7.19.1 Younger smokers
Effective smoking cessation interventions for young people are valuable for several reasons; firstly, many of the adverse health effects and risk of early death associated with smoking can largely be prevented with cessation at a young enough age.1 For those who start, and continue, to smoke from early in life, susceptibility to disease is higher than for those who start smoking later in life. Many young people want to quit smoking soon after they begin, with many studies reporting more than 50% of teenage smokers making a quit attempt within six months. Lastly, young people with mental health or behavioural problems are far more likely to smoke than their peers, which may cause and/or worsen mental health symptoms (see Section 9A.3).
In a 2017 survey of Australian school students aged 12-17 years, 21% of past year smokers intended not to smoke in the coming year, while 25% were undecided. Two per cent of all Australian students aged 12-17 years old in 2017 already identified as ex-smokers.2 In 2019, 4.1% of Australians aged 15–24 identified as ex-smokers.3
7.19.1.1 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.4 5 Quitting may be a much more stressful, uncomfortable, and socially isolating experience for young people than research typically acknowledges.6 7 Young smokers may receive little active support from family and friends in their quit attempts.7 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.8 Two systematic reviews of longitudinal studies published between 1984 and 20109 and between 2010 and 201810 have together identified 63 predictors of cigarette smoking cessation among adolescents. Eighteen factors were found to be ‘probable’ i predictors of cessation, five of these were positively associated with cessation and included: self-efficacy/confidence in quitting; no intention to smoke cigarettes; negative beliefs about smoking; older age at smoking onset; and perception that health is good. Six were negatively associated with cessation including: friends who smoke; household members who smoke; frequency/intensity of smoking; daily smoking; nicotine dependence and receipt of cigarette coupons.
Young poly-tobacco users, that is, young people who use more than one tobacco product including smokeless tobacco, hookah, and cigars, have been found to be just as likely to intend to quit as those using only cigarettes.11
Maintenance of regular physical activity among young smokers appears to help to facilitate smoking cessation,12 as does adding physical activity to an adolescent cessation program, particularly among boys.13
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.14 Although withdrawal symptoms may be uncomfortable for adolescent smokers trying to quit, they do not appear to be the most important factor causing relapse.15
7.19.1.2 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.16
A 2017 Cochrane review of cessation interventions for young people concluded that while evidence remained limited for all intervention types, findings for group counselling interventions and behavioural interventions designed using complex theoretical models were the most promising. There continued to be little evidence about the effectiveness of pharmacotherapies available for this age group.17
In 2020 a systematic review18 of smoking cessation interventions for US young adults aged 18–24 years found text message interventions, sustained quit-and-win contests, and multiple behaviour interventions to be promising, however quit rates remained low across all studies included in the review. Combining these interventions with pharmacotherapy, and addressing the transitions inherent to young adulthood, which can be at odds with sustaining quit attempts, may improve quit rates.18
Despite limited evidence of its efficacy, nicotine replacement therapy is recommended for use with teenagers who exhibit symptoms of dependence.16 If used, it should be individualised and combined with psychosocial and behavioural interventions.19 Counselling is a vital component of interventions for young people.20
There is some evidence that specialist settings for young people can be effective venues for the delivery of tailored cessation programs.21 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.22 Earlier research found that programs that are delivered in a context that is structured for young people, such as a school, and that extend for at least five sessions seem to be more effective than community-based and single session interventions;23, 24 however, there are many barriers to delivering such programs within schools.24 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.25 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.26, 27 Similarly, community services for young people should develop policy that addresses smoking by clients and staff, and encourages and supports smoking cessation. A national evaluation of community-based cessation programs for young people in the US concluded that providing evidence-based treatment to young people in community-based settings results in successful cessation.28
Proactive, personalised telephone counselling is effective for adolescent smoking cessation.29 Although fewer than 1% of Quitline clients in Australia are under 18 years of age,30 protocols for young callers have been developed as part of the set of national minimum Quitline standards.31 These recommend, firstly, incorporating “youth friendly” practices especially during assessment, the use of a dedicated counsellor, consideration of situational dependence and adjusting strategies to focus on situations where the young person smokes, and lastly, while nicotine replacement therapy (NRT) is approved from 12 years of age for those with nicotine dependence, Quitline standards recommend referring young people under 18 years to their health professional for further discussion .31 Internet- and mobile phone-based interventions offer enormous potential for reaching young people, and these are discussed in detail in Section 7.14.
A small pilot study in 2019 found potential in the use of virtual reality for increasing motivation to quit smoking among young adult smokers who were previously unmotivated. The virtual reality experience simulated the progression of smoking related illnesses in the body and took the participant on a journey ending with them dying in hospital from smoking related causes. The virtual reality session was found to be more motivating than other stimuli including shocking images on a pack of cigarettes and a brief film showing pulmonary effects of smoking.32
7.19.1.3 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.33, 34 In a longitudinal US study, exposure to advertisements from anti-tobacco media campaigns (104–155 ads over 24 months) was found to significantly increase the odds of 2-year quitting among all young adult smokers, and 2-year reduction or quitting among young adult daily smokers.35
Australia’s mass media campaign ‘Sponge’ was voted the most impressive and appreciated campaign among Italian adolescents aged 13–17 years in a study evaluating global anti-tobacco campaigns and young people’s emotions, opinions and attitudes. The adolescents felt disgusted but also thoughtful about the Australian campaign, which used a scientific approach with a clear, simple, strong and not emotionally shocking approach incorporating explanations of the structure of the lung and description of pathological changes caused by tobacco.36
A systematic review that assessed the equity impact of interventions/policies on smoking among young people found that price/tax increases had the most consistent positive equity impact (i.e., reduced smoking inequity between high- and low-SES young people).37
For a detailed discussion of the effects of social marketing campaigns on young people, see Chapter 14, Section 14.4.1.2.
7.19.1.4 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.38 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.16 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, the health problem of the patient, and a lack of standardised tobacco control efforts can hinder the delivery of interventions in this setting.23, 39-42 Nonetheless, health professionals’ training should emphasise the importance of smoking cessation as a part of their everyday practice.16
7.19.2 Older smokers
Tobacco is the leading risk factor for the burden of disease for older Australians aged 65–74 and 75–84. In 2019, 34% of Australians aged 50 and older were ex-smokers.43 The proportion of daily smokers in their 50s was 16%, while 11% were in their 60s and 4.6% were in their 70s or older.44 Compared to younger smokers, older smokers tend to smoke more heavily. In 2019, younger smokers (aged 18–24) smoked an average of 8 cigarettes per day, while smokers aged in their 60s smoked 17, and those in their 70s or older smoked 16 cigarettes per day.44 Compared with younger smokers, older smokers were also less likely to have intentions to quit smoking, the main reason being, their enjoyment of it. In 2019, 40% of smokers in their 60s, and 46% of smokers in their 70s or over, were not planning to quit smoking.44 This is compared to 29.5% of current smokers aged 18 years and over with no future intentions to quit.45
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.46 A large Australian study similarly found that smoking cessation, even at older ages, reduces the risk of preventable hospitalisation for chronic conditions.47
7.19.2.1 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, hold inaccurate beliefs about smoking behaviours and health effects, are less confident about being able to quit, do not see any health benefit of quitting, and are overall less willing to quit, or to use quitline support.48 ,49
Depression50 and loneliness51 also appear to act as important barriers to quitting in older smokers. Older smokers experiencing loneliness are likely to smoke a higher number of cigarettes per day.52 In one study, the risk of smoking was 1.80 times higher for men living alone than when living with others. For women, the risk of smoking was higher when living alone, or living with those of a younger generation, than if they were living with a partner and a younger generation.53
Factors that appear to encourage older smokers to quit include increasing the price of cigarettes, advice from a health professional, and cheaper cessation medications.48 As in the general population, developing health problems can also trigger cessation attempts.54 One study found that older smokers who quit tended to be those who took more medications and had greater cognitive dysfunction.51
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.55, 56
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.57 One study found elderly parents of more highly educated children were more likely to quit smoking as a result of the ‘spillover’ effect of health knowledge from their children’s education.58
7.19.2.2 Cessation interventions
When provided with an appropriate intervention, older smokers can, and do, quit successfully.59 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,60 while another suggested that the use of NRT may be an effective strategy for smokers aged 65 and over.61 Research in the US demonstrated that adding extended cognitive behavioural therapy to standard cessation treatment (i.e., 12 weeks of NRT) was cost-effective.62 Among community-dwelling elderly smokers, one study found that behavioural group therapy achieved higher short-and long-term abstinence rates than education alone.63 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.48 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.64 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.65
7.19.2.3 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.48 (See Section 7.10.) Older adults tend to visit 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.48, 59 Studies have found however, that health professionals may be less likely to promote smoking cessation to older patients.59 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.67 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.59, 68
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.) Further research is warranted in this area.69
7.19.3 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 gendered marketing from the tobacco industry targeting women through the feminisation of smoking, and the promotion of smoking as a symbol of emancipation, equality and liberation,70 as well as the production of specially formulated products for women, such as ‘light’, ‘slim’, ‘super-slim’, low-tar, light-coloured packaging, and menthol cigarettes.71 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, decreased fertility, premature menopause and cervical and breast cancer.72 ,73
7.19.3.1 Factors influencing smoking and quitting
Women and men tend to have different reasons for initiating, and continuing tobacco use, and may experience different barriers to quitting smoking.74
Barriers to quitting that are unique to or experienced to a greater degree among women can be sociological, psychological or biological. Concerns about weight control and weight gain can result in abstinence failure,75 as well as limiting gender roles hindering women’s ability to access treatment and support due to heightened stigma surrounding substance use among women, particularly pregnant women and mothers.76 While women are generally more willing to seek healthcare including advice and assistance for quitting smoking, they often face barriers with access to services due to lack of transport and childcare commitments.70
Women may experience psychological barriers to quitting more so than men,77 including worse mood symptoms compared to men when trying to quit smoking, with significant increase in anxiety, anger/irritability, depressed mood /sadness, and composite negative affect in the 24 hours following smoking cessation, or as soon as three hours post-quit attempt.78 While depression consistently predicts lower rates of abstinence in both men and women, the effects are stronger among women.79
Cyclical changes may play a role in smoking and quitting behaviours. Research investigating the effect of reproductive hormones on women's daily smoking across the menstrual cycle suggest that elevated progesterone levels lessen the propensity to smoke in women, estrogen levels influence women's subjective experience of smoking, and simultaneous drops or increases in these hormones are associated with increased smoking.80 However, a large proportion of premenopausal smokers use oral contraceptives. A 2017 review of literature on the use of oral contraceptives and smoking behaviours and cessation reported mixed findings.81 Use of oral contraceptives appears to increase in nicotine metabolism and physiological stress responses in smokers, while results on cravings and negative affect were mixed.81
Biological sex may play a role in cigarette use and cessation outcomes. Neuroimaging studies have demonstrated that cigarette smoking is associated with sex-related differences in brain structure and function.82 Sex differences have been documented both in the reinforcing effects of nicotine and in tobacco smoking treatment. Men experience greater nicotine induced reinforcement than women.83 Women are more reinforced by smoking cues, report greater psychological withdrawal, tend to relapse to smoking in response to stress84 and craving85 and have a harder time maintaining long-term abstinence.84, 86 Smoking appears to activate different brain systems modulated by noradrenergic activity in women compared with men, and noradrenergic compounds may preferentially target these sex-sensitive systems.87 Other studies have explored the sex differences in the mesocortical mesolimbic dopamine system in men vs. women,86, 88 sex-specific alterations in spontaneous brain activity,82 sex differences in brain circuitry underlying cognitive control.89
7.19.3.2 Cessation interventions
Research on women’s success with the use of pharmacotherapies for smoking cessation provides mixed findings. 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.90 However, 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 using medication, women had 31% lower odds of success.91 Many clinical trials report higher rates of successful cessation in men versus women, though research has disputed this gender disparity, arguing that when basing evidence on the general population rather than atypical clinical sample, men in general are not more likely to quit smoking successfully than women.92 Gender differences observed in clinical trials may be attributable to differences between male and female help-seekers. Most smokers do not seek formal help with stopping smoking, and the majority of successful cessation is unaided.92 Sex-sensitive approaches to medication development for smoking cessation may be a critical next step for addressing low quit rates and exacerbated health risks among women. Within health research, women are underrepresented in clinical trials and in smoking cessation drug trials. A lack of focus on gender/sex at the trial stage results in women being more likely to develop adverse reactions to medication due to differences in female and male responses.70
A 2014 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.74 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.93 Participants in a theory-based, culturally, and gender-relevant smoking cessation intervention delivered by Community Health Workers among Brazilian women had 1.88 times the odds of self-reported smoking cessation than the control participants.94 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.95
7.19.3.3 Population-wide strategies
The World Health Organization (WHO) recommend addressing the issue of gender through a gender lens and making sure that national tobacco-control policies are in line with the WHO-FCTC and are both intersectional and gender-responsive.70 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.”96 The preamble to the FCTC likewise highlights “the need for gender-specific tobacco control strategies.”97 Women are underrepresented in pictorial health warnings internationally. An examination of women’s representation in 42 pictorial health warnings used in the European Union in 2005 found that the most severe health risks of smoking were portrayed using males, whereas women were featured for cosmetic risks, such as wrinkles. In 2014 these images were revised, with women being represented in 31% of images and males in 40%.70
i Probable predictor (i.e., the variable was statistically significant in at least three studies or, if only three or four studies were conducted, then two studies needed to show statistically significant association)
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