Chapter 7 Smoking cessation

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Greenhalgh, EM|Jenkins, S|Stillman, S|Ford, C. 7.2 Quitting intentions, attempts and success among people who smoke. In Greenhalgh, EM|Scollo, MM|Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne : Cancer Council Victoria; 2019. Available from https://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-2-quitting-activity
Last updated: February 2025

7.2 Quitting intentions, attempts and success among people who smoke

7.2.1 Population prevalence of ex-smokers, quit proportions

Data from the 2022–23 National Drug Strategy Household Survey (NDSHS) showed that among Australians aged 14 years and over, about one-quarter (24%) of the population were people who had quit smoking and almost two-thirds (65%) had never smoked.1

Table 7.2.1 shows that the percentage of people who had quit smoking remained relatively stable over the past several decades,1-12 suggesting that increases in the numbers of people not taking up smoking in the first place (‘never’ smokers) rather than increases in the number of people quitting (‘ex-smokers’) might have been more important in reducing the prevalence of current smoking. However it should be noted that the proportion of ex-smokers is also affected by relative rates of mortality among older Australians who smoke compared to those who smoked as young adults but who quit over subsequent decades.

The final column of Table 7.2.1 also sets out the proportion of people who have ever smoked and have quit. A change in definition of ex-smokers in 2001 makes it difficult to be certain, but it appears that the proportion of people who have ever smoked who have quit smoking was about 66% higher in 2022–23 than it was in 1991. Figure 7.2.1 shows this trend since 2001. The proportion of the population that are ‘ex-smokers’ has stayed at about the same level despite the increase in the quit rate due to the mathematical effect of fewer people haven taking up smoking in the first place (and therefore fewer people having been in a position to have quit).

7.2.2 Population trends in intention to quit

Intentions to quit among people who smoke can indicate the likelihood of cessation attempts and success in the future; most people who smoke report wanting to quit.13,14 In 2022–23, only about one-third of Australians who smoke reported that they had no plans to give up smoking (32.8%). Roughly the same proportions reported that they were planning to quit but not within the next three months (31.6%) or that they had more immediate plans to quit (i.e., within the next three months, 30.2%).1 This is consistent with international data that also suggest that many people who smoke are in some form of transition.15 Findings from the 2020 International Tobacco Control Four Country Smoking and Vaping Survey (USA, Canada, England and Australia) showed that 70.6% of people who regularly smoked preferred to quit rather than continue smoking. About one in five (21.5%) preferred to continue smoking and 8.0% were uncertain.16

7.2.2.1 Is the remaining smoking population ‘hardening’?

As smoking prevalence declines, some people have argued that a greater proportion of the remaining people who smoke are likely to be ‘hardcore’, defined as unwilling or able to quit (also known as the ‘hardening hypothesis’).17 Australian studies indicate that the proportion of people who smoke with hardcore attributes (high levels of nicotine dependence alongside low levels of quitting activity) is small.18,19 Analysis of NDSHS data from 2001 to 2010 found that the overall rate of hardcore smoking (defined as the number of people who smoked more than 15 cigarettes a day, had not made an attempt to quit in the last 12 months, and did not plan to quit) remained stable over the 10 years, but varied by socioeconomic status (SES). The proportion of high-SES hardcore smokers decreased over time, but the proportion of low-SES hardcore smokers increased.20 Another analysis of NDSHS data, this time between 2010 and 2016, found that the prevalence of hardcore smoking was less than 5%. There was no evidence of hardening in the smoking population, though people with low levels of education and income were consistently more likely to report indicators of hardcore smoking.21 Research in Victoria examining indicators of hardening between 2001 and 2016 found that the smoking population appears to have ‘softened’ over time (i.e., there were declines in the proportion of people who reported heavy consumption and no intentions or attempts to quit), among both low and high SES groups.22

A number of international studies have reported similar findings. Research in the US,17,23,24 England,25 Finland,26 the EU,24 New Zealand,27 South Korea,28,29 and the Netherlands30 has not found evidence of hardening among the smoking populations alongside declining prevalence. Evidence on whether hardening is occurring among priority subpopulations is mixed, with some studies findings no differences31 (e.g., between Maori and non-Maori in Aotearoa New Zealand)27 and others finding less progress among, for example, low income people who smoke or those with lower education levels.23,26,32 Regardless, reaching priority groups with effective tobacco control measures is an important step in reducing overall smoking prevalence33 (see InDepth 9A).

Reviews of studies examining the hardening hypothesis consistently find no evidence to support it.34 A systematic review concluded that while classifications of ‘hardcore’ people who smoke vary across studies and countries, making comparisons challenging, the evidence overall suggests that the prevalence of hardcore smoking is small and generally declining over time.35 Another systematic review argues that the hardening hypothesis should be rejected, with almost all indicators either showing no evidence of hardening or showing softening among smoking populations.36 An editorial similarly concluded that the weight of evidence does not support the hardening hypothesis, though noted that most research is from high-income countries with comprehensive tobacco control programs and low smoking prevalence.37

7.2.3 Population trends in quit attempts and success in quitting

Overall quit rates in the population are a function of the percentage of people who smoke who try to quit, and the success rate of quit attempts.38

Different strategies exist for measuring quit attempts; each has its own limitations and current estimates of the amount of quitting activity vary considerably.39 Research in England showed that a substantial proportion of unsuccessful quit attempts go unreported, particularly attempts that last a short time or occurred longer ago.40 One study has queried the definition of a quit attempt, as many surveys require that the attempt lasts at least 24 hours. The authors suggest this may underestimate the prevalence of attempts in studies that are measuring the effects of tobacco control interventions.41

Research consistently shows that a substantial proportion of people who smoke try to quit in any given year.25,42-44 Only a minority of people who smoke have never tried to quit, and thoughts about quitting are common.39 In 2022–23, about three-quarters (76%) of Australians who currently smoked reported that they had tried to change their smoking behaviour in the past year. Twenty-nine per cent reported they had tried to quit without success, 20% had given up smoking for more than one month and 40% reduced the amount smoked per day.1 An examination of data from 28 countries found that 42.5% of people who smoked had made a quit attempt in the past year.45

While levels of quitting interest and attempts are high, a large amount of quitting activity is unsuccessful. Nonetheless, research in England46 and the US47-49 has shown a significant increase in successful quitting over time. Even a small increase in the success rate can have significant effects on prevalence, highlighting the importance of helping people who smoke to stay quit in the longer term.39 One study found that there is a subset of people who smoke who repeatedly attempt to quit, but fail. The authors suggest that it is important to determine why repeated quit attempts may be unhelpful in the long-term, as tailored interventions might be needed for people who want to quit, but persistently relapse.50 A longitudinal study concluded that previous research may have underestimated the average number of quit attempts it takes a person to successfully stop smoking, finding that for many people who smoke, it may take 30 or more quit attempts before being successful.51

Although success in quitting is clearly difficult for many, even the small percentage of people who smoke that quit, when seen at a population level, represents substantial progress. Evaluation of the National Tobacco Campaign showed a decline in smoking prevalence of 1.4% in the first six months of the campaign, which represented about 190,000 fewer people who smoke across the country.52 Motivation to quit appears to be higher in countries that have implemented comprehensive tobacco control measures,53 therefore the continuation and strengthening of such measures can promote and support quitting—see Section 7.9.

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References

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Intro
Chapter 2