This study was conducted to explore factors associated with successful smoking cessation in former smokers in Pakistan, a lower-middle-income country (LMIC) in South Asia. Our study identified personal health, promptings from one’s family, and one’s family’s health, as the most important motivating factors. Social pressures to quit smoking included peer-pressure to quit and social avoidance by non-smokers. Lastly, successful cessation on one’s first quit attempt was associated with being married, quitting cold turkey, having a negative self-image of oneself due to smoking, and having strong willpower to quit.
The commonest reasons for quitting smoking were to improve/protect own health (74.5%), family’s promptings (43%), to improve/protect the health of family members (14.8%), and to save money (14.5%). Respondents reported receiving awareness regarding the need to quit smoking most commonly from their family, friends, and colleagues (37.6%). Moreover, social pressures, such as peer-pressure to quit smoking (31.2%), social avoidance by non-smokers (22.7%), and non-smokers asserting rights to smokeless public spaces (9.1%), were also major deterrents. Studies from the United States, Poland and France have demonstrated similar results, with health concerns, discouragement of smoking at home, and the high cost of cigarettes being important deterrents (16-18). In addition, social pressure, such as having a smoke-free social network that pressurizes towards cessation, has also been found to be a strong motivator of cessation across different populations (17-19). It is interesting that promptings by doctors were reported as being a reason for quitting by only 13% of respondents, and only one quarter (24.8%) of respondents received cessation-related awareness from their doctors. A study from the United Kingdom revealed that most patients were skeptical about doctors smoking cessation advice, which was often generic and of a preaching nature, and suggested that doctors practice a more personalized approach to cessation counseling (20).
Around half (50.3%) of the respondents in our study reported quitting successfully on their first attempt, while the remaining reported needing 2-5 attempts (31.8%) and > 6 attempts (17.9%). These findings are in great contrast with what is usually suggested by smoking cessation programs. These vary from 8-14 attempts, as suggested by The American Cancer Society, the Australian Cancer Council, and the Centers for Disease Control (21-23). However, there is some literature that aligns with our findings, as it has been suggested that though the number of quit attempts may be quite high on average, between 40-52% may be successful on their first serious attempt (24, 25).
On multivariable regression, successful cessation on first attempt was associated with being married, quitting cold turkey, having a negative self-image on oneself because of being a smoker, telling oneself they have the willpower to resist the urge to smoke and quit definitively, and consciously diverting one’s thoughts to distract oneself from smoking. While the concept of willpower has been debated for a long time for its actual contribution to smoking cessation (26), it has been demonstrated to be an important factor in Pakistan previously (11). Moreover, personal willpower is an essential feature of the “5A’s” model in “Treating Tobacco Use and Dependence” (27), of which the first three A’s build towards willingness to quit and the last two A’s facilitate those willing to quit to take the final decision to quit. This concept of personal willpower being an important factor in single-attempt cessation is strengthened by how family’s promptings as a major reason for cessation was negatively associated with single-attempt cessation in our study. This suggests how personal motivation that arises from within the individual is more likely to lead to successful cessation than when it arises externally. Additionally, quitting cold turkey has been recommended as more successful in smoking cessation, as compared to gradually tapering off cigarette use (28). Interestingly in our study, use of a smoking cessation aid was negatively associated with quitting on the first attempt, a finding corroborated by a survey by Manis et al. in Switzerland (29). With regards to self-image, while having a negative self-image due to one’s addiction may cause distress to the smoker (30), it can also function as a powerful motivator to quit smoking as it negates the perceived benefits of smoking (31). Lastly, being with a spouse or partner who is a non-smoker, a former smoker, or who encourages and motivates quitting, is associated with a greater likelihood of success on cessation attempts (32-34).
Self-distraction by consciously diverting one’s thoughts to other matters (37.3%), trying to keep one’s hands and fingers occupied (34.5%), and engaging in work (28.8%), were useful strategies reportedly used by respondents. Moreover, consciously diverting one’s thoughts to other matters was significantly associated with single-attempt cessation on multivariable regression. These are encouraging findings, as they are simple yet effective. More technological methods of distraction, such as mobile phone applications and games (35, 36), that have been piloted in the setting of developed countries may not be feasible for a resource-constrained like Pakistan. In addition, positive reinforcement strategies, such as expecting rewards (23.6%) and receiving rewards (19.1%) from others for resisting the urge to smoke, were also employed by respondents. Rewards and incentives, often monetary, are helpful in motivating smoking cessation, especially when individualized (37, 38).
Lastly, none of the public health interventions mentioned in our survey were perceived by respondents as particularly useful for helping smoking cessation or resisting relapse, with less than 5% of respondents rating any intervention as helpful to a great extent. This is indirect contrast with studies from developed countries, such as the United States (39, 40), and may be explained by several reasons. Firstly, interventions such as government or private sector mass media anti-smoking campaigns, anti-smoking advertisements, and health warnings preceding/during films, may not effectively be effective amongst those of lower socioeconomic and less educated backgrounds. Secondly, although Pakistan subscribes to the MPOWER model of tobacco control outlined by the World Health Organization (41), it is possible that these interventions are not practically implemented in an optimal manner. Thirdly, since our results highlight how former smokers predominantly attribute the success of their cessation to personal factors, such as willpower, self-discipline, and distraction strategies, they are perhaps unable or hesitant to acknowledge the potentially subconscious impact of external motivators. Nevertheless, further studies are required to determine the efficacy of such large-scale public health interventions in the setting of a LMIC like Pakistan, in terms of both improving cessation and cost-effectiveness.
Despite the major burden of tobacco consumption in the country, Pakistan lacks any major smoking cessation programs or clinics facilitating rehabilitation, which along with the low cost and easy availability of tobacco, can prove the difficult task of quitting even more challenging (11). The results of our study provide a comprehensive and unique understanding of the factors that motivate smoking cessation in Pakistan. Strengths of our study include its generalizability, as shown by the varied distribution of socio-demographic characteristics, which was achieved by targeting five different settings for data collection in the metropolis of Karachi. Further research must investigate patterns specific to gender, age, socioeconomic status, education level, and other demographics. These would help develop evidence-based personalized programs for smoking cessation across the population.