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Quitting is easy, not smoking is hard: research with smokers of low socio-economic status

Research updates

Issue 2, December 2009

Smoking prevalence in NSW is highest in the most disadvantaged populations. In 2009, the Cancer Institute NSW commissioned qualitative research to explore opportunities for a campaign to assist and support smokers, particularly those of lower socio-economic status (SES) in quitting.

Purpose

To explore issues relating to quitting, the use of quitting aids and support services and to inform the development of a new campaign which promotes how to quit information.

Method

The research was conducted through a series of six group discussions, segmented by age, location and readiness to quit. Recruitment criteria included smoking at least five cigarettes per day, smokers from lower SES backgrounds and a mix of genders.

Key areas for discussion included:

• How aids have been used in quit attempts
• Opportunities to increase utilisation of aids, in particular prescribed medications
• Accessibility of aids and barriers to uptake
• Social context of quitting and impact on quit attempts.

Results

What does it mean to want to quit?

There was a considerable gulf between attitudes of wanting to quit and having an intention to quit.  When quizzed on these constructs, wanting was more like "I think I should", while intention was "I am going to try".

Within the group discussions, almost all reported that they wanted to quit, although the time frame tended to be less definite than in the next one or six months as they had claimed when they were recruited.  When pushed, very few participants in this research really intended to quit in this time frame.

This observation has a number of implications, one of which is that it suggests that caution needs to be used with any data that measures quitting intention by the use of questions such as "are you thinking about quitting in the next (time period)?", as these might not accurately reflect actual intention.  To some extent this difference appeared to be related to a perceptual difference between the idea of making a quit attempt and stopping smoking.

Quitting is easy; not having a cigarette is much harder!

For some smokers, while at some level they did have an aim to quit smoking, there was a substantial degree of reluctance to adopting an attitude of never having another cigarette. For example, several participants talked about how they would save themselves a few cigarettes for their quit attempt, or that they would leave a packet at a friend's place, so that they could have one when the need arose.  While they were quitting, they did not really intend to not smoke.

...quitting and not having cigarettes appeared to be quite separate constructs for some smokers.

"I find it easier ... if I'm quitting, that if I want to have one, I'll have one and then that's it.  I'll just have the one and then I'll go for a few weeks without having one, and then I'll just have another one if I feel like it.  'cause for me, I don't want to ... it's too much to just take it all away at once.  So if you are around people who are drinking, one [cigarette] to me won't do anything to my quitting ... so I give myself a few."

These observations lead to the thought that it is not so much quitting that was the difficult part of the process; the hard part for these smokers was not having a cigarette.  Indeed, quitting and not having cigarettes appeared to be quite separate constructs for some smokers.  To some extent, part of the failure of these participants' past attempts was related to their belief that they could smoke cigarettes while they were quitting.

Interestingly, these allowances tended to be made even in cases when participants knew that similar actions had been the downfall of previous quit attempts.  Again, it was apparent that, even in the process of quitting, there was considerable reluctance to giving up cigarettes completely.

All you need is willpower

There was a strong belief that wanting to quit was the most important factor in the decision to quit and the efficacy of quit attempts.   There was a similarly strong belief that will power was the most important factor in ability to quit.  To some extent participants equated 'wanting to quit' with 'willpower to quit', believing that if they really wanted to quit they would have the willpower to be able to.

Interestingly, given that their experiences have shown them that willpower has not been enough for past attempts to succeed, these experiences have not been sufficient to shift this belief in the value of will power. Participants tended to explain these failed attempts by way of some other justification (drinking, socialising, just decided to have one, etc) rather than to acknowledge that they did not have sufficient will power at the time that they relapsed.

Even more interestingly, these past attempts were in fact still classified as demonstrating the success of willpower.  That they had managed to stop for a period, independently of their subsequent return to smoking, demonstrated that will power was sufficient to stop.

Again, these observations demonstrated that quitting and staying stopped were not the same constructs in smokers' minds, although it was also apparent that they had not really thought through the implications of this distinction.  To a considerable extent it appeared that the inconsistencies between stated beliefs, reported intentions and behavioural experiences could be explained by the inconsistent treatments given to the two phases of quitting and staying stopped.

Given the existing level of importance placed on the notion of willpower, it will be fundamental to the credibility and success of communications that this is not treated dismissively.  These findings suggest that there may be some opportunity to empathise with smokers through acknowledging the importance of willpower in their decisions to quit, while promoting messages about the aids and resources that are available to help them in the process of staying stopped.

Barriers to using resources

There was a sense that a smoker needed to be really serious about quitting before they would call on the assistance of resources such as GPs or other health professionals.  However, as previously documented, smokers tended to hold back from being really serious about their quit attempts, hence they tended not to use these resources.  Further, they believed that if they were really serious, then this attitude (i.e. wanting to quit) along with the expected concomitant willpower, should be enough to make them successful.

Commonly, participants felt that it was pointless talking to doctors because they would only get a lecture and be offered little in the way of real assistance.

Participants reported a number of specific, and often quite strong, barriers to consulting with doctors about smoking and quitting.  Some reported negative past experiences of doctors, referring to experiences that they had interpreted as indicating incompetence, and noted that this left them reluctant to ask for anything.  Some specifically reported negative past experiences in relation to smoking, most commonly that their doctors did nothing other than lecture them about why they should not smoke.  Commonly, participants felt that it was pointless talking to doctors because they would only get a lecture and be offered little in the way of real assistance.

Overall, the value and intended use of the Quitline was rated as quite low.  Participants had little understanding of how a telephone call would assist them in quitting.   They were sceptical of recorded messages, believed that there would be limited time availability and felt that it was unlikely that they would be offered any new or useful information or assistance.  There was some scepticism that the service would be provided by people who would not understand what it was really like to be a smoker or to be trying to quit.

Experience of NRT and medication

When talking about nicotine replacement and medications, it was apparent that there was a strong desire for a 'magic bullet'.  To a degree this reflected the difficulty that people experienced in their attempts to quit.  They knew that it was going to be hard and wanted something to simply stop them from smoking.  In particular, some of those who had previously experienced severe withdrawal and cravings during past attempts wanted something to take away the difficulty of these experiences.

However, this desire for a magic bullet was also, to a degree, reflective of an attitude of wanting it to be easy, or of not wanting to do the hard work that quitting might take.  That is, they wanted something to take the hard part of quitting away, and medication seemed to offer this possibility.

A potential problem with this attitude might be that taking up NRT or medication is done with a presumption that quitting will then be easy as it is the job of the aids themselves to do the quitting, rather than the smoker.  However, when smokers find that the process itself is still quite a challenge, even with the aids, then they might lose any resolve that they had and blame the aids for "not working".

Conclusions

Getting serious about not smoking

Given these apparently contradictory beliefs and behaviours, there is a clear need to get people to be serious about quit attempts. As it is, smokers do not necessarily act as if quitting smoking and not having a cigarette are the same thing, yet it seems that having cigarettes is a fundamental factor that works against the success of their quit attempts. There is a clear need to communicate that quitting means not smoking, and that not smoking means not having cigarettes.  Obviously this needs to be done in a sensitive manner that does not alienate smokers.

To achieve this, consideration should be given to communications that refer to "staying stopped" as the goal, rather than quitting.

In this process, it could be valuable to separate messages about the decision to quit from those about the process of staying stopped. However, it is important that messages acknowledge and support the necessary role of willpower in the quitting process. To do anything else would undermine the effort that quitting takes and would lessen the perception that the individual smoker has an important role to play in the process.

Hence, other aids, supports and services need to be promoted as being additional or complementary to, rather than a substitute for, will power. Consideration should be given to developing messages around the notion that individual characteristics such as willpower and the desire to quit are necessary in deciding and preparing to quit, but that aids and resources make a difference in staying stopped.

Promotion of aids and resources

Messages that refer to reducing withdrawal symptoms and cravings are regarded positively and create interest. Promoting medications, such as Champix, with endorsement from a non-pharmaceutical organisation such as the Cancer Institute NSW increases the likely uptake of the message compared to it being promoted by a pharmaceutical company. To get smokers to talk to doctors, communications need to let them know that there is something new and valuable to be gained from doing so, and that it won't just result in them getting yet another lecture.