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7.9 Approaches to increasing the proportion of ever smokers who have quit

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Success rates among those attempting to quit are currently low, with fewer than 10% of smokers who make an attempt in any given year succeeding. A key question in tobacco control is how best to maximise the proportion of ever smokers who have quit: whether it is better to focus on increasing success rates among those who are attempting to quit or whether it would be more effective to increase the percentage of smokers trying.

There is some evidence of the value in shifting the focus from the 'quality' of smokers' quit attempts to the 'quantity' of those attempts.1 Data from California indicate that 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 that most smokers still have to make multiple attempts, with or without these aids. The research concluded 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.2, 3

7.9.1 Continuation of current policies

Expert scientific bodies have concluded that success in smoking cessation at the population level is a product of a comprehensive tobacco-control approach. This includes a combination of:4–7

  • real and effective price increases
  • sustained, research-based mass media campaigns
  • bans on tobacco advertising and promotion
  • inclusion of prominent health warnings on packs and efforts to ensure the warnings remain salient
  • smokefree public environments
  • making evidence-based cessation support readily available and promoting its use to smokers
  • ensuring that smokers receive encouragement and appropriate support to quit in all healthcare settings and other public institutions such as prisons.

7.9.2 Reduced barriers to use of cessation programs and pharmacotherapies

Evidence-based smoking cessation treatments are underutilised. To increase demand for such treatments requires that smokers know about what is available and have access to them.8 There is evidence that many smokers are unaware of the full range of methods to quit smoking and that many use non-evidence-based approaches.9 Limited evidence also shows that current smokers may be less trusting of information sources such as health professionals or the Internet than are non-smokers,10 which may contribute to lack of use of treatments. A consumer-centred approach to this issue involves understanding and addressing smokers' needs and concerns about treatment and communicating effectively with them about the nature and value of treatments.11 Approaches to increasing the likelihood with which smokers use cessation medications may be more successful if they address expectations smokers have about their effectiveness and desirability.12 Viewing tobacco dependence as a chronic disease, and not just a habit that can be broken with willpower, is suggested by some researchers as integral to encouraging and promoting the use of effective cessation treatments to smokers.13

An integrated, comprehensive systems approach to cessation treatment and policy may help improve population quit rates.14 Treatment policies suggested in the literature include:14,15

  • expanding cessation treatment coverage and provider reimbursement
  • mandating adequate funding for the use and promotion of evidence-based, state-sponsored quitlines
  • supporting healthcare system changes to prompt and guide tobacco treatment
  • supporting and promoting evidence-based treatment via the Internet
  • improving individually tailored approaches and the long-term effectiveness of evidence-based treatments.

Studies from the US modelling the impact of smoking cessation treatment policies on adult quit rates have found that implementing any policy in isolation could increase quit rates from a baseline rate of 4.3% to between 4.5% and 6%. By implementing policies in combination, the quit rate would be increased even more substantially.15

One suggested way to increase the use of available smoking cessation treatment is to give more financial support through healthcare systems on a par with other medical and behavioural disorders.16 Higher out-of-pocket expense has been associated with a lower probability of a smoker using any smoking cessation medication.17,18 There is evidence that providing access to subsidised pharmacotherapy can increase usage of quit treatments and increase the proportion of quit attempts that are successful.19,20 International research examining the long-term effects of reimbursement of smoking cessation support found that it appears to be cost-effective from a healthcare perspective.21 Evidence suggests that lower socio-economic status (SES) smokers are more addicted and may benefit from more intensive support to successfully quit, highlighting the importance of providing ready access to pharmacotherapies complemented by evidence-based behavioural support.22

7.9.2.1 Availability and price of nicotine replacement therapy

UK evidence found that making non-prescription nicotine replacement therapy (NRT) smoking cessation medicines reimbursable leads to a large increase in utilisation, but does not have an impact on the number of smokers making quit attempts.23 There is evidence that adding free NRT to a smoking cessation program may increase numbers in the program and short-term quit rates, but not long-term rates.24 One study examining the impact of reduced cost NRT and a period of familiarisation with a wide range of products found no difference in quit rates at six months compared to no familiarisation.25

7.9.2.2 Subsidy of prescribed medicines

As mentioned above, there is evidence from the UK that making prescription smoking cessation medicines reimbursable leads to greater use, but does not affect the number of smokers making quit attempts.23

7.9.3 Building knowledge about and skills in quitting: population-wide education versus clinical and other one-to-one approaches

Most smokers attempt to quit on their own even though effective support methods exist. Building knowledge about and skills in quitting may play an important role in increasing successful cessation. Research suggests that smokers may be unaware of and underestimate the benefits of what is available.26 Other evidence has shown that the use of a decision aid aimed to motivate smokers to use effective cessation treatments can have a positive effect on knowledge of and attitude towards the methods, confidence about being able to quit and quit attempts but does not affect actual usage.27

To increase successful cessation at a population level it is important to understand more about the use of cessation methods by smokers and their helpfulness in the real world.28 There is evidence that going cold turkey, NRT and gradual reduction before quitting are commonly used by smokers and perceived as being very helpful, while advice from health professionals, though commonly used, is less helpful. Prescribed medication has lower use but high helpfulness.28

7.9.3.1 Intensity of intervention

An important aspect of quitting is the treatment structure or level of intensity of the interventions given to help each individual smoker to quit. Measures of intensity include the length of time of each contact, total amount of contact time, and number of person-to-person sessions. Cessation rates tend to increase with extended contacts and with the number of treatment formats (different types of counselling and educational interventions).4, 29 Low intensity interventions typically offered in Australia include brief advice from a doctor or other health professional and the Quitline service, although these interventions have the potential to be more intense depending on the time and depth of information and counselling provided. In Australia, there are three types of high intensity interventions. These are the Quitline program of callbacks for smokers during their quit period, group programs that have multiple sessions, and individual counselling involving multiple sessions with a doctor, nurse or psychologist. The effectiveness of all levels of interventions is improved by concurrent use of proven quitting medications.30–33

As a general rule, the more intense the intervention, the greater the likelihood of success of cessation for any individual.4,32–34 However, higher intensity interventions are usually more costly (to the individual, government or other funder) and less likely to be available to all smokers. Therefore there will be a cost–benefit ratio for each individual method and level of intervention.

Evidence indicates that lower SES smokers are more addicted and are more likely to need more intensive support to be able to quit successfully.35

(See Sections 7.14 and 7.15 for further information)

7.9.3.2 Cost-effectiveness of smoking cessations (Shared content with Chapter 17)

There are two broad aspects to the question of costs and effectiveness of smoking interventions at the population level:

  • the cost-effectiveness analysis of smoking cessation compared to other public health or medical interventions
  • the cost-effectiveness analysis of different approaches or levels of intensity to smoking cessation.

Both aspects are complex to estimate and information is scarce for Australia. The value of smoking cessation in comparison to other health interventions is clearly demonstrated in studies from around the world that can be extrapolated to Australia.36 Interventions that promote cessation of smoking typically cost between hundreds of dollars and several thousand dollars per life year saved, while other medical interventions more typically cost tens of thousands of dollars, making smoking cessation therapies one of the most cost-effective health interventions.37 In Australia, consulting firm Applied Economics prepared a report for the Commonwealth Department of Health and Ageing in 2003 that compared public health programs to reduce tobacco consumption, coronary heart disease, HIV/AIDS, measles and Hib-related diseases, and road trauma. For tobacco, it was concluded that for government, there was a saving of $2 for every $1 spent on tobacco-control campaigns. Based on very conservative assumptions (e.g. that Quit Campaigns were responsible for only 10% of the reduction in tobacco use) the estimated present value of overall social benefits was $8.6 billion, compared to costs of $176 million.38

The cost-effectiveness of differing approaches to smoking cessation has never been estimated for Australia, but overseas research suggests the costs per life year saved vary from a few hundred dollars for media campaigns to several thousand dollars for intensive interventions by health workers.39 One study found general practitioner (GP) training plus free quitting medication training or a combination of this approach with GP remuneration to be cost-effective, but GP training and remuneration alone to not be effective.40 The actual values depend on success rates and smoker characteristics. Since more intense interventions are more often used by more dependent smokers and those with other problems that make quitting harder, these estimates may overestimate the costs of more intensive approaches were they to be used by ordinary smokers.41 Even cross-country studies that show significant variation in cost-effectiveness of different smoking cessation medications have found results to be favourable compared to other common preventive pharmacotherapies.42

Another issue is whether children rather than adults should be the target for intervention.

There are several reasons for a broader focus, rather than concentrating on smoking prevention. School-based educational programs have generally proved to be ineffective,43 however children are positively affected by campaigns aimed at the whole community.44 Smoking cessation campaigns can reduce smoking among young people, by direct influence through exposure to the campaign, and by indirect influence through parents quitting45–47 and through the effects of making the home smokefree.48–50 In addition, a focus on cessation will bring much faster returns. Mortality from tobacco use over the next 50 years will be affected much more by the number of adults who quit than by the number of adolescents who start.51

7.9.4 A middle way: population education plus system-wide minimal interventions combined with tailored but low-cost, high-reach services

One of the key categories of tobacco control is interventions designed to directly influence tobacco users and potential users, such as education campaigns, product warnings and provision of stop smoking services.35 The 2004–09 National Tobacco Strategy highlighted a comprehensive approach to tobacco control in Australia that included population education through increased promotion of Quit and Smokefree messages in combination with improved quality of and access to services and treatment for smokers and tailoring of messages and services to ensure access by disadvantaged groups.52

What combination of approaches to smoking cessation is likely to lead to the greatest reduction of smoking for the least cost at a population level?

Australia's National Preventative Health Strategy53 and National Tobacco Strategy52 envisage a three-level approach:

  • Effective population-wide education via the continuation of anti-tobacco mass media campaigns, pack warnings and other information dissemination to influence tobacco users and potential users.35
  • The implementation of policies to increase health-system-wide minimal cessation interventions such as requiring all healthcare organisations and professionals to offer cessation advice and brief support as part of routine care, further promotion of the national Quitline number and the development and marketing of stop-smoking treatments that are more appealing to smokers trying to quit.35 Even small effects of such treatments are clinically significant. A combination of services, health professional training, referral arrangements, remuneration and subsidies has the capacity to provide evidence-based services and treatments for those who want assistance or are likely to benefit.
  • The provision of tailored but high-reach cessation services for particular high-risk groups delivered through the Quitline or through computer technologies and through commonly used health services and community networks including social clubs, schools and workplaces. This includes, for example, training of Indigenous health workers and other health professionals working in Aboriginal and Torres Strait Islander health services, building the capacity of local health services, and ensuring access to information, treatment and services for those with mental health problems.

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