Resources Relating to Smoking in England

Addiction (Abingdon, England) [114(2):1360-0443]

BACKGROUND AND AIMS E-cigarettes have the potential either to decrease or increase health inequalities, depending on socio-economic differences in their use and effectiveness. This paper estimated the associations between socio-economic status (SES) and e-cigarette use and examined whether these associations changed between 2014 and 2017.

DESIGN A monthly repeat cross-sectional household survey of adults (16+) between January 2014 and December 2017. This time-period was chosen given that the prevalence of e-cigarette use stabilized in England in late 2013.

SETTING England.

PARTICIPANTS Participants in the Smoking Toolkit Study, a monthly household survey of smoking and smoking cessation among adults (n = 81 063; mean age = 48.4 years, 49% were women) in England. Subsets included past year smokers (n = 16 232; mean age = 42.8, 46% women), smokers during a quit attempt (n = 5305, mean age = 40.6, 49% women) and long-term ex-smokers (n = 13 562, mean age = 59.3, 44% women).

MEASUREMENTS The outcome measure for the analyses was current e-cigarette use. We also included smokers during a quit attempt where use of an e-cigarette during the most recent quit attempt was the outcome measure. Social grade based on occupation was the SES explanatory variable, using the National Readership Survey classification system of AB (higher and intermediate managerial, administrative and professional), C1 (supervisory, clerical and junior managerial, administrative and professional), C2 (skilled manual workers), D (semi-skilled and unskilled manual workers) and E (state pensioners, casual and lowest-grade workers, unemployed with state benefits only). The analyses were stratified by year to assess the changes in these associations over time.

FINDINGS Among past-year smokers, lower SES groups had lower overall odds of e-cigarette use compared with the highest SES group AB (D: odds ratio = 0.53, 95% confidence interval = 0.40-0.71; E: 0.67, 0.50-0.89). These differences in e-cigarette use reduced over time. The use of e-cigarettes during a quit attempt showed no clear temporal or socio-economic patterns. Among long-term ex-smokers, use of e-cigarettes increased from 2014 to 2017 among all groups and use was more likely in SES groups C2 (2.03, 1.08-3.96) and D (2.29, 1.13-4.70) compared with AB.

CONCLUSIONS From 2014 to 2017 in England, e-cigarette use was greater among smokers from higher compared with lower socio-economic status (SES) groups, but this difference attenuated over time. Use during a quit attempt was similar throughout SES groups. Use by long-term ex-smokers increased over time among all groups and was consistently more common in lower SES groups.

© 2018 Society for the Study of Addiction.

The American journal on addictions [23(6):1521-0391]

BACKGROUND AND OBJECTIVES Smoking tobacco is the leading cause of preventable illness in the United States and around the world. However, much remains unknown about the factors that motivate individuals to smoke. Quality of life (QoL) has become an important measure of outcomes across all medical specialties, in both research and clinical settings. To date, there has not been a critical review of the research relevant to QoL in smokers. In this review, we describe which scales are used to quantify the QoL of smokers, the relationship between smoking and QoL and the positive impact of smoking cessation.

METHODS Fifty-four relevant studies are included in our review.

RESULTS Low QoL and depression are associated with higher odds of smoking initiation and lower odds of successful smoking cessation. There is a negative relationship between smoking and QoL and the magnitude of this association is related to the number of cigarettes smoked. Secondhand smoke also appears to be negatively associated with QoL. Smoking cessation significantly improves QoL. These findings have been replicated across populations with diverse socioeconomic and cultural groups around the world.

DISCUSSION AND CONCLUSIONS QoL data promotes smokers and practitioners to become more sensitive to the sub-clinical adverse effects of cigarette smoking, thereby improving motivation to quit, cessation rates, and treatment outcomes.

SCIENTIFIC SIGNIFICANCE Understanding the relationship between QoL and tobacco smoking is important for patients, clinicians, and researchers.

© American Academy of Addiction Psychiatry.

Psychopharmacology [231(1):1432-2072]

RATIONALE Limited evidence from randomised controlled trials suggests that varenicline might be more effective than nicotine replacement therapy (NRT) in achieving abstinence from smoking. The comparative effectiveness of varenicline when prescribed under routine circumstances and in the general population has not been tested.

OBJECTIVES To compare the abstinence rates of smokers trying to stop having used varenicline vs. NRT on prescription (Rx) when provided with minimal professional support in the general population while adjusting for key potential confounders.

METHODS A large survey of a representative sample of the English population. Participants were 1,579 adults who smoked within the previous 12 months and made at least one quit attempt with varenicline or NRT Rx in their most recent quit attempt. The main outcome measure was self-reported abstinence up to the time of the survey, adjusted for key potential confounders including urges to smoke. A sensitivity analysis was conducted in subsamples in which the quit attempt started up to 6 months or more than 6 months ago.

RESULTS The adjusted odds of abstinence in users of varenicline were 1.76 (95 % CI = 1.22-2.53) times higher compared with users of NRT Rx. However, there was no detectable difference in the subsample of smokers who started their quit attempt more than 6 months ago (adjusted OR = 1.03, 95 %CI = 0.54-1.96).

CONCLUSIONS Varenicline use with minimal professional support in the general population of smokers appears more effective than NRT Rx in achieving short-term abstinence. However, this effect may disappear in the long-term. Research is needed to confirm this and establish what may underlie it.

Addiction (Abingdon, England) [108(11):1360-0443]

AIMS To characterize publically funded tobacco control campaigns in England between 2004 and 2010 and to explore if they were in line with recommendations from the literature in terms of their content and intensity. International evidence suggests that campaigns which warn of the negative consequences of smoking and feature testimonials from real-life smokers are most effective, and that four exposures per head per month are required to reduce smoking prevalence.

DESIGN Characterization of tobacco control advertisements using a theoretically based framework designed to describe advertisement themes, informational and emotional content and style. Study of the intensity of advertising and exposure to different types of advertisement using data on population-level exposure to advertisements shown during the study period.

SETTING England.

MEASUREMENTS Television Ratings (TVRs), a standard measure of advertising exposure, were used to calculate exposure to each different campaign type.

FINDINGS A total of 89% of advertising was for smoking cessation; half of this advertising warned of the negative consequences of smoking, while half contained how-to-quit messages. Acted scenes featured in 72% of advertising, while only 17% featured real-life testimonials. Only 39% of months had at least four exposures to tobacco control campaigns per head.

CONCLUSIONS A theory-driven approach enabled a systematic characterization of tobacco control advertisements in England. Between 2004 and 2010 only a small proportion of tobacco control advertisements utilized the most effective strategies-negative health effects messages and testimonials from real-life smokers. The intensity of campaigns was lower than international recommendations.

© 2013 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of The Society for the Study of Addiction.

Addiction (Abingdon, England) [108(12):1360-0443]

BACKGROUND AND AIMS Bupropion was introduced for smoking cessation following a pivotal trial showing that it gave improved efficacy over the nicotine patch and also suggesting combination treatment was beneficial. We tested in clinical practice for an effectiveness difference between bupropion and nicotine replacement therapy (NRT), whether the combination improves effectiveness and whether either treatment might be more beneficial for certain subgroups of smokers.

DESIGN Open-label randomized controlled trial with 6-month follow-up.

SETTING Four UK National Health Service (NHS) smoking cessation clinics.

PARTICIPANTS Smokers (n = 1071) received seven weekly behavioural support sessions and were randomized to an NRT product of their choice (n = 418), bupropion (n = 409) or NRT plus bupropion (n = 244).

MEASURES The primary outcome was self-reported cessation over 6 months, with biochemical verification at 1 and 6 months. Also measured were baseline demographics, health history, smoking characteristics and unwanted events during treatment.

FINDINGS Abstinence rates for bupropion (27.9%) and NRT (24.2%) were not significantly different (odds ratio = 1.21, 95% confidence interval = 0.883-1.67), and the combination rate (24.2%) was similar to that for either treatment alone. There was some evidence that the relative effectiveness of bupropion and NRT differed according to depression (χ(2) = 2.86, P = 0.091), with bupropion appearing more beneficial than NRT in those with a history of depression (29.8 versus 18.5%). Several unwanted symptoms were more common with bupropion.

CONCLUSION There is no difference in smoking cessation effectiveness among bupropion, nicotine replacement therapy and their combination when used with behavioural support in clinical practice. There is some evidence that bupropion is more beneficial than nicotine replacement therapy for smokers with a history of depression.

© 2013 Society for the Study of Addiction.

Drug and alcohol dependence [132(3):1879-0046]

BACKGROUND There is an urgent need to find better ways of helping pregnant smokers to stop. Randomized controlled trials (RCTs) have not detected an effect of nicotine replacement therapy (NRT) for smoking cessation in pregnancy. This may be because of inadequate dosing because of faster nicotine metabolism in this group. In England, many pregnant smokers use single form and combination NRT (patch plus a faster acting form). This correlational study examined whether the latter is associated with higher quit rates.

METHODS Routinely collected data from 3880 pregnant smokers attempting to stop in one of 44 Stop Smoking Services in England. The outcome measure was 4-week quit rates, verified by expired-air carbon monoxide level<10 ppm. Outcome was compared between those not using medication versus using single form NRT (patch or one of the faster acting forms), or combination NRT. Potential confounders were intervention setting (specialist clinic, home visit, primary care, other), intervention type (one-to-one, group, drop-in, other), months pregnant, age, ethnicity and occupational group in multi-level logistic regressions.

RESULTS After adjustment, combination NRT was associated with higher odds of quitting compared with no medication (OR=1.93, 95% CI=1.13-3.29, p=0.016), whereas single NRT showed no benefit (OR=1.06, 95% CI=0.60-1.86, p=0.84).

CONCLUSIONS Use of a combination of nicotine patch and a faster acting form may confer a benefit in terms of promoting smoking cessation during pregnancy. While this conclusion is based on correlational data, it lends support to continuing this treatment option pending confirmation by an RCT.

Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Addiction (Abingdon, England) [108(9):1360-0443]

AIMS To assess the incidence of long-term smoking cessation as a function of age, gender, social grade and their interactions.

DESIGN AND SETTING Cross-sectional surveys of population representative samples of smokers in England.

PARTICIPANTS A total of 24 094 ever smokers (≥21 and ≤60 years of age) participating in household surveys between November 2006 and February 2011.

MEASUREMENTS The ratio of long-term (>1 year) ex-smokers to ever-smokers was calculated for each age. Regression analyses were used to model the association between age and quit ratio, with the change in quit ratio by year of age n years versus all years up to n-1 years, yielding an estimate of the quitting incidence at that age. Analyses were conducted for the entire sample and then for the sample stratified by gender and social grade, and interactions assessed between these variables.

FINDINGS A cubic trend was needed to fit the data. The estimated quitting incidence between ages 21 and 30 was 1.5% (95% CI: 1.0%-2.0%), between 31 and 50 it was 0.3% (95% CI: 0.2%-0.5%) and between 51 and 60 it was 1.2% (95% CI: 0.7%-1.7%). Age interacted with gender and social grade: women and smokers from higher social grades had a higher incidence of quitting than men and those from lower social grades specifically in young adulthood. CONCLUSIONS : The incidence of smoking cessation in England appears to be greater in young and old adults compared with those in middle age. Women and higher social grade smokers show a greater incidence of quitting than men and those from lower social grades specifically in young adulthood.

© 2013 Society for the Study of Addiction.

Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco [15(7):1469-994X]

INTRODUCTION Behavioral support improves smokers' chances of quitting, but quit rates are typically lower for smokers supported by "community practitioners" for whom smoking cessation is a small part of their job than for those supported by "specialist practitioners" for whom it is the main role. This article examined the factors that might contribute to this.

METHOD A total of 573 specialist practitioners and 466 community practitioners completed a 42-item online survey that covered demographic and employment information, current practices, levels of training, and 4-week CO-verified quit rates. Responses were compared for community and specialist practitioners. Mediation analysis was undertaken to assess how far "structural" and "modifiable" variables account for the difference in quit rates.

RESULTS Specialist practitioners reported higher 4-week CO-verified quit rates than community practitioners (63.6% versus 50.4%, p < .001). Practitioners also differed significantly in employment variables, evidence-based practices, and levels of training. Six "modifiable" variables (proportion of clients using an "abrupt" quit model, duration of first session, always advising on medications, number of days training received, number of sessions observed when starting work, and number of sessions having been observed in practice and received feedback) mediated the association between practitioners' role and quit rates over and above the "structural" variables, explaining 14.3%-35.7% of the variance in the total effect.

CONCLUSIONS "Specialist" practitioners in the English stop-smoking services report higher success rates than "community" practitioners and this is at least in part attributable to more extensive training and supervision and greater adherence to evidence-based practice including advising on medication usage and promoting abrupt rather than gradual quitting.

Addictive behaviors [38(10):1873-6327]

INTRODUCTION The most commonly used threshold of expired-air carbon monoxide (CO) concentration to validate self-reported smoking abstinence is <10 parts per million (ppm). It has been proposed to reduce this threshold. This study examined what effect a reduction would have on short-term success rates in clinical practice.

METHODS A total of 315,718 quit attempts supported by English NHS Stop Smoking Services were included in the analysis. The proportion of 4-week quits as determined by the Russell standard (<10ppm) that also met lower thresholds was calculated for each unit change from <9ppm to <2ppm. Additionally, associations of established predictors with outcome were assessed in logistic regressions for selected thresholds.

RESULTS At <10ppm, 35% of quit attempts were regarded as successful. Differences for a single unit reduction increased with each reduction; small reductions had very little impact (e.g. <8ppm: 34.7% success), but at <3ppm, only 26.3% would still be regarded as successful. With the threshold reduced to <3ppm established predictors of cessation showed a weaker association with outcome than with the threshold at <10ppm suggesting an increase in error of outcome measurement.

CONCLUSIONS Reducing the threshold for expired-air CO concentration to validate abstinence would have a minimal effect on success rates unless the threshold were reduced substantially which would likely increase error of measurement.

Copyright © 2013 Elsevier Ltd. All rights reserved.

Addictive behaviors [37(12):1873-6327]

BACKGROUND This article reports a pilot study of a new smoking cessation website ('StopAdvisor'), which has been developed on the basis of PRIME theory, evidence, web-design expertise and user-testing. The aims were to i) evaluate whether cessation, website usage and satisfaction were sufficiently high to warrant a randomised controlled trial (RCT) and ii) assess whether outcomes were affected by socio-economic status.

METHODS This was an uncontrolled pilot study. Two hundred and four adult daily smokers willing to make a serious quit attempt were included. All participants received support from 'StopAdvisor', which recommends a structured quit plan and a variety of evidence-based behaviour change techniques for smoking cessation. A series of tunnelled sessions and a variety of interactive menus provide tailored support for up to a month before quitting through until one-month post-quit (http://www.lifeguideonline.org/player/play/stopadvisordemonstration). The primary outcome was self-report of at least 1month of continuous abstinence collected at 2months post-enrolment and verified by saliva cotinine or anabasine. Usage was indexed by log-ins and page views. Satisfaction was assessed by dichotomous ratings of helpfulness, personal relevance, likelihood of recommendation and future use, which were collected using an online questionnaire at 2months post-enrolment. Outcomes according to socio-economic status were assessed.

RESULTS At 8weeks post-enrolment, 19.6% (40/204) of participants were abstinent according to the primary outcome criteria (95% C.I.=14.1% to 25.1%). Participants viewed a mean of 133.5 pages (median=71.5) during 6.4 log-ins (median=3). A majority of respondents rated the website positively on each of the four satisfaction `ratings (range=66.7% to 75.3%). There was no evidence of an effect of socio-economic status on abstinence (OR=1.01, C.I.=0.50-2.07), usage (page-views, t(202)=0.11, p=.91; log-ins, t(202)=0.21, p=.83), or satisfaction (helpfulness, OR=1.09, C.I.=0.41-2.88; personal relevance, OR=0.55, C.I.=0.20-1.56; recommendation, OR=0.98, C.I.=0.34-2.81; use in future, OR=1.45, C.I.=0.49-4.27).

CONCLUSIONS The systematic application of theory, evidence, web-design expertise, and user-testing has resulted in a website that shows sufficiently promising efficacy and usability to warrant evaluation in a RCT. The website appears to be similarly effective and acceptable to users across the social spectrum.

Copyright © 2012 Elsevier Ltd. All rights reserved.

American journal of health behavior [36(5):1945-7359]

OBJECTIVES To determine if community subjective social status (SSS) predicted smoking abstinence through 26 weeks postrandomization among 755 African American light smokers of low SES (socioeconomic status).

METHODS Participants were enrolled in a double-blind, placebo-controlled, randomized clinical trial, which examined the efficacy of nicotine gum and counseling for smoking cessation.

RESULTS Results indicated that SSS predicted smoking abstinence over time [P=.046; odds ratio (OR) =1.075 (1.001-1.155)] after adjusting for covariates.

CONCLUSIONS Further research is needed to understand the effects of community SSS on smoking cessation among heavy smokers and other ethnic groups.

Addiction (Abingdon, England) [107(5):1360-0443]

AIMS There is a growing interest in very low rate [fewer than one cigarette per day (CPD)] and light (one to nine CPD) smokers and in some parts of the world their numbers appear to be increasing. This paper examined changes in prevalence over the past 5 years, cessation patterns, and smoking and demographic characteristics of very low rate, light and moderate-to-heavy (10+ CPD) smokers in England.

DESIGN Cross-sectional and longitudinal data from aggregated monthly waves of a household survey: the Smoking Toolkit Study.

SETTING England.

PARTICIPANTS A total of 23,245 smokers interviewed between November 2006 and May 2011 and 4147 who provided data at 6-month follow-up.

MEASUREMENTS We compared the demographic and smoking characteristics between the three groups of smokers at baseline, and the rate of attempts to quit, use of aids to cessation and success of quit attempts at follow-up.

FINDINGS Very low rate smoking remained extremely rare (1.9% of smokers in 2006 to 2.8% in 2011), but light smoking became increasingly common (23.9-32.8%). Compared with moderate-to-heavy smokers, very low rate and light smokers were younger, more often female and from a higher socio-economic background. They were more motivated to quit and enjoyed smoking less. During the 6-month follow-up period, light smokers, but not very low rate smokers, were more likely to attempt to quit than moderate-to-heavy smokers. When they tried to quit, very low rate and light smokers used aids to cessation less than moderate-to-heavy smokers but still used them to a substantial degree: 18%, 31% and 44% used over-the-counter nicotine replacement therapy in their most recent quit attempt for the three types of smoker, respectively. Even very low rate smokers had a substantial failure rate: 65% failed in their most recent quit attempt within 6 months.

CONCLUSIONS Very low rate (fewer than one cigarette per day) and light (one to nine cigarettes per day) smokers in England are at least as motivated to quit as heavier smokers. Although they use cessation medication less than heavier smokers and are more likely to succeed, they still use such medication and fail in quit attempts to a substantial degree.

© 2011 The Authors, Addiction © 2011 Society for the Study of Addiction.

Drug and alcohol dependence [121(1-2):1879-0046]

BACKGROUND Happiness has become established as an important psychological dimension and not merely the obverse of depression and anxiety. Ex-smokers report that they are happier than when they were smoking but this could reflect biased recall. To date, no studies have examined happiness as a function of smoking status in ex-smokers of varying length of abstinence compared with current and never smokers.

METHODS A cross-sectional household study of a nationally representative sample of adults examined the association between smoking status (never smoker, smoker, ex-smoker<1 year, ex-smoker ≥ 1 year) and two standard measures of happiness adjusting for sociodemographic characteristics (N=6923).

RESULTS After adjusting for age, gender and social grade, ex-smokers of ≥ 1 year reported higher levels of happiness than smokers (p<0.001) and similar levels to never smokers. Ex-smokers of <1 year had similar levels to smokers. Smoking to feel less depressed (p<0.001) or anxious (p<0.044) were the only smoking characteristics associated with lower happiness among current smokers.

CONCLUSIONS Ex-smokers who have stopped for a year or more are happier than current smokers and similar to never smokers. Whilst these results are cross-sectional and have to be interpreted with caution, this adds to the evidence that smoking may decrease happiness and stopping may increase it.

Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.