quitting attempts.27 Apart from concerns about the effects of secondhand smoke, at least one study has found that 'setting an example' for children can be an important reason for quitting.28
7.4.5 Seeing an anti-smoking commercial
Both local29–31 and international32 evidence support the positive effect of anti-smoking mass media advertising in encouraging smoking cessation and helping smokers remain quit. (See Chapter 14, Section 14.4 for further information.) Such campaigns are effective across education levels30 and different racial groups.33 (See Chapter 9, Section 9.8.1 for further information.)
Anti-smoking commercials work at a number of levels. Over the long term they increase awareness about and understanding of the health effects of smoking, which helps to shape beliefs and attitudes about smoking and contributes to the decision to quit. In the short term, seeing an anti-smoking commercial–particularly one that effectively conveys the health effects of smoking at a visceral level31 or one that evokes a strong emotional response and a sense of personal identification with a character suffering the tragedy of suffering a smoking-related disease34–can bring forward or prompt an immediate decision to quit. Such advertisements can also prompt individuals to take immediate action such as calling a quitline35 or purchasing an anti-smoking medication, both of which are likely to firm up what may have been a passing impulse into a serious quit attempt. It is not surprising, then, that increasing the frequency of such advertising accelerates the decline of smoking.36
7.4.6 Experiencing an increase in the price of cigarettes
Price increases have been consistently shown to prompt quitting attempts among adults.37 Increase in price appears to prompt quit attempts among all socio-economic status groups, with a significantly greater effect among those on low incomes. (See Chapter 13, Section 13.1.5 and Chapter 9, Section 9.8.2 for further information.) Smokers with financial stress are more likely than others to be interested in quitting, although they tend to be less successful in their attempts.38 Given that tax increases have an immediate effect on the cost of tobacco products across the entire population, it is not surprising that increases leading to an immediate reduction in affordability of tobacco products have been found to be the most significant of a range of policy measures in achieving reductions in smoking prevalence measurable in the short run.36 (See Chapter 13, Section 13.5 for further information.)
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