This section describes strategies for increasing smoking cessation at the population level, including:
Increasing the proportion of people who have successfully quit smoking requires a combination of increasing the number of people who smoke who try to quit, increasing the success rates of quit attempts, and encouraging people who have tried to quit and relapsed to try again.
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 increased cessation activity and reductions in smoking prevalence both in Australia5 and internationally.6-10 An examination of data from a multi-country trial of cessation medications found that participants in countries with a greater degree of tobacco control policy implementation had higher odds of achieving short-term abstinence.11 Comprehensive tobacco control policies can also increase the use of evidence-based cessation support.12,13 Maintaining the high proportions of people who smoke 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
- comprehensive bans on tobacco advertising and promotion
- inclusion of prominent health warnings on packs and efforts to ensure the warnings remain salient and
- ensuring that people who smoke 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 people who smoke
All of these interventions are likely not just to prompt quit attempts among people who smoke, but also to help people who have quit smoking to maintain cessation.
7.9.2 Increasing the provision and uptake of smoking cessation treatment
Evidence-based smoking cessation treatments are underutilised. Increasing knowledge of and access to such treatments can in turn increase demand for them among people who smoke.14 Many people who smoke are unaware of the full range of strategies that can help them to quit, and many use non-evidence-based approaches.15 A consumer-centred approach to increasing the use of cessation aids involves understanding and addressing people’s needs and concerns and communicating effectively with them about the nature and value of treatments.16 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.17 Addressing expectations about the effectiveness and desirability of cessation medications may also increase the likelihood that people who smoke will use them.18 A 2012 Cochrane review considered ways in which more people 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.19 Providing cessation interventions to those who don’t feel ready to quit can also be an effective strategy for increasing smoking cessation.20
An integrated, comprehensive systems approach to cessation treatment and policy may help improve population quit rates.21 Australia currently has no national strategy for tobacco dependence treatment, and many opportunities to provide cessation advice and treatment are missed.22 Such a strategy could include:21-27
- 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 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)
- sustaining and strengthening monitoring and evaluation of smoking prevalence and cessation policies and programs
- promoting ongoing and innovative research to support and accelerate smoking cessation.
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%.23
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.28 Higher out-of-pocket expense has been associated with a lower probability of a person who smokes using any smoking cessation medication,29,30 and vice versa.31-33 Providing access to subsidised pharmacotherapy can increase usage and increase the proportion of quit attempts that are successful.34,35 A 2017 Cochrane review concluded that covering the costs of cessation treatment increased the proportion of people who smoke attempting to quit, using smoking cessation treatments, and succeeding in quitting, when compared to providing no financial benefits.36 Providing free cessation medications can also increase treatment adherence, which increases the odds of a successful quit attempt.37 People from low socioeconomic backgrounds have substantially higher smoking rates (see Section 9.1), and may particularly benefit from free or subsided cessation treatments.38-40
7.9.2.1 Availability and cost of nicotine replacement therapy (NRT)
Since February 2011, Australians who smoke 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.41 In line with best-practice cessation support, a condition for the subsidy is that they participate in cessation counselling. Although this requirement may reduce use of cessation medications,42 ‘real-world’ studies have highlighted the importance of combining pharmacotherapies with behavioural support, to increase their odds of successful cessation. People who smoke who use NRT with no behavioural support appear no more likely to successfully quit than those who do so unassisted.43-45
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 people who smoke who tried to quit, the policy increased the proportion of quit attempts that were aided by medication.46 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,47 though research in the US found that providing free nicotine patches by mail increased short-term but not long-term cessation.48 In Queensland, people who smoke who phone the Quitline are offered 12 weeks of free NRT, which research in the US suggests is an effective strategy, particularly for reducing smoking disparities.49
7.9.2.2 Subsidy of other prescribed quit-smoking medicines
As with distribution of low-cost NRT, making prescribed pharmacotherapies more affordable appears to increase their use. Evidence from the UK shows that making prescription smoking cessation medicines reimbursable leads to greater use.46 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 2008.50 Total use of prescribed medicines by people eligible for a concessional, higher subsidy also rose substantially and overtook numbers of non-concessional prescriptions after addition of NRT to the PBS in 2011—see Section 7.16 and Figure 9.9.2.
7.9.3 Increasing the number and success of quit attempts
Despite most people who smoke wanting to quit (see Section 7.2), 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.51 Most people who smoke attempt to quit on their own even when effective support is available (see Section 7.6.3). Building knowledge about and skills in quitting may play an important role in increasing successful cessation. People who smoke are often unaware of and underestimate the benefits of available cessation assistance.52-54 While the large number of people who have quit unassisted has undoubtedly played a major role in the reduction in smoking prevalence,55 evidence-based cessation support can increase the likelihood of a quit attempt being successful.56
To increase successful cessation at a population level it is important to understand which cessation methods are most often used, and which are most helpful.57 In 2022–23, among Australians who had in the past year smoked and made a quit attempt, going cold turkey was the most popular approach (37%), followed by NRT (22%), e-cigarettes (22%), asking their doctor for help (12%), cessation medications (6%), a mobile phone app (6%), and contacting the Quitline (2%).58 Earlier Australian research found that going cold turkey, NRT, and gradual cigarette reduction before quitting are strategies commonly used by people who smoke 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.57
A key consideration among public health experts is whether it is more beneficial to focus on increasing success rates among people who have quit smoking (i.e., preventing relapse) or whether it would be more useful to try and increase the number of people who smoke who make quit attempts. There is some evidence that shifting the focus from the quality of quit attempts to the quantity of those attempts produces greater overall benefits.59 Data from California indicated that people who smoke on average tried 12 to 14 times before quitting for good: 12 if they used cessation aids, and 14 if they did not.60 More recent research suggests that it can take 30 or more attempts to quit before being successful.61 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,56 given most people who smoke will need to make multiple attempts, an important part of increasing the proportion of people who have quit smoking appears to be encouraging people to try again if they relapse.60,62 Even after an unsuccessful attempt, motivation to quit remains high.63
For a discussion of the effectiveness of quitting strategies used by people who smoke, 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).1,64 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.65,66
People who undergo more intense interventions generally have a greater likelihood of achieving successful smoking cessation.65,67 People who smoke from low socioeconomic groups in particular are often more addicted and may therefore be more likely to need more intensive support to quit successfully.68 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 people who smoke. There are also interventions (such as motivational interviewing) that appear to be more effective when they are less intense.69 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 National Tobacco Strategy 2023–3070 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.71
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.
Appendix 2 provides an overview of forward-looking or ‘endgame’ strategies that aim to drastically and rapidly reduce smoking prevalence, both through preventing uptake and through promoting and supporting smoking cessation.
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References
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