7.19 Interventions for particular groups

Every smoker is different, but there are some groups that share social, cultural, and personal characteristics to a sufficient degree to justify the development of tailored evidence-based approaches to smoking cessation. These include groups with very high smoking rates, with disproportionate tobacco-related health disparities, where special barriers and less access to cessation treatment exist, or where current mainstream approaches are less successful. They are also groups where the research as to most effective approaches is often limited.^1,2

Smoking rates remain very high among those who are both socially excluded and socio-economically disadvantaged.³ Some population-level interventions are effective in reducing smoking among disadvantaged groups, however there is very limited published research on the most effective smoking cessation strategies for highly disadvantaged groups.⁴  Findings regarding the outcomes for behavioural interventions, though inconsistent, show some promise.⁵  An Australian study of disadvantaged smokers attending social and community service organisations highlights their interest in quitting and the importance of overcoming barriers, including increasing their knowledge and use of evidence-based cessation strategies and support services.³  

Some groups who have received particular attention in state and national tobacco strategies are described below. These include:

7.19.1 Aboriginal and Torres Strait Islander people

7.19.2 Low-income groups

7.19.3 Homeless people

7.19.4 Single parents

7.19.5 People with serious health conditions, including surgical patients, cardiovascular disease, respiratory diseases, cancer, diabetes, and HIV/AIDs

7.19.6 People with substance use and other mental disorders

7.19.7 Culturally and linguistically diverse groups

7.19.8 Smokers living in remote areas

7.19.9 Lesbian, gay, bisexual, and transgender (LGBT) people

7.19.10 Prisoners and others involved in criminal justice system

7.19.11  Veterans

7.19.12 Younger smokers

7.19.13 Older smokers

7.19.14 Women

7.19.15 Users of other tobacco products

7.19.1 Aboriginal peoples and Torres Strait Islanders

The prevalence of smoking is substantially higher among Indigenous Australians compared with the general population,⁶  and  tobacco use plays a significant role in their poorer health status and lower life expectancy.^7,8  Tobacco use among Aboriginal peoples and Torres Strait Islanders, and interventions to address it, are covered in greater detail in  Chapter 8. For further information on smoking, ill-health, financial stress and smoking-related poverty among Indigenous communities see  Chapter 9, Section 9.6.9.

7.19.2 Smoking cessation among low-income groups

While smoking has declined over time in most developed countries, inequalities in smoking rates have persisted or increased.⁹  Smoking cessation interventions aimed at the general population have successfully reduced overall smoking prevalence, but have likely increased inequalities in smoking.¹⁰  An analysis of smoking in 11 European countries found that while socioeconomic inequalities in smoking cessation rates declined between 1987 and 1995, they strongly increased since the 1990s and during the 2000s, suggesting that tobacco control measures implemented over this period  were not able to counter this trend.¹¹ Similarly, a systematic review in Europe found higher proportions of tobacco users among those with lower socioeconomic level, and that people who suffered downward mobility (i.e., began life in a higher socioeconomic group and subsequently moved downward) tended to mimic smoking habits of the new group when they migrated to a lower social group.¹²  In Australia, the prevalence of smoking remains substantially higher among those with low educational attainment and lower income levels compared with the general population (see Section 1.7). Such smokers are also more highly dependent on nicotine, and are less likely to intend to quit.¹³  Further, smoking exacerbates financial stress and poverty both for adults,¹⁴  and children.¹⁵  

Social (e.g. low social support for quitting), psychological (e.g., low self-efficacy) and physical factors (e.g. greater nicotine dependence) all contribute to the higher tobacco use among socially disadvantaged populations.¹⁶  An analysis of the effects of wages on a person’s smoking decisions found that a 10 per cent increase in wages led to about a 5 per cent drop in smoking rates among men and those with a high school education or less, and significantly improved their chances of quitting.¹⁷  The development of interventions that address smoking among low-socioeconomic status (low-SES) groups is a high clinical and economic priority to reduce health inequalities and improve life expectancies,⁹  and to reduce the financial burden of smoking.¹⁵  However, a systematic review of research over the past decade into cessation among low-SES and other disadvantaged groups concluded that the current research output is not ideal or optimal to decrease smoking rates.⁹  Nonetheless, recent research has attempted to develop interventions to reduce socioeconomic disparities caused by tobacco use. 

Researchers in the US have attempted to adapt evidence-based treatment to more fully meet the needs of lower SES smokers, and have produced a revised treatment that will be examined in a randomised controlled trial.¹⁸  Another US study assessed two strategies (direct mail and opportunistic telephone referrals) that offered financial incentives to low-income smokers for being connected to the Quitline. Both strategies successfully connected smokers to the Quitline and encouraged quit attempts and continuous smoking abstinence.¹⁹  A large randomised controlled trial in Switzerland similarly found that large financial incentives improved long-term quit rates in low-income smokers.²⁰  Two studies have examined interventions among Salvation Army client smokers: one that challenged beliefs about the effectiveness of various quit methods, which was associated with greater smoking reduction and greater likelihood of contacting the Quitline,²¹  and another that showed that a brief, targeted motivational intervention increased the initiation of an evidence-based tobacco cessation treatment.²²  A brief intervention comprising counselling, referral to the Quitline, and free nicotine replacement therapy resulted in quit attempts and successful quits among low-income smokers visiting an emergency department.²³  Barrier to using the Quitline among low socioeconomic smokers can include not having access to a phone,²⁴  and the cost of making the call from a mobile.²⁵  

Integrating interventions into existing community programs also holds promise for promoting cessation among low-income smokers.^{26, 27}  In the UK, NHS stop-smoking services appear to reduce inequalities in smoking through increased relative reach through targeting services to low-SES smokers.¹⁰  In terms of recruiting socioeconomically disadvantaged smokers into smoking cessation studies, mailed invitations and follow-up from health professionals appears to be effective, while recruitment via community outreach approaches may be largely ineffective.²⁸  One study found that a smoking reduction intervention for economically disadvantaged smokers that involved personal support to increase physical activity was more effective than usual care in achieving reduction and may promote cessation.²⁹  Peer support interventions also appear to have potential to address the high prevalence of smoking in vulnerable populations, particularly among disadvantaged groups who experience fewer opportunities to access such support informally.¹⁶

In terms of population-wide strategies, researchers in the US concluded that population-based proactive tobacco treatment (proactive outreach plus free cessation treatment) increases engagement in evidence-based treatment and is effective in long-term smoking cessation among socioeconomically disadvantaged smokers.³⁰  A qualitative study explored how Australian socioeconomically disadvantaged smokers respond to rising cigarette prices. Participants reported frequent experiences of deprivation and financial stress caused by their smoking, such as going without meals, substituting food choices and paying bills late in order to purchase cigarettes. In order to maintain smoking, price-minimisation strategies (such as switching to roll-your-own) and sharing tobacco resources within social networks were adopted. Price increases were perceived as helpful for preventing uptake, with larger price rises and subsidised cessation aids needed to assist with quitting. The authors highlight that assistance for socioeconomically disadvantaged smokers who struggle to quit should be a priority.³¹  Another Australian qualitative study aimed to better understand why socially disadvantaged populations may be resistant to cessation interventions. Findings showed that smoking behaviour, smoking identity and feelings about smoking were reflective of individual circumstances and social and environmental context. Participants felt 'trapped' by their smoking, due to not being able to control the stressful life circumstances that triggered and sustained their smoking:

The people who can give it [smoking] up have support, they’re 9 to 5ers…they have good friends, a good place to live, they’re not homeless, they don’t have to go to the 139 club for a rotten meal. 

—Male, mature person at risk of homelessness (Pateman et al.,³²  p. 1052)

The smokers' views involved contradictions between believing that smoking cessation involves individual responsibility while at the same time being caused by factors outside of their control. The authors conclude that tobacco control programs aiming to reduce smoking among disadvantaged groups are unlikely to be successful unless the complex interplay of social factors is carefully considered.³²  

7.19.3 Homeless people

People who are homeless have disproportionately high smoking and low quitting rates compared with those who are housed. (See  Chapter 1 Section 1.10.4 and Chapter  9 Section 9.6.6.) Homeless people are more likely to smoke discarded cigarette butts or used filters or to share cigarettes in order to save money, which puts them at greater risk for infectious diseases, in addition to the usual risks of cancer, respiratory illness, and cardiovascular disease. ³³  Although motivated to stop smoking, homeless smokers are faced with unique social and environmental barriers that make quitting more difficult and therefore flexible and innovative interventions are needed.³³  Qualitative research in the UK revealed that homeless smokers were generally highly dependent and did not display good knowledge of smoking related harms. Many also reported engaging in high risk smoking behaviours. Despite this, most participants reported motivation and confidence to quit in the future. Many had tried to quit in the past, all unassisted, and several described a lack of support or active discouragement by practitioners to address smoking.³⁴  Another qualitative study with homeless smokers, this time in the US, found that most planned to quit eventually, citing concern for their children as their primary motivation. Significant barriers to quitting included the ubiquity of cigarette smoking, its central role in social interactions in the family shelter setting, and its importance as a coping mechanism. Participants expressed interest in quitting "cold turkey" and in e-cigarettes, but were sceptical of the nicotine patch and pharmacotherapy.³⁵   

Despite being interested in doing so, providers of homeless services often do not provide cessation assistance, citing lack of resources (e.g., money, personnel) to support the programs, staff training, and concern that smoking cessation may not be a high priority for homeless youth themselves as significant barriers.³⁶  On the contrary, surveys have shown that many homeless youth are motivated to quit and are interested in smoking cessation products and services.³⁷  Research in the US found that healthcare providers were equally likely to use the 5A’s with homeless patients, but among patients for whom treatment was ‘Arranged’, homeless patients were less likely than housed patients to attend the smoking cessation program suggesting that they may experience barriers to participation.³⁸   

A relatively small body of research has examined cessation interventions for people experiencing homelessness. Among homeless men attending a cessation clinic in Sydney, about half were receiving treatment for psychotic illness, and there were high rates of other psychiatric disorders, physical illness and substance use disorder. Although quit rates were low, attendees significantly the reduced the number of cigarettes smoked per day, and reduced their carbon monoxide readings.³⁹  A 12-week program for homeless smokers was conducted in Melbourne, which offered weekly nurse-delivered smoking cessation appointments, doctor-prescribed free nicotine patch, bupropion or varenicline, and Quitline phone support. While quit rates were low, the program was feasible and acceptable, and led to meaningful benefits for participants including reduced consumption and butt smoking, significant financial savings, and psychological benefits.⁴⁰  In the US, one small study found that homeless adults preferred NRT as the method of assistance and were more likely to be ready to quit if they had tried previously and had social support for their attempt.⁴¹  Another focused on motivational interviewing approaches and found the intervention feasible, with promising results for NRT and counselling.33 Similarly, results from a 12-week program for sheltered homeless people suggested that counselling plus pharmacotherapy approaches may be feasible and effective.⁴²   

Researchers have also explored factors that might promote success or failure in quit attempts. Reducing negative affect, restlessness, and stress appear to predict abstinence among homeless people,⁴³  while lower subjective social status (i.e., ranking one’s own social standing lower than others) has been shown to predict increased risk of relapse on the quit day or the inability to quit at all.⁴⁴  Achieving smoking abstinence may be associated with a reduction in alcohol consumption but appears not to be associated with a substantial change in other drug use.⁴⁵

7.19.4 Smoking cessation for single parents

The prevalence of smoking in single-parent households is significantly higher than among those with two parents, with single mother families making up the vast majority of one parent families. (See  Chapter 1, Section 1.10.3.) Lone parenthood is associated with social and economic disadvantage (see  Chapter 9), and low-income single mothers experience heightened stress, loneliness, depression and anxiety.^46,47   

The strong relationship between single motherhood and smoking can be partly explained by low SES, younger age, living alone,⁴⁸  poor mental health, higher proportion of friends who smoke, and earlier smoking initiation;⁴⁹  however, Australian research has also shown that being a single mother is independently associated with a greater likelihood of smoking.⁵⁰  While improving the socio-economic status, mental health, and social environment of lone mothers may help to reduce smoking rates, further research is needed to better understand smoking and quitting among this group.⁵⁰   

7.19.5 Serious health conditions

Health concerns are a major motivator for smoking cessation, named by two-thirds of smokers changing their smoking behaviour as a major factor motivating that change (refer NDHS 29019, tables 2.42 and 2.41).⁵¹  Diagnosis of a smoking-related illness, especially if it results in a period of hospitalisation or intensive treatment, is a good opportunity to promote smoking cessation.⁵²  Treatment of some health problems is substantially improved if patients stop smoking. For example, quitting after a heart attack improves recovery and reduces the risk of recurrence.^{53, 54} Cancer patients show improved response to treatment if they quit, and have a lower rate of recurrence.^{54, 55}  The management and progression of many chronic and acute diseases, including diabetes, asthma, peripheral vascular disease and emphysema, is improved after quitting,⁵⁶  and intervention is worthwhile. ^{54, 56-63}  Smoking is a serious problem after orthotopic liver transplantation and increases the risk for malignancy.⁶⁴  There has been a vigorous debate in the medical profession about the ethics, economics, and health effects of refusing some hospital treatments for patients who fail to stop smoking.⁶⁵   

A review of interventions for smoking cessation in hospitalised patients concluded that high intensity behavioural interventions that begin during a hospital stay and include at least one month of supportive contact after discharge promote smoking cessation.⁵²  Smoking cessation advice and/or counselling given by nurses also appears to be effective.⁶⁶  Oncology nurses play a pivotal role in supporting cessation among cancer survivors.⁶⁷  For smokers receiving outpatient treatment, brief or intense interventions by their physician will increase quit rates,⁶⁸  which may include referral of those interested in quitting to appropriate services. A randomised clinical trial found that a post-hospital discharge intervention comprising automated telephone calls and free medication resulted in higher rates of smoking cessation at 6 months compared with a standard recommendation to use counselling and medication.⁶⁹  In hospital, people are likely to be more open to receiving help, and they are likely to find it easier to quit in a place where smoking is prohibited.⁵²  At the very least, there is a need to encourage abstinence, provide nicotine replacement therapy (NRT) to manage withdrawal symptoms, and/or explain the necessity of smoking offsite or in a designated area if available. More intensive programs are likely to have greatest success.⁷⁰  For example, referral to the Quitline or in-house support staff for cessation may help improve outcomes, as may consideration of smoking status and intentions for discharge planning, and providing support for continued abstinence or encouragement to consider quitting in the future. New South Wales Health has developed a good example of a comprehensive policy approach for all inpatient facilities.⁷¹   

Current practice falls well short of potential.⁷²  For example, healthcare providers working with cancer survivors do not always take advantage of opportunities to provide cessation advice and interventions.⁷³ Another study found that the majority of smokers continued to smoke five years after stroke, and few recalled smoking cessation advice from their health professionals.⁷⁴  For more information on the role of healthcare professionals in supporting cessation, see  Section 7.10.

7.19.5.1 Surgical patients

For people undergoing surgery, smoking cessation decreases postoperative complications. A systematic review published in 2012 concluded that at least four weeks of abstinence from smoking reduces respiratory complications, and abstinence of at least three to four weeks reduces wound-healing complications.⁷⁵  The Australian and New Zealand College of Anaesthetists recommend that, based on the current available evidence, anaesthetists and surgeons should not be dissuaded from advising patients to quit at any time before surgery.⁷⁶  A Cochrane review of interventions for preoperative smoking cessation concluded that preoperative smoking interventions providing behavioural support and offering NRT increase short-term smoking cessation and may reduce postoperative morbidity. One trial of varenicline found a benefit on long-term cessation but did not detect an effect on early abstinence or on postoperative complications.⁷⁷  Another systematic review and meta-analysis found that preoperative smoking cessation programs will likely precipitate long-term cessation, highlighting the additional benefits of cessation support at this time.⁷⁸

7.19.5.2 Cardiovascular disease

Quitting smoking is the single greatest lifestyle change people with cardiovascular disease (CVD) can make to reduce their morbidity and mortality risk; however, many continue to smoke, even after experiencing a major cardiac event.⁷⁹  While many smokers hospitalised with CVD report being prepared to quit smoking, many who do try do not use effective methods.⁸⁰  There is also high underreporting of smoking status among cardiac patients who participate in smoking cessation programs.⁸¹  Factors such as higher income, fewer household smokers, having a partner, and being a lighter smoker are associated with successful quitting among people with CVD.^82,83  Alternatively, the inability to engage in previously valued activities may contribute to depressed mood and failure to quit smoking in people with heart conditions.⁸⁴ Understanding the relationship between depressive symptoms often experienced by patients hospitalised for acute CVD and relapse following discharge may assist the development of more effective interventions.⁸⁵  One study found that those with stroke/transient ischaemic attack do not necessarily associate their illness with smoking and boredom and lack of social support were cited as additional barriers to quitting. Pharmacotherapy and vocational and rehabilitation programs were perceived positively as resources to assist quitting.⁸⁶   

A review of smoking cessation for cardiovascular patients concluded that there are promising approaches for enhancing quit rates with existing cessation medications, such as combination treatment, extended use of pharmacotherapy, reduce-to-quit strategies, and tailored treatments. The use of cytisine appears promising, and despite its relatively low use, the Quitline is also effective.⁸⁷  The safety of pharmacotherapy for smoking cessation in cardiovascular patients has been demonstrated by a network meta-analysis.⁸⁸  Another review highlighted the importance of a systematic approach with focus on the 5A's (Ask, Advise, Assess, Assist, and Arrange), as well as the efficacy of pharmacotherapies, NRT, and counselling for smoking cessation in patients with vascular disease.⁶¹  A Cochrane review of psychosocial interventions for smoking cessation in patients with coronary heart disease concluded that such interventions are effective in promoting long-term abstinence, as long as they are sufficiently intensive.⁷⁹   

Providing intensive smoking cessation programs for patients hospitalised for CVD increases abstinence.⁸⁹  In the UK, a nurse-led preventive cardiology program in high CVD risk smokers using optional varenicline substantially increased smoking abstinence over 16 weeks and also reduced overall cardiovascular risk compared with usual care.⁹⁰  A systematic review and meta-analysis of bupropion for cessation in patients hospitalised with cardiovascular disease found that while bupropion improved abstinence over placebo at the end of treatment, this effect did not persist at 12 months.⁹¹  German research found that a low-intensity smoking intervention embedded in an adherence program for patients with an increased risk for cardiovascular disease promoted smoking cessation, although the intervention effect diminished over time.⁹²  There is some evidence that intensive outpatient cessation intervention is effective for patients with peripheral vascular disease.⁹³  A small study found support for the use of phone counselling and text messaging for smoking cessation and lifestyle changes among patients who had undergone percutaneous coronary intervention.⁹⁴   

7.19.5.3 Respiratory diseases

Smoking has detrimental effects on asthma.⁹⁵  There is a significant association between asthma and early smoking,^{96, 97}  and adolescents with asthma who smoke are more likely to be girls, have a relatively higher body mass index, be in higher school levels, use marijuana or alcohol, have minor to severe depressive symptoms, not live with both biological parents, be exposed to environmental tobacco smoke at home, and have friends who smoke. Cessation interventions are more likely to assist this group if they address such psychosocial and environmental factors.^{98, 99}  A qualitative study found that most patients understood that smoking exacerbates asthma. Fear of asthma-related exacerbations and poor self-control appeared to be the major triggers for quitting smoking. Most patients wanted quit smoking; however, motivation often needed to be combined with public, social, professional, and therapeutic support to achieve and maintain abstinence.¹⁰⁰  Counselling and use of pharmacological treatments is a good approach for smoking cessation in asthma patients; however, there is a lack of smoking cessation trials in this patient population.⁹⁵  Further research is warranted in this area.⁹⁶   

Smoking cessation is the most effective measure for controlling the progression of chronic obstructive pulmonary disease (COPD).⁹⁵  A 2016 Cochrane review concluded that there is high-quality evidence that smokers with COPD who receive a combination of high-intensity behavioural support and medication are more than twice as likely to quit as those who receive behavioural support alone. There was no clear evidence that one particular form of behavioural support or medication is better than another.¹⁰¹  First-line drugs licensed to aid smoking cessation (nicotine replacement therapy, bupropion, and varenicline) are effective in patients with COPD.¹⁰²  A combination of two or more NRT products, higher than usual dosing, extended use prior to quitting and extended use post-quitting can improve treatment efficacy. Extended use of varenicline prior to and after the target quit date, and the combination of varenicline with nicotine patches or bupropion can improve treatment outcomes.⁹⁵  A meta-analysis of behaviour change techniques in cessation interventions for people with COPD concluded that such interventions appear to benefit from focusing on forming detailed plans and self-monitoring.¹⁰³

For smokers with either COPD or asthma, an intensive smoking cessation program with regular and long-term follow-up can help them to achieve high abstinence rates and prevent relapse.¹⁰⁴  Several studies have called for the development of tailored interventions for people with COPD, taking into account both inter- and intragroup differences.^{105, 106}  COPD patients express motivation to quit and often make multiple quit attempts; however, boredom, mood disturbances, the strong sense of identity as a smoker, peer reinforcement, irritability, cravings, hunger, and weight gain can act as barriers to quitting,¹⁰⁷  along with patient misinformation, levels of motivation, health beliefs and poor communication with health professionals.¹⁰⁸  Depression also appears to decrease the likelihood that patients with chronic respiratory conditions will quit smoking.¹⁰⁹  Qualitative research found that smokers with COPD often trivialise the health consequences of smoking, and may be less knowledgeable about its health effects. Autonomy was very important among participants, and many were indignant about a perceived lack of empathy from doctors. There was little faith in the efficacy of smoking cessation aids.¹¹⁰  Some patients may inaccurately report their smoking status, which hampers effective intervention.^111,112   

The prevalence of smoking among people with tuberculosis (TB) is higher than in the general population, and smoking leads to worse TB outcomes. Smoking cessation strategies for TB patients include: a combination of counselling (brief behavioural intervention at diagnosis followed by monthly behavioural support throughout the TB treatment course) and pharmacological treatment (nicotine replacement therapy, bupropion and varenicline).⁹⁵  Motivational interviewing also appears to increase self-efficacy and abstinence rates among tuberculosis patients.^113,114

7.19.5.4 Cancer

A diagnosis of cancer, even a cancer not strongly related to smoking and with a relatively good prognosis, may be associated with increased quitting that is sustained well after diagnosis.¹¹⁵  Motivation and interest in smoking cessation appear to greatly increase following cancer diagnosis, therefore this could be an effective time for encouraging and supporting quitting.^96,116  However, many patients and family members continue to smoke following cancer diagnosis, and feelings of guilt can lead to the concealment of smoking status from health care professionals.¹¹⁷  Continued tobacco use limits the effectiveness of major cancer treatments and increases the risk of complications and of developing secondary cancers.¹¹⁸   

There is limited research regarding smoking consumption, smoking cessation interventions and relapse prevention strategies among cancer patients.¹¹⁶  A systematic review concluded that interventions combining non-pharmacological and pharmacological approaches have resulted in an improvement in smoking cessation rates compared to usual care.¹¹⁹  Bupropion may have advantages for cancer patients, including low risk for nausea.¹²⁰  A systematic review and meta-analysis of smoking cessation counselling for patients with head and neck cancer found that patients who received counselling supplemented with NRT achieved cessation considerably more often that those who received usual care.¹²¹  The US National Comprehensive Cancer Network clinical practice guidelines recommend that treatment plans for all smokers with cancer include evidence-based pharmacotherapy, behaviour therapy, and close follow-up with retreatment, as needed.¹²²  However, a lack of appropriate resources and provider training has been cited as a major barrier to integrating tobacco treatment in healthcare systems.¹¹⁸   

Among childhood and young adult cancer survivors, factors such as self-efficacy, social support, fear of recurrence, perceived vulnerability and depression are associated with smoking.¹²³  Web-, print-, and telephone-based interventions appear to be equally effective for this group,¹²⁴  and educational and behavioural risk-counselling interventions may also be beneficial in reducing smoking risk up to 12 months after intervention.¹¹⁶   

Cigarette smoking causes most cases of lung cancer, and adversely impacts prognosis once lung cancer is diagnosed (see  Chapter 3, Section 3.4). However, most smokers with lung cancer continue to smoke post-diagnosis, or fail to maintain abstinence following quit attempts. A recent Cochrane review aimed to examine smoking cessation interventions for people diagnosed with lung cancer, which represents an important factor in improving their prognosis. The review found no randomised controlled trials that met selection criteria, therefore the efficacy of cessation interventions could not be evaluated. These authors call for further research in this area.¹²⁵  Limited research suggests that smoking cessation strategies for lung cancer patients should include counselling and use of pharmacological treatment (nicotine replacement therapy, bupropion and varenicline).⁹⁵  Screening programs for lung cancer might also benefit from the inclusion of cessation interventions.¹²⁶  Lung cancer survivors who are exposed to secondhand smoke, particularly those exposed in multiple settings, are less likely to quit.¹²⁷

In general, because each patient with cancer has unique medical, psychological, and social circumstances, cessation treatment needs to be individualised.¹²⁸  Patient age, gender and type of cancer may be important factors to consider when developing and implementing smoking cessation interventions for cancer patients. Persistent smoking post-diagnosis is associated with younger age, lower education and income, greater alcohol consumption,¹²⁹  the presence of household members who smoke, high body mass index, and a longer duration of smoking.¹³⁰  Pain may also be a barrier to quitting among cancer patients who smoke.¹³¹  People who continue smoking subsequent to a cancer diagnosis often perceive fewer health risks from smoking and fewer benefits of quitting.^{132, 133}  Other challenges for people with cancer can include long histories of smoking, pressure for immediate quitting, high levels of stress and distress, delayed relapse, and medical contraindications to certain pharmacotherapies.^96,134   

7.19.5.5 Diabetes

People with diabetes who quit smoking have a lower risk of death and cardiovascular events compared with those who continue to smoke.¹³⁵  However, recent research has shown while quitting generally decreases the risk of diabetes overall, smoking cessation is associated with an increased risk and deterioration in blood glucose control in the first 2–3 years of abstinence.^{136, 137}  A recent review similarly found that cessation can cause weight gain and can be associated with diabetes or obesity onset.¹³⁸  Therefore, it is important that quit attempts are accompanied by preparation, extra care, and careful monitoring to keep the person’s blood glucose well controlled during this time.^136,139  Additional challenges to achieving abstinence for people with diabetes include early uptake of smoking, difficulty with weight management, negative affect, and low motivation for quitting at the time of hospitalisation.⁹⁶  Lower education level is also associated with smoking in young people with diabetes.¹⁴⁰

There is a dearth of evidence to inform treatment strategies for smoking cessation in type 2 diabetes. A randomised controlled trial found that an intensive, individualised intervention using motivational interviewing, therapies, and medications adapted to the patient's stage of change delivered to people with diabetes in primary care was feasible and effective, with a smoking cessation rate of 26.1% after 1 year.¹⁴¹  One program partnership in California that aimed to promote referrals to the quitline by diabetes educators resulted in an increase in the percentage of quitline calls from people with diabetes and the proportion of callers referred by healthcare providers¹⁴²   

A systematic review of randomised trials of smoking cessation interventions in diabetes published in 2014 identified only a small number of trials, which tested interventions similar to those used in the general population, comprising counselling, referral and advice, and for some, the addition of diabetes-specific education. The results did not provide evidence of efficacy for the interventions. Only one trial reported data on glycaemic outcomes, which were not significantly different between intervention groups.¹⁴³  A more recent review of randomized, placebo-controlled studies of varenicline in smokers with diabetes concluded that it was an effective and well-tolerated aid for smoking cessation, and safety was comparable with participants without diabetes.¹⁴⁴  Bupropion should be used with great caution among people with diabetes, as the risk of seizures is greater in individuals taking insulin or oral diabetes medication.¹⁴⁵

7.19.5.6 HIV/AIDS

Adults with HIV are more likely to smoke and less likely to quit than the general population.¹⁴⁶  Data from the Australian HIV Futures 6 study show that 42.3% of people living with HIV/AIDS smoke.¹⁴⁷  HIV infection appears to confer an increased susceptibility to the harmful effects of smoking,¹⁴⁸  including non-AIDS-defining cancers, cardiovascular disease, and pulmonary disease.¹⁴⁹  Smoking also adversely affects the health-related quality of life of people living with HIV/AIDS.¹⁴⁹  Cessation may result in better disease management and increased length of survival.¹⁴⁹ When asked, as many as two-thirds of smokers with HIV report being interested in or considering quitting.150 Diagnosis of HIV may be an effective time for intervention.¹⁴⁹

Successful quitting among people with HIV is influenced by a complex range of social, economic, psychiatric, and medical factors.^{149, 151, 152}  Research in the US found that among people with HIV, current smokers had higher unemployment and increased rates of other substance use than former smokers or never smokers. Being unemployed and having used inhalant drugs were also associated with current smoking. Lower education was associated with decreased readiness to quit.¹⁵³  National surveys in the US have found that people with HIV who binge drink or who have been treated for drug or alcohol use are more than 5 times more likely to be current smokers than never smokers.¹⁵⁴  Another study found that older age and lifetime use of NRT/medications were associated with interest in quitting smoking, while older age and having a supporter who had used NRT/medications for cessation were associated with lifetime NRT/medications use.¹⁵⁵  Surveys in the US found that people with HIV cite cost and a belief that they can quit unassisted as the main reasons for not using pharmacotherapy. Physician assistance was the strongest correlate of prior use. Willingness to use pharmacotherapy was associated with perceived benefits and self-efficacy.¹⁵⁶  Self-efficacy plays an important role in outcomes of smoking cessation interventions¹⁵⁷  and cessation medication adherence,¹⁵⁸  and measures aimed at increasing self-efficacy to abstain may enhance the effect of targeted tobacco treatment strategies.¹⁵⁹  Social support can also promote NRT use adherence.¹⁶⁰

Limited evidence shows that interventions for this group are potentially effective, can significantly decrease smoking rates, and can be incorporated within HIV clinics.^{96,149,151,161,162}  A review published in 2013 found that smoking cessation rates ranged from 6% to 50% across studies employing pharmacologic and behavioural approaches. However, the studies were often small and the effect was often not sustained over time. Smoking was associated with emotional distress, which may be a barrier to successful cessation. Declining adherence to pharmacologic therapy also may have contributed to low cessation rates. Nicotine replacement therapy combined with a mobile phone-delivered intensive counselling intervention appears to be a promising intervention. The authors highlight need for innovative and effective interventions tailored to this population.¹⁵⁰  Preliminary findings from a recent randomised controlled trial suggest that web-based treatment is a feasible and effective cessation strategy for smokers with HIV.¹⁶³   

A meta-analysis published in 2016 concluded that targeted behavioural smoking cessation interventions are effective for people with HIV, with interventions consisting of eight sessions or more having the greatest treatment efficacy.¹⁶⁴  Another 2016 review also found evidence (albeit sparse and mixed) for the efficacy of behavioural interventions.¹⁶⁵  A Cochrane review published in 2016 found very low quality evidence that combined cessation interventions (behavioural support and pharmacotherapy) were effective in helping achieve short-term abstinence among people living with HIV/AIDS, and moderate quality evidence that the effects were not sustained. Despite this, the authors recommend that interventions be offered to this group, given the benefits of short-term cessation.¹⁶⁶

While health professionals working with patients living with HIV/AIDS agree on the importance of smoking cessation, they often fail to implement interventions.¹⁶⁷  Healthcare professionals should actively pursue smoking cessation as a major objective in the clinical care of people with HIV.¹⁶⁸  Future cessation interventions for HIV-infected smokers may be enhanced by the inclusion of medical adherence and depression as components of the program. ^152,169   

7.19.5.7 Other conditions

Research related to smokers who are hearing or sight impaired is scarce. Access to smoking cessation programs for those who are deaf is limited due to cultural, linguistic and geographic barriers. Internet-based interventions may provide greater access to cessation assistance, but research is very limited. One pilot study of an interactive website has been positively evaluated by deaf community members.¹⁷⁰   

Little is known about the smoking rates of adults with intellectual disability or about effective interventions for this population. UK data suggest that those not using disability services are more likely to smoke.¹⁷¹ Limited research supports the use of mindfulness-based cessation programs.^172,173  A systematic review concluded that the body of evidence on the feasibility, appropriateness, meaningfulness, and effectiveness of tobacco-related interventions for people with intellectual disability is small, and the evidence that does exist is of poor/moderate quality. The strongest study developed materials that educated people with intellectual disabilities about smoking, which led to significantly lower rates of smoking.¹⁷⁴   

7.19.6 Substance use and other mental disorders

Compared with the general population, people with mental illness have higher smoking rates, higher levels of nicotine dependence, and a disproportionate health and financial burden from smoking.¹⁷⁵  Health professionals and smokers with mental health disorders often erroneously believe that smoking is helpful for relieving or managing psychiatric symptoms, such as feelings of depression, anxiety, and stress.¹⁷⁶ However, recent evidence suggests that the reverse is true; quitting smoking actually improves mental health, mood, and quality of life.¹⁷⁶  Interventions for reducing smoking among those with a mental health problem are covered in detail in  Section 7.12.

7.19.7 Culturally and linguistically diverse groups

Generally speaking, people born outside of Australia are less likely to be smokers than those born in Australia. Similarly, the prevalence of smoking is higher in English-speaking households compared with those that mainly speak a language other than English (See  Chapter 1, Section 1.8). Nonetheless, among some smaller population sub-groups, smoking is much more common. For example, small studies have found that as many as half of men with Chinese or Vietnamese backgrounds in Australia are smokers. ^{177, 178}  Smoking rates among women immigrants from non-Western countries (where smoking is typically rare) may also increase as they acculturate and adopt new social norms.¹⁷⁹  Morbidity and mortality from smoking-related diseases can therefore disproportionately affect culturally and linguistically diverse (CALD) populations.¹⁸⁰   

Patterns of tobacco use and types of products used can differ between groups, and along with the interplay between smoking and complex psychosocial and cultural factors, this necessitates tailored and targeted cessation interventions. Such interventions should consider unique patterns of risk and protective factors among CALD groups, as well as other potentially relevant dimensions such as values, beliefs and practices.^180,181  Qualitative research in Sydney found that among Arabic speakers, male smoking was normalised in home, social and religious settings. While there was concern about children's exposure to secondhand smoke, there was less concern for adults, particularly wives. Smoking created conflict within families, and attempts to quit were often unassisted. There was a lack of enthusiasm for telephone support services, however participants suggested that free NRT and programs in religious settings might be useful strategies.¹⁸²   

A systematic review of adapted cessation interventions for ethnic minority groups found that while such interventions are more acceptable, this does not translate into improvements in smoking cessation outcomes.¹⁸⁰  Another systematic review reported more promising results for the effectiveness of specific cultural adaptations for cessation, and highlighted that interventions may be more effective if adaptations are implemented as a package, the adaptation includes family level, and where the adaptation results in a higher intensity of the intervention.¹⁸³

The Quitline service provides access to many printed resources in a range of community languages, and callers can request an interpreter. Some culturally specific programs have been initiated by various Australian organisations, mostly on a short-term basis.^184,185  One New Zealand pilot study suggests that a language-specific home-, workplace- or clinic-based intervention is acceptable and effective among Asian communities in assisting cessation and establishing smokefree homes.¹⁸⁶  An Australian study investigating a telephone support service for Arabic smokers initiated in primary medical care found the support acceptable, but there were no significant abstinence differences compared to usual care at six or 12 months.¹⁸⁷   

7.19.8 Smokers living in remote areas

People living in remote and very remote areas are about twice likely to smoke than those living in major cities.⁵¹  Those who live in rural and remote areas face unique challenges regarding smoking cessation. Living some distance from major population centres, such people often lack access to specialist medical and other health services. Availability of pharmaceutical treatments and free telephone and internet services providing advice and assistance to quit are therefore very important for Australian smokers living in rural and remote areas.¹⁸⁸  (See Chapter 9, Section 9.6.) The role of health professionals in rural and remote areas in promoting cessation is important despite lack of services in many regions.¹⁸⁹  

7.19.9 Lesbian, gay, bisexual, trans and intersex (LGBTI) people

A growing body of evidence shows that smoking rates are significantly higher among lesbian, gay, bisexual, trans and intersex (LGBTI) people compared with the heterosexual population.^190-192 In the 2019 National Drug Strategy Household Survey, people who were homosexual or bisexual were more likely than heterosexuals to smoke daily (16.0 +/-1.5 compared with 10.7% =/-0.3 (see National Drug Strategy Household Survey, table 2.58).⁵¹  US research found that sexual minority cancer survivors had twice the odds of current smoking as their heterosexual counterparts.¹⁹³  The roles of gender non-conformity, masculine self-consciousness and sexual orientation stress appear to be important influences on smoking behaviour in young gay men.¹⁹⁴  A survey in the US found that psychological distress was higher among lesbian, gay, bisexual, and trans smokers than non-smokers,¹⁹⁵  while another found that sexual minority-specific traumatic experiences increased the odds of smoking among gay and bisexual men.196 Less educational attainment, hazardous drinking, and cocaine/heroin use are associated with continued smoking among sexual minority women.¹⁹²  Findings from a community sample of trans women in the US showed that discrimination was associated with smoking, unsuccessful cessation, and never making a quit attempt.¹⁹⁷

There is some international evidence that sexual and gender minority persons may be less positive about public and private smokefree environments, highlighting a need to examine ways to increase their support.¹⁹⁸  Social environments that encourage tobacco use among gay men is an important consideration in cessation interventions for this group.¹⁹⁹  Limited findings suggest that because of the relationships between smoking and other behaviours, cessation interventions for young gay men should be part of larger more holistic health and wellbeing programs.²⁰⁰  For young lesbian and bisexual women, addressing experiences of gay-related stress, internalised homophobia, and emotional distress should inform effective cessation interventions.¹⁹¹

A 2014 review of cessation promotion for LGBT people found evidence that tailored group programs are feasible and effective. Community interventions, although feasible, lack rigorous outcome evaluations. Clinical interventions show little difference between LGBT and heterosexual people. Findings from focus groups suggested that care is needed in selecting the messaging used in media campaigns.²⁰¹  An analysis of national US survey data found that LGBT individuals have similar exposure to tobacco cessation advertising, as well as similar awareness of and use of evidence-based cessation methods as compared to heterosexual peers. This highlights the need for LGBT-specific efforts to reduce smoking disparities, such as increasing awareness, access, and acceptability of existing interventions, developing tailored interventions, and denormalising smoking.²⁰²  A study in San Francisco concluded that sexual and gender minority smokers appear as likely to quit or abstain as nonminority smokers in extended, non-tailored interventions; however, the authors note that the findings may not generalise to geographic areas where access to treatment is limited or a higher stigma of sexual orientation exists.²⁰³  In Switzerland, a modified version of a British smoking intervention program tailored to gay men improved short-term and sustained abstinence rates, as well as participants’ mental health.²⁰⁴  The design of a randomised controlled trial was published in 2014, the results of which will examine the effectiveness of a culturally targeted versus standard smoking cessation intervention for LGBT smokers.²⁰⁵   

A 2016 systematic review of smoking cessation programs for LGBTI people concluded that quit rates were high across studies; however, none included control groups. Most studies included cultural modifications, such as meeting in LGBTI spaces, discussing social justice, and discussing LGBTI-specific triggers. Common behaviour change techniques included providing normative information, boosting motivation/self-efficacy, relapse prevention, social support, action planning, and discussing consequences. Individual populations were not proportionately represented in the studies, with findings most often relevant to gay men.²⁰⁶

7.19.10 Prisoners and others involved in the criminal justice system

The prevalence of smoking in the prison population has traditionally been far higher than among the general population, with tobacco use commonly accepted as part of prison life.²⁰⁷ In 2018, two in three (66%–69%) prison entrants aged 18–44 were daily smokers, compared with just one in seven (14%–16%) people of the same age in the general community.²⁰⁸ Priority populations that have much higher smoking prevalence than the general population, such as those from socially disadvantaged backgrounds, those with a history of mental illness and substance abuse, and those from Aboriginal or Torres Strait Islander backgrounds, are substantially overrepresented in Australian prisons.^{207, 209-212}

Despite very high smoking rates, and fewer than one in 10 (5%–10%) prison entrants having successfully quit smoking in the past, many detainees express an interest in quitting. In 2018, about two in five (41%) prison entrants who were current smokers wanted to quit.²⁰⁸ Of the 41% of prison entrants who wanted to quit smoking, almost half (47%) thought NRT would help, 25% thought counselling would help, 22% thought a quit program would help, and one-third (33%) said they did not want any help to quit. Upon exiting prison, dischargees, who were current smokers on entry, were asked what cessation assistance they had utilised while in prison. Eighteen per cent had utilised nicotine replacement, 2% had utilised counselling or other, 6% had utilised a quit smoking program, and 27% had not wanted assistance to quit.

Barriers to quitting in this population have included a strong smoking culture in prison; the role of tobacco as a de facto currency; high levels of nicotine dependence; mental illness; limited access to nicotine replacement therapy and cessation programs; boredom; and stressful events such as prison transfer, family and legal stressors. Further problems include a lack of evidence for best practice for smoking cessation in this group, confusion over the ownership of the problem between the health department and custodial authorities, and poor access to smoking cessation programmes while outside the prison system.^{207,209,210,213}

As at February 2020, all Australian territories and states (except Western Australia) have introduced or announced intentions to introduce complete smoking bans in prisons. Prior to the implementation of bans, prisoners were provided with access to intensive cessation support.²¹⁴  In The health of Australia’s prisoners 2018 report, about one-third (30%) of dischargees from prisons that had banned smoking said they were current smokers, compared with more than half (56%) of dischargees from prisons which allowed smoking. However, there was only a two percentage point difference between prison dischargees’ intentions to smoke upon release from prisons that had banned smoking and prisons which allowed smoking (42% and 44% respectively).²⁰⁸

A 2018 systematic review investigating factors influencing smoking following release from smokefree prisons found a high and rapid rate of smoking relapse among dischargees.²¹⁵ A systematic review in 2016 similarly found indoor bans on smoking in prisons to have little impact on prisoner smoking behaviour, with prisoners who had experienced a ban typically resuming smoking shortly after release. ²¹⁶ Pre-release intentions to remain abstinent using motivational counselling have been cited as positively associated with post release smoking abstinence.²¹⁵ Multi-component interventions using a combination of behavioural support and smoking-cessation pharmacotherapy has also been found to maximise chances of sustained cessation,²¹⁵ as was refraining from risky drinking.²¹⁷ Despite the availability of smoking cessation pharmacotherapy (SCP) at a heavily subsidised rate in Australia, once released, only a small proportion of prison dischargees go on to use SCP, pointing to a missed opportunity in this vulnerable community.²¹⁸ While maintaining support for dischargees post release is important for successful smoking abstinence, this support has typically fallen outside the scope of the implementation of smokefree prisons.²¹⁸ Findings from a 2019 pilot study in Victoria Australia suggest more intensive support is required in order to reduce post-release relapse to smoking and to encourage those who do relapse to make further quit attempts.²¹⁹

For further information on smoking, ill-health, financial stress and smoking-related poverty among the prison population see Chapter 9, Section 9.6.6.

7.19.11 Veterans

Australian research published in 2010 that examined smoking in the Australian Defence Force found that the highest prevalence of current smoking was among individuals with lower levels of education and those serving in the Navy (26%). The percentage of current smokers in the Army was 22% and the lowest prevalence of smokers was in the Air Force (8%).²²⁰ Based on the relative incidence of smoking-related cancers, smoking rates among veterans of the Korean War are estimated to be higher than those of the general population.²²¹ (See Chapter 9, Section 9.6.8.) Data in the US also show that the prevalence of smoking is higher among veterans than the general population, particularly among younger veterans; for those born between 1975 and 1989, the prevalence of smoking is similar to that of the US adult population during the late 1960s/early 1970s, at about 36%.²²²

There is limited Australian research on cessation interventions for veteran populations, however a number of US studies have provided evidence as to which strategies may be most effective. A large multi-site study concluded that the Tobacco Tactics program, which comprises nurse counselling, informational materials, pharmaceuticals, and post-discharge telephone calls, has the potential to significantly decrease smoking among veterans.²²³ Intensive interventions that combine medication with counselling from the tobacco cessation pharmacists also appear promising.²²⁴ A small study found that a smartphone-based contingency management intervention may be a useful adjunctive smoking cessation treatment component for reducing smoking among homeless veterans.²²⁵ A larger study found that a smoking cessation text messaging intervention developed for veterans effectively supported abstinence, particularly among veterans who were highly engaged with the program or who also used cessation medications.²²⁶ Including tobacco cessation education in veterans’ treatment for other substance use disorders can promote quitting,²²⁷ but smoking cessation is often not prioritised in these settings.²²⁸ Chaplains, who provide meaningful physical and mental healthcare support to veterans, have expressed willingness to be involved in cessation efforts, and could represent another avenue for promoting quitting.²²⁹   One study found that, among veterans with a history of mental health treatment, smoking abstinence was associated with improvements on a number of behaviour and symptom measures.²³⁰

7.19.12 Younger smokers

Although adults experience the major burden of disease from tobacco use, interventions that influence children’s and adolescents’ smoking behaviours are an integral part of ending the tobacco epidemic. Almost all smokers start smoking when they are teenagers, and those who start earlier appear to have more difficulty quitting and be more susceptible to tobacco-related disease.²³¹ Young people with mental health or behavioural problems are also far more likely to smoke than their peers, with emerging evidence showing that smoking appears to play a causal role in some mental disorders.^{232, 233}

In a 2017 survey of Australian school students aged 12–17 years, about 13% of those who had smoked more than 100 cigarettes in their lifetime (who comprised about 2% of students) identified as ex-smokers. Just over half (53%) of students who had smoked in the past twelve months intended not to smoke in the next year.²³⁴

7.19.12.1 Factors influencing smoking and quitting

A complex range of factors influence adolescent smoking and quitting. Some findings suggest that while many younger smokers intend to quit, they have negative attitudes towards most formal cessation approaches and their quit attempts are more likely to be unaided compared to adults.^235,236 Quitting may be a much more stressful, uncomfortable, and socially isolating experience for youth than research typically acknowledges.^{237, 238} Young smokers may receive little active support from family and friends in their quit attempts²³⁸ They may rationalise continuing to smoke by downplaying the health risks of smoking, emphasising the perceived health benefits such as stress relief, and thinking of smoking as a temporary activity that they can easily stop once they enter adulthood.²³⁹

In terms of individual differences, lower nicotine dependence, being older at smoking initiation, perceived peer and parental tolerance of smoking, self-efficacy, resisting peer pressure to smoke, negative beliefs about the consequences of smoking, not having intentions to smoke in the future, and less smoking among social networks are associated with quitting among young people.^240-244 Maintenance of regular physical activity among young smokers also appears to help to facilitate smoking cessation,²⁴⁵ as does adding physical activity to an adolescent cessation program, particularly among boys.²⁴⁶   Factors that can predict relapse include socialising with friends, cravings, social pressure, desire for a cigarette, abstinence–violation cognitions (it’s okay to smoke occasionally, wanted to see what it was like) and negative emotions.²⁴⁷ Although withdrawal symptoms may be uncomfortable for adolescent smokers trying to quit, they do not appear to be the most important factors causing relapse.²⁴⁸

7.19.12.2 Cessation interventions

Unlike the extensive body of literature studying smoking cessation among adults, there is a paucity of good quality studies focusing on smoking cessation intervention and cessation programs for young people. Prevention and cessation are intertwined, but most of the effort with young people to date has focused on preventing uptake rather than promoting cessation.²⁴⁹ A 2013 Cochrane review of cessation interventions for young people concluded that complex approaches show promise, with some promoting maintained abstinence, especially those incorporating elements sensitive to stage of change and using motivational enhancement and cognitive-behavioural therapy.  A small number of studies investigated the use of pharmacological interventions for adolescent smokers (nicotine replacement and bupropion), but none demonstrated effectiveness. The authors call for well-designed and robust trials of interventions for young smokers.²⁵⁰

Despite limited evidence of its efficacy, nicotine replacement therapy is recommended for use with teenagers who exhibit symptoms of dependence.²⁴⁹ If used, it should be individualised and combined with psychosocial and behavioural interventions.²⁵¹ Counselling is a vital component of interventions for young people.²⁵²  

There is some evidence that specialist youth settings can be effective venues for the delivery of tailored cessation programs for young people.²⁵³ A systematic review and meta-analysis published in 2015 found that the mostly moderate quality evidence suggested targeted behavioural interventions can assist with cessation in school-aged children and adolescents.²⁵⁴ Earlier research found that programs that are delivered in a context that is structured for youth, such as a school, and that extend for at least five sessions seem to be more effective than community-based and single session interventions;^{255, 256} however, there are many barriers to delivering such programs within schools.²⁵⁶ Further, a seven-year follow up study found no evidence that previously positive effects of a high school-based cessation intervention for teens were sustained long-term.²⁵⁷ One of the single most inexpensive actions a school can take to reduce smoking is to introduce and enforce a no-smoking policy for students, teachers and visitors.^{258, 259} Similarly, community youth services should develop policy that addresses smoking by clients and staff, and encourages and supports smoking cessation. A national evaluation of community-based youth cessation programs in the US concluded that providing evidence-based treatment to youth in community-based settings results in successful cessation.²⁶⁰

Proactive, personalised telephone counselling is effective for adolescent smoking cessation.²⁶¹ About 4% of callers to the Victorian Quitline are under 18 years of age, and protocols for young callers have been developed as part of the set of national minimum standards.²⁶² These recommend that services focus on the immediate harmful effects of smoking and issues of appearance and youth-specific reasons for smoking, such as rebellion or aspiring to be more grown up. Recognising differences in patterns of smoking between adolescents and adults, for example infrequent and situation-dependent smoking, is important in appropriately tailoring interventions, as is referring young people to youth-specific resources, especially internet sites.²⁶³ Internet- and mobile phone-based interventions offer enormous potential for reaching young people, and these are discussed in detail in Section 7.14.

7.19.12.3 Social marketing and public education campaigns

Population-wide approaches can also effectively shape young people’s smoking-related attitudes and behaviours. Despite primarily targeting young to middle-aged adults, the impact of Australia’s national campaigns to promote smoking cessation also reach younger people. For example, evaluation of the early National Tobacco Campaign showed that adolescents learnt as much, if not more, than the 18–40 years target group from the television advertisements, and the campaigns prompted changes in smoking behaviour.^{264, 265} A systematic review that assessed the equity impact of interventions/policies on youth smoking found that price/tax increases had the most consistent positive equity impact (i.e., reduced smoking inequity between high- and low-SES young people).²⁶⁶

7.19.12.4 The role of health professionals

As with adult smokers, health professionals play an important role in encouraging and assisting younger smokers to quit, and paediatric-based interventions are feasible and effective.²⁶⁷ Paediatric healthcare professionals can provide opportunistic evidence-based brief interventions to adolescents and their carers, and/or can provide referrals to specialist services and resources. However, many health professionals have not received appropriate smoking cessation training.²⁴⁹ Practitioners’ low levels of confidence in helping young smokers to quit, their lack of clarity about what strategies and pharmacotherapies should be used, their concern for maintaining rapport with their adolescent patients, and the health problem of the patient can hinder the delivery of interventions in this setting.^{255, 268, 269} Nonetheless, health professionals’ training should emphasise the importance of smoking cessation as a part of their everyday practice.²⁴⁹  

7.19.13 Older smokers

The greatest proportion of burden of disease due to smoking affects those aged 55–75 years. (See Chapter 1, Section 1.5.) A comprehensive study on the impact of smoking and smoking cessation on cardiovascular events and mortality among adults aged 65 years and over found that smoking cessation in these age groups is still beneficial in reducing the excess risk, thus should be supported and encouraged.²⁷⁰ A large Australian study similarly found that smoking cessation, even at older ages, reduces the risk of preventable hospitalisation for chronic conditions.²⁷¹

7.19.13.1 Factors influencing smoking and quitting

Results from surveys in the UK, US, Canada, and Australia suggest that older smokers tend to perceive themselves as being less vulnerable to the health effects of smoking, are less convinced or concerned about these health effects, believe that smoking has not affected their own health so far, are less confident about being able to quit, do not see any health benefit of quitting, and are overall less willing to quit.²⁷² Depression²⁷³ and loneliness²⁷⁴ also appear to act as important barriers to quitting in older smokers. Factors that appear to encourage older smokers to quit include increasing the price of cigarettes, advice from a health professional, and cheaper stop-smoking medications.²⁷² As in the general population, developing health problems can also trigger cessation attempts²⁷⁵ A large German survey found that high-risk older patients with comorbidities are highly motivated to quit and would benefit from effective assistance.²⁷⁶ One study found that continuing older smokers who quit tended to be those who took more medications and had greater cognitive dysfunction.²⁷⁴

There is evidence that transition into retirement represents a time when smokers are more likely to quit, suggesting that interventions could be developed to take greater advantage of this lifestyle change.²⁷⁷ Older people’s continued smoking, quitting, and relapse appear to be significantly influenced by friends and family members, especially a spouse, and their attempts to quit are often unplanned.²⁷⁸ When provided with an appropriate intervention, older smokers can and do quit successfully.²⁷⁹ Indeed, Danish research found that, following a “gold standard” intensive six-week smoking cessation program, participants over the age of 60 years had significantly higher continuous abstinence rates than participants under 60 years.²⁸⁰

7.19.13.2 Cessation interventions

A number of recent studies have reviewed the evidence on smoking cessation interventions for middle-aged and older adults. Although the research is limited, a systematic review and meta-analysis study found support for pharmacological, non-pharmacological, and multimodal interventions in adults over fifty years,²⁸¹ while another suggested that the use of NRT may be an effective strategy for smokers aged 65 and over.²⁸² Research in the US demonstrated that adding extended cognitive behavioural therapy to standard cessation treatment (i.e., 12 weeks of NRT) was cost-effective.²⁸³ Among community-dwelling elderly smokers, one study found that behavioural group therapy achieved higher short-and long-term abstinence rates than education alone.²⁸⁴ Interventions may need to address the underestimation by older smokers of the risks of smoking and their misperceptions that there are no benefits of quitting. ²⁷² Findings from focus groups in the US revealed that anti-tobacco messages with a positive frame that outline immediate and long-term benefits of cessation would be an effective approach for older long-term smokers.²⁸⁵

7.19.13.3 The role of health professionals

Health professionals have an important role to play in educating older people about the health benefits of quitting and a range of opportunities exist in which to advise and assist older patients to stop smoking.²⁷² (See Section 7.10.) Older adults tend to visit their health professionals more frequently, creating many opportunities for intervention. They are able to quit at high rates when given effective advice and support by health professionals, including behavioural therapy and pharmacotherapy.^{272, 279,286} Studies have found however, that health professionals may be less likely to promote smoking cessation to older patients.²⁷⁹ Interviews with older ex-smokers revealed that they may need additional education on tobacco risks and cessation benefits provided by health care providers during routine office visits.²⁸⁷ Health professionals cite a number of misperceptions and perceived barriers to providing interventions, including that older smokers are unwilling and unable to quit, that they would not respond positively to advice, that they understand the risks of continuing to smoke, that quitting would not have any great benefit, that it is wrong to take away something pleasurable in their life, and that quitting might actually harm the patient’s health. They also report lack of organisational support and concerns about harming the health professional–patient relationship. There is some evidence that nurses who do not smoke are more likely to provide advice to quit.^{279, 288}

Cigarette smoking may contribute to worse health outcomes for peri- and postmenopausal women and cessation may be particularly challenging for this group. (See Chapter 3, Section 3.6.1.3.) Further research is warranted in this area.²⁸⁹

7.19.14 Women

Cessation interventions for pregnant women are covered in detail in Section 7.11.

While the prevalence of smoking has typically been higher among men than women, this gap has narrowed over time (See Chapter 1, Section 1.3). This has largely been attributed to aggressive tobacco industry marketing targeting women, as well as the production of specially formulated products for women, such as ‘light’, ‘slim’, ‘super-slim’, low-tar, light-coloured packaging, and menthol cigarettes²⁹⁰ Although women and men who smoke share excess risks for diseases such as cancer, heart disease, and emphysema, women also experience unique smoking-related disease risks related to pregnancy, oral contraceptive use, menstrual function, and cervical cancer. ²⁹¹ Women and men tend to have different reasons for initiating and continuing tobacco use and may experience different barriers to quitting smoking, some of which are gendered.²⁹² Barriers to quitting that are unique to or experienced to a greater degree among women include fear of weight gain, certain social factors, withdrawal and craving in response to environmental cues, the point in the menstrual cycle in which an attempt is made to quit, and depression.²⁹³ For example, while depression consistently predicts lower rates of abstinence, the effects are stronger among women.²⁹⁴ Women taking oral contraceptives also appear to experience different patterns of smoking-related symptomatology during short-term smoking abstinence.²⁹⁵ Further, during the follicular phase (the first half) of the menstrual cycle, cognitive control appears to be lower and cue reactivity higher, which could potentially hinder quit attempts. ²⁹⁶ Gendered roles and experiences can limit women’s ability to access treatment and support due to heightened stigma surrounding substance use among women, particularly pregnant women and mothers.²⁹⁷

Compared with men, women may be less successful at quitting,^298,299 and have worse health outcomes.^291,299 Results from the International Tobacco Control Four Country Survey showed that although women were equally as likely as men to want, plan, and try to quit,  among quit attempters, women had 31% lower odds of success.³⁰⁰ Women also tend to relapse faster, and experience more difficulties with maintaining abstinence.²⁹⁰ While bupropion and varenicline appear to be equally effective among men and women,^{301, 302} results regarding NRT are mixed. A number of studies have suggested that NRT may be less effective in women,^303,304 and that women experience less quitting success when using nicotine patches.³⁰⁵ Others have found no gender differences.³⁰⁶ Another study found that abstinence rates were lower in women who used gum, patches and spray compared with men; however, women experienced greater success than men after using an inhaler.³⁰⁷ Regardless, due to its safety and efficacy, NRT is also recommended for women trying to quit.²⁹³ A meta-analysis of sex differences in the comparative efficacy of transdermal nicotine, varenicline, and sustained release bupropion for smoking cessation concluded that the advantage of varenicline over bupropion and nicotine patches is greater for women than men, and the authors suggest that clinicians should strongly consider varenicline as the first-line treatment for women. Among men, the relative advantages were less clear.³⁰⁸

Together, these issues have led to calls for the importance of attending to gender to be recognised in health promotion interventions²⁹² One of the recommendations of a 2007 policy brief by the WHO was to “Increase availability and access to treatment services for tobacco dependence and train health professionals in these services to take into account sex and gender specificities when treating tobacco dependence.”³⁰⁹ The preamble to the FCTC likewise highlights “the need for gender-specific tobacco control strategies.”³¹⁰ However, a recent review found that tobacco use interventions designed with an understanding of the effect of gender roles, norms, and behaviours on women’s health are limited, and primarily focused on pregnant and postpartum women. The authors conclude that much work remains to encourage practitioners to use a gender-sensitive approach when designing interventions.²⁹² Others have called for policy and program developers to apply gender theory in designing their initiatives, with the goal of changing negative gender and social norms and improving social, economic, health and social indicators along with tobacco reduction.³¹¹ A recent study examining cessation outcomes following an intervention that included gender-tailored components found no short- or long-term gender differences in the effectiveness of the intervention.³¹² A small qualitative study from Canada suggests that smoking cessation programs for women should ideally include: a women's centred approach with sufficient variety and choice; free pharmacotherapy; non-judgmental support; accessible services; and clear communication of program options and changes.³¹³

Gender-sensitive approaches to medication development for smoking cessation may also be a critical next step for addressing low quit rates and exacerbated health risks among women. Smoking appears to activate different brain systems modulated by noradrenergic activity in women compared with men, and noradrenergic compounds may preferentially target these gender-sensitive systems.³¹⁴ Researchers have also suggested that investigation of any nicotine addiction protective effect of progesterone in women may be worthwhile.^315,316 A recent cessation medication trial found that increases in progesterone level in women smokers were associated with a 23% increase in the odds for being abstinent within each week of treatment.³¹⁷  

7.19.15 Users of other tobacco products

Use of waterpipes (hookah/shisha) has increased dramatically throughout the world in recent years.³¹⁸ (For prevalence of use in Australia, see Section 1.11). Researchers have called for waterpipe-specific cessation programs, which address unique features of waterpipe smoking (e.g., its cultural significance, social uses, and intermittent use pattern) and characteristics and motivations of users who want to quit.³¹⁹ A randomised controlled trial concluded that brief behavioural cessation treatment for waterpipe users appears to be feasible and effective.³²⁰ A 2015 review of cessation interventions concluded that people who received either behavioural treatment or behavioural treatment plus buproprion were more likely to quit waterpipe smoking at six months follow-up than those who received usual care.³²¹ A subsequent systematic review concluded that there is a lack of evidence of effectiveness for most interventions for waterpipe smoking. Limited evidence supports bupropion/behavioural support and group behavioural support.³²²

Relatively few treatment programs have been developed specifically for smokeless tobacco users who want to quit. A 2015 Cochrane review concluded that varenicline, nicotine lozenges, and behavioural interventions may help smokeless tobacco users to quit; however, the authors report limited confidence in the results regarding lozenges and behavioural interventions.³²³ A systematic review and meta-analysis concluded that varenicline is effective in achieving abstinence from smokeless tobacco at 12 weeks, but this effect was not sustained at 26 weeks.³²⁴ A randomised trial found that combining nicotine lozenges and phone counselling significantly increased tobacco abstinence rates compared with either intervention alone.³²⁵ Another randomised trial found that internet- and phone-based interventions were more effective than self-help in helping motivated smokeless tobacco users quit tobacco, but a combination of the two did not increase their effectiveness.³²⁶

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