Utilisation of smoking cessation aids among South African adult smokers: findings from a national survey of 18 208 South African adults

Introduction

During 2016, 21.5% of South African adults smoked cigarettes.1 About 20% of deaths from pulmonary tuberculosis, and 8% of all deaths in South Africa are attributable to smoking.2 3 Several of the 10 leading causes of death in South Africa (eg, tuberculosis, pneumonia, heart disease, cerebrovascular disease, diabetes, hypertensive disease and chronic respiratory disease) are caused, exacerbated or associated with smoking.2 4 5 Quitting smoking reduces the risk for smoking-related morbidity and mortality. While several cessation aids exist in South Africa, including the national quit-line (011 720 3145) and clinical resources (eg, pharmacotherapy and cessation counselling), the limited evidence to date reveals gaps in access and utilisation.6 7 Only 29.3% of South African smokers received healthcare professional advice to quit smoking during 2012.8 South Africa has progressively passed several policies over the past few decades to encourage smoking cessation.9–12 However, smoking cessation medications are not included in the essential medicines list for South Africa, and therefore, all associated costs for these medications must be paid out-of-pocket, a challenge for individuals of low socioeconomic position.13–15 Data are needed, not only on what smokers are using to quit smoking (ie, cessation aids), but also why smokers are trying to quit (ie, cessation triggers), as this could inform public health policies, programmes and practice.

The Health Belief Model provides an appropriate framework through which to examine and address smoking cessation interventions in South Africa.16 Applied to smoking cessation, this psychosocial model suggests that smokers will attempt to quit if they perceive themselves to be susceptible to smoking-attributable morbidity or mortality (eg, because of an underlying health condition or a health scare), and believe that the benefits of smoking cessation (health and/or economic) outweigh any perceived downsides (eg, diminished smoking sensory experience). Other components of the model have some implications for clinical and public health practitioners. For example, cues to action may include advice or assistance from a healthcare provider to motivate quitting. Such cues may also include comprehensive smoke-free policies and other population-level educational interventions that have been demonstrated in previous research to be associated with quitting behaviour.4 Perceived self-efficacy (belief in being able to quit successfully) is a very important component of the model as it offers insights into the smoker’s current stage of change (precontemplation, contemplation, action, maintenance),17 and may also have implications for usage of evidence-based cessation aids.18 For example, smokers who are not confident of their ability to quit successfully cold turkey may be more inclined to use smoking cessation aids as part of their quit attempt.

To better understand these issues within the South African context, this study analysed a large sample of current combustible tobacco smokers to assess use of cessation aids as well as demographic and psychographic correlates of cessation behaviour. Specific research questions were as follows: (1) What percentage of current combustible smokers have ever attempted to quit during their lifetime, and what types of cessation aids have they ever used? (2) What are barriers to smoking cessation among current combustible smokers who have never attempted to quit during their lifetime? A better understanding of these issues is important for comprehensive tobacco prevention and control activities in South Africa.

Methods

Sensitivity analyses

The inherent limitations of the web survey in terms of potential measurement and selection biases led us to conduct sensitivity analyses to determine how certain key measures from the weighted analyses compared with those from a nationally representative household survey of South African adults—the 2017 South African Social Attitudes Surveys (SASAS). We compared the following indicators that were present in both surveys: (1) prevalence of current any tobacco use and of current cigarette smoking; (2) percentage of smokers who made a quit attempt (lifetime quit attempt assessed in web survey vs past year quit attempt in SASAS) and (3) percentage of those who made a quit attempt that used any cessation aid.

Results

Weighted distributions among all respondents overall revealed that most individuals (68.8%) were Black Africans and women (52.2%). Other demographic characteristics are available in table 1. Overall, 72.0% of the population reported ever use prevalence of at least one tobacco product. Current use prevalence was as follows: any tobacco product (23.2%); any combustible tobacco product (22.4%) and cigarettes (22.1%); (table 1). Overall, 98.7% of current smokers of any combustible tobacco were current cigarette smokers.

Significant differences in tobacco use prevalence were seen among all demographic groups assessed, as evidenced from non-overlap of CIs in table 1. Awareness of cessation aids was as follows among current combustible smokers: smoking cessation programmes, 50.8%; NRT, 92.1%; prescription cessation medication, 68.2%. Awareness of cessation aids was lowest among Black Africans, men, and persons with little or no income (table 2).

Differences in cessation behaviours and attitudes by psychographic and other tobacco-use characteristics

Among current combustible smokers who had made a quit attempt, ever e-cigarette users were more likely than never e-cigarette users to have ever used cessation counselling (AOR=1.92; 95% CI=1.55 to 2.37); NRT (AOR=1.73; 95% CI=1.50 to 1.99); prescription medication (AOR=1.55; 95% CI=1.33 to 1.81) and any cessation aid (AOR=1.72; 95% CI=1.50 to 1.97), after adjusting for age, gender, race, income and heaviness of smoking. Among current combustible smokers, ever and current e-cigarette users were also more likely to report current use of cessation aids at the time of the survey (table 5). Figure 1 compares the number of different cessation aids ever used of the four specific aids assessed: nicotine patch, nicotine spray, prescription medication and cessation counselling. The results showed that among e-cigarette never users, the percentages that reported ever use of 0, 1, 2, 3 or all 4 cessation aids were 64.1%, 23.2%, 8.8%, 2.8% and 1.1%, respectively; the corresponding percentages among e-cigarette ever users were 49.4%, 26.3%, 15.8%, 6.0% and 2.5% (p<0.05). Among all ever e-cigarette users, 43.5% were current combustible tobacco smokers; of current e-cigarette users, 97.5% were current combustible tobacco smokers.

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Figure 1

Number of distinct cessation aids ever used by current combustible smokers who had made a quit attempt, overall and by e-cigarette use status. Denominator was smokers who had tried to quit at least once in their lifetime. Ever use of the assessed cessation aids was defined as use of the specified cessation aid at least once in a lifetime. Four distinct cessation aids were assessed including ‘nicotine sprays (eg, Quit)’; ‘nicotine gums (eg, Nicorette)’; ‘pharmaceutical medication to stop smoking (eg, Zyban, Champix)’ and ‘smoking cessation programmes (eg, SmokEnders, Allan Carr)’. E-cigarette never users defined as smokers who have never used e-cigarettes in their lifetime, not even once or twice. E-cigarette ever users defined as smokers who have used e-cigarettes at least once in their lifetime. E-cigarette current users defined as persons who indicated that they used at least one ‘smoke or smokeless’ tobacco product regularly and also indicated e-cigarette use at any frequency at the time of the survey.

Table 5

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Smoking cessation behaviours and attitudes among South African current combustible tobacco smokers who made a past quit attempt,* by e-cigarette use status,† 2018 (n=4309)

Among current combustible smokers, increasing cost of cigarettes predicted an attempt to quit cigarette smoking among e-cigarette ever versus never users (AOR=1.24; 95% CI=1.09 to 1.41). E-cigarette ever users were also more likely to attempt to quit smoking cigarettes because of advice from a doctor or pharmacist (AOR=1.21; 95% CI=1.02 to 1.44).

Among current combustible smokers overall, reasons for smoking predicted quit attempts (figure 2). The odds of making a quit attempt were higher among those who smoked to relieve stress (AOR=1.26); because they thought it was ‘cool’ (AOR=1.30) or because of peer pressure (AOR=1.35) (all p<0.05). Conversely, those who smoked because they enjoyed the smoking experience had lower odds of making a quit attempt (AOR=0.72) or intending to quit smoking (AOR=0.65) (all p<0.05). Reasons cited for smoking relapse included quitting is hard (56.9%), smoking is enjoyable (34.1%), low self-efficacy in quitting successfully (13.8%) or the perception that smoking is safe (1.2%). Similarly, the most commonly cited reason for having never made a quit attempt was that it is too hard to quit (57.1%) followed by enjoyment of smoking (49.2%); 4.4% had never attempted to quit because they perceived smoking to be safe.

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Figure 2

Reason for smoking as a predictor of past quit attempts and future quit intentions among current smokers of combustible tobacco products. Note: solid=statistically significant; hollow=non-significant. ORs were computed adjusting for age, gender, race/ethnicity, income, self-rated health status and nicotine-dependence status. Quit attempters were smokers who had made at least one quit attempt in their lifetime. Smokers were classified as not having a quit intention if they indicated: ‘I’ve never tried to quit and don’t want to’ or ‘I’ve tried before and failed, so why try again?’

Among those who had never tried to quit smoking, inveterate smokers—comprising 6.1% of all current combustible smokers—differed from other non-attempters who otherwise had a quit intention in some respects (figure 3). Inveterate smokers were less likely to consider comprehensive smoke-free laws (3.7% vs 23.7%) or increasing cost of cigarettes (15.6% vs 27.0%) as things that could ever make them consider quitting (all p<0.05). No significant differences were observed by other factors.

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Figure 3

Actual triggers of a past quit attempt among current combustible tobacco smokers who have attempted to quit, as well as potential (perceived) triggers among those who have never tried to quit. Health reasons among those who tried to quit include ‘health scare’ or ‘wanted a healthy lifestyle’. The response options analysed as ‘increasing age’ were slightly different for ever quit attempters (‘New Year’s Resolution’) versus never quit attempters (‘when I am older’).

Discussion

Awareness of cessation aids among current combustible smokers varied by type of cessation aid: smoking cessation programmes, 50.8%; prescription cessation medication, 68.2% and NRT, 92.1%. Awareness of cessation aids was lowest among Black Africans, men and persons with little or no income. Of all current combustible smokers, 74.6% had ever attempted to quit and 42.8% of these quit attempters had ever used any cessation aid. Among past quit attempters, ever e-cigarette users were more likely than never e-cigarette users to have ever used any cessation aid (50.6% vs 35.9%, p<0.05). Of current combustible smokers intending to quit, 66.7% indicated interest in using a cessation aid for future quitting and only 33.3% wanted to quit cold turkey.

Despite high awareness of cessation aids among South African smokers, utilisation was low. Awareness and use were much lower for cessation counselling programmes and for prescription medications compared with NRT, possibly because of the ubiquitous display of NRT at retail outlets. Most NRT formulations, including oral spray and inhaler, can be purchased in South Africa as over-the-counter medication within pharmacies, supermarkets or online. However, as our findings revealed, low-income smokers may face severe limitations in accessing these medications. A complete regimen of nicotine patch lasting up to 12 weeks long, one patch per day, for a heavy smoker (10+ cigarettes), could cost between R9070 ($605) and R21 580 ($1438), based on current retail prices in South Africa and recommended usage.15 Including drugs for nicotine-dependence treatment on the South African Essential Drugs list,13 14 and expanding coverage for smoking cessation treatment within the National Health Insurance19 may increase access and utilisation of evidence-based cessation aids among South African smokers.

Current utilisation rates for cessation aids in our study were very similar to those reported in the USA, including for cessation counselling (7.1% vs 6.8%), any medication use (28.0% vs 29.0%) and use of any cessation aid (31.0% vs 31.2%, South Africa vs the USA, respectively).20 The pattern of disparities in access and use of cessation aids by socioeconomic status is also consistent with those reported elsewhere.6 21 In our study, Black Africans reported greater interest in using cessation aids and higher intentions to quit, but reported lower past use of cessation aids, suggesting that the gap in utilisation of cessation aids is largely driven by differences in socioeconomic status, rather than differences in interest or motivation. Increasing delivery of brief cessation counselling within all clinical settings (including public health facilities that serve low-income groups), as called for in Article 14 of the WHO Framework Convention on Tobacco Control,22 can help smokers quit and improve their health.23 24 In addition, enhancing the effectiveness of clinical smoking cessation services (eg, the 5As) can help increase cessation. For example, our findings suggest that asking smokers the reason why they smoke could be potentially useful in assessing their willingness to quit. Certain life-changing moments, such as the diagnosis of a serious condition associated with, or exacerbated by smoking (eg, chronic obstructive pulmonary disease) can be leveraged to provide counselling and motivate quitting.25 Our results showed that a health scare was associated with quitting, especially among those with poor health conditions. Notably, older adults were less likely to make a quit attempt just for maintaining a healthy lifestyle but were more likely to do so on account of a health scare.

South Africa has not officially adopted tobacco harm reduction, however, some in the public health community have argued for the effectiveness of this strategy among ‘inveterate’ smokers who are unwilling or unable to quit.26 The potential viability of a harm reduction approach, from a public health context, however rests on assumptions that: (1) there is a large pool of inveterate smokers; (2) that these smokers will be interested in switching to, and exclusively using ‘reduced-risk’ products which would help them quit; and (3) that a regulated climate exists to prevent unwanted consequences among youth. Our findings however disprove several of these assumptions within the South African context. Only about 6% of current combustible smokers were considered ‘inveterate’, and even these were open to quitting for health reasons (50%), family considerations (29%), increasing age (24%) and increasing costs of cigarettes (15.6%).

As the tobacco market and regulatory landscapes in South Africa continue to evolve rapidly, regulation of novel products is critical to minimise potential population-level harms, including relapse and perpetuation of smoking behaviour among smokers. Deeming and regulating e-cigarettes as tobacco products under the proposed legislation may benefit public health,11 27 not only in South Africa, but regionally as well, given the leadership role South Africa plays in the region. These findings can help inform comprehensive tobacco prevention and control efforts, including restricting unsubstantiated marketing claims of e-cigarettes as effective smoking cessation aids within South Africa.

Socioeconomic status was not a significant predictor of quitting on account of ‘increasing cigarette cost’, possibly because of the use of price-minimising strategies by smokers, including buying cheap brands, single sticks or switching to cheaper RYO cigarettes.28 29 Policies that address cross-product price inequalities can help reduce demand and use of tobacco products.30 We also found that older adults, who had the lowest smoking prevalence, were the only demographic group to attempt to quit smoking in response to public bans on smoking, suggesting limited compliance. Stronger enforcement of policies that prohibit smoking in public places may prevent relapse by reducing social cues and denormalising smoking.31 32

More robust epidemiological studies that address threats to internal validity are needed to test some of the hypothesis generated from our study. For example, our results suggested that claims of e-cigarettes being effective cessation aids may be probably overstated in the South African context, given the observation that smokers who used e-cigarettes were more likely than non-e-cigarette users to have used other cessation aids. Clinical or real-world effectiveness trials are needed to evaluate the independent effect of e-cigarettes on smoking cessation in South Africa.

This study is not without limitations. First, it is impossible to determine temporality with the cross-sectional design (eg, order of using e-cigarettes and evidence-based cessation aids). Second, triggers of past quit attempt could have varied for individuals with multiple quit attempts as could also the types of cessation aids used. Third, the self-reported measures are subject to misreporting. Finally, despite the use of calibration weights, the weighted sample may still not be entirely representative of the South African adult population because adjustments were only made for a few variables for which information was available in the dataset. We however found that comparison of results with 2017 SASAS, a household-based survey, yielded similar results on assessed indicators.

Conclusion

Most smokers were interested in quitting, but only about one-third of smokers who had tried to quit had ever used any cessation aid; NRT was the most used cessation aid. Disparities existed in the use of any cessation aid, with utilisation being least among Black Africans and individuals of low socioeconomic position. Smokers who tried to quit and used e-cigarettes reported higher use of pharmacological cessation aids and counselling than non-e-cigarette users. Intensified implementation of comprehensive tobacco prevention and control strategies that include barrier-free access to cessation aids, price increases on tobacco products, comprehensive smoke-free laws and mass media educational campaigns that warn of the dangers of tobacco use may accelerate cessation rates among South African adults.