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Smoking Cessation in Ontario: Increasing Cessation Rates by Increasing Quit Attempts


I Introduction
II Smoking Cessation in Ontario
III A Population-based Model for Smoking Cessation
IV Opportunities to Increase Quit Attempts in Ontario
V Conclusion
VI References

-- Submitted by Steven Savvaidis, Manager, Program Training and Consultation Centre (PTCC)

I Introduction

Smoking rates in Ontario have declined substantially over the past decades but have stalled in recent years. In 2013, approximately 17% of Ontarians 12 years of age and older were current smokers (i.e., daily or occasional smokers) representing approximately two million people. [1] The Ontario government has set the ambitious target of becoming the province with the lowest smoking prevalence in Canada. [2] Among Canadian provinces and territories, British Columbia has the lowest current smoking rate at 15 percent. [1]

II Smoking Cessation in Ontario

A key goal of comprehensive tobacco control is to increase the population cessation rate. The Ontario Tobacco Research Unit has estimated Ontario’s cessation rate, that is, the proportion of smokers who remain quit for twelve months, to be only 1.9%. [1] This cessation rate has remained unchanged for many years. The OTRU has estimated that the provincial smoking cessation rate would need to double in order to achieve a five percentage point reduction in smoking prevalence, a five-year target set in 2010 by the provincial Tobacco Strategy Advisory Group. [3,4] This five percentage point reduction is equivalent to 490,000 fewer smokers in Ontario. [4]

III A Population-based Model for Smoking Cessation

Dr. Shu-Hong Zhu, a leading tobacco control researcher from the University of California, San Diego School of Medicine, has examined cessation rates in the United States and other jurisdictions. Dr. Zhu’s research concludes that the strongest driver of population cessation is the quit attempt rate. [5]  

While cessation treatments such as pharmacotherapy and counselling have been shown to be effective at increasing quitting success, the high cost and low reach of these interventions means that they are unlikely to influence the provincial cessation rate. In Ontario it is estimated that clinical treatment services funded under the Smoke-Free Ontario Strategy reach only about 5% of smokers. [1] By comparison increasing the rate of quit attempts is more amenable to change given that most smokers quit on their own without the aid of formal treatment and most will need to make repeated quit attempts before succeeding. [6,7] The OTRU has estimated that it takes an average of 30 quit attempts over a smokers’ lifetime before quitting successfully. [8]

It is therefore imperative that smokers be encouraged to quit and to quit again as soon as possible after relapse. According to Dr. Zhu, smokers should be encouraged to step on to the “quit machine” and keep cycling though this machine by making repeated quit attempts. [7] Jurisdictions need to invest in strategies that can increase the output of this quit machine (i.e., increase rate of quit attempts) and avoid any actions which may inadvertently slow it down (i.e., reduce the rate of quit attempts). The promotion of cessation medications in a manner which suggests that they are necessary for quitting success may have the unintended effect of reducing smokers’ confidence in their ability to quit on their own and could affect the rate of quitting in the population. [5]

IV Opportunities to Increase Quit Attempts in Ontario

Smokers’ interest in quitting remains high with over half of Ontario smokers reporting intentions to quit in the next six months. However, only four in ten smokers in Ontario report making a quit attempt in the past year. [1] Among those who make quit attempts, the frequency of making multiple attempts is even smaller. Data from the Canadian Tobacco Use Monitoring Survey indicates that only one in three Canadian smokers made repeated quit attempts in the past year. [9] A number of policy, program and media interventions hold promise for increasing the rate of quit attempts. Many of these actions can be implemented or supported at the community level.

Tax Increases

Raising the price of tobacco products through tobacco taxes has been consistently shown to reduce tobacco consumption and encourage smokers to quit. Youth and those of lower socio-economic status are especially price sensitive. [10] The World Health Organization’s Framework Convention on Tobacco Control MPOWER measures recommend that tobacco taxes constitute more than 75% of the total price of tobacco products. [11] In Ontario, the price of a carton of cigarettes is the second lowest in all of Canada and tobacco taxes account for only 67% of the total retail price. [12]

Continued Expansion of Smoke-free Spaces

In addition to reducing physical and social exposure to tobacco use, smoke-free policies can also support smoking cessation. Smoke-free workplace policies are associated with reduced tobacco consumption, increased quit intentions, quit attempts, and reduced relapse. [10] Smoking bans in the home have also been associated with cessation outcomes and some studies have suggested even stronger cessation effects for smoke-free homes policies than for smoke-free workplace policies. [13] While tremendous progress has been made in Ontario to reduce involuntary exposure to second-hand smoke, exposure remains high in multi-unit dwellings, blue collar worksites, building entranceways, and some outdoor settings. [1]

Public Education Campaigns

Public education campaigns have been shown to increase quit attempts and increase population cessation rates. [14] Evidence has shown that messages that communicate the negative health effects of smoking and elicit a strong emotional response through the use of testimonials and graphic imagery are more effective at promoting recall and in motivating quitting behavior. A recent mass media campaign conducted by the Centres for Disease Control (CDC) in the United States featuring testimonials from former smokers about the serious harms they experienced from smoking was found to be effective, resulting in over 1.6 million quit attempts and over 100,000 quit attempts lasting at least six months. [15] There are many opportunities for local communities to use paid and earned media to extend the messages of larger campaigns that may be implemented at a provincial level. State-wide and local partnerships were critical to securing additional media coverage, both paid and earned, for the CDC campaign, contributing to the overall success of the campaign.

Brief Cessation Advice by Health Care Providers

Even a brief three-minute intervention delivered by a physician, pharmacist, dentist or other health care provider can encourage quit attempts and support cessation. [16] Evidence-based guidelines have been developed which encourage clinicians to intervene with smokers such as the 5As (Ask, Advise, Assess, Assist, Arrange), and simplified versions such as Ask, Advise, Refer. Brief cessation advice has the potential to reach large numbers of smokers. Only 60% of smokers in Ontario report being advised to quit by their doctor. Intervention rates among dentists and pharmacists are even lower. [1] In addition to providing smoking cessation counseling training to health care professionals, routine cessation counselling is more likely to occur when it becomes a standard of care and is incorporated into electronic medical records and organizational policies and procedures. [16] 

V Conclusion

Increasing the number of smokers in Ontario who make quit attempts is critical for achieving further declines in smoking prevalence. Policy, program and media interventions can promote quit attempts and drive up smoking cessation rates in Ontario. Local communities can participate in many of these actions and have a key role to play in motivating smokers to make a quit attempt.

VI References

1. Ontario Tobacco Research Unit. Smoke-free Ontario Strategy Monitoring Report. Toronto: Ontario Tobacco Research Unit, 2015.
2. Government of Ontario. Patients First: Action Plan for Health Care, 2015. Available at:
3. Ontario Tobacco Research Unit. Smoke-free Ontario Strategy Monitoring Report. Toronto: Ontario Tobacco Research Unit, 2014.
4. Tobacco Strategy Advisory Group. Building on Our Gains, Taking Action Now: Ontario’s Tobacco Strategy for 2011-2016. Toronto: Ontario Ministry of Health Promotion, 2010 Available at:
5. Zhu SH, Lee M, Zhuang YL, Gamst A, Wolfson T. Interventions to Increase Smoking Cessation at the Population Level: How Much Progress Has Been Made in the Last Two Decades? Tob Control 2012; 21(2):110-118.
6. Edwards SA, Bondy SJ, Callaghan R, Mann RE. Prevalence of unassisted quit attempts in population-based studies: a systematic review of the literature. Addictive Behaviours 2014; 39: 512-519.
7. Roeseler A, Andersen CM, Hansen K, Arnold M, Zhu SH. Creating Positive Turbulence. A Tobacco Quit Plan for California. Sacramento, California. California Department of Public Health, California Tobacco Control program, 2009. Available at:
8. Ontario Tobacco Research Unit. Infographic – Smoking Cessation in Ontario, 2013. Available at:
9. Reid JL, Hammond D, Rynard VL, Burklater R. Tobacco use in Canada: Patterns and Trends, 2014 Edition. Waterloo, ON: Propel Centre for Population Health Impact, University of Waterloo; 2015.
10. Smoke-Free Ontario- Scientific Advisory Committee. Evidence to Guide Action: Comprehensive Tobacco Control in Ontario.  Toronto, ON: Ontario Agency for Health Protection and Promotion, 2010.
11. World Health Organization. WHO Report on the Global Tobacco Epidemic. Raising Taxes on Tobacco. Luxembourg: World Health Organization, 2015.
12. Cancer Care Ontario. The Prevention System Quality Index: an inaugural report evaluating Ontario’s efforts in cancer prevention. Toronto: Queen’s Printer for Ontario, 2015.
13. Mills A, Messer K, Gilpin EA, Pierce J. The effect of smoke-free homes on adult smoking behavior: a review. Nicotine and Tobacco Research 2009; 11(10): 1131-1141.
14. Durkin S, Brennan E, Wakefield M. Mass media campaigns to promote smoking cessation among adults: an integrative review. Tobacco Control2012; 21:127-138.
15. McAfee T, Davis KC, Alexander Jr R, Pechacek T, Bunnell R. Effect of the first federally funded US antismoking national media campaign. The Lancet. Published online Sept 9, 2013:
16. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service; May 2008.

[Updated October 2, 3:15 p.m. to remove resources list]