The role of smoking-related biomarkers in smoking cessation

Much progress has been made in the field of tobacco control but the fact that the smoking prevalence in most Western countries is declining only slowly and still rising in many non-Western countries underlines the need to develop new ways to increase smoking cessation rates. Smoking-related biomarkers - biochemical, physiological or anatomical indices of exposure, risk and harm linked to smoke constituents - have been instrumental in furthering tobacco control, and this thesis examines the role of these biomarkers in smoking cessation. Study 1 evaluated whether biomarkers of exposure can be substituted by self-report and found that most smokers have only limited awareness regarding their level of exposure. Study 2 qualitatively explored smoking cessation in smokers and ex-smokers and examined their views on existing interventions in the NHS as well as on novel interventions involving biomarker feedback. Most participants commented positively on the Stop Smoking Services and welcomed the use of biomarkers in smoking cessation interventions. Study 3 tested the effectiveness of such an intervention adding feedback of an exposure and risk biomarker to brief advice in a randomised controlled trial. The intervention successfully altered cognitive antecedents of behaviour change but increased cessation rates only among smokers with high self-efficacy levels in comparison with the control group. Studies 4 and 5 used exposure and harm biomarkers from a nationally representative sample to determine smoking rates among people with objective signs of chronic obstructive pulmonary (COPD) or cardiovascular (CVD) diseases and to evaluate the potential impact of a diagnosis on smoking cessation. People with COPD but not CVD were more likely to smoke a disease diagnosis was associated with higher motivation to stop among smokers with COPD and with higher cessation rates in smokers with a CVD. The importance of these findings for the measurement of smoke intake, improvement of interventions and detection and treatment of smokers with diseases is discussed

How much improvement in mental health can be expected when people stop smoking? Findings from a national survey

Background and aims: There is evidence that mental health improves when smokers stop. This study aimed to assess in a nationally representative sample how far anxiety and depression in long-term ex-smokers can be expected eventually to reach levels found in those who have never smoked. Methods: Data from the Smoking Toolkit Study (STS) were used. The STS involves monthly household surveys of representative samples of the adult population of England. Anxiety and depression were compared using an item from the EQ5-D in respondents aged 40+ years where were either current smokers, never smokers, or had stopped for at least a year, adjusting statistically for age, gender and social grade. Results: The prevalence of anxiety or depression was 10.0% (95% CI 9.1-10.9) in never smokers, 18.3% (95% CI 16.0-20.6) in current smokers, and 11.3% (95% CI 9.6-13.0) in long-term ex-smokers. After adjusting for age, sex and social grade, long-term ex-smokers were similar to never smokers (OR=1.15, 95% CI=0.94-1.41). Current smokers had higher prevalence than never smokers (OR=1.69, 95% CI=1.39-2.04) and ex-smokers (OR=1.47, 95% CI=1.15-1.86). Conclusions: Prevalence of anxiety and depression in long-term ex-smokers appears to be similar to what is found in never smokers

Cardiovascular disease and varenicline (Champix)

Whilst findings were not uniform, based on the findings of these reviews, the risk of cardiovascular events associated with the use of varenicline is judged to be minimal and clinically insignificant. Note: The recent changes to the service product characteristics (SPC) for varenicline do not substantially change the points raised in this briefing nor the advice that it is safe and effective

Psychological Aspects of Tobacco Control

World-wide, tobacco use is a leading cause of morbidity and mortality. However, the health effects of smoking are reversible, making smoking cessation an important target for public health policy. ‘Tobacco control’ is a field of public health science which is dedicated to reducing tobacco use, and thereby reducing cigarette-related morbidity and mortality. In order for tobacco control to be effective, it is necessary for policy-makers to understand the personal and interpersonal factors which encourage people to smoke, factors which motivate smokers to quit (e.g. health, social pressure, cost), and the personal and population-level methods which are most effective at encouraging and prolonging quit attempts. Research has identified that social norms, mental health, and individual personality factors are most associated with smoking uptake and so interventions which reduce social smoking (e.g. smoking bans, plain packaging) would be most effective at preventing uptake. Conversely, the use of cigarettes is maintained by nicotine addiction and quit attempts are often motivated by health concerns, social pressure and the cost of tobacco products. As such, interventions which address physiological and behavioural addiction inherent in tobacco product use (such as nicotine replacement therapy combined with counselling), create social pressure to stop (such as mass media campaigns), or increase the cost of tobacco products, are most likely to be effective at encouraging quit attempts

Characterization of long-term users of nicotine replacement therapy: evidence from a national survey

Introduction: Harm reduction involving partial or complete substitution of cigarettes with nicotine replacement therapy (NRT) is likely to benefit smokers by reducing exposure to carcinogens and by increasing the likelihood of permanent cessation. This article aimed to assess the determinants of short- and long-term NRT use for harm reduction in order to inform interventions aimed at helping smokers struggling to quit to switch to complete NRT substitution. / Methods: Data were used from the Smoking Toolkit Study, a population-based survey of adults in England aged 16 years and older (n = 9,224). Participants were asked about their sociodemographic characteristics and tobacco use. Attitudes toward smoking were also assessed using questions covering 4 factors: motives, identity, evaluations, and plans. / Results: Concurrent short-term (<3 months) and long-term (≥3 months) NRT use was uncommon among smokers at 10.8% (95% confidence interval [CI] = 10.1–11.4) and 5.0% (95% CI = 4.6–5.4), respectively. Long-term NRT users had higher odds of being older, in nonmanual occupations, and more addicted than smokers with short-term or no NRT use (all p < .01). They reported lower odds of attempting to stop and higher odds of exhibiting a positive smoker identity than short-term users (p < .001). Conversely, long-term NRT users had higher odds of having made a recent quit attempt, to have plans to stop, and lower odds of a positive smoker identity than smokers not using NRT (all p < .001). / Conclusions: While users of NRT for harm-reduction purposes are a heterogeneous group, it appears they are more critical of smoking than never users and tend to positively modulate their behavior, setting them on a path toward cessation

Estimating the population impact of e-cigarettes on smoking cessation in England

An important consideration when assessing the public health impact of e-cigarettes is how far they contribute to, or detract from, smoking cessation in the population. There has been speculation about this (1), but without engaging appropriately with the relevant data and based on unreliable assumptions. England has data that can help to address this question, at least so far. Addiction's readers may be interested in the following analysis. It focuses on 2014, the most recent year for which full data are available. It leads to an estimate of 16K-22K as the number of additional long-term quitters generated by e-cigarettes in that year

Prevalence and characteristics of ever regular use of non-combustible nicotine for one-year or more: a population survey in England

Introduction: Up-to-date monitoring of non-combustible nicotine products (e.g. e-cigarettes, nicotine replacement therapies (NRT), heated tobacco products (HTP); NNP) is important to assess their impact. To date, there is little evidence on the association between ever regular use (defined here as 1 year or more) of NNP and current smoking status. Aims/methods: The purpose of this study was to examine the prevalence, and sociodemographic, alcohol and smoking status correlates, of ever regular use of NNP in England in 2020. A cross-sectional survey of adults in England was conducted between February and June 2020. Results: A total of 8486 adults were surveyed; 94.9% (8055) were complete cases. The weighted prevalence of ever regular NNP use was 5.4% (n = 436; 95% CI 5.0–6.0), of which 82% (n = 360; 95% CI 78.7–85.8) was single and 18% (n = 79; 95% CI 14.8–22) multiple product use. Amongst ever regular NNP users, the prevalence of ever regular NRT, e-cigarette and HTP use was 64.7% (95% CI 60.1–69), 43.4% (95% CI 38.8–48) and 2.5% (95% CI 1.4–4.5), respectively. In adjusted analysis, ever regular NNP use was associated with smoking status, being significantly higher among current (22.3%; adjusted OR (aOR) 34.9, 95% CI 24.0–50.8) and ex-smokers (12.7%, aOR 19.8, 95% CI 11.1–14.4) than among never-smokers (0.6%). More advantaged occupational grade (aOR, 1.27 95% CI 1.02–1.57) and at least hazardous alcohol use (aOR, 1.38 95% CI 1.06–1.78) were associated with greater prevalence of ever regular NNP use. Conclusions: Ever regularly using NNP was highest among smokers and ex-smokers and rare among never-smokers. Among people who have ever regularly used NNP, NRT is the most popular

Profile of menthol cigarette smokers in the months following the removal of these products from the market: a cross-sectional population survey in England

Introduction: In May 2020, the EU Tobacco Products Directive ban on the sale of menthol cigarettes was implemented in England. This study examined the prevalence of menthol cigarette smoking after the ban, according to sociodemographic and smoking characteristics. / Methods: Cross-sectional data came from a representative survey of current smokers (18+) in England (unweighted n=2681) between July 2020 and June 2021. The weighted prevalence of menthol cigarette smoking as a proportion of total cigarette smoking was calculated, log-binomial regression explored trends over time, and χ2 statistics assessed the relationship between menthol smoking, sociodemographic and smoking characteristics. Sources of purchase of menthol cigarettes were explored. / Results: Between July 2020 and June 2021, 15.7% (95% CI 14.5 to 17.1) of smokers reported smoking menthol cigarettes. The fitted non-linear trend supported no initial change followed by a possible reduction across April–June 2021 and fit the data better than linear and null (no change) models (χ2(2)=2519.7, p=0.06; χ2(3)=2519.7, p=0.006). Menthol cigarette smoking was more common among younger groups (16–24=25.2%; 25–34=19.9%) and women (19.4%). Menthol cigarette smokers showed lower cigarette dependence compared with other smokers. Past-6-month purchases of menthol cigarettes from any illicit or cross-border source declined from 30.1% in the last 6 months of 2020 to 17.5% in the first 6 months of 2021. / Conclusions: A substantial minority of current smokers in England reported menthol cigarette smoking between July 2020 and June 2021, despite the ban, possibly reflecting mitigation of restrictions by a variety of licit means, such as legal menthol accessories. The reduction in menthol smoking across April–June 2021 warrants further monitoring