“Smoke-Free in May”: Results of a Public Participation Program on Nicotine Product Abstinence

Smoking is a major risk factor for increased morbidity and premature mortality. Due to nicotine’s highly addictive potential, relapse rates following smoking cessation are high. Moreover, the number of serious attempts to quit has been falling in Germany for years (1). The public participation program “Smoke-Free in May” was aimed at increasing people’s motivation to quit smoking. Adults who regularly consumed nicotine products—tobacco in various forms, including tobacco heaters, and e-cigarettes—were eligible to participate. Cash prizes were offered to encourage participation. As an accompanying feature, participants received daily digital messages in May.

Methods

A one-group pre-test/post-test design with three measurement points was implemented. The baseline sample included all individuals that had signed up for “Smoke-Free in May” (www.rauchfrei-im-mai.de). In early June and again in November 2024, this population was invited by email to take part in online follow-up surveys.

Primary endpoints included continuous nicotine abstinence in May 2024 as well in the 6-month follow-up. Statistical analyses followed the complete-case approach using complete datasets on the one hand, while on the other using the data of all registered persons as a reference value, similar to an intention-to-treat analysis (ITT). For the prediction of successful nicotine abstinence, logistic regressions were calculated using the following predictors: age, sex, subjective social status (3), number of attempts to quit in the previous 12 months, number of nicotine products consumed, confidence regarding cessation, perceived level of addiction, and registering with a support person.

The secondary endpoint was the reduction in nicotine consumption among those individuals who did not abstain.

Results

Primary endpoints

A total of 6386 individuals signed up for “Smoke-Free in May.” In June 2024, 2102 individuals took part in the survey (response rate: 32.9%), while in November 2024 this number was 974 individuals (response rate: 15.3 %). In June 2024, 1356 out of 2102 individuals (64.5%, 95% confidence interval: [62.4; 66.6]) reported having been smoke-free, and in November 2024, this figure was 529 out of 974 respondents (54.3%; [51.1; 57.5], complete cases). Analogous to an ITT analysis that includes all 6386 registered participants, the abstinence rate was 21.2% [20.2; 22.3], n = 1356) in June 2024 and 8.3% [7.6; 9.0]; n = 529) in November 2024 (Figure).

Figure

Nicotine abstinence in May 2024 and in the 6-month follow-up (November 2024)

The following participants were more successful regarding nicotine abstinence in November (complete cases): individuals with higher subjective social status, individuals with greater confidence regarding their ability to quit, and individuals who had not attempted to quit in the preceding 12 months (Table). Individuals who had registered with another person for support were also more successful. Age, subjectively rated addiction, and the number of nicotine products consumed did not significantly covary with nicotine abstinence in the follow-up. The success rate tended to be higher among men compared to women (p = 0.054).

Table

Predictors of nicotine abstinence

Secondary endpoint

Of the 445 individuals who were not abstinent in November 2024, 52.6% [47.8; 57.3] reported having reduced their nicotine consumption compared to April 2024 (complete cases).

Discussion

In May 2024, over 6300 regular consumers of nicotine products attempted to stop smoking as part of the public participation program “Smoke-Free in May.” Of these individuals, at least one in 12 was abstinent at 6-month follow-up (as in the ITT analysis). Of the non-abstinent individuals, more than 50% reduced their nicotine consumption (complete-case analysis). In agreement with data in the literature, individuals with higher subjective social status as well as those with greater confidence in their ability to quit were more successful at nicotine abstinence; in addition, men tended to be more successful. Support from a close friend or relative also appeared to be helpful, as did the absence of an unsuccessful attempt to quit smoking in the preceding 12 months. However, a recently failed attempt may have led to negative selection and a lower willingness to participate in the campaign.

Follow-up for 6-months and an ITT analysis are standard criteria for conducting clinical studies in this field. Although the criteria also include biochemical verification of the self-reported information on smoking status (4), this could only be implemented in prize winners. Moreover, one needs to bear in mind when interpreting the data that the experimental design without a control group reduces the validity of findings and that the predictor analysis is based on a selective sub sample.

In recent years, tobacco and nicotine companies have diversified their nicotine product lines and introduced new products to the market, such as e-cigarettes and tobacco heaters. The conceptual approach to tackling this challenge lay in making the “Smoke-Free in May” public participation program open to all individuals who consume any type of nicotine product. Accordingly, the primary endpoints were defined not only as tobacco but also nicotine abstinence.

To classify the abstinence rate in the follow-up, the results of meta-analyses of randomized controlled trials can be used (5). The percentage of consumers who managed to abstain from all tobacco and nicotine products for at least 6 months post-intervention without any aids was 2–3%, while 3–4% managed with e-cigarettes, 4–6% with medical advice, 6–7% with nicotine replacement products, and 20–22% through a combination of intensive behavioral support and nicotine replacement products. Against this backdrop, the 8.3% success rate of this very low-threshold public participation program can be considered satisfactory.

For years, Germany has lagged behind in terms of its tobacco control policy. The goal of a tobacco-free society by 2040 can only be achieved if evidence-based smoking cessation support is implemented nationwide and free of cost.

Barbara Isensee, Friederike Barthels, Reiner Hanewinkel

Funding

This study was funded by the German Federal Ministry of Public Health (Bundesinstitut für Öffentliche Gesundheit) on behalf of the German Federal Ministry of Health (Bundesministerium für Gesundheit) and the German Cancer Aid Foundation (Stiftung Deutsche Krebshilfe).

Ethics declaration

The study was reviewed by the Ethics Committee of the Medical Faculty at the Christian-Albrechts University of Kiel, Germany, and found not to raise any concerns in terms of professional ethics or professional law (file number D 518/24).

Conflict of interest statement
All authors are responsible for the design, implementation, and scientific support of “Smoke-Free in May.”

RH is a board member of the German Action Alliance for Non-Smoking (Aktionsbündnis Nichtrauchen) and the scientific advisory board of the German Centre for Addiction Issues (Deutsche Hauptstelle für Suchtfragen). He is also a member of the expert group tasked with updating the S3 guideline on tobacco.

Manuscript submitted on 14 January 2025, revised version accepted on 13 March 2025.

Translated from the original German by Christine Rye.

Cite this as
Isensee B, Barthels F, Hanewinkel R: “Smoke-Free in May”: Results of a public participation program on nicotine product abstinence. Dtsch Arztebl Int 2025; 122: 227–8. DOI: 10.3238/arztebl.m2025.0051

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