Summary of main findings
This study engaged a unique sample of treatment seeking low-SES smokers who had recently embarked on a quit attempt, and obtained their subjective experiences of this attempt. All of the low-SES smokers and ex-smokers participating in this study had previously tried to quit and several factors preventing engagement with current behavioural and pharmacological cessation treatments were identified. Smoking cessation treatments received mixed reactions with most participants reporting undesirable or unhelpful treatment experiences. Overall, participants were receptive and positive about the potential role of technology-based cessation support in the form of text-messages and provided feedback about its acceptability and possible content. There were mixed views on the use of ECs as a potential cessation aid with concerns raised over their safety and efficacy and the legality of their use within Australia. Overall, current treatment approaches were perceived as not well-suited to meet the needs of low-SES smokers. Nonetheless, on a positive note, low-SES smokers and ex-smokers provided insights on alternative treatment strategies, and outlined how these treatment approaches can assist in overcoming some of the barriers affecting treatment.
Main themes
Prior research has investigated the effects of tobacco control policies on smoking prevalence and tobacco consumption [
31‐
33]. However, the current study provides insight into how smokers subjective experiences of these policies affect treatment seeking behaviours. Our findings suggest that there is a complex interplay between the changes in tobacco control policies and reform and how participants perceive their smoking behaviour within the wider social context. The dominant anti-smoking public health discourse in Australia [
2] shapes policies and treatment programmes, and people’s experiences with these policies and programmes shape their identity [
34]. The internalised view that non-smoking is the norm conceptually positions ‘smoking and smokers’ as a negatively constructed group. Further to this, recent tobacco excise increases in Australia has promoted smoking as unaffordable which may further marginalise low-SES smokers [
35]. Consequently, the stigmatisation of being a smoker and the associated feelings of shame, guilt, and failure shaped a relatively negative viewpoint on quitting, and acted as a key barrier to accept or engage with quit support and therefore prevented treatment seeking behaviours. Our findings provide insights that may help to serve policy makers both nationally and internationally when developing and implementing new tobacco control policies.
The experience of stigmatisation highlights the connection between treatment services and the experience of disenfranchisement. Rather than Quitline being viewed as a support service, treatment seeking to this service was likened to admitting failure. Accepting help functioned as a barrier because it reinforced the stigma associated with being a smoker. Participants expressed a desire to be left alone during a quit attempt which could be a reaction to tobacco control policies and societal judgements placed on low-SES smokers. This finding provides insight into why some low-SES smokers are reluctant to call telephone counselling hotlines and do not perceive such services as helpful. This finding may indicate that the current treatment service model could be reoriented to address the feelings of guilt, shame, and the stigmatisation associated with smoking to encourage wider reach and participation. Treatment engagement is disproportionately low among disadvantaged groups [
36,
37] and these study findings may help to re-shape current service models to meet the needs of low-SES smokers.
Increasing quit rates is a key challenge for the wider tobacco control field. To date, smoking cessation randomised controlled trials (RCT) targeting smokers from low-SES populations have found no intervention effect on cessation outcomes [
38‐
40]. While low-SES smokers are willing and motivated to try to quit [
41] the probability of success is low [
6]. Despite the majority of participants in this study being treatment failures, they were still motivated to quit but expressed the need for alternative cessation support options. Technology-based quit support was seen as a potential alternative that could compliment current treatment approaches. Text-messaging has the potential to be easily accessible and less judgemental and is supported by the
WHO Tobacco Free Initiative [
22].
Overall, the function of text-messaging was to provide intensive quit support within the first two-weeks of quitting. Adherence support via text-messaging could also be considered since most participants did not adhere to NRT beyond two-weeks. The importance of personalised and interactive text-messaging was seen as providing your own one-on-one quit buddy which could overcome the stigma and resistance to accept quit support. This study provides preliminary feasibility and acceptability findings of text-messaging quit support for low-SES smokers, which may be applicable to low-SES smokers in similar countries such as the United States and the United Kingdom. Developing interventions within a community-based participatory research framework [
42] is relevant to researchers both nationally and internationally and our findings add to the knowledge base for researchers and policy makers.
Participants expressed a desire for text message content that demonstrated progress e.g. number of days quit or money saved, reinforcement of health benefits from quitting, and increased willpower, and medication reminders. Despite low-SES smokers and ex-smokers expressing a willingness and positive attitude towards the use of text-message support, there is a lack of methodologically rigorous text-message intervention studies aimed at increasing quit rates among disadvantaged groups [
43,
44]. A recent systematic review and meta-analysis examining technology based smoking cessation interventions for disadvantaged smokers found that technology based quit support increased the odds of cessation at 18-months follow-up [
44]. However, of the 13 included studies, only one study used mobile phone text messaging. Based on this systematic review and the current study’s findings, there is a need for future research to develop mobile phone based cessation support for low-SES smokers which may overcome social inequalities, increase treatment engagement and adherence. Further research on the effectiveness of text-message cessation support in combination with or without Quitline support is required for this group.
The proliferation and growing popularity of ECs as a harm-reduction or cessation aid in the US, UK, and New Zealand [
45‐
47] was not reflected among smokers and ex-smokers in this study. This may be an artefact of Australia’s stringent tobacco control policy on ECs, where selling and the distribution of liquid nicotine is illegal [
48]. When faced with purchasing cigarettes or an EC product, participants did not see the advantage in purchasing an illegal device, over legally available tobacco products. The illegality surrounding ECs may foster suspicion around their safety and efficacy and blurs their function as a potential cessation aid. Although Australia’s strong regulatory framework prohibits the sale of EC containing liquid nicotine, ECs may provide an alternative and less harmful nicotine delivery method [
20]. However, while Australian Government policy bans the sale of liquid nicotine vaporising devices, the effectiveness of ECs as a harm reduction or cessation aid among low-SES Australians may not be known.
In contrast to ECs, pharmacotherapy treatments were seen as an essential component to a quit attempt. However, concerns about the cost of treatment and PBS restrictions were factors impacting quit attempts. PBS restrictions delayed participant’s future quit attempts to coincide with their yearly prescription entitlement renewal. Although prior research has identified the cost of NRT as a barrier to treatment [
19], participants considered the cost of NRT and cigarettes to be comparable. However, NRT was unaffordable when they considered the combined cost of cigarettes and NRT in the event they lapsed or relapsed.
Lower rates of cessation among disadvantaged groups have been linked to poor treatment adherence [
4,
49,
50]. Barriers to pharmacotherapy adherence included side-effects, safety concerns, and transferring one addiction for another, and these findings are supported elsewhere [
19,
51]. Although most participants had heard of varenicline only a few had used this product with most expressing a willingness to try it in the future. Overall, pharmacotherapies were viewed positively and participants expressed a willingness to use these products in future quit attempts.
Limitations
This study drew on the experiences of low-SES smokers and ex-smokers who had previously taken part in a smoking cessation trial and most were treatment failures. The method of recruitment limited our sample to treatment seeking individuals who resided in inner-city areas and were low-SES. Smokers from high-SES background were not included in this study and future research should consider whether the key findings from this study are shared by or differ from high-SES smokers. Such studies may be useful to guide the design and potential tailoring of cessation support services for smokers from all SES backgrounds. The perspectives expressed in this study may differ from opinions of smokers or ex-smokers who do not engage with treatment services and have a preference for unassisted methods. The views expressed may also differ among rural and remote smokers and ex-smokers and among other population groups where high smoking rates persist e.g. Indigenous populations, people experiencing homelessness, prisoner populations, and people living with HIV or severe mental illness. Interview methodology is a further limitation of the study. While face-to-face interviews can provide rich sources of data they are costly and can be a source of response bias [
52], however, conducting telephone interviews can also lead to some information being lost due to the inability of the researcher to use visual help [
53]. Future research may wish to analyse the data by interview type to see if patterns in the data differ by focus group and in-depth interview. Since participants were recruited from the previous RCT the researchers were involved in, participants were informed that their feedback will help guide a future quit project to overcome a desirability effect or social acceptability in reporting. Although every effort was made by the researchers to engage participants in a safe and non-judgemental environment, there is a possibility that some participants may have felt judged and modified their views to overcome this.