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Why most smoking cessation programmes lose people before they quit
What the pre-quit conversation needs to do, and why personalisation is the difference between a quit and a drop-off.
Every smoker who contacts a stop-smoking service has already decided, at least in that moment, that they want to quit. The question isn’t whether motivation exists. It’s whether the programme is designed to work with the specific motivation that person has. Most of the time, it isn’t.
Nationally, Xyla has helped 353,197 people start a life-changing programme over the past decade. What that scale of delivery teaches you is that the clinical framework matters far less than what happens in the first conversation.
I’ve been running the Healthier Futures Quit Smoking programme across East Riding for four years, supporting people aged 12 and over through a structured programme combining one-to-one sessions, free nicotine replacement therapy and ongoing digital support. Reducing drop off rates is key to helping people stop smoking,
Reducing drop-off is key to helping people quit smoking. In my experience, it’s the patterns behind that drop-off, and what prevents it, that have reshaped how I approach cessation delivery
Charlotte Walker – Health and Wellbeing Coach and Engagement Lead at Xyla
The motivation assumption that undermines most stop-smoking programmes
Public health messaging about smoking tends to lead with cost and health risk. Quitting adds years to your life. Smoking costs the average person over £3,000 a year. Both are true. Neither is why most people who struggle to quit are still smoking.
For a significant proportion of the people I work with, particularly in more deprived parts of East Riding, smoking isn’t a habit they haven’t got round to breaking. It’s a coping mechanism. In areas like Bridlington and Goole, I’ve seen people buying cheap knockoff cigarettes for around £5 a pack because even that feels worth prioritising over other essentials. For these individuals, the financial argument for quitting isn’t the lever. The psychological one is.
Mental health challenges, housing stress, financial pressure, caring responsibilities are the real context in which smoking sits for many of our participants. A programme that leads with behaviour change techniques without engaging with that context will see high drop-off rates regardless of how clinically sound the framework is. Commissioners who specify programmes based on protocol alone, without requiring genuine individual assessment, are commissioning for the easier cohort.
“Nine times out of ten it’s not really about cigarette. It’s everything else going on. The smoking is just what they’re using to cope with it.”
Smoking cessation coach
What happens in a pre-quit conversation
Our Quit Smoking programme starts before anyone sets a quit date. The pre-quit stage is a detailed one-to-one call, around 30 minutes, and it’s probably the most important part of the whole programme. I let people talk. Sometimes it’s a brain dump: they’re moving house, they’ve left a relationship, there’s something going on with their kids, money is tight. People tell you everything. What I’m listening for is what’s actually driving the smoking, because that’s what shapes the support we build around them.
That conversation also establishes which nicotine replacement therapy (NRT) option is most likely to work, whether patches, gum, spray or, for some people, a vape through our partnership with Totally Wicked. It creates a detailed record that means any health coach covering a session has the full picture. Early on in the programme, we didn’t always have that. Coaches would ring participants and essentially start from scratch each time. People disengaged. Once we built structured note templates from that feedback, continuity improved and so did retention.
The programme then runs across nine sessions, six weekly, then three fortnightly, with the AmaraHealth app providing support between sessions for tracking mood, managing cravings and accessing resources. Participants receive follow-up at six and 12 months. That follow-through matters: a quit rate at 12 weeks is a process measure. Whether someone is still not smoking at 12 months is closer to the real outcome.
“’In the beginning it was very difficult to make changes to my routine, it was more about finding the preferred strategies for coping with the craving for a cigarette. By being able to have 1 to 1 support with either Finley or Charley, I found it beneficial to be able to talk through my frustrations week by week, in the initial part of my journey. As my breathing became easier, I was able to enjoy walking again, and the aspects of my garden I am physically able to perform, became a large part of my routine once more. This in turn led me to spend more time in the place I love. Not only was the 1 to 1 support very beneficial to me, but the ability to access alternative nicotine aids easily and efficiently was a great favourite. I opted to use a vape in the end, and am now using the lowest level of nicotine that is available from the programme.”
Quit Smoking programme participant.
Vaping as a cessation tool: what the evidence supports and what it doesn’t
Xyla’s Quit Smoking programme offers vaping alongside traditional NRT for eligible adult participants. It’s worth being precise about this, because the public conversation about vaping tends to conflate two very different situations: vaping as a harm reduction bridge for established adult smokers, and vaping as a behaviour among young people who’ve never smoked. These need different responses.
For adult smokers who haven’t managed to quit with patches or gum, a vape provides a hand-to-mouth substitute that replicates the physical routine of smoking while delivering controlled nicotine. We use it as a stepping stone, not a destination, and we’re explicit with participants about that distinction. In practice, older participants often prefer traditional NRT; they don’t want to swap one habit for another, as some put it. Younger adults are more open to vaping as a bridge. The right tool depends on the person, which is exactly why the pre-quit conversation must come first.
In our own delivery, around 78% of people remain engaged with the programme, with over half achieving a 4-week quit. This shows that success is more likely where support is properly tailored, and only when people stay engaged long enough to benefit.
Mental health, addiction and the population commissioners are trying to reach
The people hardest to engage in smoking cessation, and whose health would benefit most from quitting, are disproportionately likely to have mental health conditions. Nicotine has a short-term anxiolytic effect that people learn to rely on. Removing it without addressing that leaves a gap that must be filled with something else, and programmes that don’t account for this will lose people at exactly the point where sustained support matters most.
In our Healthier Futures delivery, our health coaches carry a caseload that regularly includes participants managing significant mental health challenges alongside their quit attempt. The continuity of that relationship, the same person, across multiple sessions, who knows the full picture, is what allows people to stay in the programme when things get hard.
What this means for commissioning effective stop-smoking services
Programme specifications should require individual motivational assessment at the outset, not just eligibility screening. The pre-quit conversation is where cessation is won or lost for high-need participants.
NRT provision should include vaping as an option for adult smokers. Excluding it reduces the toolkit available to people for whom traditional NRT hasn’t worked.
Outcome frameworks should include 12-month sustained quit rates alongside 12-week verified quits. The latter is easy to optimise for; the former is the measure that reflects genuine population health impact.
Mental health shouldn’t be a contraindication. Programmes that under-serve participants with mental health conditions are consistently optimising for the easier cohort.
Build a more effective stop-smoking programme
If you’re reviewing your current smoking cessation or behaviour change programme and want to understand how a more personalised, community-embedded approach could improve outcomes and reduce drop-off rates, we’d welcome the conversation. Get in touch:
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