Use and perceived helpfulness of smoking cessation methods: results from a population survey of recent quitters

Cigarette smoking remains the leading preventable cause of death and disease in the developed world [1, 2], and increasing the number of smokers successfully quitting is one of the most effective measures available to improve population health. Cessation activity among smokers is relatively common; more than 40% of current U.S. smokers report having made a serious attempt to quit in the past 12 months [3] and in the Australian state of New South Wales (NSW) less than 20% of smokers have never tried to quit [4]. However, only about 3% - 5% of smokers maintain abstinence up to one year after quitting [5]. To advance the goal of increasing successful cessation at the population level, it is imperative that we understand how smokers quit, one aspect of which is the use and helpfulness of various cessation methods and aids.

Over the last decade, numerous studies have documented the proportion of smokers using various cessation methods. In the U.S., it is estimated that around one quarter of smokers use pharmacologic treatments such as nicotine replacement therapy (NRT) and bupropion when attempting to quit [3, 6, 7]. The use of behavioural treatments is estimated to be under 8% [3, 7]. Among behavioural treatments, self-help material is the most commonly used, but others include individual, group and telephone counselling [3]. In NSW, the most common aid used in quit attempts is NRT (approximately 33%), followed by bupropion (13.2%), with very small proportions of smokers reporting that they used behavioural aids such as telephone helplines [4, 8]. Despite the increasing availability and marketing of pharmacological and behavioural interventions, population studies consistently show that the largest proportion of smokers who permanently quit smoking do so without any form of assistance [3, 6, 8‐12]. That is, the most common method used by people who have successfully stopped smoking remains unassisted cessation (cold turkey or reducing before quitting).

When evaluating cessation methods, it is important to consider not just how often a cessation method is used, but also how helpful it is achieving smoking abstinence. Research investigating the effectiveness of various cessation methods and aids has fallen primarily into two categories - randomized controlled trials and retrospective population surveys. Controlled trials have generally demonstrated the efficacy of behavioural and pharmacological cessation interventions [13]. However, there has been a divergence between the findings from these trials and the results of retrospective population surveys in which smokers who report using behavioural or pharmacologic treatment are less likely to be successful in quitting [3, 8, 11, 14]. Only one recent survey has indicated greater quitting success in individuals who sought assistance than those not seeking assistance [6]. Some researchers have suggested that the inconsistency between the controlled studies and population surveys may be due to selection bias, with heavier or more addicted smokers being more likely to use cessation programs [3, 6, 7, 11], and also being the most likely to relapse [15].

In the current study, using reports from recent quitters, we take into account both the reported use and perceived helpfulness of different cessation methods. In doing so, we can identify methods which have high impact - those which are used frequently and rated as helpful - as well as those which are rated as helpful, but used less frequently. The latter category could be a target for increased promotion. Conversely, identifying methods which have a low helpfulness rating could inform policy decisions and research priorities. We explore differences in use and perceived helpfulness of cessation methods by quitters who vary by socio-demographic characteristics, as well as by length of abstinence.

Throughout the study period (2007-2009), a range of quitting methods was available to smokers in Australia. A free national telephone cessation helpline (the Quitline) exists and is advertised on all cigarette packets and in media campaigns. NRT has been available over-the-counter since 1997. Bupropion (Zyban^®) has been available since 2000 by prescription (with government subsidy since early 2001) and prescribed varenicline (Champix^®) has been available with subsidy since January 2008. Additionally, a number of community-outreach groups provide counselling and support, and web-based support is increasingly available.

Consistent with a growing body of literature documenting that the majority of ex-smokers successfully quit without assistance, in the current study, more than two-thirds of recent quitters reported that they had used the cold turkey method to help them quit. Because this study did not explicitly ask about cessation methods used in their last quit attempt, we cannot claim that these smokers finally quit successfully using cold turkey. Nonetheless, our measure of perceived helpfulness for each of the methods provides a good indication that not only is cold turkey used by a large proportion of smokers in quitting and attempting to quit, it is also perceived as being more helpful than any other method. Research shows that smokers often make more than one attempt to quit smoking [22, 23], potentially using a variety of methods either at the same time or over the course of many quit attempts [4]. In this case, the measure of perceived helpfulness is particularly useful, as it allows quitters to make a distinction between the methods that have helped them and those which have not.

Pharmacological aids such as NRT and prescribed medication were also considered helpful by most of the recent quitters who used them. However, NRT was used by less than one third of recent quitters, and prescribed medications less than that. This level of use, despite widespread promotional activity, is consistent with evidence suggesting that, as a population-based strategy, pharmacological aids are unlikely to have as great an impact on lowering smoking prevalence rates as cold turkey [24, 25].

From the quadrant analysis, it was apparent that GP advice, though used relatively frequently, was rated as just below the average level of helpfulness. In 2009, 40% of a sample of NSW smokers had discussed their smoking on their last GP visit, and even more (63%) were open to seeking advice from their doctor [4]. In combination, these findings confirm that physicians' perceptions of patients' disinterest in quitting [26] should not be a barrier to their engagement in cessation assistance.

From our analysis of individual characteristics associated with use of the various cessation methods, we can develop profile of quitters who used assisted method of quitting. We found that older quitters were more likely to have used GP advice or prescribed medication than younger quitters; less educated quitters were more likely to have used GP advice or prescribed medication than more educated; and individuals who had been quit for less than six months were more likely to have used NRT than those who had been quit for longer. Conversely, the quitters who reported quitting cold turkey were either younger, had been quit for longer, or were of moderate-high SES. Consistent with previous research [3, 6, 7, 11], these findings suggest that more heavily addicted smokers (based quit duration and age) are more likely to use assistance in quitting, while less addicted smokers are more likely to quit cold turkey. These quitting profiles have implications for targeted promotion of assisted cessation services and products.

Emerging research has suggested that internet-based cessation programs might be effective [27], and this is supported by the relatively high perceived helpfulness of online programs in the current study. However, the overall use of online programs was low. In a recent study, only 24% of 'quit smoking' searches ended at a professional smoking cessation website, with many searches ending at alternative therapy sites [28], perhaps indicating a paucity of accessible and effective programs. Though the numbers of younger quitters who used online programs in the current study were small, those who did were more likely than older individuals to report that they were helpful. Future research might explore ways to increase young smokers' engagement with effective online support.

This study, along with others [29‐31], shows a very low utilisation rate of telephone cessation helplines. In 2009, 81% of ex-smokers and smokers who had tried to quit in NSW were aware of the Quitline but had never called it [4], suggesting that factors other than awareness might influence use of this service. The low use and perceived helpfulness of the Quitline among NSW quitters suggests that, in its current form, this mode of service may not be an effective population-level strategy for lowering smoking prevalence. Future research might explore how to increase the helpfulness of the service through integration with online support and whether the service may be best promoted to certain subgroups of smokers. The results of this study are also in accordance with accumulating evidence that some cessation aids - such as self-help materials [32] and natural therapies [33] - have only marginal helpfulness. Interestingly, of the 105 individuals in this study who reported that 'something else' helped them quit, about 40% of their responses related to advice, support or urging from family and friends. Other researchers have noted this [3], and it supports recent research indicating that conversations with family and friends might play an important role in the quitting process, and that anti-smoking media campaigns might be helpful in stimulating these kinds of conversations[34, 35].

Strengths of this study are the relatively large sample of recent quitters and the breadth of cessation methods included. However, it relied on retrospective recall of cessation methods, with the possibility that memories of quitting could have become distorted over time. We found an association between duration of quitting and use of cold turkey methods. There are several potential explanations for this. The first is that individuals who have more durable cessation are more likely to have used cold turkey methods, perhaps because they smoked occasionally and did not need more intensive cessation assistance. An alternative explanation is that the longer the duration of cessation, the more likely it is that individuals forget about other methods which may have been helpful such as NRT and instead recall their personal efforts. However, we prompted respondents with each of the different cessation methods in an effort to capture all methods used, rather than simply 'top-of-mind' recall. Our analyses indicated no association between perceived helpfulness of each reported cessation method and duration of quitting. The somewhat low response rate of this survey may have led to some unknown bias, though this rate is comparable with other population surveys which use similarly conservative estimates both in Australia [36] and the U.S. [37]. Further, the rates of use of the various cessation methods in this study were similar to that in other surveys of NSW smokers [4, 8], suggesting that the sample is representative in this respect. We also note that the survey did not include questions about adherence to any treatment guidelines, details about prior cigarette consumption or quitting history.

Current U.S. Clinical Practice Guidelines recommend that all smokers be advised to use medication and behavioural treatment in quitting [23]. Chapman and Mackenzie raise a potential negative consequence of all smokers being imbued with the message that serious cessation efforts require treatment: they might become disempowered and inhibited in their quit attempts through self-defeating fatalism [25]. Our study confirms that many smokers quit without pharmacological or other interventions and that methods such as quitting cold turkey or gradual reduction are as likely to be rated as helpful as assisted cessation methods. This finding highlights the opportunity for presenting this empowering message to smokers who are ready to try to quit. At the same time, we acknowledge the importance of providing effective support to smokers who need it particularly more heavily nicotine dependent individuals. In addition, population-level strategies such as smoke-free environments [38], graphic pack warnings [39], increased cigarette prices [24], and well funded and effective media campaigns [7, 24], must continue to be emphasised, as they are important sources of motivation and support for smokers - particularly young adults - who make less use of conventional forms of quitting assistance.

This work was not supported by any funding.