Trends in motives for trying to stop smoking: a population study in England, 2018–2023

Introduction

Health concerns are generally the primary motive for people trying to stop smoking.1 Social (eg, family pressure, effects on others, a friend or family member wanting to quit) and financial concerns and advice from a health professional are also commonly cited reasons for wanting to quit.1 However, since 2020, England has undergone a period of substantial societal instability, which might have caused people’s motives for trying to stop smoking to change. Understanding the factors motivating people to stop smoking, how they differ between key population groups and how this is changing over time is important for informing interventions to encourage and aid smoking cessation.2

From early 2020, the COVID-19 pandemic introduced a new health risk, which for people living in many countries around the world resulted in prolonged periods of reduced social contact and for some, isolation, and left many people experiencing financial strain.3

In England specifically, there has also been a series of economic and monetary policy changes that have led to a period of financial instability and stress. Since late 2021, there has been a cost-of-living crisis in the UK, whereby high rates of inflation have caused the cost of everyday essentials, like groceries, energy and household bills, to rise faster than average household incomes.4 Inconsistent government leadership and subsequent financial budgets also created a shock in financial markets, which saw the value of the pound fall and the cost of government borrowing and mortgage interest rates rise sharply.5 In addition, an ongoing healthcare crisis has seen increased pressures on the NHS and across the healthcare and social care sector, resulting in substantial delays for patients seeking emergency and primary care.6 It is possible that these pressures have increased the salience of the health risks associated with smoking and boosted people’s motivation (whether based on want or need) to stop smoking to save money. There has been a sustained rise in the proportion of smokers making attempts to quit since the start of the pandemic, which might have prompted others to also try to quit.7 It is also possible that delays and difficulties in accessing healthcare might have reduced the proportion of attempts to quit that are motivated by advice from a general practitioner (GP) or other health professional.

The impacts of the pandemic and other recent events have not been experienced equally across the population. For example, older adults were at higher risk of becoming seriously ill or dying from COVID-19,8 while younger adults experienced greater social and financial impacts,9 10 and women disproportionately carried the burden of additional care.11 12 The cost-of-living crisis has seen particularly high rates of food insecurity in households with children and those receiving state benefits.13 More recently, the healthcare crisis is likely to disproportionately affect groups who seek emergency care more frequently, including older adults and people from deprived areas.14 As a result, any increases in wanting to stop smoking for health or financial reasons might have been greater among these population subgroups. There have also been dramatic recent shifts in the prevalence of vaping in England and harm perceptions,15–17 and given the majority of people who vape are also current or recent ex-smokers, there might have been important changes in motives to quit smoking as a function of vaping status.

This study aimed to estimate time trends in motives for trying to stop smoking between 2018 and 2023 and explore differences by key potential moderators. Specifically, we aimed to address the following research questions:

1. How have the proportions of attempts to stop smoking that are motivated by (a) health concerns, (b) cost, (c) social factors and (d) health professional advice changed over the past 5 years?

2. To what extent have changes in motives for attempts to stop smoking differed by age, gender, socioeconomic position (indexed by occupational social grade), presence of children in the household and vaping status?

Materials and methods

Results

There was a total of 101 919 respondents to the survey between March 2018 and May 2023. Of the 17 812 who reported smoking in the past year, 17 031 (95.6%) provided data on past-year attempts to quit, among whom 5777 (33.9%) reported having made at least one serious attempt to quit in the past year and formed our sample for analysis.

Overall estimates of motives for trying to stop smoking

Table 1 shows the proportion who reported each motive as contributing to their most recent attempt to quit, across the study period. Health concerns were most frequently reported (52.0%)—in particular, concerns about future health (35.5%). Cost was the next most frequent motive (22.7%), followed by social factors (19.0%) and health professional advice (11.6%). Other motives were endorsed by between 0.6% and 3.7% of participants.

Table 1

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Proportion reporting each factor as a motive driving the most recent attempt to quit smoking

Table 2 shows the proportion reporting the four most popular motives within participant subgroups, across the study period. While health concerns were consistently the most common motive for trying to stop smoking, reported by around half (range 47.6–55.9%) of participants in all subgroups, they were slightly more frequently reported by those aged over 35 and those without children in the household. Current health problems were more frequently reported as a motive by older (vs younger) adults, women (vs men) and those from less (vs more) advantaged social grades, while the opposite was observed for future health concerns. Those without children in the household were more frequently motivated by both current and future health concerns than those with children at home. Cost was more frequently reported as a motive by those from intermediate social grades (C1, C2 and D) and by those who reported current vaping. Social factors were more frequently reported by those who were younger, from mid-range social grades, had children in the household and reported current vaping. Health professional advice was reported more frequently by those who were older, women and from less advantaged social grades. The contrasting age gradients in the proportions of attempts to quit motivated by social factors and health professional advice meant that, of the two motives, health professional advice more frequently motivated attempts to quit among those aged over 55, while social factors more frequently motivated those aged 18–54.

Table 2

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Proportion reporting key motives driving the most recent attempt to quit smoking by participant characteristics

Time trends in motives to stop smoking

Figure 1 shows modelled monthly trends in motives to stop smoking and table 3 compares modelled estimates from March 2018 and May 2023 (the first and last months in the time series). Up to the start of 2020, one in two attempts to quit were motivated by health concerns (mean modelled monthly proportion, March 2018 to December 2019 = 51.0%); one in five by current health problems (20.1%) and one in three by concern about future health (33.8%). One in five was motivated by social factors (20.2%) and cost (19.9%) and one in six by health professional advice (16.5%).

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Figure 1

Time trends in motives for attempts to stop smoking, March 2018 to May 2023. Panels show the proportion of past-year smokers in England reporting that their most recent attempt to quit was motivated by (A) health concerns (current health problems, future health concerns, the coronavirus outbreak or pregnancy), (B) current health problems, (C) future health concerns, (D) cost, (E) social factors and (F) health professional advice. Lines represent modelled weighted prevalence by survey month, modelled non-linearly using restricted cubic splines (five knots). Shaded bands represent standard errors. Points represent observed quarterly weighted prevalence.

Table 3

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Modelled weighted estimates of the proportion of attempts to quit smoking motivated by health concerns, cost, social factors and health professional advice in March 2018 and May 2023

There was little overall change in the proportion of attempts to quit that were motivated by health concerns from the start to the end of the study period (PR=0.99, 95% CI 0.86 to 1.14; table 3). However, there were changes over time within this period: the proportion reporting health concerns as a motive for their most recent attempt to quit increased during 2020, peaking at 56.2% in October 2020, then returning to baseline by the end of 2021 (figure 1A). This pattern was largely driven by future health concerns (figure 1C), with negligible change over time in attempts to quit motivated by current health problems (figure 1B). Time trends differed significantly by age (interaction p=0.013; online supplemental figure 1A), social grade (interaction p=0.023; online supplemental figure 1C) and the presence of children in the household (interaction p=0.002; online supplemental figure 1D). Those aged ≥65 years and those from the most disadvantaged social grade (E) showed (i) a more pronounced rise in 2020 than those who were younger and from more advantaged social grades; and (ii) evidence of a further increase since early 2022 that was not observed among younger and more advantaged groups. Those without children in the household reported being motivated by health concerns more frequently than those with children in the household at the start of the study period, but the gap narrowed during 2020.

The proportion of attempts to quit that were motivated by cost increased significantly over the study period, from 19.1% in March 2018 to 25.4% in May 2023 (PR=1.33, 95% CI 1.01 to 1.76; table 3). This rise was non-linear: the proportion of attempts to quit motivated by cost changed very little up to 2020, increased during 2020 (peaking at 25.8% in November 2020), declined slightly during 2021 and subsequently increased from early 2022 (figure 1D). Time trends differed significantly by gender (interaction p=0.035), with cost-motivated attempts to quit increasing between 2018 and 2019 among men but declining among women, and increasing from early 2022 among women but not men (online supplemental figure 2B).

There was an uncertain decline in the proportion of attempts to quit that were motivated by social factors, from 21.6% in March 2018 to 16.0% in May 2023 (PR=0.74, 95% CI 0.54 to 1.01; table 3). Again, the trend was non-linear, with an increase during 2020 (peaking at 23.9% in August 2020) and subsequent decline during 2021 (figure 1E). There was a significant interaction with social grade (p<0.001), with the proportion of attempts to quit motivated by social factors (i) increasing between 2018 and 2019 among the most advantaged groups (AB and C1) but falling among less advantaged groups (C2 and D); (ii) showing a rise during 2020 only among the mid-range social grades (C1, C2 and D); and (iii) changing very little over the study period among the most disadvantaged group (E; online supplemental figure 3C). The rise during 2020 also appeared to be more pronounced among men online supplemental figure 3B) and those with children in the household (online supplemental figure 3D), but interactions were not statistically significant (p=0.053 and p=0.055, respectively).

The proportion of attempts to quit that were motivated by health professional advice declined significantly over the study period, from 14.2% in March 2018 to 8.5% in May 2023 (PR=0.60, 95% CI 0.40 to 0.89; table 3). It increased early in the study period, peaking at 18.4% in February 2019, then fell to 8.0% by the end of 2020, remaining relatively stable (between 8.0% and 10.3%) thereafter (figure 1F). Time trends differed significantly by gender (interaction p=0.015) and social grade (interaction p=0.012; online supplemental figure 4C). The early increase in the proportion of attempts to quit motivated by health professional advice was observed only among men (online supplemental figure 4B) and those from social grades C2 and D (the second and third least advantaged groups; online supplemental figure 4C). The subsequent fall during 2019 and 2020 appeared absent among the most and least advantaged social grades (AB and E; online supplemental figure 4C).

Discussion

Adults in England try to stop smoking for a variety of reasons. In line with previous studies,1 we found that health concerns were consistently the most common factor motivating people to try to quit. The cost of smoking, social factors such as pressure from family and friends and advice from a GP or other health professional were also frequently reported. However, we observed changes in the relative contribution of these different motives to attempts to quit over recent years. Up to 2020, one in two attempts to quit were motivated by health concerns (one in three by concern about future health and one in five by current health problems), one in five by social factors and by cost and one in six by health professional advice. In 2020, the proportion of attempts to quit motivated by health concerns (driven by concern about future health), social factors and cost increased—to highs of 56.2%, 23.9% and 25.8%, respectively—and the proportion motivated by health professional advice fell to 8.0%. Rises in health-related and social motives were short-lived: the former soon returned to baseline levels and the latter fell below baseline. However, the proportion of attempts to quit motivated by cost increased further during 2022–2023 (reaching 25.4% in May 2023) and the proportion motivated by health professional advice remained suppressed.

Many of these changes are likely to have been driven by the COVID-19 pandemic, which began to affect England in March 2020. The timing of the onset of the pandemic coincided with rises in the proportion reporting health concerns (driven by concern for future health), social factors and cost as motives for trying to stop smoking. It is likely the pandemic made health concerns (an already prevalent motive) even more salient, particularly during its first year when the virus was spreading rapidly and vaccinations were not yet available. Consistent with this, we saw a more pronounced rise in attempts to quit motivated by health concerns among the oldest age group (≥65 years), who had the highest risk of mortality from COVID-19,8 and among those from the most disadvantaged occupational social grade, who were more likely to have pre-existing comorbidities (eg, diabetes26) linked to poor COVID-19 outcomes.27 Once the immediate threat of the virus had been attenuated via the vaccination programme, the proportion of health-related attempts to quit returned to pre-pandemic levels.

Concerns about the health risks of COVID-19 might also have led to the short-term rise in the prominence of social factors in motivating attempts to quit, if they prompted people to encourage their loved ones to try to stop smoking or if people were motivated to try to quit by others around them doing the same.7 The rise in attempts to quit motivated by social factors was more pronounced among mid-range social grades, who were less able to work remotely (and thus avoid exposure to infection), which might have caused concern for family and friends during the early stages of the pandemic.

Beyond its immediate risk to health, the pandemic also had wider implications. Social distancing, self-isolation and travel restrictions resulted in a reduced workforce across sectors, causing loss of income and jobs for many people.28 These economic pressures probably contributed to the rise in cost-motivated attempts to quit around this time. But while the pandemic’s acute risks to health—and, as a result, attempts to quit motivated by concern for health or social factors—waned over time, its economic impacts have been compounded by a cost-of-living crisis.4 This crisis has seen household budgets stretched as the cost of essentials has risen rapidly since late 2021, which coincides with the timing of the further, post-pandemic rise in cost-motivated attempts to quit that we observed.

Additionally, the pandemic had a substantial impact on healthcare delivery: general practice shifted to a remote delivery model to mitigate the risk of infection, lack of capacity in secondary care increased demand on GPs,29 and acute and urgent care were prioritised over prevention and chronic disease management.30 There was also evidence of patients delaying presentation to healthcare services.31 These circumstances might have contributed to the decline in 2020 in the proportion of attempts to quit that were motivated by health professional advice, which remained suppressed through to 2023. Healthcare services continued to be pushed to their limits as they attempted to tackle long waiting lists that built up before and during the early stages of the pandemic, while continuing to provide care to the high numbers of patients with COVID-19.29 This resulted in long delays to accessing healthcare, which a report by the House of Lords Public Services Committee in January 2023 described as ‘a national emergency’. In the context of this ongoing healthcare crisis, the proportion of attempts to quit motivated by health professional advice has remained low—in addition to delays, health professionals might have less time or feel less able to deliver advice remotely—and the proportion motivated by health concerns has increased among the oldest and most socioeconomically disadvantaged groups (who tend to have poorer health and therefore likely to be most affected by difficulty in accessing treatment).

These findings have implications for smoking cessation interventions and clinical practice. First, they indicate that cost is an increasingly important factor motivating people to try to stop smoking. Communicating the potential savings people can make by stopping smoking (even if they switch to alternative nicotine products32 33) could therefore be an effective means for motivating attempts to quit. Second, they highlight a decline in attempts to quit motivated by health professional advice. It is not clear whether this is the result of missed opportunity (ie, health professionals having reduced contact with smokers) or reduced motivation or capability (ie, health professionals not feeling motivated or able to offer advice and support for smoking cessation when seeing patients). Given attempts to quit motivated by health professional advice have remained low since the start of the pandemic while changes in those motivated by health concerns and social factors have rebounded, it seems likely to be related to the wider issues the NHS is facing rather than only the direct impacts of the pandemic. Whatever the cause may be, it is noteworthy in the context of previous research showing that attempts motivated by health professional advice are more likely to involve the use of evidence-based treatments.2

Conclusion

Health concerns remain the most common motive for trying to stop smoking. The relative importance of other motives has shifted since 2020, with cost motivating a greater proportion of attempts to quit and social factors and health professional advice motivating a smaller proportion.