There are many factors that can influence the success or failure of quit attempts,1-5 including:1,2
Of all these factors, greater nicotine dependence is the factor most consistently predictive of failure in quitting.6,7 Social smoking cues and a recently failed quit attempt are also important predictors.8,9 Some of these factors are examined in more detail below.
While factors associated with quitting vary between studies and individuals, there are some reasonably consistent findings. The focus of most studies has been on individual psychological and demographic factors associated with success or failure in quitting. Some of these factors can also influence how satisfied a person feels with quitting.10 There are large changes in a person’s beliefs, experiences and expectations in the days and weeks after quitting.11,12 Lower abstinence self-efficacy (i.e. belief in their own ability to stay quit) and higher frequency of urges to smoke can predict subsequent relapse,13,14 as can deficits in impulse control.12 Differences have been observed in factors affecting cessation among younger compared with older people, and men compared with women; these are detailed in 7.19 Interventions tailored for age and/or gender.
The evidence on whether age improves success in quitting is mixed; older studies found that older people were more likely to succeed in quitting, however more recent studies have found that younger people have greater success or no differences between age groups. One study found that the higher quit success observed among younger people was largely explained by their lower levels of nicotine dependence.22
People with a higher level of nicotine dependence are less likely to make an attempt to quit and also to find it more difficult,6-8,15,24-27 particularly in the early stages of a quit attempt.28 This may reflect more severe withdrawal symptoms, more pronounced neuro-adaptation (changes to the brain from nicotine exposure), a greater constitutional need for nicotine, a more highly learned and deeply ingrained habit, or possibly a physical or social environment that discourages staying quit (i.e. one with more cues and opportunities to smoke).3,6,29,30 There is also evidence that people who are more dependent experience greater negative affect and craving pre- and post-quit regardless of their cessation status and that these factors are associated with relapse.31,32 Getting out of bed to smoke during the night is an indicator of nicotine dependence, and there is some evidence that people who smoke at night report significant sleep disturbance and may be at particular risk of relapse when they try to quit.33,34 A longitudinal study in California found that people with higher nicotine dependence started smoking earlier in life, highlighting the importance of preventing nicotine use among young people.21 Another study found that lower nicotine dependence was associated with quitting success only among younger adults.35 Data from the Californian Quitline shows that dependent people often make numerous attempts to quit before they are successful, suggesting that those who are unsuccessful on any one attempt should be encouraged to try again.36,35 There is also evidence that people who smoke both cigarettes and other tobacco products, such as cigars, pipes and waterpipes, are less likely to successfully quit smoking.37
One of the main motives for continued smoking is to relieve nicotine withdrawal syndrome3 (discussed more fully in Chapter 6). The major symptoms of nicotine withdrawal syndrome include mood changes such as irritability, aggression, anxiety and depression; restlessness; poor concentration; increased appetite; cravings/urges to smoke; disturbed sleep; decreased heart rate; and decreased levels of adrenaline and cortisol.38 Withdrawal symptoms are generally most intense in the first week after quitting, and last a further two to four weeks.38 However, withdrawal symptoms can be highly variable, both between persons and over time.39 In some people symptoms can be chaotic; they may fall and rise, or they may not decline for a number of weeks.29,38,40 In one study tracking withdrawal symptoms in real time, reports of recent smoking, exposure to someone smoking, and stress were all associated with worse cravings, negative affect, and greater experiences of other withdrawal symptoms in the weeks after quitting, but individual responses varied greatly.41 Although withdrawal can last several weeks or more, prolonged withdrawal states beyond six months do not appear to occur with cigarette cessation.38 Relapse is often related to greater severity of symptoms, greater day-to-day symptom volatility, increases in symptoms over time, and a greater degree of symptom relief associated with re-uptake of smoking.40,42
Urges to smoke/cravings are a core component of withdrawal and a powerful predictor of relapse.3,13,15,32,43,44 Nicotine replacement products can help reduce their severity.3,29,45 Cravings appear to be related to negative affect.31 However, urges to smoke can also be triggered by cues associated with smoking, even, in some cases, months or years after quitting.46-48
Building on earlier observations that smoking and quitting rates are more similar among monozygotic (identical) than dizygotic twins,49 modern research has identified robust genetic influences on nicotine dependence.50,51 Multiple large-scale meta-analyses have supported the relationship between certain genetic variants and smoking heaviness (defined by cigarettes per day) and quitting success/smoking persistence.52-57 Carrying a high-risk genetic variant seems to be an important predictor of how heavily a person will smoke, their level of addiction, and the probability of relapse after attempting to quit.56,58
Genetic influences have been estimated to account for about half of the variance in risk for unsuccessful smoking cessation,59 and along with level of dependence, genetic variants can also influence the effectiveness of pharmacologic cessation therapies—see Section 7.16. Variants in another gene have been shown to affect the rate of nicotine metabolism. Fast metabolisers are less likely to quit smoking,60 this may be because when their nicotine levels drop rapidly, they experience more cravings.61 Studies indicate that individuals with slow nicotine metabolism are more likely to quit smoking using NRT patches than those with fast or normal nicotine metabolism.62 One study also found that varenicline was more effective compared to NRT patches among normal/fast metabolisers.63 Taken together, these findings have prompted suggestions that developing personalised smoking cessation interventions based on a person’s genetic risk factors could lead to greater success in smoking cessation interventions.61,62,64
A cohort study of people who smoke in the UK found that attributing smoking to genetic factors is associated with lower levels of perceived control over smoking but not lower quit rates, suggesting that learning of one's genetic predisposition to smoking as part of a personalised smoking cessation intervention may not deter quitting.65
Research indicates that previous attempts at quitting, and the recency and duration of quit attempts predicts making another quit attempt.6,17 People who have made recent attempts to quit are more likely to try again, and those whose previous attempts have lasted longer are more likely to successfully stop.6,66-68 Results from a longitudinal study of adults who smoke from Canada, the US, the UK, and Australia (the ITC-4 study) showed that ever having made a quit attempt, especially within the previous year, strongly predicted subsequent quit attempts. The likelihood of subsequent attempts decreased with time since last quit attempt, suggesting that rather than being demoralised by failed attempts, people may instead be motivated to try again. However, findings also showed that the likelihood of achieving sustained abstinence was reduced for people with a failed quit attempt within the last year, and even more so for those with two or more failed attempts.9 Multiple failed attempts can result in cessation fatigue. Another ITC-4 study similarly found that people reporting cessation fatigue were more likely to make a quit attempt, but less likely to sustain abstinence.69 People who repeatedly try to quit, but fail, may therefore need tailored support in order to stay quit.9 Nonetheless, even unsuccessful quit attempts can be beneficial; people who relapse are more likely to reduce consumption compared to those not making a quit attempt,70 which can be a useful step toward complete cessation.71 Many Australians who successfully quit smoking also report that insights gained from past quit attempts contributed to their eventual success.72
Self-efficacy is the belief or confidence that one has the capacity to perform a behaviour, and that the action will achieve its desired outcome. Self-efficacy is an important tenet of social cognitive theory (see Section 7.3), and is often thought to underpin motivation and to be a requirement for behaviour change, along with having actual skills, knowledge and opportunity.73,74 According to the theory, behaviour change comprises a number of phases, each affected by self-efficacy beliefs.74 In the context of smoking cessation, these can include considering quitting, motivation to stop smoking, persevering with the change, being vulnerable to relapse, recovering after a setback, and adjusting to and maintaining a non-smoking lifestyle. One study has shown that self-efficacy judgements and expectations are predicted by a person’s smoking behaviour and quitting history.75
In general, high self-efficacy is a predictor of success at smoking cessation in the short to medium term.13,76-78 Self-efficacy is reinforced by success,73 but tends to decrease following relapse.79 Self-efficacy may therefore reflect recent smoking behaviour change rather than solely cause it.80 Evidence suggests that drops in self-efficacy are associated with progression from one lapse to the next.81 Some additional factors can also affect a person’s self-efficacy; in one study, self-efficacy for quitting tended to be lower in people from low socio-economic backgrounds,82 while in another, people who were experiencing pain had reduced self-efficacy for future smoking abstinence.83 One ITC-4 study also found that quit efficacy was associated with abstinence only among older people (aged 40 or older).35
There is some evidence that self-efficacy may be less influential than previously thought, and that its importance may have been overestimated by failing to appropriately control for smoking behaviour at the time of self-efficacy assessment.84 The predictive power of people’s self-efficacy beliefs may be limited by their limited understanding of the challenges associated with quitting, or influenced by the phase of change they are in at the time of measuring self-efficacy. For example, if a person bases their self-efficacy beliefs on his or her confidence at resisting temptations to smoke immediately after quitting, but does not consider the need to adjust to a non-smoking lifestyle in the longer term, then self-efficacy may not have as much value for predicting long-term success.76,85-87 Further, self-efficacy beliefs based on past quitting experience may be better informed than pre-quitting expectations.77 Nonetheless, a number of studies have affirmed self-efficacy as an important predictor of quitting behaviours and maintaining abstinence.88-91
Impulsivity and sensation seeking are related, individual differences that have been linked to risky behaviour, including smoking.92 Sensation seeking refers to a person’s tendency to seek out and engage in thrilling activities, while impulsivity is a person’s tendency to act in haste, without sufficient reflection or restraint.93 Several studies have found that people with higher sensation seeking and/or impulsivity scores are less likely to succeed in quitting smoking.94-100 Several studies using data from the ITC-4 study found that the related construct of time perspective is also an important determinant of smoking cessation; people with a stronger future orientation at baseline (i.e., a tendency to consider future outcomes, and value them more highly than more immediate happenings) were more likely to have tried to quit at follow-up.92,99,101 People with stronger future orientation were also more likely to have quit at follow-up and this relationship was largely explained by an greater tendency to try to quit among future-oriented people.92 However future-orientated people were more likely to relapse after making a quit attempt. This relationship appeared to be moderated by financial stress, with greater future-orientation increasing the likelihood of successful quitting among people who were financially distressed, but reducing the likelihood of abstinence among people who were not financially distressed.99
In an attempt to better understand the mechanisms underlying these relationships, one study found that higher sensation seeking predicted lower compliance with NRT and cessation strategies, which in turn reduced the odds of abstinence.94 Researchers have theorised that people high in sensation seeking may be less able to engage in non-automatic planned strategies (such as making plans for high risk situations, thinking about the benefits of quitting, or avoiding situations that could trigger smoking) that would help them to avoid relapse. They suggest that people high in sensation seeking might therefore benefit from behavioural rehearsal of cessation strategies and emphasis on compliance, in order to alleviate the effects of strategic processing deficits among such people.94 Similarly, results from the ITC-4 study suggest that encouraging people who smoke to adopt a future-oriented time perspective, and emphasising the importance of maintaining engagement in the quit cycle by making repeated cessation attempts over time, may be useful components of a tailored intervention.92
Fear of weight gain is a significant factor in discouraging quitting and provoking relapse.5,102-110 Researchers that developed a specific measure of smoking-related weight concerns found that four factors—smoking to suppress appetite, smoking to prevent overeating, smoking to cope with body dissatisfaction, and withdrawal-related appetite increases—predicted smoking frequency, eating pathology, and body image concerns.111 Some evidence suggests that weight gain after quitting is of greater concern to younger women.112 Concerns about weight when trying to quit is associated with higher body mass index, intention to quit, more previous quit attempts, and less support for quitting.113 Such concerns can also attenuate the effectiveness of tobacco control policies—including cigarette price increases, smokefree laws, or anti-tobacco messaging—on quit attempts.114
Negative affect is a core component of withdrawal, and an important predictor of craving,31,115 urge to smoke, and relapse.32,116,117 Compared to sustained quitters, those who relapse are more likely to report symptoms of emotional distress24 and negative mood.14 There is evidence that smoking may decrease happiness and stopping may increase it.118 Research also suggests that anhedonia (an affective dimension related to the inability to experience pleasure) is associated with poor smoking cessation outcomes.119 For those who have quit smoking, positive experiences—such as the capacity to enjoy life’s simple pleasures, ability to calm down when stressed or upset, and ability to control negative emotions—increase over time.12
People who smoke frequently perceive smoking to be a way of managing stress. However, individual’s understanding of how smoking relates to stress can vary.120 Smoking is commonly perceived to promote relaxation, calmness or ease.3,120 It is sometimes used as a distraction from problems, or in an attempt to convey to others that the person is under stress.120
Negative affect is the tendency to experience more negative emotions, such as anger, sadness, nervousness, rejection, and guilt.121 Findings on the relationship between negative affect, stress and smoking have been mixed and suggest a complex association.122,123 People who smoke report more stress and negative affect relative to non-smokers.122,124-127 In Australia in 2022-23, people who smoke daily were twice as likely to have high/very high levels of psychological distress compared with people who had never smoked and were also twice as likely to have been diagnosed or treated for a mental health condition.128 It is possible that smoking itself, withdrawal symptoms, or a combination of the two create higher stress levels among people who smoke.122
Researchers have tried to determine whether nicotine genuinely improves mood or merely relieves withdrawal symptoms. The strongest evidence suggests that the interplay between stress, negative affect, and smoking can be explained by withdrawal escape (i.e., the relief of withdrawal symptoms).122 The daily mood changes of people who smoke show a normal pattern during smoking, but a worsening mood pattern between cigarettes.3,129 Withdrawal symptoms include irritability, anger, frustration, anxiety and depressive symptoms,38,130 which are generally experienced within two hours of last smoking,41,123,131 and are relieved by smoking. After repeated experiences of alleviating these withdrawal mood symptoms, negative affect may become a cue for smoking even when it occurs independently of nicotine withdrawal.122
Despite people commonly citing relief from negative affect as a motive for smoking, real-time studies have found little correlation between affect and smoking behaviour during regular smoking.40 However, during smoking cessation there appears a strong connection between stress, negative affect and lapses to smoking, particularly first lapses.12,40,122 This relationship may be partly explained by coping self-efficacy, with a study finding that people who perceived that their ability to cope with stress had worsened since quitting were more likely to relapse.132 Another study found that negative affect and concentration difficulty during early withdrawal, most notably anxiety, predicted poorer quit attempt outcomes.133 Conversely, people with a positive outlook are more likely to succeed in quitting and have less desire to smoke again.126 Further, lapses appear to mostly result in increases in negative affect, particularly guilt and discouragement and a decrease in self-efficacy.122,125 One study found that compared with people who relapsed, people who remained abstinent reported lower withdrawal symptoms, craving, and negative affect.134 Evidence also suggests that people with more financial stress are less likely to quit135 and more likely to relapse.136,137 Individuals who are high in personality traits such as hostility and anger also seem to experience greater negative affect and severe symptoms during quit attempts.138-140
Quitting generally results in lower stress and negative affect over time. Although people usually experience an increase in stress and negative affect in the weeks after they quit, these symptoms eventually diminish to levels lower than when they smoked.3,122,141
Smoking and depression often co-occur. Compared to non-smokers, people who smoke report more depressive symptoms, more frequent and severe episodes of depression and higher rates of suicidal ideation and suicide.142
Having a history of depression, in itself, does not seem to substantially jeopardise successful quitting.143-145 However, depressive symptoms may increase the likelihood of relapse.146,147
Studies have consistently shown that high anxiety sensitivity (i.e., fear of anxiety-related sensations) plays an important role in smoking maintenance and cessation failure. People who smoke with high anxiety sensitivity are more likely to perceive and experience smoking as effective in reducing negative affect148,149 and anxiety.150 Such people also perceive quitting as more difficult compared with those low in anxiety sensitivity,151 experience more intense withdrawal symptoms,152 and have greater odds of early smoking lapse153 and relapse.154 A 2014 experimental study found that anxiety sensitivity amplified the effects of acute abstinence on nicotine withdrawal symptoms and smoking urges, which may help explain the greater likelihood of relapse among people who score highly on this measure.155 See Section 9A.3 for further information.
Many Australians who have quit smoking attribute their success to being ‘serious’ about quitting. Threats to personal identity or existential concerns, such as a desire to be a good parent or confronting potential consequences of smoking such as death, illness or disability, often contributed to becoming ‘serious’ about quitting.72 See Section 7.4 for further information on what motivates people to quit. Motivation to quit appears to predict quit attempts, but findings regarding its effect on sustained abstinence are inconsistent.8,156-158 A study using data from the ITC-4 survey found that motivation and plans to quit were positively associated with abstinence among younger people, though the inverse relationship was found among older people, among whom motivation and plans to quit were negatively associated with abstinence.22,159
The evidence as to whether alcohol consumption affects relapse is mixed. A study of NRT cessation program participants found heavy, hazardous drinking was associated with lower odds of successful quitting. While, an ITC-4 study found that in the first year of abstinence, those who drank moderately or heavily had lower relapse risk compared to never or low-level drinkers. However, after a year of abstinence their risk of relapse was higher.160 See Section 9A.3.5.5 for more information on substance use disorders and cessation
External factors that increase the difficulty of staying quit include environmental ‘cues’ to smoke. Cue reactivity, which refers to peoples’ heightened physiological and subjective reactions to smoking-related stimuli, is increasingly being studied in relation to cessation.161,162,163-165 The roles of cue reactivity, social factors, and tobacco advertising and promotion in promoting cravings and underminin
A person’s environment plays an important role in his or her likelihood of achieving abstinence from smoking.166 Many Australians who quit smoking report that timing and circumstances, such as changes to social circles, workplaces or legislative changes, contributed to their success in quitting.72
People whose social contexts include a greater number of people who smoke may be exposed to more positive norms toward smoking and more cues to smoke,167 which can make quitting more difficult.30 The smell of other people’s smoke can cause a general urge to smoke, which relates to relapse.168 An ITC-4 study found that quitters whose closest friends smoked or who gained friends that smoked while quit were nearly 5 times more likely to relapse.169 Conversely, people who lose smoking friends over time are more likely to intend to quit, attempt to quit, and succeed in their quit attempts.167 While quitting is associated with less contact with people who smoke over time, overall it appears to widen a person’s social circle, rather than narrow it.170
People often report that receiving support from close others was an integral part of achieving successful cessation.171 Among a sample of women who smoke in the US, increased social support appeared to act as a buffer from the harmful effects of cessation-related withdrawal symptoms, which in turn improved cessation outcomes.172
The smoking status of a person’s partner can substantially influence smoking persistence and behaviour change,173,174 with partners of people who currently smoke being significantly less likely to quit and more likely to relapse than those with non-smoking partners.175-177 People who smoke tend to be less supportive than non-smokers of their partner’s quit attempt.178 Living in a smokefree home, where friends and family members do not smoke, also increases the likelihood of successful quitting.179
A person’s working environment can also affect their desire to quit or success in quitting. Working long hours can increase the chances that people will relapse, reduce the chances that people will quit, and increase cigarette consumption among people who regularly smoke, particularly for people who usually work very long hours (50 or more hours a week).180 Being unemployed, or having an unemployed partner, also predict greater odds of smoking.181 A Japanese study found that people who work remotely were more likely to be tobacco dependent.182
A robust body of research shows that people who smoke experience increases in self-reported craving, and moderate changes in autonomic reactivity (e.g., heart rate, skin conductance, blood pressure) when they are exposed to smoking-related stimuli, which is known as cue reactivity.184 Cues commonly include environmental stimuli such as cigarettes, matches, ashtrays, the smell of smoke, seeing another person smoking or alcohol, but can also include feelings such as stress or negative affect.185,186 One study found that people who smoke also have an attentional bias for smoking cues in movies, such as seeing actors smoke or showing an ashtray on screen.187 Point-of-purchase cigarette displays act as cues to smoke, even among those not explicitly intending to buy cigarettes and those trying to avoid smoking.188 People who smoke can also experience cravings in response to environments where cigarette cues are not present, but normally are (such as in convenience stores, even when no smoking-related stimuli is visible).189 Cue-induced cravings in turn predict smoking behaviours, such as lapses in quit attempts, shorter latency to smoke, as well as increased number of puffs and puff volume.190,191 This reactivity occurs similarly among men and women,192 and among intermittent, daily,193 and nondependent people who smoke.194
Environmental cues, such as embarrassment, cost of cigarettes, and messages in the media, can prompt quit attempts.195 People who formerly smoked often intentionally avoid smoking cues, which can help them maintain abstinence.196 There are a number of promising cessation interventions that are informed by cue reactivity research, such as training people who smoke to preferentially attend to non-smoking related cues,197 and using behavioural techniques to extinguish the learned responses between smoking-related stimuli and cravings.198
Exposure to tobacco advertising can reduce motivation to quit among people who smoke and increase likelihood of relapse among people who formerly smoked. (See Chapter 11, Section 11.1.) For example, displays of tobacco products at the point-of-sale (now banned in Australia) can create temptation and lead to impulse purchases, increase a person’s chances of relapse,199-202 and make quitting more difficult.200 (See Chapter 11, Section 11.9). AnITC-4 study shows that implementing POS tobacco display bans does result in lower exposure to tobacco marketing and less frequent impulse purchasing of cigarettes.203
The global pandemic of coronavirus disease 2019 (COVID-19) created unprecedented social and economic disruption globally, as lockdowns, isolation, social distancing measures and closures of schools, workplaces and other venues were imposed to stop the spread of COVID-19.204 Evidence suggests that the COVID-19 pandemic had mixed effects on smoking behaviour, with meta-analyses and reviews finding evidence of increased smoking, decreased smoking, and increased intention and attempts to quit.205-208 The COVID-19 pandemic led to an increase in mental health conditions, particularly depression and anxiety, as well as greater stress, frustration and loneliness,209,210 which are known to share a strong relationship with smoking (see Section 9A.3). Studies indicated that these psychological impacts and COVID-19 pandemic-specific stress and anxiety were associated with increased smoking.211-214 Note that many studies from this period are at a high risk of bias due to the use of non-representative samples, non-response bias and use of non-validated questions due to the restrictions of the pandemic, therefore findings should be interpreted with caution.207 Section 3.9.12 details the research on the relationship between smoking and COVID-19 risk.
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