Quitting activity and use of cessation assistance reported by smokers in eight European countries: Findings from the EUREST-PLUS ITC Europe Surveys
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Department of Health Promotion, Maastricht University, Maastricht, the Netherlands
Department of Family Medicine, Maastricht University, Maastricht, the Netherlands
IVO Research Institute, The Hague, the Netherlands
Department of Psychology & School of Public Health and Health Systems, University of Waterloo, Waterloo, Canada
Ontario Institute for Cancer Research, Toronto, Canada
University of Crete (UoC), Heraklion, Greece
European Network on Smoking and Tobacco Prevention (ENSP), Brussels, Belgium
Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
Health Promotion Foundation, Warsaw, Poland
UK Centre for Tobacco and Alcohol Studies, London, United Kingdom
Department of Behavioural Science and Health, University College London, London, United Kingdom
Cancer Prevention Unit & WHO Collaborating Centre for Tobacco Control, German Cancer Research Center (DKFZ), Heidelberg, Germany
Department of Communication, University of Amsterdam (ASCoR), Amsterdam, the Netherlands
Netherlands Expertise Center for Tobacco Control, Trimbos Institute, Utrecht, the Netherlands
Cancer Council Victoria, Melbourne, Australia
Tobacco Control Unit, Catalan Institute of Oncology (ICO), and Cancer Control and Prevention Group, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet, Catalonia, Spain
School of Medicine and Health Sciences, University of Barcelona, Catalonia, Spain
Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
Maria Sklodowska-Curie Institute - Oncology Center, Warsaw, Poland
Smoking or Health Hungarian Foundation (SHHF), Budapest, Hungary
University of Medicine and Pharmacy ‘Grigore T. Popa’ Iasi, Iasi, Romania
Aer Pur Romania, Bucharest, Romania
Karin Hummel   

Department of Health Promotion, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, the Netherlands
Publish date: 2018-12-21
Tob. Induc. Dis. 2018;16(Suppl 2):A6
*EUREST-PLUS consortium members: European Network on Smoking and Tobacco Prevention (ENSP), Belgium: Constantine I. Vardavas, Andrea Glahn, Christina N. Kyriakos, Dominick Nguyen, Cornel Radu-Loghin, Polina Starchenko University of Crete (UoC), Greece: Aristidis Tsatsakis, Charis Girvalaki, Chryssi Igoumenaki, Katerina Nikitara, Sophia Papadakis, Aikaterini Papathanasaki, Manolis Tzatzarakis, Alexander I. Vardavas Kantar Public (TNS), Belgium: Nicolas Bécuwe, Lavinia Deaconu, Sophie Goudet, Christopher Hanley, Oscar Rivière Smoking or Health Hungarian Foundation (SHHF), Hungary: Tibor Demjén, Judit Kiss, Piroska A. Kovacs Catalan Institut of Oncology (ICO); Bellvitge Biomedical Research Institute (IDIBELL), Spain: Esteve Fernández, Yolanda Castellano, Marcela Fu, Sarah O. Nogueira, Olena Tigova Kings College London (KCL), United Kingdom: Ann McNeill, Katherine East, Sara C. Hitchman Cancer Prevention Unit and WHO Collaborating Centre for Tobacco Control, German Cancer Research Center (DKFZ), Germany: Ute Mons, Sarah Kahnert University of Athens (UoA), Greece: Yannis Tountas, Panagiotis Behrakis, Filippos T. Filippidis, Christina Gratziou, Paraskevi Katsaounou, Theodosia Peleki, Ioanna Petroulia, Chara Tzavara Aer Pur Romania, Romania: Antigona C. Trofor, Marius Eremia, Lucia Lotrean, Florin Mihaltan European Respiratory Society (ERS), Switzerland; Goethe University Frankfurt, Germany: Gernot Rohde, Tamaki Asano, Claudia Cichon, Amy Far, Céline Genton, Melanie Jessner, Linnea Hedman, Christer Janson, Ann Lindberg, Beth Maguire, Sofia Ravara, Valérie Vaccaro, Brian Ward Maastricht University, the Netherlands: Marc Willemsen, Hein de Vries, Karin Hummel, Gera E. Nagelhout Health Promotion Foundation (HPF), Poland: Witold A. Zatoński, Aleksandra Herbeć, Kinga Janik-Koncewicz, Krzysztof Przewoźniak, Mateusz Zatoński University of Waterloo (UW); Ontario Institute for Cancer Research, Canada: Geoffrey T. Fong, Thomas K. Agar, Pete Driezen, Shannon Gravely, Anne C. K. Quah, Mary E. Thompson
There is clear evidence that the use of cessation aids significantly increases the likelihood of successful smoking cessation. The aim of this study was to examine quitting activity and use of cessation aids among smokers from various European countries. Subgroup differences were also examined for sex, income, education, and age in each country.

Cross-sectional data were collected in 2016 from 10683 smokers in eight European countries participating in the ITC Project: England (n=3536), Germany (n=1003), Greece (n=1000), Hungary (n=1000), the Netherlands (n=1136), Poland (n=1006), Romania (n=1001), and Spain (n=1001). We measured quitting activity, including quit attempts in the previous 12 months and intention to quit, use of cessation aids (i.e. medication, quitlines, internet, local services, e-cigarettes), and whether respondents had received advice from health professionals about quitting and e-cigarettes.

Quit attempts were most common in England (46.3%) and least common in Hungary (10.4%). Quit intention was highest in England and lowest in Greece. Use of e-cigarettes to quit was highest in England (51.6%) and lowest in Spain (5.0%). Use of cessation aids was generally low across all countries; in particular this was true for quitlines, internetbased support, and local services. Receiving health professional advice to quit was highest in Romania (56.5%), and lowest in Poland (20.8%); few smokers received advice about e-cigarettes from health professionals. No clear differences were found for sex and income groups. Across countries, smokers with lower education reported less quitting activity.

Quitting activity and use of cessation methods were low in most countries. Greater quit attempts and use of cessation aids were found in England, where large investments in tobacco control and smoking cessation have been made. Health professionals are important for motivating smokers to quit and promoting the effectiveness of various methods, but overall, few smokers get advice to quit.

World Health Organization. Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003.
Raw M, Ayo-Yusuf O, Chaloupka F, et al. Recommendations for the implementation of WHO Framework Convention on Tobacco Control Article 14 on tobacco cessation support. Addiction. 2017;112(10):1703-1708. doi:10.1111/add.13893
Pine-Abata H, McNeill A, Murray R, Bitton A, Rigotti N, Raw M. A survey of tobacco dependence treatment services in 121 countries. Addiction. 2013;108(8):1476- 1484. doi:10.1111/add.12172
Raw M, Regan S, Rigotti NA, McNeill A. A survey of tobacco dependence treatment services in 36 countries. Addiction. 2009;104(2):279-287. doi:10.1111/j.1360-0443.2008.02443.x
Nilan K, Raw M, McKeever TM, Murray RL, McNeill A. Progress in implementation of WHO FCTC Article 14 and its guidelines: a survey of tobacco dependence treatment provision in 142 countries. Addiction. 2017;112(11):2023-2031. doi:10.1111/add.13903
Raw M, Mackay J, Reddy S. Time to take tobacco dependence treatment seriously. Lancet. 2016;387(10017):412-413. doi:10.1016/s0140-6736(15)00950-2
West R, Raw M, McNeill A, et al. Health-care interventions to promote and assist tobacco cessation: a review of efficacy, effectiveness and affordability for use in national guideline development. Addiction. 2015;110(9):1388-1403. doi:10.1111/add.12998
Aveyard P, Begh R, Parsons A, West R. Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis to compare advice to quit and offer of assistance. Addiction. 2012;107(6):1066-1073. doi:10.1111/j.1360-0443.2011.03770.x
Patnode CD, Henderson JT, Thompson JH, Senger CA, Fortmann SP, Whitlock EP. U.S. Preventive Services Task Force Evidence Syntheses, Formerly Systematic Evidence Reviews. In: Behavioral Counseling and Pharmacotherapy Interventions for Tobacco Cessation in Adults, Including Pregnant Women: A Review of Reviews for the U.S. Preventive Services Task Force. Rockville, MD: Agency for Healthcare Research and Quality (US); 2015.
Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. The Cochrane Database of Systematic Reviews. 2016;3:CD008286. doi:10.1002/14651858.CD008286.pub3
Lam C, West A. Are electronic nicotine delivery systems an effective smoking cessation tool? Canadian Journal of Respiratory Therapy. 2015;51(4):93-98.
McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. The Cochrane Database of Systematic Reviews. 2014;(12):CD010216. doi:10.1002/14651858.CD010216.pub2
Ghorai K, Akter S, Khatun F, Ray P. mHealth for Smoking Cessation Programs: A Systematic Review. Journal of Personalized Medicine. 2014;4(3):412-423. doi:10.3390/jpm4030412
Warner KE, Mendez D. E-cigarettes: Comparing the Possible Risks of Increasing Smoking Initiation with the Potential Benefits of Increasing Smoking Cessation. Nicotine & Tobacco Research. 2018. doi:10.1093/ntr/nty062
Stead LF, Carroll AJ, Lancaster T. Group behaviour therapy programmes for smoking cessation. The Cochrane Database of Systematic Reviews. 2017;3:CD001007. doi:10.1002/14651858.CD001007.pub3
Filippidis FT, Gerovasili V, Vardavas CI, Agaku IT, Tountas Y. Determinants of use of smoking cessation aids in 27 European countries. Preventive Medicine. 2014;65:99-102. doi:10.1016/j.ypmed.2014.05.004
World Health Organization. Guidel ines for implementation of Article 14. Guidelines.pdf. Published, 2010. Accessed May 11, 2018.
Borland R, Li L, Driezen P, et al. Cessation assistance reported by smokers in 15 countries participating in the International Tobacco Control (ITC) policy evaluation surveys. Addiction. 2012;107(1):197-205. doi:10.1111/j.1360-0443.2011.03636.x
Filippidis FT, Laverty AA, Mons U, Jimenez-Ruiz C, Vardavas CI. Changes in smoking cessation assistance in the European Union between 2012 and 2017: pharmacotherapy versus counselling versus e-cigarettes. Tobacco Control. 2018. doi:10.1136/tobaccocontrol-2017-054117
Hiscock R, Bauld L, Amos A, Fidler JA, Munafo M. Socioeconomic status and smoking: a review. Annals of the New York Academy of Sciences. 2012;1248:107-123. doi:10.1111/j.1749-6632.2011.06202.x
Reid JL, Hammond D, Boudreau C, Fong GT, Siahpush M. Socioeconomic disparities in quit intentions, quit attempts, and smoking abstinence among smokers in four western countries: findings from the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research. 2010;12 Suppl1:S20-S33. doi:10.1093/ntr/ntq051
Kasza KA, Hyland AJ, Borland R, et al. Effectiveness of stop-smoking medications: findings from the International Tobacco Control (ITC) Four Country Survey. Addiction. 2013;108(1):193-202. doi:10.1111/j.1360-0443.2012.04009.x
Hyland A, Li Q, Bauer JE, Giovino GA, Steger C, Cummings KM. Predictors of cessation in a cohort of current and former smokers followed over 13 years. Nicotine & Tobacco Research. 2004;6 Suppl 3:S363-S369. doi:10.1080/14622200412331320761
ITC Project. International Tobacco Control Policy Evaluation Project. 2018. Accessed June 6, 2018.
Thompson ME, Fong GT, Hammond D, et al. Methods of the International Tobacco Control (ITC) Four Country Survey. Tobacco Control. 2006;15 Suppl 3:iii12-iii18. doi:10.1136/tc.2005.013870
Fong GT, Cummings KM, Borland R, et al. The conceptual framework of the International Tobacco Control (ITC) Policy Evaluation Project. Tobacco Control. 2006;15 Suppl 3:iii3-iii11. doi:10.1136/tc.2005.015438
Vardavas CI, Bécuwe N, Demjén T, et al. Study Protocol of European Regulatory Science on Tobacco (EURESTPLUS): Policy implementation to reduce lung disease. Tobacco Induced Diseases. 2018;16(Suppl 2:A2). doi:10.18332/tid/93305
European Commission. Special Eurobarometer 458. “Attitudes of Europeans towards tobacco and electronic cigarettes”. publication-detail/-/publication/2f01a3d1-0af2-11e8- 966a-01aa75ed71a1/language-en. Published, 2017. Accessed May 11, 2018.
Joossens L, Raw M. The Tobacco Control Scale 2016 in Europe. https://www.tobaccocontrolscal... uploads/2017/03/TCS-2016-in-Europe-COMPLETELoRes. pdf. Published, 2017. Accessed May 11, 2018.
Fong GT, Thompson ME, Boudreau C, et al. The Conceptual Model and Methods of Wave 1 (2016) of the EUREST-PLUS ITC 6 European Countries Survey. Tobacco Induced Diseases. 2018;16(Suppl 2:Α3). doi:10.18332/tid/99881
ITC Project. International Tobacco Control Policy Evaluation Survey (ITC). Four Country Project. Waves 2-8 Technical Report. sept2011.pdf. Published, 2011. Accessed May 11, 2018.
ITC Project. Technical Report United Kingdom. https:// Published, 2018. Accessed May 11, 2018.
Nagelhout GE, Willemsen MC, Thompson ME, Fong GT, Van den Putte B, De Vries H. Is web interviewing a good alternative to telephone interviewing? Findings from the International Tobacco Control (ITC) Netherlands survey. BMC Public Health. 2010;10:351. doi:10.1186/1471-2458-10-351
Zethof D, Nagelhout GE, De Rooij M, et al. Attrition analysed in five waves of a longitudinal yearly survey of smokers: findings from the ITC Netherlands survey. European Journal of Public Health. 2016;26(4). doi:10.1093/eurpub/ckw037
ITC Project. Technical Report Netherlands. https://www. Published, 2018. Accessed May 11, 2018.
Hummel K, Candel M, Nagelhout GE, et al. Construct and predictive validity of three measures of intention to quit smoking: Findings from the International Tobacco Control (ITC) Netherlands Survey. Nicotine & Tobacco Research. 2017;20(9). doi:10.1093/ntr/ntx092
Durkin S, Brennan E, Wakefield M. Mass media campaigns to promote smoking cessation among adults: an integrative review. Tobacco Control. 2012;21(2):127- 138. doi:10.1136/tobaccocontrol-2011-050345
Ross H, Blecher E, Yan L, Hyland A. Do cigarette prices motivate smokers to quit? New evidence from the ITC survey. Addiction. 2011;106(3):609-619. doi:10.1111/j.1360-0443.2010.03192.x
Filippidis FT, Tzoulaki I. Greece giving up on tobacco control. Addiction. 2016;111(7):1306-1307. doi:10.1111/add.13357
Hammond D, McDonald PW, Fong GT, Borland R. Do smokers know how to quit? Knowledge and perceived effectiveness of cessation assistance as predictors of cessation behaviour. Addiction. 2004;99(8):1042-1048. doi:10.1111/j.1360-0443.2004.00754.x
Fu SS, Burgess D, van Ryn M, Hatsukami DK, Solomon J, Joseph AM. Views on smoking cessation methods in ethnic minority communities: a qualitative investigation. Preventive Medicine. 2007;44(3):235-240. doi:10.1016/j.ypmed.2006.11.002
Papadakis S, Hurtubise R, Galley S, et al. Tobacco users knowledge, attitudes, and barriers regarding quit smoking support: a cross-sectional survey. Submitted.
Edwards SA, Bondy SJ, Callaghan RC, Mann RE. Prevalence of unassisted quit attempts in populationbased studies: a systematic review of the literature. Addictive Behaviors. 2014;39(3):512-519. doi:10.1016/j.addbeh.2013.10.036
Papadakis S, McDonald P, Mullen KA, Reid R, Skulsky K, Pipe A. Strategies to increase the delivery of smoking cessation treatments in primary care settings: a systematic review and meta-analysis. Preventive Medicine. 2010;51(3-4):199-213. doi:10.1016/j.ypmed.2010.06.007
van Rossem C, Spigt MG, Kleijsen JR, Hendricx M, van Schayck CP, Kotz D. Smoking cessation in primary care: Exploration of barriers and solutions in current daily practice from the perspective of smokers and healthcare professionals. The European Journal of General Practice. 2015;21(2):111-117. doi:10.3109/13814788.2014.990881
Johnston KN, Young M, Grimmer-Somers KA, Antic R, Frith PA. Why are some evidence-based care recommendations in chronic obstructive pulmonary disease better implemented than others? Perspectives of medical practitioners. International Journal of Chronic Obstructive Pulmonary Disease. 2011;6:659-667. doi:10.2147/copd.s26581
van Eerd EAM, Bech Risor M, Spigt M, et al. Why do physicians lack engagement with smoking cessation treatment in their COPD patients? A multinational qualitative study. NPJ Primary Care Respiratory Medicine. 2017;27(1):41. doi:10.1038/s41533-017-0038-6
Martinez C. Barriers and challenges of implementing tobacco control policies in hospitals: applying the institutional analysis and development framework to the Catalan Network of Smoke-Free Hospitals. Policy, Politics & Nursing Practice. 2009;10(3):224-232. doi:10.1177/1527154409346736
West R, DiMarino ME, Gitchell J, McNeill A. Impact of UK policy initiatives on use of medicines to aid smoking cessation. Tobacco Control. 2005;14(3):166-171. doi:10.1136/tc.2004.008649
Gravely S, Thrasher JF, Cummings KM, et al. Discussions between health professionals and smokers about e-cigarettes: Results from the ITC Four Country Tobacco and E-Cigarette Survey. Submitted.
Giskes K, Kunst AE, Benach J, et al. Trends in smoking behaviour between 1985 and 2000 in nine European countries by education. Journal of Epidemiology and Community Health. 2005;59(5):395-401. doi:10.1136/jech.2004.025684
Siahpush M, McNeill A, Borland R, Fong GT. Socioeconomic variations in nicotine dependence, selfefficacy, and intention to quit across four countries: findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control. 2006;15 Suppl 3:iii71-iii75. doi:10.1136/tc.2004.008763
Hummel K, Nagelhout GE, Willemsen MC, et al. Trends and socioeconomic differences in policy triggers for thinking about quitting smoking: Findings from the International Tobacco Control (ITC) Europe Surveys. Drug and Alcohol Dependence. 2015;155:154-162. doi:10.1016/j.drugalcdep.2015.07.678
Kasza KA, Hyland AJ, Borland R, et al. Cross-country comparison of smokers’ reasons for thinking about quitting over time: findings from the International Tobacco Control Four Country Survey (ITC-4C), 2002-2015. Tobacco Control. 2017;26(6):641-648. doi:10.1136/tobaccocontrol-2016-053299
van den Brand FA, Nagelhout GE, Reda AA, et al. Healthcare financing systems for increasing the use of tobacco dependence treatment. The Cochrane Database of Systematic Reviews. 2017;9:CD004305. doi:10.1002/14651858.CD004305.pub5
Trofor AC, Man MA, Marginean C, Dumitru F, Trofor L. Smoking cessation for free: outcomes of a study of three Romanian clinics. Open Medicine. 2016;11(1):605-610. doi:10.1515/med-2016-0098
Hyland A, Borland R, Li Q, et al. Individual-level predictors of cessation behaviours among participants in the International Tobacco Control (ITC) Four Country Survey. Tobacco Control. 2006;15 Suppl 3:iii83-iii94. doi:10.1136/tc.2005.013516
Zhang X, Cowling DW, Tang H. The impact of social norm change strategies on smokers’ quitting behaviours. Tobacco Control. 2010;19 Suppl 1:i51-i55. doi:10.1136/tc.2008.029447
Feliu A, Filippidis FT, Joossens L, et al. Impact of tobacco control policies on smoking prevalence and quit ratios in 27 European Union countries from 2006 to 2014. Tobacco Control. 2018. doi:10.1136/tobaccocontrol-2017-054119
Levy DT, Tam J, Kuo C, Fong GT, Chaloupka F. The Impact of Implementing Tobacco Control Policies: The 2017 Tobacco Control Policy Scorecard. Journal of Public Health Management and Practice. 2018;24(5). doi:10.1097/phh.0000000000000780
Hartmann-Boyce J, Chepkin SC, Ye W, Bullen C, Lancaster T. Nicotine replacement therapy versus control for smoking cessation. The Cochrane Database of Systematic Reviews. 2018:CD000146. doi:10.1002/14651858.CD000146.pub5
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