7.9 Increasing smoking cessation at the population level

Last updated: August 2022

Suggested citation: Greenhalgh, EM., Stillman, S., & Ford, C. 7.9 Increasing smoking cessation at the population level. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2022. Available from http://www.tobaccoinaustralia.org.au/7-9-policy-measures-associated-with-quitting

 

To increase the proportion of ever smokers who have quit requires a combination of increasing the number of smokers who attempt to quit, increasing the success rates among those who do make attempts and encouraging further attempts even among those who have tried and failed before.

7.9.1 Strengthening of comprehensive tobacco control policy

Expert scientific bodies have concluded that increasing smoking cessation at the population level requires a comprehensive approach to tobacco control.1-4 The implementation of multi-faceted tobacco control programs has led to reductions in smoking prevalence both in Australia5 and internationally.6-8 Comprehensive tobacco control policies can also increase the use of evidence-based cessation support.9 , 10 Maintaining the high proportions of smokers attempting to quit is likely to require:

  • reducing the affordability of tobacco products
  • evidence-based mass media campaigns at sufficient intensity and duration
  • expansion of smokefree public environments
  • extension of bans on tobacco advertising and promotion
  • inclusion of prominent health warnings on packs and efforts to ensure the warnings remain salient and
  • ensuring that smokers receive advice and support to quit in all healthcare settings and other public institutions such as prisons
  • making evidence-based cessation support readily available and affordable and promoting its use to smokers

All of these interventions are likely not just to prompt quit attempts among current smokers, but also to prevent relapse among ex-smokers.

7.9.2 Increasing the provision and uptake of smoking cessation treatment

Evidence-based smoking cessation treatments are underutilised. Increasing smokers’ knowledge of and access to such treatments can in turn increase demand for them.11 Many smokers are unaware of the full range of strategies that can help them to quit, and many use non-evidence-based approaches.12 A consumer-centred approach to increasing the use of cessation aids involves understanding and addressing smokers’ needs and concerns and communicating effectively with them about the nature and value of treatments.13 For example, a study in the UK found that presenting information about the effectiveness of the National Health Service (NHS) stop smoking service improved service attendance.14 Addressing smokers’ expectations about the effectiveness and desirability of cessation medications may also increase the likelihood that they will use them.15 A 2012 Cochrane review considered ways in which more smokers might be encouraged to enter smoking cessation programs. It concluded that that increasing contact time with potential participants may be an important strategy, along with tailored and proactive strategies.16 Providing cessation interventions to smokers who don’t feel ready to quit can also be an effective strategy for increasing smoking cessation.17

An integrated, comprehensive systems approach to cessation treatment and policy may help improve population quit rates.18 Australia currently has no national strategy for tobacco dependence treatment, and many opportunities to provide cessation advice and treatment are missed.19 Such a strategy could include:18-23

  • expanding cessation treatment coverage and provider reimbursement
  • mandating adequate funding for the use and promotion of evidence-based, state-sponsored quitlines
  • supporting healthcare system changes to embed tobacco treatment as part of routine care
  • increasing smokers’ knowledge of the availability and effectiveness of evidence-based cessation support
  • tailoring and targeting cessation support to best meet the needs of priority and disadvantaged populations (see InDepth 9A).

One study from the US that modelled the potential impact of smoking cessation treatment policies on adult quit rates estimated that implementing any policy in isolation could increase quit rates from a baseline rate of 4.3% to between 4.5% and 6%. By implementing policies in combination, the quit rate would increase to 10.9%.20

One way to increase the use of smoking cessation treatment may be to provide greater financial support through healthcare systems to people who want treatment for their tobacco addiction.24 Higher out-of-pocket expense has been associated with a lower probability of a smoker using any smoking cessation medication,25 , 26 and vice versa.27-29 Providing access to subsidised pharmacotherapy can increase usage and increase the proportion of quit attempts that are successful.30 , 31 A 2017 Cochrane review concluded that covering smokers’ costs of cessation treatment increased the proportion of smokers attempting to quit, using smoking cessation treatments, and succeeding in quitting, when compared to providing no financial benefits.32  Providing free cessation medications can also increase treatment adherence, which increases the odds of a successful quit attempt.33 People from low socioeconomic backgrounds have substantially higher smoking rates (see Section 9.1), and may particularly benefit from free or subsided cessation treatments.34-36  

7.9.2.1 Availability and cost of nicotine replacement therapy (NRT)

Since February 2011, Australian smokers have been able to access a 12-week supply of subsidised nicotine replacement therapy under the Pharmaceutical Benefits Scheme (PBS) as long as they have a medical prescription.37 In line with best-practice cessation support, a condition for the subsidy is that the smoker participates in cessation counselling. Although this requirement may reduce use of cessation medications,38 ‘real-world’ studies have highlighted the importance of combining pharmacotherapies with behavioural support, to increase their odds of successful cessation. Smokers who use NRT with no behavioural support appear no more likely to successfully quit than those who do so unassisted.39-41

Subsidy of NRT was associated with a substantial increase in use in Australia, particularly among concessional patients—see Sections 7.16 and 9.9. UK research found that while making pharmacotherapies for cessation reimbursable did not increase the proportion of smokers who tried to quit, the policy increased the proportion of quit attempts that were aided by medication.42 There is evidence from the US that adding free NRT to a smoking cessation program may increase numbers in the program and short-term quit rates, but not sustained abstinence.43 Research in Canada examining the effectiveness of mass distribution of nicotine patches found that odds of cessation at six months were significantly greater among groups receiving nicotine patches compared to those who did not,44 though research in the US found that providing free nicotine patches by mail to a proactively recruited sample of smokers did not lead to increases in tobacco cessation five years later.45

7.9.2.2 Subsidy of other prescribed quit-smoking medicines

As with distribution of low-cost NRT, making prescribed pharmacotherapies more affordable for smokers appears to increase their use. Evidence from the UK shows that making prescription smoking cessation medicines reimbursable leads to greater use.42 Similarly, Australian research has found that reported use of prescription medication to quit smoking rose sharply with the addition of varenicline to the PBS in 200846 —see Section 7.16.

7.9.3 Increasing the number and success of quit attempts

Success rates among those attempting to quit are relatively low. A longitudinal study of smokers from Canada, the US, the UK, and Australia (the ITC-4 study) found that among those who reported at least one quit attempt within the past year, about half lasted a week or less on their most recent attempt, and only about one-fifth successfully abstained for more than a month.47 Most smokers attempt to quit on their own even when effective support is available (see Section 7.6.3). Building smokers’ knowledge about and skills in quitting may play an important role in increasing successful cessation. Smokers are often unaware of and underestimate the benefits of available cessation assistance.48-50 While the large number of smokers who have quit unassisted has undoubtedly played a major role in the reduction in smoking prevalence,51 evidence-based cessation support can increase the likelihood of a quit attempt being successful.52

To increase successful cessation at a population level it is important to understand which cessation methods are most often used by smokers, and which are most helpful.53 In 2019, among Australian adult smokers who had tried to quit in the previous year, going cold turkey was the most popular approach (35%), followed by NRT (23%), asking their doctor for help (14%), e-cigarettes (12%), cessation medications (10%), a mobile phone app (9%), and contacting the Quitline (3%).54 Earlier Australian research found that going cold turkey, NRT, and gradual cigarette reduction before quitting are strategies commonly used by smokers and are perceived as being very helpful, while receiving advice from health professionals, although common, is perceived as less helpful. Although the number of prescriptions filled is very high (see Section 7.16), surveys suggest that prescribed medication has low use but high perceived helpfulness.53

A key consideration among public health experts is whether it is more beneficial to focus on increasing success rates among smokers who have quit (i.e., preventing relapse) or whether it would be more useful to try and increase the number of smokers who make quit attempts. There is some evidence that shifting the focus from the quality of smokers’ quit attempts to the quantity of those attempts produces greater overall benefits.55 Data from California indicated that smokers on average tried 12 to 14 times before quitting for good: 12 if they used cessation aids, and 14 if they did not.56 More recent research suggests that some smokers may make 30 or more attempts to quit before being successful.57 While the use of best-practice cessation support (i.e., pharmacotherapy combined with behavioural counselling) can increase the odds of a quit attempt being successful,52 given most people who smoke will need to make multiple attempts, an important part of increasing the proportion of ever-smokers who have quit appears to be encouraging smokers to try again if they relapse.56 , 58 Even after an unsuccessful attempt, smokers remain motivated to quit.59

For a discussion of the effectiveness of quitting strategies used by smokers, see Section 7.6. Sections 7.14–7.16 discuss the effectiveness of behavioural interventions and pharmacotherapies.

7.9.3.1 Intensity of intervention

An important consideration in implementing cessation interventions is their structure or level of intensity, including the duration of each contact/session, total amount of contact time, and number of person-to-person sessions.  Cessation rates tend to increase with extended contacts and with the number of treatment formats (different types of counselling and educational interventions).1 , 60 Low intensity interventions typically offered in Australia include brief advice from a doctor or other health professional. Examples of high intensity interventions include multi-session behavioural counselling such as that provided by Quitline, a face-to-face counsellor or health professional,  or group therapy. The effectiveness of all levels of behavioural interventions is improved by concurrent use of cessation medications.61 , 62  

Smokers who undergo more intense interventions generally have a greater likelihood of achieving successful cessation.61 Lower SES smokers in particular are often more addicted and may therefore be more likely to need more intensive support to quit successfully.63 However, higher intensity interventions are usually more costly (to the individual, government or other funders) and less likely to be available or attractive to all smokers. There are also interventions (such as motivational interviewing) that appear to be more effective when they are less intense.64 The relative costs and benefits of each intervention is therefore an important consideration to individuals and policy makers.   

7.9.4 National policy to promote and support cessation

The draft National Tobacco Strategy 2022–3065 outlines a comprehensive approach to tobacco control in Australia that included several priority areas and actions specifically for prompting or assisting people to quit:

  • develop, implement and fund mass media campaigns and other communication tools to motivate people who use tobacco to quit
  • continue to reduce the affordability of tobacco products
  • continue and expand efforts and partnerships to reduce tobacco use among Aboriginal and Torres Strait Islander people
  • strengthen efforts to prevent and reduce tobacco use among populations at a higher risk of harm from tobacco use and populations with a high prevalence of tobacco use
  • further regulate the contents and product disclosures pertaining to tobacco products
  • strengthen regulation to reduce the supply, availability and accessibility of tobacco products
  • provide greater access to evidence-based cessation services to support people who use tobacco to quit

Australia’s National Preventative Health Strategy 2021–2030 also named these strategies as key action areas for state and federal tobacco control policies.66

See Section 7.20 for a discussion of national policy and progress in encouraging and supporting cessation in Australia, and Section 8.13 for a discussion of policies for advancing tobacco control programs among Aboriginal and Torres Strait Islander peoples.

 

Relevant news and research

For recent news items and research on this topic, click  here. ( Last updated April 2022)

 

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