If at First You Don’t Try …

Cessation research has long focused on identification and evaluation of treatments to help smokers already motivated to quit. Cessation-focused clinical trials have always been and will surely continue as the backbone of this treatment literature. Yet cessation is really a two-step process of (1) engaging in a quit attempt and (2) succeeding in that attempt. Thus, it is equally important to understand, and to focus our clinical and public health attention on quit attempts per se. This themed issue spotlights a range of studies that focus on quit attempts as a necessary step toward successful cessation.

For example, Beard et al.¹ demonstrate that trends in quit attempt incidence within the United Kingdom have not been uniform across all smokers, and in some segments of the population, these trends have been decreasing. This is consistent with data within the United States, showing that just over half of all smokers make a quit attempt annually,² a rate that has not markedly changed in over a decade. The epidemiological data make clear that novel interventions and public health approaches are continually needed to move this needle.

Two papers within this themed issue report on predictors of making a quit attempt. In one,³ based within a sample of smokers with serious mental illness, rates of quit attempts are even lower than national samples. There were evident demographic and smoking history predictors of quit attempts within this sample. As the population of smokers continues to shift toward underserved smokers, it will be increasingly important to understand the motivations and barriers to making a quit attempt within this group.⁴ In another paper that examined predictors of quit attempts among smokers not ready to quit,⁵ the factors associated with attempting are different from those associated with succeeding, a replication of similar findings elsewhere.⁶ These papers provide further data on the subsamples of smokers who are and are not making a quit attempt.

It is equally important to recognize that most quit attempts occur spontaneously,⁷ often with success. Garnett et al. provide further evidence on potential moderators that account for the association between spontaneous attempts and their success. These data complement and expand upon prior literature on spontaneous quit attempts.⁸ Across these and other studies, findings on spontaneous quitting offer further reminders of the need for opportunistic availability of treatment options so that quit attempts, no matter how induced or planned, can be supported with evidence-based treatments that are easily accessible whenever the moment strikes.

Such is the case for an interesting pilot trial from China,⁹ which demonstrated that opportunistic availability of nicotine replacement therapy (NRT) in public areas, offered to a wide spectrum of smokers, is not only feasible to deliver but potentially efficacious to induce quit attempts. Though results were not statistically significant, all results trended in favor the brief intervention. The more important interpretation from this study rests on its innovative approach. Imagine if community kiosks could dispense NRT to smokers without formal engagement in treatment; would that not entice more smokers to make medication-supported quit attempts? This is a novel approach to engage smokers proactively, in contrast to reactive approaches that rely on smokers to initiate treatment. Proactive outreach is an integral part of mass media campaigns as well, an example of which is reported within this themed issue.¹⁰ This manuscript demonstrates that population-oriented approaches, just like clinical approaches, can also effectively induce quit attempts. The stronger the campaign (ie, the higher the budget to support it, as just one metric), the better the outcome.

A number of more conventional clinical trials reported within this themed issue aimed to increase quit attempts, cessation, or both, and most of these involved some element of proactive outreach. Kruse et al.¹¹ adopted a factorial design that tested text messaging and brief starter kits of NRT within a small-scale pilot trial. Though outcomes were generally statistically nonsignificant, there was a clear sense that phone counseling and NRT starter kits (but not necessarily the combination of both) led to improved outcomes. Two other trials took a proactive treatment approach in underserved populations. Japuntich et al.¹² tested telephone outreach in comparison to usual care among mental health patients treated within the Veterans Administration. Though telephone outreach and mental health counseling improved treatment utilization and abstinence, there was no effect on rates of quit attempts alone. Another trial, focused low socioeconomic status smokers alone,¹³ also tested NRT sampling, as well as motivational interviewing. Nonsignificant results suggested that the former may induce quit attempts. This is consistent with larger trials of medication sampling that we^14–16 and others^17,18 have conducted, though not within this important and challenging population. Yet another randomized clinical trial within this themed issue tested the interesting idea of inducing tension, or as the authors termed it, looming vulnerability.¹⁹ The results were largely null but stood in contrast to the authors’ prior work along similar themes. Whether quit attempts can be “pulled” through positive methods or “pushed” through negative methods, remains an interesting research question in need of additional studies.

It bears repeating that successful quitting begins with the act of making a quit attempt. Whether planned versus spontaneous, whether induced or cajoled, or whether and under what conditions a brief versus sustained effort is effective in promoting quit attempts are all interesting questions covered within this themed issue. Many of these answers remain unclear. What is certainly clear that is that research must continue to identify and evaluate new and improved strategies to get more smokers to make better (ie, stronger) quit attempts, sooner.

Funding

Funding in support from the National Institute on Drug Abuse (R01 DA 021619 to MJC).

Declaration of Interests

Dr. Carpenter has received consulting honoraria from Pfizer. Dr. Hughes has received consulting and speaking fees from several companies that develop or market pharmacological and behavioral treatments for smoking cessation or harm reduction and from several nonprofit organizations that promote tobacco control. He also consults to tobacco companies regarding their harm reduction products.