Ten years of Stoptober
Jamie Brown, University College London, and Martin Dockrell, Public Health England, reflect on the Stoptober national smoking cessation campaign as it enters its tenth year.
Stoptober is a national smoking cessation campaign led by Public Health England that encourages smokers to start by abstaining from smoking for 28 days during the month of October. In England, it is now entering its tenth year having been first implemented in 2012, and versions have since been adopted in other countries, including New Zealand, the Netherlands, and France, following a positive evaluation of the first campaign1.
Development of Stoptober
Research from the Smoking Toolkit Study (STS) provided two foundations to the first campaign: first was an 2007-2009 STS evaluation that ‘No Smoking Day’ had cost-effectively generated 238,000 attempts to stop2. Secondly, STS trends identified that Autumn in England was a period with less quitting activity. This led to the idea of a national campaign to generate a burst of activity around that time.
Stoptober campaigns, originally run by the Department of Health in England, set people the challenge of being smoke-free for 28 days starting on 1 October. Campaigns emphasising “harms” were well established, but Stoptober emphasised “hope”. The call to action was reinforced by the positive message that smokers achieving 28 days abstinence are typically five times more likely to become permanent ex-smokers than they were at the start, having recovered from the worst of the cravings and withdrawal symptoms.
The campaign also aimed to help people achieve a difficult behavioural goal (stopping completely) by beginning with a realistic intermediary goal (28 days smokefree), which was objective, well-specified and bound to a particular target date. The approach was first used in a smartphone app called SmokeFree28 that Robert West and colleagues developed3. The app asked users to record whether they had smoked each day, visualised progress towards their 28-day goal and provided digital quitting tools. A promising preliminary evaluation showed that of 1,170 app users who met the inclusion criteria, 18.9% abstained from smoking for ≥ 28 days, compared with an estimated 15% quitting success rate for people who were unaided in their attempts to give up smoking3.
Stoptober was a campaign with a strong theoretical basis and materials were informed by the PRIME theory of motivation4. The theory, which recognises that the motivational system is inherently unstable and requires constant balancing input to maintain adaptive behaviour patterns, informed the decision to provide a wide variety of easily available support to help smokers achieve a smokefree month.
An evaluation of the first Stoptober campaign used data on quit attempts from more than 30,000 past-year smokers1, collected during nationally representative monthly household surveys between 2007 and 2012 as part of the STS. The effectiveness of the campaign was assessed by estimating the increase in national quit attempt rate in October relative to other months in 2012 vs. 2007 to 2011. In 2012, there was an approximately 50% increase in quitting during October compared with other months of the same year, whereas in 2007 to 2011 the rate in October was less than in other months of the same period.
In just one month, Stoptober 2012 was estimated to have generated an additional 350,000 quit attempts. Using a standard model for calculating the cost-effectiveness of smoking cessation interventions with the conservative assumption that only 2.5% of these attempts would result in permanent success, saved 10,400 discounted life years (DLY) at less than £415 per DLY in the modal age group (35 to 44) and less than £560 per DLY for the overall population1. Life years gained in the future (in this case from stopping smoking) are standardly discounted to reflect the reduced value of extended life being realised in the future rather than immediately. These estimates compared favourably with other estimates concerning UK anti-tobacco campaigns, which have, for example, ranged between £40 and £2,000 per DLY gained5 6. A further evaluation published in 2020 of subsequent campaigns indicated a prolonged effect over at least the first six years of Stoptober in England7. The effect appeared greater when the campaign budgets were higher compared with lower campaign spending.
Stoptober in a changing world
A lot has changed since Stoptober ran for the first time in 2012. A total of 19.3% of all adults aged 18 and over were smoking in 2012. In 2019, the most recent year for which we have an official estimate, the figure is now almost a third lower, at just 13.9%. This is a huge reduction in the prevalence of people who smoke in England. Since the beginning of Stoptober, there have been 1.4 billion fewer cigarettes smoked per year largely because of quitters and people reducing the number of cigarettes they smoke8.
The profile of who smokes has also changed during that time. In a detailed analysis of current smokers across a similar period from 2008 to 2017 in England, there was a decline in cigarette dependence (indicated by fewer cigarettes smoked a day and longer time to smoke the first cigarette)9. There were increases in the proportions of people who were non-daily smokers and used roll-your-own cigarettes. Use of e-cigarettes increased, while nicotine replacement therapy decreased. The proportion of people cutting down or making a quit attempt in the past year decreased. Of those making a quit attempt, those attempting to stop abruptly (without cutting down first) decreased. Use of no support – but also behavioural support – decreased in quit attempts, while use of pharmacological support increased. The proportion of smokers of low social grade remained stubbornly high, indicating a lack of progress in reducing the social gradient in smoking prevalence and highlighting the need for targeted interventions and policies9.
We also know that the pandemic and lockdowns appear to have had a big impact on smoking10. We are still awaiting more data but initial analyses suggest that the number of 18- to 34-year-olds who smoke increased by 25% in England during the first lockdown10. There were also increases in the number of existing smokers quitting successfully, and overall levels of smoking in adults remained stable. However, the increased number of young adults who smoke sets the scene for a new Tobacco Control Plan, including future iterations of Stoptober, to achieve the government’s target for England to be smoke-free by 2030.
Jamie Brown 1 2 and Martin Dockrell 2 3
1 Department of Behavioural Science and Health, University College London, London, UK; 2 SPECTRUM Consortium, London, UK; 3 Public Health England, London, UK
JB has received unrestricted research funding to study smoking cessation from pharmaceutical companies who manufacture licensed smoking cessation medications (Pfizer and J&J). All authors declare no financial links with tobacco companies or e-cigarette manufacturers or their representatives.
Cancer Research UK primarily funds the Smoking Toolkit Study in England (C1417/A22962). We acknowledge co-authors of the articles summarised in this blog – particularly Robert West, Mirte Kuipers, Claire Garnett, Sarah Jackson, Daniel Kotz and Harveen Kaur Ubhi.
1. Brown J, Kotz D, Michie S, et al. How effective and cost-effective was the national mass media smoking cessation campaign ‘Stoptober’? Drug and Alcohol Dependence 2014;135:52-58. doi: 10.1016/j.drugalcdep.2013.11.003
2. Kotz D, Stapleton JA, Owen L, et al. How cost-effective is 'No Smoking Day'? Tob Control 2011;20(4):302-4. doi: 10.1136/tc.2009.034397 [published Online First: 2010/05/18]
3. Ubhi HK, Michie S, Kotz D, et al. A mobile app to aid smoking cessation: preliminary evaluation of SmokeFree28. J Med Internet Res 2015;17(1):e17. doi: 10.2196/jmir.3479 [published Online First: 2015/01/18]
4. West R, Brown J. Theory of Addiction. Oxford: Wiley Blackwell 2013.
5. Raikou M, McGuire A. Cost-effectiveness of a mass media campaign and a point of sale intervention to prevent the uptake of smoking in children and young people: economic modelling report. LSE Health 2008
6. Atusingwize E, Lewis S, Langley T. Economic evaluations of tobacco control mass media campaigns: a systematic review. Tob Control 2015;24(4):320-7. doi: 10.1136/tobaccocontrol-2014-051579 [published Online First: 2014/07/06]
7. Kuipers MAG, West R, Beard E, et al. Impact of the 'Stoptober' smoking cessation campaign in England from 2012 to 2017: A quasi-experimental repeat cross-sectional study. Nicotine Tob Res 2019 doi: 10.1093/ntr/ntz108
8. Jackson SE, Beard E, Kujawski B, et al. Comparison of Trends in Self-reported Cigarette Consumption and Sales in England, 2011 to 2018. JAMA Network Open 2019;2(8):e1910161-e61. doi: 10.1001/jamanetworkopen.2019.10161
9. Garnett C, Tombor I, Beard E, et al. Changes in smoker characteristics in England between 2008 and 2017. Addiction 2020;115(4):748-56. doi: https://doi.org/10.1111/add.14882
10. Jackson SE, Beard E, Angus C, et al. Moderators of changes in smoking, drinking and quitting behaviour associated with the first COVID-19 lockdown in England. Addiction;n/a(n/a) doi: https://doi.org/10.1111/add.15656