Smokers' preferences for how to quit: the importance of promoting both assisted and unassisted cessation.

In their article in The Lancet Regional Health – Western Pacific, Joanne Dono and colleagues report the long-term trends in Australian smokers’ quit attempt methods (i.e. using nicotine replacement therapy (NRT) or prescription medication, asking doctor for help or advice, using telephone counselling services, using app or text messaging services, or quitting unassisted) across 20 years. This is an important and under-reported area of research directly relevant to tobacco control policy and public health in Australia and internationally.

The 20-year study period provides us with vital insights into quitting activity across demographic groups over time. It also helps us to understand how polices such as the introduction of government-subsidised smoking cessation pharmacotherapies (i.e. NRT and prescription medications) have impacted on the amount of quitting activity and the methods used by smokers to quit. The authors document three important patterns relating to quitting that are directly relevant to clinicians, policymakers and researchers.

First, the authors report that although socio-economic disadvantage and mental health conditions are more likely among smokers, there were no differences in quit attempts by these characteristics. Smokers from lower socio-economic groups and smokers who report a mental health condition were as likely to attempt to quit as more socially advantaged smokers or smokers who did not report a mental health condition. These are important findings. The comparable levels of quit attempts across these demographic groups challenges the validity of the ‘hardening hypothesis’, which proposes that over time we will be left with a hard-core group of smokers who are less interested in or capable of quitting than previous generations of smokers. The hardening hypothesis is often posited by those supportive of harm-reduction strategies, such as e-cigarettes and heated tobacco products. We can be further reassured that quitting remains important to all smokers regardless of socio-economic or mental health status.

Second, the authors report that despite the increased availability of assisted means of cessation, unassisted quitting remains the most common means of attempting to quit. The proportion of smokers quitting unassisted has gradually declined from 61% in 1998 to 40% in 2017 yet unassisted quitting continues to remain more popular than any form of assisted quitting. The most common method of assistance is asking for help from a doctor, increasing from 18% of smokers in 1998 to 34% in 2017. The increase in help seeking from doctors coincides with the availability of government-subsidised prescription-only varenicline in 2008 and subsidised prescription NRT patches in 2011. Interestingly, after peaking shortly after government-subsidised prescription varenicline became available in 2008, the proportion of smokers using quit smoking medications plateaued in 2012 at about 20%, suggesting that although prescription medications can improve a smokers’ chances of quitting, not all would-be quitters are necessarily interested in using the medications.

Third, using assistance to quit was more common among older (60+ years), more dependent (10+ cigarettes a day), socially disadvantaged smokers and those with a mental health condition. This might reflect greater engagement with the healthcare system by older patients and those with mental health conditions. Alternatively, it might indicate that although there are comparable levels of quit attempts among demographic groups, there are some groups that might need additional support to quit.

As Dono and colleagues conclude, in order to drive ongoing quitting we need to embrace a variety of approaches that can be tailored to the needs of the individual smoker. Research shows these needs vary across time. Achieving sustained abstinence from smoking is a complex, personal, often protracted process that typically requires multiple quit attempts with many smokers making both assisted and unassisted quit attempts., Although most smokers’ initial quit attempts are unassisted, if unsuccessful they are likely to be followed by assisted quit attempts. The limited data that exist around how ex-smokers actually quit indicate that many smokers choose to quit unassisted having learnt what they need from previous assisted and unassisted quit attempts.,

Dono and colleagues’ conclusion that unassisted quitting remains a dominant and legitimate method for many concurs with what in-depth qualitative research with Australian ex-smokers has reported. However, some ex-smokers report that even after having gained considerable experience over multiple quit attempts they would never have succeeded in achieving sustained abstinence if it was not for the help provided by pharmacological assistance. Clearly, unassisted and assisted quitting are both important. If widespread quitting is to be achieved, it may be far more productive to focus on motivating more smokers to try to quit and to do so more frequently than to worry about whether these quit attempts are assisted or unassisted.

Ultimately, we must not forget that offering help to quit, although an integral part of the World Health Organization's Framework Convention on Tobacco Control, is just one component of a broad array of supply- and demand-reduction tobacco control measures. Australia's success in reducing smoking prevalence has been achieved through a comprehensive approach to tobacco control with considerable attention being given not just to support of the individual smoker but to population-wide, mass-reach interventions that de-normalise and disincentivise smoking including price control, mass-media antismoking campaigns, advertising and sponsorship bans, smoke-free policies, plain packaging, graphic health warnings, and point-of-sale display bans. Critically, these population-wide policies are not just effective in discouraging uptake of smoking but are also effective in encouraging and supporting smokers to quit.

Declaration of interests

The author has not any conflict of interest to declare.