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Most attempts to stop smoking are unsuccessful even in countries with long-standing and well-established tobacco control movements.

Nicotine dependence is a chronically relapsing disorder (Hughes, 1999; RCP, 2007; USPHS, 2000). Evidence from the UK and the US indicate that only a very small proportion of cigarette smokers quit smoking each year for a period of a year or longer (Jarvis, 1997; US Department of Health and Human Services, 2000). Jarvis (1997) estimated that the chances of successfully quitting on an unaided quit attempt for a UK smoker ranged from 0.5–3%. The Department of Health and Human Services data estimated that each year only about 3–5% of US smokers are successful when quitting without support.  The US statistic was confirmed in an analysis of relapse among untreated smokers (Hughes et al., 2004).

Reasons for the high relapse rate among smokers are numerous. First, tobacco product design and marketing hinders a smoker’s ability to stop smoking easily (e.g. by optimizing nicotine delivery, by the use of flavors and additives, the failure to provide smokers with accurate information about the product they are using, and using misleading terms such as “light” and “low tar” to promote an alternative to quitting). In addition, tobacco outlets are ubiquitous, and the ease of purchase of tobacco products normalizes their use in society, making it difficult for many smokers to quit and creating triggers for relapse. Additionally, many smokers are also highly over-optimistic about their likelihood of successful quitting (Jarvis et al., 2002) which may lead them to prepare inadequately for the challenges they face; for example, attempting to quit without any support.  This is particularly the case among youth in the US, where it has been shown that the use of support during quit attempts is considerably lower than for adults, with higher levels of failed quit attempts than adults.

Importantly, Hammond and colleagues (2004) point out that many smokers are not aware of the availability of effective methods to stop smoking, and underestimate their benefit. These findings are echoed by reports that smokers are misinformed about the health risks of nicotine and the safety and utility of NRT (Bansal et al., 2004), which can lead smokers to both not use treatments to help them quit and, even if they do elect to use them, to use too little of them and for too short a duration for optimal benefit. Shiffman and colleagues (2008b) examined NRT misperceptions in a national mail survey of 2,866 current U.S. smokers and 337 former U.S. smokers who had quit smoking within a year of completing the questionnaire. The majority of respondents believed that NRT was or might be as dangerous as smoking (66%). Only one third of smokers understand what scientists know -- that smoking is far more hazardous than using NRT (Shiffman et al., 2008b).

Thus, even though a greater proportion of smokers now use support when giving up smoking (West, 1997; Hughes, 1999, Burton et al., 2000; US Department of Health and Human Services, 2000; CDC, 2003) than over a decade ago (Fiore et al., 1990), many smokers still try to stop without the use of evidence-based treatments such as behavioral or pharmacological assistance (CDC, 2011). Zhu and colleagues (2000), using data from California which has one of the most active and long-standing smoking control programs, reported that the use of assistance had increased from 8% in 1986 to 20% in 1996 and the use of assistance was associated with a greater success rate. More recently, Shiffman et al. (2008a) reported that the majority of smokers (64%) fail to utilize any treatment in their cessation efforts.

In countries where there is a strong tobacco control movement and where the health consequences of tobacco use are broadly understood and accepted (mostly industrialized countries), it has been shown that the majority of smokers want to quit (West et al., 2001; Boyle et al., 2000; USDHHS, 2000). In many such countries, it has also been demonstrated that around a third or more of smokers attempt to quit each year (West et al., 2001; Canadian Tobacco Use Monitoring Survey, 1999). However, even within these countries there are key differences between subgroups of smokers and quit attempts. For example, survey data in Canada, the United States, the UK, and Australia found that lower education and income smokers were significantly less likely to plan a quit attempt (Reid et al., 2010; ITCPEP, 2010).

In developing countries or countries where there are weak tobacco control measures, the proportion of former smokers is much lower than in developed nations, and intention to quit is much lower than high-income countries. For example, the International Tobacco Control Policy Evaluation Project surveys of smokers from year 2007 demonstrated that prevalence of smokers that had ever tried to quit were higher for high income countries (around 80%) compared to medium income countries (around 60%) (Borland et al., 2012; ITCPEP, 2010). Some researchers have pointed out that several obstacles that could impede the adoption of smoking cessation in developing nations include (Abdullah and Husten, 2004):

  • Economic factors;
  • Lack of awareness by policy makers of the health consequences and costs of tobacco;
  • Low perception of risks among the public;
  • Lack of policies that promote cessation;
  • Smoking behavior of service providers and their own lack of knowledge or awareness;
  • Poor healthcare systems;
  • Lack of infrastructure; and
  • Industry action.

Abdullah AS, Husten CG. Promotion of smoking cessation in developing countries: a framework for urgent public health interventions. Thorax. 2004; 59: 623-630.

Bansal MA, Cummings KM, Hyland A, Giovino GA
. Stop-smoking medications: Who uses them, who misuses them, and who is misinformed about them? Nicotine Tob Res. 2004; 6(Suppl3): S303–S310.

Borland R, Li L, Driezen P, Wilson N, Hammond D, Thompson ME, Fong GT, Mons U, Willemsen MC, McNeill A, Thrasher JF, Cummings KM. Cessation assistance reported by smokers in 15 countries participating in the International Tobacco Control (ITC) policy evaluation surveys. Addiction. 2012;107(1):197-205.

Boyle P, Gandini S, Robertson C et al. Characteristics of smokers’ attitudes towards stopping: survey of 10,295 smokers in representative samples from 17 European countries. Eur J Public Health. 2000; 10(Suppl 3): 5-14.

Burton SL, Gitchell JG, Shiffman S. Use of FDA-approved pharmacologic treatments for tobacco dependence – United States, 1984–1998. Morb Mortal Wkly Rep. 2000; 49: 665-668.

Canadian Tobacco Use Monitoring Survey. Trends in Smoking. 1999.

Centers for Disease Control and Prevention. Use of cessation methods among smokers aged 16-24 years--United States, 2003. Morb Mortal Wkly Rep. 2006; 55(50): 1351-1354.

Centers for Disease Control and Prevention. Quitting smoking among adults--United States, 2001-2010. Morb Mortal Wkly Rep. 2011; 60: 1513-1519.

Fiore MC, Novotny TE, Pierce JP, Giovino GA, Hatziandreu EJ, Newcomb PA,Surawicz TS, Davis RM. Methods used to quit smoking in the United States. Do cessation programs help. JAMA. 1990; 263: 2760-2765.

Hammond D, MacDonald PW, Fong GT, Borland R. Do smokers know how to quit? Knowledge and perceived effectiveness of cessation assistance as predictors of cessation behaviour. Addiction. 2004; 99(8): 1042-1048.

Hughes JR. Four beliefs that may impede progress in the treatment of smoking. Tob Control. 1999; 8: 323-326.

Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction. 2004; 99: 29-38.

International Tobacco Control Policy Evaluation Project (ITCPEP). FCTC Article 14: Tobacco Dependence and Cessation. 2010; November), 1-8.

Jarvis MJ. Patterns and predictors of smoking cessation in the general population. In: The Tobacco Epidemic. Progress in Respiratory Research. Edited by CT Bolliger and KO Fagerstrom. Basel: Karger. 1997; pp.151-164.

Jarvis MJ, McIntyre D, Bates C, Foulds J. Effectiveness of smoking cessation initiatives. Efforts must take into account smokers' disillusionment with smoking and their delusions about stopping. BMJ. 2002; 324: 608.

Miller N, Frieden TR, Liu SY, et al. Effectiveness of a large-scale distribution programme of free nicotine patches: a prospective evaluation. Lancet. 2005; 365(9474): 1849-1854.

Pierce JP, Gilpin EA. News media coverage of smoking and health is associated with changes in population rates of smoking cessation but not initiation. Tob Control. 2001; 10: 145-153.

Reid JL, Hammond D, Boudreau C, Fong GT, Siahpush M; ITC Collaboration
. Socioeconomic disparities in quit intentions, quit attempts, and smoking abstinence among smokers in four western countries: findings from the International Tobacco Control Four Country Survey. Nicotine Tob Res. 2010; 12 Suppl: S20-33.

Royal College of Physicians. Harm reduction in nicotine addiction: Helping people who can't quit. London: RCP, 2007; 1-242.

Shiffman S, Brockwell SE, Pillitteri JL, Gitchell JG. Use of smoking-cessation treatments in the United States. Am J Prev Med. 2008a; 34(2): 102-111.

Shiffman SS, Ferguson SG, Rohay J, Gitchell JG. Perceived safety and efficacy of nicotine replacement therapies among US smokers and ex-smokers: relationship with use and compliance. Addiction 2008b; 103: 1371-1378.

Shiffman S, Pillitteri JL, Burton SL, et al
. Smokers’ beliefs about 'Light' and 'Ultra Light' cigarettes . Tob Control. 2001; 10(Suppl.I): i17-i23.

Thorndike AN, Biener L, Rigotti NA. Effect on smoking cessation of switching nicotine replacement therapy to over-the-counter status. Am J Public Health. 2002; 92: 437-442.

US Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services. 2000.

US Department of Health and Human Services. Treating tobacco use and dependence. A Report of the Surgeon General. Rockville, MD: Agency for Healthcare Research Quality. 2000.

West R. Getting serious about stopping smoking. A review of products, services and techniques. A report for No Smoking Day. London. 1997.

West R, McEwen A, Bolling K, Owen L. Smoking cessation and smoking patterns in the general population: a one-year follow-up. Addiction. 2001; 96: 891-902.

Zhou X, Nonnemaker J, Sherrill B, Gilsenan AW, Coste F, West R. Attempts to quit smoking and relapse: factors associated with success or failure from the ATTEMPT cohort study. Addict Behav. 2009; 34: 365-373.

Zhu S, Melcer T, Sun J, Rosbrook B, Pierce JP. Smoking cessation with and without assistance: a population-based analysis. Am J Prev Med. 2000; 18: 305-311. logo
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