If you smoke more than ten cigarettes a day or have experienced cravings while trying to quit, your doctor has probably recommended a cigarette substitute such as nicotine patches or gum to help you.
But our research suggests most Australians don’t want to quit smoking this way, and continuing to make these substitutes (pharmacotherapy) more affordable and readily available is not necessarily going to persuade smokers to quit.
Pharmacotherapies are government-subsidised and widely available to all Australian smokers. Nicotine-replacement therapy (such as gum) has been available from pharmacies since 1997.
Zyban®, an oral prescription drug to reduce cravings and other withdrawal symptoms, has been subsidised via the Pharmaceutical Benefits Scheme (PBS) since 2001. Champix®, a drug that reduces the pleasure from smoking, has been available since 2008. Patches have been subsidised on the PBS since 2011.
Even supermarkets and convenience stores have sold nicotine-replacement therapies since 2006.
This is all based on the assumption by researchers and health-care practitioners that if we provide smokers with effective interventions they will seek them out to quit smoking.
Turns out, they often don’t. The majority of smokers in Australia still choose not to use assistance to quit. Approximately half to two-thirds quit unassisted and about half who attempt to quit do so unassisted.
The importance of experience
Our research tried to understand why this is the case. We found the knowledge of other smokers and ex-smokers was far more influential for people trying to quit than expert or research-based knowledge.
Smokers trade off the pros and cons of quitting with or without assistance. Unassisted quitting often wins as it is seen as a more convenient way to quit.
Smokers and ex-smokers trade stories about their experience of quitting, and have their own personal experience to draw on. This often conflicts with what they have been told about assistance by their doctor, pharmacist or through marketing by pharmaceutical companies.
Experts tell smokers that assistance will work. But when smokers try it, it often doesn’t, or at least not in the way they expected. This is unsurprising, as the likelihood of succeeding in any single quit attempt is quite low, whether or not you use assistance. Most smokers will quit eventually, but only after a number of failed attempts.
When the official message about quit assistance conflicts with their personal experience, smokers unsurprisingly give preference to their prior knowledge and that of other smokers.
The right way?
Researchers and experts tend to see unassisted quitting as the poor cousin to assisted quitting. But from a smoker’s perspective it has real advantages. It allows you to define yourself as a non-smoker straight away, instead of having a messy “treatment” period when you are neither a smoker nor a non-smoker.
Using assistance requires the adoption of new — but temporary — routines and habits. This feels like a waste of energy and attention for people who want to get on with establishing the habits and routines of being a non-smoker. For many, spending money on nicotine-replacement therapies, which would keep you addicted to nicotine, just did not make sense.
Smokers often talk about quitting unassisted as being “the right way” or “a better way” to quit. This contrasts with the dominant health promotion and medical discourse in Australia and the United Kingdom, which tends to frame quitting with assistance as being the better or more logical choice for smokers who want to quit. Some even frame quitting unassisted as being foolhardy or unwise.
Underlying these beliefs may be a set of values that certain smokers and perhaps society as a whole endorse. These include independence, strength, autonomy, self-control and self-reliance. Our research showed many smokers believe they have achieved something of value by quitting unassisted. They appear to take this achievement as an indicator of the strength of their moral character, or evidence of personal virtue.
Quitting smoking offers enormous health benefits. Some people need help to do it and it should be easy for them to access it. But it is not the be all and end all of quitting. Benefits of getting help vary and many smokers who try assistance will go on to successfully quit unassisted.
Our research shows that if health professionals want smokers to trust their advice, they would do well to do two things. First, avoid overselling smoking cessation assistance. And second, be careful not to buy into the idea that people who quit unassisted are “better people”.