While the majority of smokers regret ever trying smoking,1-3 indicating an underlying desire to quit,4 the highly addictive nature of smoking means that a persons’ motivation to quit can fluctuate as a person’s negative thoughts about smoking compete with their dependence on nicotine and a range of environmental and biopsychosocial factors that can promote smoking (see Section 7.7 ). As such, reaching the point of making and sustaining a quit attempt can be a challenge. Smokers may also believe that a rational, unambivalent desire to quit is needed before it is worthwhile trying, and that short-term impulses to act are not sufficient.4 Helping smokers to overcome their ambivalence about quitting is crucial to increasing quit attempts.
7.5.1 Personalisation of risk
Studies of smokers’ risk perceptions have generally found that many are unrealistically optimistic about their personal health risks. 5,6 Smokers show a clear tendency to believe that they are at lesser risk than other smokers of becoming addicted or suffering health effects.5,7,8 One study found that those who perceived their own risk of developing lung cancer to be less than the actual risk were more likely to accept myths associated with smoking, overestimate the number of lung cancers that are cured, and be less likely to quit.9 While the risk of lung cancer and other smoking-related diseases are acknowledged by smokers, they often judge the size of these risks to be smaller and less well established than do non-smokers or than scientific evidence would justify. 5,7 Smokers also estimate that the health consequences of smoking occur much later in life than non-smokers do.10 A US study of smokers found that those who never plan to quit are more likely deny or doubt that smoking causes disease or death.11
Correcting unrealistic judgements about risk may facilitate increased quitting.12 For example, providing adults with an estimation of their risk of global coronary heart disease can improve the accuracy of their risk perception and may increase the intention of those at medium to high risk to initiate preventative actions such as quitting smoking.13 There is some evidence that encouraging smokers to think and worry more about their smoking behaviour, rather than focusing on their beliefs about the risks involved, encourages them to try to quit.14 A study that presented participants with a simulated and personalised experience of a heart attack combined with motivational interviewing found that more than half of participants were abstinent at six months.15
Another strategy that has been suggested for increasing smoking cessation rates is to provide smokers who have contact with healthcare systems feedback on the biomedical or potential future effects of smoking. However, a 2019 Cochrane review found little evidence that feedback on the physical effects of smoking using physiological measurements (for example, exhaled carbon monoxide measurement or lung function tests) aids in long-term quitting16 and subsequent research has produced mixed findings.17-20 Section 7.18.4 provides a more detailed overview of biofeedback methods for smoking cessation and their effectiveness.
7.5.2 Addressing risk-minimising and self-exempting beliefs
According to cognitive dissonance theory, people seek consistency among their beliefs, attitudes, and behaviours. When there is inconsistency (dissonance), people experience discomfort, and attempt to resolve it through changing or rationalising their thoughts and/or actions.23 Smokers widely accept that smoking is bad for them, yet continue to do it. A high proportion of smokers hold various beliefs that serve to minimise the reality of the harms caused by smoking or rationalise their behaviour, and allow them to avoid engaging in the task of quitting.12,24-27 For example, there is evidence that use of dietary supplements may create perceptions of invulnerability in smokers and discourage changes in their smoking behaviour.28
Four categories of these beliefs have been identified:24
- Sceptic beliefs indicate smokers do not believe the evidence about the health effects of smoking : ‘Lots of doctors and nurses smoke, so it cannot be all that harmful’, ‘More lung cancer is caused by such things as air pollution, petrol and diesel fumes than smoking’.
- Bulletproof beliefs allow smokers to think that they are personally immune to smoking-related illness : ‘You can overcome the harms of smoking by doing things like eating healthy food and exercising regularly’, ‘I think I would have to smoke a lot more than I do to put my health at risk’.
- ‘Worth it’ beliefs suggest the benefits of smoking outweigh the risks : ‘You have got to die of something, so why not enjoy yourself and smoke’, ‘I would rather live a shorter life and enjoy it than a longer one where I would be deprived of the pleasure of smoking’.
- Jungle (i.e., normalising) beliefs normalise the risks of smoking : ‘Everything causes cancer these days’, ‘It is dangerous to walk across the street’.
Australian research found that each of the four sets of risk-minimising and self-exempting beliefs was inversely related to intention to quit, however some were more important than others. ‘Worth it’ beliefs in particular were more prevalent among smokers not planning to quit. Higher knowledge of the hazards of smoking and being able to recall at least one anti-smoking commercial was linked to holding fewer such beliefs.24
Subsequent research in the USA, Canada, UK, and Australia found that after controlling for demographic factors, the risk-minimising beliefs (’sceptic’, ‘worth it’, and ‘jungle’ beliefs) predicted lower quit intentions and attempts among smokers, but the self-exempting belief (‘bulletproof’ belief) did not. The authors conclude that countering risk-minimising beliefs may facilitate increased quitting, but this may not be so important for self-exempting beliefs.12
A survey of socioeconomically disadvantaged smokers in New South Wales (NSW) found many endorsed risk-minimising and self-exempting beliefs in relation to smoking, particularly ‘jungle’ and ‘sceptic’ beliefs. Though only ‘sceptic’ beliefs were associated lower quit intentions, after controlling for other smoking-related factors.29
Australian research has also indicated that smokers who placed greater importance on their own experiences rather than external sources of cessation advice (e.g., evidence-based sources or alternatives) were less likely to be concerned about the health effects of smoking and were more likely to believe that the harms of smoking are exaggerated. Smokers who considered all sources of advice about smoking to be unimportant were more likely to endorse ‘jungle’ beliefs and were less likely to be concerned about the health effects of smoking.30
Creative interventions and campaigns that address the risk-minimising and self-exempting beliefs held by smokers may assist in motivating more ambivalent smokers. Researchers suggest using messages that emphasise the relative risks of smoking, the reduced quality of life associated with smoking-related diseases and the risks of premature death.24
7.5.3 The role of media in promoting thoughts about quitting
The level of media attention that a particular issue receives can affect how important the issue is perceived to be, and the extent to which it is prioritised. For example, a greater volume of news coverage has been linked to increased contraceptive use31 and breast screening.32 Research in NSW found that high levels of self-reported exposure to tobacco news were associated with important smoking-related cognitions, including beliefs about harm from smoking and frequent thoughts about quitting. The authors highlight that the media are an important source of information for smokers, and can put or keep quitting on the smokers’ agenda.33 A survey of Aboriginal and Torres Strait Islander people who smoke found self-reported noticing of anti-tobacco news stories in the past six months was associated with significantly higher levels of worry about the dangers of smoking to individual health and desire to quit smoking.2 US research has also found that following the news coverage of lung cancer diagnoses or deaths of high-profile individuals, which often included mention of smoking as a risk factor for lung cancer, attitudes toward lung cancer were less fatalistic and a sustained increase in quitline calls was observed.34 Media attention about the risks of smoking on SARS-CoV-2 virus (COVID-19) susceptibility and survival may have affected quitting intention and behaviour over the COVID-19 pandemic—see Section 7.7.3.
Section 14.6 provides further detail on news media coverage of tobacco issues.
Media coverage of the implementation of new health warnings on cigarette packs can stimulate discussions in social settings, and talking with family and friends about health warnings is an independent predictor of subsequent quit attempts.36 See Section 12A.3 for further detail on the efficacy of health warnings for promoting quitting intentions and behaviours. Additional population-wide strategies that are known to increase quitting activity include price increases (see Section 13.5) and public education campaigns (see Section 14.4). Campaigns can influence individual decision-making about quitting as smokers view or hear campaign messages directly and reflect on their own lives, as well as prompt discussions about tobacco use within family and friendship networks.39
Relevant news and research
For recent news items and research on this topic, click here. ( Last updated January 2023)
1. Fong G, Hammond D, Laux F, Zanna M, Cummings K, et al. The near-universal experience of regret among smokers in four countries: findings from the International Tobacco Control Policy Evaluation Survey. Nicotine and Tobacco Research, 2004; 6(suppl 3):S341–S51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15799597
2. Nicholson AK, Borland R, Sarin J, Wallace S, van der Sterren AE, et al. Recall of anti-tobacco advertising and information, warning labels and news stories in a national sample of Aboriginal and Torres Strait Islander smokers. Medical Journal of Australia, 2015; 202(10):S67-72.
3. Sansone N, Fong GT, Lee WB, Laux FL, Sirirassamee B, et al. Comparing the experience of regret and its predictors among smokers in four Asian countries: findings from the ITC surveys in Thailand, South Korea, Malaysia, and China. Nicotine and Tobacco Research, 2013; 15(10):1663-72. Available from: https://doi.org/10.1093/ntr/ntt032
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18. Ronaldson SJ, Dyson L, Clark L, Hewitt CE, Torgerson DJ, et al. The impact of lung function case-finding tests on smoking behaviour: A nested randomised trial within a case-finding cohort. Health Sci Rep, 2018; 1(6):e41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30623078
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