Feasibility of a telephone-based intervention for support persons to help smokers quit: a pilot study

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of telephone support to help smokers quit, including proactive or reactive counselling, or the provision of other information to smokers calling a helpline.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2018.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which offered proactive or reactive telephone counselling to smokers to assist smoking cessation.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We pooled studies using a random-effects model and assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I2 statistic. In trials including smokers who did not call a quitline, we used meta-regression to investigate moderation of the effect of telephone counselling by the planned number of calls in the intervention, trial selection of participants that were motivated to quit, and the baseline support provided together with telephone counselling (either self-help only, brief face-to-face intervention, pharmacotherapy, or financial incentives).

MAIN RESULTS

We identified 104 trials including 111,653 participants that met the inclusion criteria. Participants were mostly adult smokers from the general population, but some studies included teenagers, pregnant women, and people with long-term or mental health conditions. Most trials (58.7%) were at high risk of bias, while 30.8% were at unclear risk, and only 11.5% were at low risk of bias for all domains assessed. Most studies (100/104) assessed proactive telephone counselling, as opposed to reactive forms.Among trials including smokers who contacted helplines (32,484 participants), quit rates were higher for smokers receiving multiple sessions of proactive counselling (risk ratio (RR) 1.38, 95% confidence interval (CI) 1.19 to 1.61; 14 trials, 32,484 participants; I2 = 72%) compared with a control condition providing self-help materials or brief counselling in a single call. Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate.In studies that recruited smokers who did not call a helpline, the provision of telephone counselling increased quit rates (RR 1.25, 95% CI 1.15 to 1.35; 65 trials, 41,233 participants; I2 = 52%). Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate. In subgroup analysis, we found no evidence that the effect of telephone counselling depended upon whether or not other interventions were provided (P = 0.21), no evidence that more intensive support was more effective than less intensive (P = 0.43), or that the effect of telephone support depended upon whether or not people were actively trying to quit smoking (P = 0.32). However, in meta-regression, telephone counselling was associated with greater effectiveness when provided as an adjunct to self-help written support (P < 0.01), or to a brief intervention from a health professional (P = 0.02); telephone counselling was less effective when provided as an adjunct to more intensive counselling. Further, telephone support was more effective for people who were motivated to try to quit smoking (P = 0.02). The findings from three additional trials of smokers who had not proactively called a helpline but were offered telephone counselling, found quit rates were higher in those offered three to five telephone calls compared to those offered just one call (RR 1.27, 95% CI 1.12 to 1.44; 2602 participants; I2 = 0%).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that proactive telephone counselling aids smokers who seek help from quitlines, and moderate-certainty evidence that proactive telephone counselling increases quit rates in smokers in other settings. There is currently insufficient evidence to assess potential variations in effect from differences in the number of contacts, type or timing of telephone counselling, or when telephone counselling is provided as an adjunct to other smoking cessation therapies. Evidence was inconclusive on the effect of reactive telephone counselling, due to a limited number studies, which reflects the difficulty of studying this intervention.

Enhancing partner support to improve smoking cessation

BACKGROUND

While many cessation programmes are available to assist smokers in quitting, research suggests that support from individual partners, family members, or 'buddies' may encourage abstinence.

OBJECTIVES

To determine if an intervention to enhance one-to-one partner support for smokers attempting to quit improves smoking cessation outcomes, compared with cessation interventions lacking a partner-support component.

SEARCH METHODS

We limited the search to the Cochrane Tobacco Addiction Group Specialised Register, which was updated in April 2018. This includes the results of searches of the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (via OVID); Embase (via OVID); and PsycINFO (via OVID). The search terms used were smoking (prevention, control, therapy), smoking cessation and support (family, marriage, spouse, partner, sexual partner, buddy, friend, cohabitant and co-worker). We also reviewed the bibliographies of all included articles for additional trials.

SELECTION CRITERIA

We included randomised controlled trials recruiting people who smoked. Trials were eligible if they had at least one treatment arm that included a smoking cessation intervention with a partner-support component, compared to a control condition providing behavioural support of similar intensity, without a partner-support component. Trials were also required to report smoking cessation at six months follow-up or more.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the included studies from the search results, and extracted data using a structured form. A third review author helped resolve discrepancies, in line with standard methodological procedures expected by Cochrane. Smoking abstinence, biochemically verified where possible, was the primary outcome measure and was extracted at two post-treatment intervals where possible: at six to nine months and at 12 months or longer. We used a random-effects model to pool risk ratios from each study and estimate a summary effect.

MAIN RESULTS

Our update search identified 465 citations, which we assessed for eligibility. Three new studies met the criteria for inclusion, giving a total of 14 included studies (n = 3370). The definition of partner varied among the studies. We compared partner support versus control interventions at six- to nine-month follow-up and at 12 or more months follow-up. We also examined outcomes among three subgroups: interventions targeting relatives, friends or coworkers; interventions targeting spouses or cohabiting partners; and interventions targeting fellow cessation programme participants. All studies gave self-reported smoking cessation rates, with limited biochemical verification of abstinence. The pooled risk ratio (RR) for abstinence was 0.97 (95% confidence interval (CI) 0.83 to 1.14; 12 studies; 2818 participants) at six to nine months, and 1.04 (95% CI 0.88 to 1.22; 7 studies; 2573 participants) at 12 months or more post-treatment. Of the 11 studies that measured partner support at follow-up, only two reported a significant increase in partner support in the intervention groups. One of these studies reported a significant increase in partner support in the intervention group, but smokers' reports of partner support received did not differ significantly. We judged one of the included studies to be at high risk of selection bias, but a sensitivity analysis suggests that this did not have an impact on the results. There were also potential issues with detection bias due to a lack of validation of abstinence in five of the 14 studies; however, this is not apparent in the statistically homogeneous results across studies. Using the GRADE system we rated the overall quality of the evidence for the two primary outcomes as low. We downgraded due to the risk of bias, as we judged studies with a high weighting in analyses to be at a high risk of detection bias. In addition, a study in both analyses was insufficiently randomised. We also downgraded the quality of the evidence for indirectness, as very few studies provided any evidence that the interventions tested actually increased the amount of partner support received by participants in the relevant intervention group.

AUTHORS' CONCLUSIONS

Interventions that aim to enhance partner support appear to have no impact on increasing long-term abstinence from smoking. However, most interventions that assessed partner support showed no evidence that the interventions actually achieved their aim and increased support from partners for smoking cessation. Future research should therefore focus on developing behavioural interventions that actually increase partner support, and test this in small-scale studies, before large trials assessing the impact on smoking cessation can be justified.

Skill Sets for Family Members and Friends to Help Motivate a Smoker to Seek Treatment: Research to Practice

Translation of effective behavioral interventions is a key challenge for the addictions treatment field. With the goal of disseminating an effective behavioral intervention to practice, this narrative study describes tobacco cessation coaches' skills sets and provides an illustrative case study of a 1-session phone intervention between a coach and a concerned family member who wants to help their smoker quit. Delivered through a quitline by quitline coaches, the intervention consisted of a 15-30 minute phone session and written materials. The goal of the intervention was for family members and friends (support persons) to encourage their smoker to use a quitline. Data were collected from transcripts of 193 audiotapes of the one session phone intervention from a previous trial (Patten et al., In Print). Using content analysis, major themes regarding barriers and challenges within the sessions and coaches' solutions assisted in selecting case study illustrating the dialogue between a coach and a support person, as well as demonstrating the coaches' skill sets used to deliver the session. In addition, the barriers and challenges among support persons (i.e., uncertainty about how to approach the smoke, the smoker is not ready to quit) and the coaches' responses and suggestions are illustrated. These types of data could be useful to clinicians, providers and others interested in implementing a behavioral intervention for nonsmokers who want to support a smoker to quit.

Linking smokers to a quitline: randomized controlled effectiveness trial of a support person intervention that targets non-smokers

Evidence-based treatments (e.g. quitlines) are greatly underutilized by smokers limiting their public health impact. A three-session phone intervention for nonsmoking family members and friends (i.e. support persons) was successful for increasing smoker quitline enrollment. To enhance the intervention's potential translatability, in this study, we delivered treatment for the non-smoker within ongoing quitline services and compared the efficacy of the three-call intervention to a streamlined version (one call). A total of 704 adult non-smokers (85% female, 95% White) wanting to help a smoker quit and recruited statewide in Minnesota participated in this randomized controlled trial with parallel groups. Non-smokers received mailed written materials and were randomly assigned to a control condition (no additional treatment, n = 235), or to a one- (n = 233) or three-call (n = 236) intervention delivered by quitline coaches. The main outcome was smoker quitline enrollment through 7-month follow-up. Smoker quitline enrollment was similar for those linked to non-smokers in the one- and three-call interventions (14.6% [34/233] and 14.8% [35/236]), and higher than for smokers linked to control participants (6.4% [15/235]), P = 0.006. Just one quitline coaching call delivered to non-smokers increased treatment enrollment among smokers. The reach of quitlines could be enhanced by targeting the social support network of smokers.

Applying Psychological Theories to Promote Long-Term Maintenance of Health Behaviors

Behavioral health theory provides a framework for researchers to design, implement, and evaluate the effects of health promotion programs. However, limited research has examined theories used in interventions to promote long-term maintenance of health behaviors. The purpose of this review was to evaluate the available literature and identify prominent behavioral health theories used in intervention research to promote maintenance of health behaviors. We reviewed theories used in intervention research assessing long-term maintenance (≥ 6 months post-intervention) of physical activity, weight loss, and smoking cessation. Five prominent behavioral theories were referenced by the 34 studies included in the review: Self-Determination Theory, Theory of Planned Behavior, Social Cognitive Theory, Transtheoretical Model, and Social Ecological Model. Descriptions and examples of applications of these theories are provided. Implications for future research are discussed.

Relationship of Autonomy Social Support to Quitting Motivation in Diverse Smokers

BACKGROUND

Research examining relationships between social support and smoking cessation has paid little attention to non-treatment seeking smokers and not considered the role of autonomy support for fostering quitting motivation. This study examined if autonomy support received from family and friends was associated with quitting motivation and making a quit attempt among diverse smokers with varying levels of quitting motivation. Demographic characteristics associated with autonomy support were explored.

METHODS

Participants (N=312) responded to advertisements seeking smokers "not quite ready to quit," and were primarily Black, low-income, and unemployed. Most (255) enrolled in a clinical trial of smoking cessation induction strategies (treatment sample). An additional 57 not meeting the trial eligibility criteria of low quitting motivation enrolled for baseline assessments only. Participants completed baseline measures of autonomy support received from friends and autonomous quitting motivation. In the treatment sample, quit attempts were assessed at 6-months follow-up.

RESULTS

Females reported higher levels than males of autonomy support from friends (p=0.003). Participants with a high school diploma/GED reported higher levels of support from family (p<0.001) and friends (p=0.014) than those with less education or a college/graduate degree. Both family (p=0.007) and friend (p=0.004) autonomy support scores were significantly, albeit weakly, associated with autonomous quitting motivation. Autonomy support was not associated with making a quit attempt.

CONCLUSIONS

Support from family and friends may promote autonomous reasons to quit among diverse smokers. Research is needed to assess the role of social support in the pre-quitting phases among racial and socio-economically diverse populations.

A Social Network Family-Focused Intervention to Promote Smoking Cessation in Chinese and Vietnamese American Male Smokers: A Feasibility Study

INTRODUCTION

Smoking prevalence is high among limited English-proficient Chinese and Vietnamese American men, who are frequently unmotivated to quit and who underutilize smoking cessation resources. This study applied lay health worker outreach to leverage peer and family networks to promote smoking cessation among these men.

METHODS

We integrated qualitative formative research findings and Social Network Theory to develop a social-network family-focused intervention. In a pilot single-group trial, 15 lay health workers recruited 96 dyads (N = 192, 75% Vietnamese) of Chinese or Vietnamese male daily smokers and their family members and delivered the intervention consisting of two small group education sessions and two individual telephone calls over 2 months.

RESULTS

At baseline, 42% of smokers were at precontemplation. At 3 months following the initiation of the intervention, 7-day and 30-day point prevalence smoking abstinence rates as reported by smokers and independently corroborated by family members were 30% and 24%, respectively. Utilization of smoking cessation resources (medication, quitline, physician's advice) increased from 2% to 60% (P < .001). Findings showed high acceptability of the intervention as it facilitated learning about tobacco-related health risks and cessation resources, and communications between smokers and their families.

CONCLUSIONS

This novel social network family-focused intervention to promote smoking cessation among Chinese and Vietnamese smokers appears to be acceptable, feasible, and potentially efficacious. Findings warrant evaluation of long-term efficacy of the intervention in a larger scale randomized controlled trial.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of proactive and reactive telephone support via helplines and in other settings to help smokers quit.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2013.

SELECTION CRITERIA

randomized or quasi-randomised controlled trials in which proactive or reactive telephone counselling to assist smoking cessation was offered to smokers or recent quitters.

DATA COLLECTION AND ANALYSIS

One author identified and data extracted trials, and a second author checked them. The main outcome measure was the risk ratio for abstinence from smoking after at least six months follow-up. We selected the strictest measure of abstinence, using biochemically validated rates where available. We considered participants lost to follow-up to be continuing smokers. Where trials had more than one arm with a less intensive intervention we used only the most similar intervention without the telephone component as the control group in the primary analysis. We assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I² statistic. We considered trials recruiting callers to quitlines separately from studies recruiting in other settings. Where appropriate, we pooled studies using a fixed-effect model. We used a meta-regression to investigate the effect of differences in planned number of calls, selection for motivation, and the nature of the control condition (self help only, minimal intervention, pharmacotherapy) in the group of studies recruiting in non-quitline settings.

MAIN RESULTS

Seventy-seven trials met the inclusion criteria. Some trials were judged to be at risk of bias in some domains but overall we did not judge the results to be at high risk of bias. Among smokers who contacted helplines, quit rates were higher for groups randomized to receive multiple sessions of proactive counselling (nine studies, > 24,000 participants, risk ratio (RR) for cessation at longest follow-up 1.37, 95% confidence interval (CI) 1.26 to 1.50). There was mixed evidence about whether increasing the number of calls altered quit rates but most trials used more than two calls. Three studies comparing different counselling approaches during a single quitline contact did not detect significant differences. Of three studies that tested the provision of access to a hotline two detected a significant benefit and one did not.Telephone counselling not initiated by calls to helplines also increased quitting (51 studies, > 30,000 participants, RR 1.27; 95% CI 1.20 to 1.36). In a meta-regression controlling for other factors the effect was estimated to be slightly larger if more calls were offered, and in trials that specifically recruited smokers motivated to try to quit. The relative extra benefit of counselling was smaller when it was provided in addition to pharmacotherapy (usually nicotine replacement therapy) than when the control group only received self-help material or a brief intervention.A further eight studies were too diverse to contribute to meta-analyses and are discussed separately. Two compared different intensities of counselling, both of which detected a dose response; one of these detected a benefit of multiple counselling sessions over a single call for people prescribed bupropion. The others tested a variety of interventions largely involving offering telephone counselling as part of a referral or systems change and none detected evidence of effect.

AUTHORS' CONCLUSIONS

Proactive telephone counselling aids smokers who seek help from quitlines. Telephone quitlines provide an important route of access to support for smokers, and call-back counselling enhances their usefulness. There is limited evidence about the optimal number of calls. Proactive telephone counselling also helps people who receive it in other settings. There is some evidence of a dose response; one or two brief calls are less likely to provide a measurable benefit. Three or more calls increase the chances of quitting compared to a minimal intervention such as providing standard self-help materials, or brief advice, or compared to pharmacotherapy alone.

Development of a tobacco cessation intervention for Alaska Native youth

Tobacco cessation treatments have not been evaluated among Alaska Native (AN) adolescents. This pilot study evaluated the feasibility and acceptability of a targeted cessation intervention developed for AN youth. Intervention components were informed by prior focus groups assessing treatment preferences among AN youth, a social cognitive theoretical framework and feedback obtained from a teen advisory group. The intervention consisted of a weekend program where youth traveled by small airplane from their villages to stay overnight with other adolescents who quit tobacco use together. The program included recreational activities, talking circles, personal stories from elders and teen advisors, and cognitive behavioral counseling. Two intervention pilots were conducted from October 2010 to January 2011 using a non-randomized, uncontrolled study design with assessments at baseline and six-week follow-up. One village in Western Alaska was selected for each pilot with a targeted enrollment of 10 adolescents each. Participants were recruited for each pilot within five days, but recruitment challenges and ''lessons learned'' are described. The first pilot enrolled nine adolescents (all female) aged 13-16 years; all nine attended the intervention program and 78% (7/9) completed follow-up. The second pilot enrolled 12 adolescents (eight females, four males) aged 12-17 years, of which seven attended the intervention program. Six of these seven participants (86%) completed follow-up. In both pilots, participants rated the intervention as highly acceptable. A targeted cessation intervention was feasible and acceptable to AN youth. The intervention will be tested for efficacy in a subsequent randomized controlled trial.

A true challenge for any superhero: an evaluation of a comic book obesity prevention program

The purpose of this study was to pilot test the Comics for Health program, a theory-based nutrition and physical activity intervention for children. Twelve after-school programs were randomized to either a theory-based (n = 37) or a knowledge-based (n = 34 children) version of the intervention. Pretests, posttests, and 3-month follow-up tests were administered to evaluate the programmatic effects on body mass index percentile, obesity-related behaviors, and constructs of social cognitive theory. Both interventions found significant, yet modest effects for fruit and vegetable consumption (P < .005), physical activities (P < .004), and water and sugar-free beverage consumption (P < .001) and self-efficacy for fruit and vegetable consumption (P < .015) and physical activities (P < .009).

Enhancing partner support to improve smoking cessation

BACKGROUND

While many cessation programmes are available to assist smokers in quitting, research suggests that partner involvement may encourage long-term abstinence.

OBJECTIVES

The purpose of this review was to determine if an intervention to enhance partner support helps smoking cessation when added as an adjunct to a smoking cessation programme, and to estimate the size of any effect.

SEARCH METHODS

For the most recent update, the search was limited to the Cochrane Tobacco Addiction Group Specialized Register. This was searched in December 2011. The Specialized Register includes reports of controlled trials of smoking cessation identified from electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL) to Issue 4, 2011, MEDLINE to update 20110826, EMBASE to 2011 week 33, PsycINFO to 20110822 and Web of Science. The search terms used were smoking (prevention, control, therapy), smoking cessation, and support (family, marriage, spouse, partner, sexual partner, buddy, friend, co-habitees and co-worker).

SELECTION CRITERIA

Randomized controlled trials of smoking cessation interventions that compared an intervention that included a partner support component with an otherwise identical intervention and reported follow-up of six months or longer.

DATA COLLECTION AND ANALYSIS

Two authors independently identified the included studies and extracted data using a structured form. A third author was consulted to aid in the resolution of discrepancies. Abstinence, biochemically validated if possible, was the primary outcome measure and was extracted at two post-treatment intervals: six to nine months and 12 months or greater. Partner Interaction Questionnaire and Support Provided Measure scores were also analysed to assess partner support. A fixed-effect model was used to pool relative risks from each study and estimate a summary effect.

MAIN RESULTS

A total of 57 articles were identified for this review. Twelve articles (13 studies, > 2000 participants) met the inclusion criteria. The definition of partner varied between studies. All studies gave self-reported smoking cessation rates, but there was limited biochemical validation of abstinence. The pooled risk ratio for self-reported abstinence was 0.99 (95% confidence interval (CI) 0.84 to 1.15) at six to nine months and 1.04 (95% CI 0.87 to 1.24) at 12 months or more post-treatment. Of the eight studies that measured partner support at follow-up, only two studies reported a significant increase in partner support in the intervention groups. One study reported a significant increase in partner support in the intervention group, but smokers' reports of partner support received did not differ significantly in this study.

AUTHORS' CONCLUSIONS

In this review of randomized controlled trials of interventions designed to enhance partner support for smokers in cessation programmes, we failed to detect an increase in quit rates. Limited data from several of the trials suggest that these interventions also did not increase partner support. No conclusions can be made about the impact of partner support on smoking cessation. Additional studies with larger samples are needed to adequately explore the effects of partner support interventions for smoking cessation.

Support-person promotion of a smoking quitline: a randomized controlled trial

BACKGROUND

Quitlines and other evidence-based cessation treatments are greatly underutilized by smokers, limiting their public health impact. Social support is correlated with successful cessation. Thus, efforts targeting the social network of smokers could be a potential avenue to promote quitline utilization.

PURPOSE

This study examined the efficacy of an intervention for nonsmokers interested in helping a smoker (i.e., support people) to promote smoker utilization of the Minnesota QUITPLAN(®) Helpline. Data were collected from 2007 to 2010, and analyses were conducted from 2010 to 2011.

DESIGN

Two-group randomized design evaluating the support-person intervention (n=267) compared with a control condition (written materials, n=267).

SETTING/PARTICIPANTS

Enrolled were 534 support people (91% female, 93% Caucasian) residing in Minnesota.

INTERVENTION

Written materials plus three weekly telephone sessions lasting 10-30 minutes each. Based on Cohen's theory of social support, the intervention provided participants with information and skills needed to encourage their smoker to call the QUITPLAN Helpline.

MAIN OUTCOME MEASURES

Participants completed the Support Provided Measure (SPM) by mail at baseline and Week 4 (end-of-treatment). Helpline intake staff documented smoker calls to the Helpline through 6 months of follow-up.

RESULTS

The proportion of calls to the Helpline was significantly (p=0.012) greater for smokers linked to support people in the intervention group (16.1%, 43/267) than in the control group (8.6%, 23/267). The treatment effect remained significant after adjusting for support person residing with the smoker (OR=2.04, 95% CI=1.19, 3.49, p=0.010). Among support people randomly assigned to the intervention group, greater number of sessions completed was associated with increased smokers' calls to the Helpline (p=0.004). After adjusting for the baseline score, the M±SD SPM score at Week 4 was significantly higher for support people in the intervention group (16.4±3.3) than for those in the control group (15.3±3.6), p=0.002.

CONCLUSIONS

A support-person intervention is effective in increasing smoker utilization of the QUITPLAN Helpline. There is potential for increasing the reach of quitlines by targeting the social network of smokers. TRIAL REGISTRATION #: NCT01311830.

Individual and family factors associated with intention to quit among male Vietnamese American smokers: implications for intervention development

Smoking prevalence among Vietnamese American males remains higher than the U.S. general population. This study examined the associations of individual and family factors with quit intention among Vietnamese male smokers in California to guide intervention development to reduce their smoking prevalence. Data for Vietnamese male current smokers (n=234) in the 2008 California Vietnamese Adult Tobacco Use Survey (N=1101 males) were analyzed to describe quit intention and previous quit attempts. One-third of Vietnamese male smokers (33%) had no intention to quit at any time, 36% intended to quit soon (in the next 30 days), and 31% intended to quit later (beyond the next 30 days). Half (51.7%) of the sample was in "precontemplation," indicating no intention to quit within 6 months. Many (71%) had made a serious quit attempt in the past year, but 68% of those who tried to quit used no cessation assistance. Multivariate logistic regression adjusting for age, depression, smoking intensity, nicotine dependence, health knowledge, children in the household and home smoking ban revealed that having smoking-related family conflicts and a quit attempt in the past year with or without assistance were independently associated with an intention to quit either in the next 30 days or later. Higher education was associated with no intention to quit. Findings underscore the importance of designing strategic interventions that meet the needs of smokers at both individual and family levels to promote quit intention and to facilitate successful quitting in this population.

Smokers' reasons for quitting in an anti-smoking social context

OBJECTIVE

To examine the impact of the social denormalization of smoking on smokers' motives for quitting and on subsequent abstinence in a context of intensified anti-smoking measures.

STUDY DESIGN

This study is based on data from 13,746 French smokers who were registered in cessation services nationwide between September 2006 and September 2007.

METHODS

Motives freely reported by smokers on their first visit to a cessation service were explored through open coding. Bivariate methods and multivariate logistic regression analyses were used to assess the association with biochemically validated abstinence at 1 month follow-up.

RESULTS

Motives most frequently expressed by smokers were health concerns (55.0%) and cost of smoking (24.2%), but no significant association was found with abstinence. The highest abstinence rates were achieved by smokers motivated by their social network: 'motivated or pressured by others' (20.9%), 'setting a good example' (20.7%) and 'having a smoke-free social network' (20.3%). Smokers could no longer bear the social constraints of smoking: '[my] friends and family have all quit, [I] smoke outside all alone and feel left out' and 'I no longer want people to say with disgust that I smell of tobacco. I would like to be freed from this addiction because I'm ashamed of smoking, not at home but on the street'.

CONCLUSION

French smokers' motives for quitting reflect a social unacceptability of smoking which has been buttressed by measures intended to reduce tobacco use. Through smoke-free social networks, the denormalization of smoking appears to improve short-term abstinence.