Population-level predictors of changes in success rates of smoking quit attempts in England: a time series analysis

Impact of Standardised Packaging of Tobacco Products Regulations on cigarette consumption and youth smoking in England: interrupted time-series analysis

BACKGROUND

In the UK in May 2016, standardised packaging of tobacco products was implemented, including minimum pack sizes of 20 sticks or 30 g loose tobacco. The change was intended to reduce uptake by increasing upfront costs to young people, but there was concern it may unintentionally increase consumption among people smoking. This study aimed to assess whether the introduction of the policy was associated with changes in (1) mean daily factory-made (FM)/roll-your-own (RYO) cigarettes consumption among people smoking predominantly (a) FM and (b) RYO cigarettes; and (2) current smoking prevalence among 16-24-year-olds.

METHODS

Data (N=257 929) were from a representative monthly cross-sectional survey of adults (≥16 years) in England, collected between November 2007 and January 2020. Outcome measures were mean daily (FM/RYO) cigarette consumption among those smoking FM/RYO cigarettes, and prevalence of current smoking among 16-24-year-olds. Time-series analyses were conducted using Autoregressive Integrated Moving Average with Exogenous variables (ARIMAX) regression models including a gradual level change starting in June 2017 and ending in May 2018 for cigarette consumption and a step change in June 2016 for prevalence of current smoking.

RESULTS

The ARIMAX model was not able to detect a change in mean daily cigarette consumption-for FM (Badj=-0.543, 95% CI -1.381 to 0.296) or RYO (Badj=0.002, 95% CI -0.518 to 0.522) following the implementation of standardised packaging. The unadjusted analysis suggested the implementation of standardised packaging was associated with a small (3%) decrease in smoking prevalence among 16-24-year-olds (Bunadj=-0.031, 95% CI -0.062 to 0.000), but this association was attenuated after adjustment for covariates (Badj=-0.010, 95% CI -0.039 to 0.019).

CONCLUSIONS

The implementation of standardised packaging of tobacco products was not associated with a meaningful change in the mean number of FM or RYO cigarettes consumed by people smoking in England, suggesting the larger pack size has not had an unintended consequence of substantially increasing cigarette consumption. However, there was also little evidence that the policy substantially reduced smoking among 16-24-year-olds.

Developing content for a virtual reality scenario that motivates quit attempts in adult smokers: A focus group study with art-based methods

Virtual reality (VR) could be used to deliver messages to smokers that encourages them to attempt quitting. For a VR smoking cessation intervention to be effective, the target population must find the content engaging, relevant, inoffensive, and compelling. Informed by health behaviour theory and narrative transportation theory, this study used focus groups combined with art-based methods (participant sketches) to inform the development of VR content that will appropriately address smokers' beliefs about quitting smoking. Data were analysed using reflexive thematic analysis. Four in-person focus groups (N = 21) were held between July and August 2023. Just under half the sample were from an ethnic minority (42.8%) and women (42.9%), and the mean age was 33.6 years (standard deviation = 15.9). More than half the sample had a low motivation to quit (61.0%). We developed six themes concerning: the VR content suggested by participants, the rationale behind it, its technological execution and potential widescale implementation. Many participants downplayed the health consequences of smoking, prioritising the immediate rewards of smoking over quitting's long-term benefits. Therefore, participants suggested content set in the future, showing the benefits of cessation or the negative consequences of continued smoking. Family members were recommended as supporting VR characters to increase the contents' emotional salience. Participants also suggested graphic content that would trigger anxiety about smoking, suggesting that fear appeals were welcome. Participants wanted a truly novel intervention- not a leaflet about smoking statistics presented through VR. Participants suggested healthcare locations (e.g., doctors' offices) for implementation, as home ownership of VR headsets is low. Also, this would make the VR appear more legitimate as a health intervention (rather than casual entertainment) and could complement in-person advice. Future research will refine the participant-generated ideas with experts in VR design and smoking cessation.

Have there been sustained impacts of the COVID-19 pandemic on trends in smoking prevalence, uptake, quitting, use of treatment, and relapse? A monthly population study in England, 2017-2022

BACKGROUND

Studies conducted during the early stages of the pandemic documented mixed changes in smoking behaviour: more smokers quitting successfully but little change in prevalence. This study aimed to examine whether there have been sustained impacts of the COVID-19 pandemic on smoking patterns in England.

METHODS

Data were from 101,960 adults (≥ 18 years) participating in the Smoking Toolkit Study, a monthly representative household survey, between June 2017 and August 2022. Interviews were conducted face-to-face until March 2020 and via telephone thereafter. Generalised additive models estimated associations of the pandemic onset (March 2020) with current smoking, uptake, cessation, quit attempts, and use of support. Models adjusted for seasonality, sociodemographic characteristics, and (where relevant) dependence and tobacco control mass-media expenditure.

RESULTS

Before the COVID-19 pandemic, smoking prevalence fell by 5.2% per year; this rate of decline slowed to 0.3% per year during the pandemic (RRΔtrend = 1.06, 95% CI = 1.02, 1.09). This slowing was evident in more but not less advantaged social grades (RRΔtrend = 1.15, 1.08, 1.21; RRΔtrend = 1.00, 0.96, 1.05). There were sustained step-level changes in different age groups: a 34.9% (95% CI = 17.7, 54.7%) increase in smoking prevalence among 18-24-year-olds, indicating a potential rise in uptake, in contrast to a 13.6% (95% CI = 4.4, 21.9%) decrease among 45-65-year-olds. In both age groups, these step-level changes were followed by the pre-pandemic declines stopping, and prevalence remaining flat. There were sustained increases in quitting among past-year smokers, with a 120.4% (95% CI = 79.4, 170.9%) step-level increase in cessation and a 41.7% (95% CI = 29.7, 54.7%) increase in quit attempts. The main limitation was the change in modality of data collection when the pandemic started; while this may have contributed to the step-level changes we observed, it is unlikely to explain changes in the slope of trends.

CONCLUSIONS

In England, the rate of decline in adult smoking prevalence stagnated during the COVID-19 pandemic through to 2022. At the start of the pandemic, a potential reduction in smoking prevalence among middle-aged adults and increases in quitting among smokers may have been offset by an increase in smoking among young adults. The slowing in the rate of decline was pronounced in more advantaged social grades.

Examining the influence of tobacco control mass media campaign expenditure on the association between motivation to stop smoking and quit attempts: A prospective study in England

OBJECTIVE

To explore whether expenditure on national tobacco control mass media campaigns moderates the association between motivation to stop smoking and future quit attempts.

METHOD

Data were from 2601 people who smoke participating in a population survey with 12-month follow-up between April 2015 and February 2021. We used logistic regression to test associations of (i) baseline level of motivation to stop smoking, (ii) mean monthly tobacco control mass media campaign expenditure in England between baseline and follow-up, and (iii) their interaction, on past-year quit attempts assessed at 12-month follow-up. Covariates included age, sex, occupational social grade, and region.

RESULTS

Between baseline and follow-up, 38.6% of participants made a quit attempt. Each one-point increase in baseline motivation to stop smoking was associated with 1.37 times greater odds (95%CI = 1.31-1.43) of making a quit attempt over 12-month follow-up. Each one standard deviation increase in tobacco control mass media expenditure between baseline and 12-month follow-up was associated with 13% greater odds of making a quit attempt (95%CI = 1.05-1.23). There was no significant interaction between mass media expenditure and motivation to stop on quit attempts (OR = 1.01, 95%CI = 0.97-1.05); the data provided strong evidence for the null (Bayes factors = 0.07 and 0.04 based on expected effect sizes of OR = 1.5 and OR = 0.67, respectively).

CONCLUSIONS

Among people who smoke, self-reported level of motivation to stop strongly predicted whether they made a quit attempt in the subsequent year. Increased expenditure on tobacco control mass media campaigns was associated with increased quit attempts. The association between motivation and quit attempts did not differ according to tobacco control mass media expenditure over this period.

What drives public perceptions of e-cigarettes? A mixed-methods study exploring reasons behind adults' perceptions of e-cigarettes in Northern England

BACKGROUND

Despite growing evidence that e-cigarettes are likely less harmful than cigarettes, perceptions of equal or more harm have increased worldwide. This study aimed to identify the most common reasons behind adults' perceptions of the (i) relative harm of e-cigarettes compared with cigarettes and (ii) effectiveness of e-cigarettes for smoking cessation.

METHODS

Adults (N = 1646) from Northern England were recruited through online panels from December-March 2017/2018, using quota sampling to guarantee socio-demographic representativeness. Qualitative content analysis of open-ended responses was performed with codes representing reasons for a given perception about e-cigarettes. Percentages of participants who gave each reason for each perception were calculated.

RESULTS

823 (49.9%) participants agreed that e-cigarettes were less harmful than cigarettes, 283 (17.1%) disagreed, and 540 (32.8%) were undecided. The most common reasons for agreeing that e-cigarettes were less harmful than cigarettes were that they produce no smoke (29.8%) and fewer toxins (28.9%). Those who disagreed were most concerned about a perceived lack of trustworthy research (23.7%) and safety issues (20.8%). Lacking knowledge (50.4%) was the most common reason for being undecided. 815 (49.5%) of participants agreed that e-cigarettes were an effective smoking cessation aid, 216 (13.2%) disagreed, and 615 (37.4%) were undecided. The most common reasons participants gave for agreeing were related to e-cigarettes being successful smoking replacements (50.3%) and advice from family, friends or health professionals (20.0%). Respondents who disagreed were most concerned about e-cigarettes being addictive (34.3%) and containing nicotine (15.3%). Lacking knowledge (45.2%) was the most common reason for being undecided.

CONCLUSIONS

Negative perceptions of e-cigarette harm were driven by concerns about a perceived lack of research and safety issues. Adults who viewed e-cigarettes as ineffective for smoking cessation feared that they perpetuate nicotine addiction. Campaigns and guidelines that address these concerns may help promote informed perceptions.

A critique of the Australian National Health and Medical Research Council CEO statement on electronic cigarettes

This paper critically analyses a statement by Australia's National Health and Medical Research Council (NHMRC) on e-cigarettes in May 2022 that will be used to guide national policy. We reviewed the evidence and the conclusions drawn in the NHMRC Statement. In our view, the Statement is not a balanced reflection of the benefits and risks of vaping because it exaggerates the risks of vaping and fails to compare them to the far greater risks of smoking; it uncritically accepts evidence of harms from e-cigarettes while adopting a highly sceptical attitude towards evidence of their benefits; it incorrectly claims that the association between adolescent vaping and subsequent smoking is causal; and it understates the evidence of the benefits of e-cigarettes in assisting smokers to quit. The Statement dismisses the evidence that vaping is probably already having a positive net public health effect and misapplies the precautionary principle. Several sources of evidence supporting our assessment were published after the NHMRC Statement's publication and are also referenced. The NHMRC Statement on e-cigarettes does not present a balanced assessment of the available scientific literature and fails to meet the standard expected of a leading national scientific body.

Smoking prevalence following the announcement of tobacco tax increases in England between 2007 and 2019: an interrupted time-series analysis

AIMS

This study aimed to evaluate the impact of announcement of tax increases on factory-made (FM) and roll-your own (RYO) cigarettes in England.

DESIGN, SETTING AND PARTICIPANTS

Autoregressive integrated moving average with exogeneous input (ARIMAX) time-series modelling in England, UK. Data were aggregated monthly on 274 890 participants between 2007 and 2019 taking part in the Smoking Toolkit Study (STS).

MEASUREMENTS

The association of sustained step level changes for tax rises for FM cigarettes and temporary pulse effects for tax rises for RYO cigarettes with smoking, quit attempt and quit success prevalence as well as per-capita self-reported cigarette consumption and cost per cigarette was assessed.

FINDINGS

A 10% rise in tax on RYO cigarettes was associated with a temporary 21.1% decline [95% confidence interval (CI) = -30.4 to -10.7] in smoking prevalence, and 20.7% decline (95% CI = -32.4 to -7.0) in per-capita self-reported cigarette consumption; while a 3% rise of tax on RYO cigarettes was associated with a temporary 20.7% decline (95% CI = -33.3 to -5.8) in the amount paid per RYO cigarette. For tax increases on FM cigarettes, a 5% above inflation tax rise was associated with a step-level increase of 33.1% (95% CI = 18.4-49.5) in quit success rates. However, some of the findings were sensitive to model specification and temporally specific.

CONCLUSION

The announcements of tax increases for cigarettes in England between 2010 and 2019 were inconsistently associated with temporary reductions in smoking prevalence, per-capita self-reported cigarette consumption and improved quit success. Paradoxically, reductions in the cost for roll-your-own cigarettes were also found. The results were not robust in all sensitivity analyses.

Smoking cessation aids and strategies: a population-based survey of former and current smokers in Norway

BACKGROUND

In Norway, tobacco consumption is equally divided between combustible (cigarettes) and non-combustible (snus) tobacco. In the process of quitting, people who smoke can choose between several smoking cessation aids and strategies based on what is available on the market or what are recommended as cessation aids. A quit attempt may be planned or unplanned and consist of a gradual decline in consumption or an abrupt quitting. This study explores smoking cessation aids and strategies used at the latest quit attempt among people who have ever smoked. How prevalent is the use of various cessation aids and strategies, and do they correlate with each other? Are there any differences in successful quits depending on the use of a specific cessation aid or strategy?

METHOD

We used repeated cross-sectional representative surveys in Norway for 2017, 2018, 2019 and 2020. The analytic sample consists of people aged 20 years or older who have ever smoked daily, more precisely current daily smokers with at least one quit attempt (n = 476), and former daily smokers who quit in 2012 or later (n = 397). Participants answered questions on cessation aids and strategies used at their last quit attempt. Logistic regression analysis was used to estimate the associations between cessation aids and strategies and sociodemographic and smoking-related variables and successful quit attempts.

RESULTS

Fifty-six percent of people who ever smoked daily reported any use of cessation aids, and nicotine replacement therapy (NRT), snus and e-cigarettes were the most commonly used cessation aids. Snus and web/mobile use was associated with successful quits, while NRT was associated with unsuccessful quit attempts. When exclusive use was separated from the combined use of several aids, only snus was associated with successful quits.

CONCLUSION

Snus use was found to be a "stand-alone" cessation aid, and only weakly associated with the use of other cessation aids. Further investigation of cessation aid preferences is needed, especially among smokers with little or no contact with health services and/or for whom traditional cessation aids have no appeal.

US Nicotine Vaping Product SimSmoke Simulation Model: The Effect of Vaping and Tobacco Control Policies on Smoking Prevalence and Smoking-Attributable Deaths

The public health impact of nicotine vaping products (NVPs) is subject to a complex set of uncertain transitions between NVP and cigarette use. Instead, we apply an indirect method to gauge the impact of NVP use on smoking prevalence and smoking-attributable deaths (SADs) using the well-established SimSmoke tobacco control policy simulation model. Upon validating the model before NVPs were more widely used, we project a No-NVP (i.e., in the absence of NVPs) while controlling for the impact of cigarette-oriented policies. The net impact of NVPs on smoking prevalence is inferred by comparing the projected No-NVP smoking trends to corresponding trends from two US national surveys. Using the TUS-CPS estimates for the period 2012-2018, we estimate that adult smoking prevalence declined in relative terms by 9.7% (95% CI: 7.5-11.7%) for males and 10.7% (95% CI: 9.1-13.0%) for females. Compared to NHIS, smoking prevalence declined by 10.7% (95% CI: 6.8-14.6%) for males and 11.3% (95% CI: 7.4-15.6%) for females. These impacts were confined mainly to ages 18-44. Vaping-related reductions in smoking prevalence were projected to avert nearly 0.4 million SADs between 2012 and 2052. Our analysis indicates that NVP use is associated with substantial reductions in US smoking prevalence among younger adults.

England SimSmoke: the impact of nicotine vaping on smoking prevalence and smoking-attributable deaths in England

BACKGROUND AND AIMS

Whereas the use of nicotine vaping products (NVPs) is widespread, their impact on smoking prevalence is controversial. This study considered the potential impact of NVPs on smoking prevalence in England.

DESIGN

Indirect simulation model. The England SimSmoke model is validated through 2012, before NVP use became more widely used by smokers. Because information on NVP-related transitions is limited, an indirect method is used; the difference in observed smoking prevalence (reflecting NVPs) is compared with a 2012-2019 counterfactual No-NVP scenario (without NVPs) to estimate the impact of NVPs on smoking and smoking-attributable deaths.

SETTING

England, 2000-2019.

PARTICIPANTS

Nationally representative sample of population.

MEASUREMENTS

England's population, mortality rates and smoking prevalence estimates from three national surveys and tobacco control policies.

FINDINGS

Between 2000 and 2012, SimSmoke projected a decline in age 18+ smoking prevalence of 23.5% in men and 27.0% in women. These projections, as well as those by specific age groups, were generally consistent with findings from the three national surveys. Comparing 2012-2019 relative reduction in age 18+ prevalence from the Annual Population Survey (males, 27.5%) with the model-predicted No-NVP reduction (males, 7.3%), the implied NVP-attributable relative reduction in adult smoking prevalence was 20.2% (95% CI, 18.8%-22.0%) for males and 20.4% (18.7%-22.2%) for females. The NVP-attributable reduction was 27.2% (22.8%-31.6%) for males and 31.7% (27.4%-36.5%) for females ages 18-24 and 18.6% (15.2%-21.8%) for males and 15.0% (11.1%-18.8%) for females ages 25-34, with similar reductions for ages 35+. The implied reduction in smoking prevalence between 2012 and 2019 equates to 165 660 (132 453-199 501) averted deaths by 2052. Other surveys yielded smaller, but relatively consistent results.

CONCLUSIONS

An indirect method of simulation modelling indicates that substantial reductions in smoking prevalence occurred in England from 2012-2019 coinciding with the growth in nicotine vaping product use.

Protocol for expansion of an existing national monthly survey of smoking behaviour and alcohol use in England to Scotland and Wales: The Smoking and Alcohol Toolkit Study

Background The Smoking and Alcohol Toolkit Study (STS/ATS) in England has delivered timely insights to inform and evaluate strategies aimed at reducing tobacco smoking- and alcohol-related harm. From the end of 2020 until at least 2024 the STS/ATS is expanding to Scotland and Wales to include all constituent nations in Great Britain. Expanding data collection to Scotland and Wales will permit the evaluation of how smoking and alcohol related behaviours respond to divergent policy scenarios across the devolved nations. Methods The STS/ATS consists of monthly cross-sectional household interviews (computer or telephone assisted) of representative samples of adults in Great Britain aged 16+ years. Commencing in October 2020 each month a new sample of approximately 1700 adults in England, 450 adults in Scotland and 300 adults in Wales complete the survey (~n = 29,400 per year). The expansion of the survey to Scotland and Wales has been funded for the collection of at least 48 waves of data across four years. The data collected cover a broad range of smoking and alcohol-related parameters (including but not limited to smoking status, cigarette/nicotine dependence, route to quit smoking, prevalence and frequency of hazardous drinking, attempts and motivation to reduce alcohol consumption, help sought and motives for attempts to reduce alcohol intake) and socio-demographic characteristics (including but not limited to age, gender, region, socio-economic position) and will be reviewed monthly and refined in response to evolving policy needs and public interests. All data analyses will be pre-specified and available on a free online platform. A dedicated website will publish descriptive data on important trends each month. Discussion The Smoking and Alcohol Toolkit Study will provide timely monitoring of smoking and alcohol related behaviours to inform and evaluate national policies across Great Britain.

Predictors of Smoking Cessation Attempts and Success Following Motivation-Phase Interventions Among People Initially Unwilling to Quit Smoking

INTRODUCTION

Most people who smoke cigarettes are not willing (ie, not ready) to make a quit attempt (QA) at any given time. Unfortunately, interventions intended to increase QAs and the success of QAs are only modestly effective. Identifying processes leading to QAs and quitting success could guide intervention development.

AIMS AND METHODS

This is a secondary analysis of a randomized factorial trial of 6 weeks of motivation-phase interventions among primary care patients (N = 517) who were initially unwilling to quit but were willing to reduce their smoking. Using logistic regression, we controlled for treatment condition and tested whether baseline or change in smoking-related constructs after 6 weeks of treatment predicted (1) making an at least 24 h QA between weeks 6 and 26 and (2) quitting success at week 26 (7-day point-prevalence abstinence among those who made a QA). Predictors included cigarettes/day, time to first cigarette, motivation to quit, quitting self-efficacy, anticipated urges to smoke if quit, positive affect, negative affect, and time spent around others who smoke.

RESULTS

In multivariable models that included all smoking-related constructs, changes in the following variables predicted initiating a QA above and beyond other variables: greater baseline time to first cigarette (odds ratio [OR] = 1.60), increases in time to first cigarette (OR = 1.27), and increases in quitting self-efficacy (OR = 1.14). Increased motivation to quit predicted conversion of a QA into quitting success at 26 weeks (OR = 1.36).

CONCLUSION

Predictors of making a QA differed from predictors of quitting success. Predictors of QAs and success could each serve as important treatment targets of motivation-phase interventions.

IMPLICATIONS

Motivation-phase interventions for people initially unwilling to quit smoking cigarettes may be improved by striving to increase their (1) time to first cigarette and quitting self-efficacy to promote QAs and (2) motivation to quit to promote quit success. Future experimental tests of such interventions are needed to identify causal determinants of QAs and quitting success.

Nicotine replacement treatment, e-cigarettes and an online behavioural intervention to reduce relapse in recent ex-smokers: a multinational four-arm RCT

BACKGROUND

Relapse remains an unresolved issue in smoking cessation. Extended stop smoking medication use can help, but uptake is low and several behavioural relapse prevention interventions have been found to be ineffective. However, opportunistic 'emergency' use of fast-acting nicotine replacement treatment or electronic cigarettes may be more attractive and effective, and an online behavioural Structured Planning and Prompting Protocol has shown promise. The present trial aimed to evaluate the clinical effectiveness and cost-effectiveness of these two interventions.

DESIGN

A randomised controlled trial.

SETTING

English stop smoking services and Australian quitlines, Australian social media and St Vincent's Hospital Melbourne, Fitzroy, VIC.

PARTICIPANTS

Ex-smokers abstinent for at least 4 weeks, with some participants in Australia also recruited from 1 week post quit date. The planned sample size was 1400, but the trial was curtailed when 235 participants were recruited.

INTERVENTIONS

Participants were randomised in permuted blocks of random sizes to (1) oral nicotine replacement treatment/electronic cigarettes to use if at risk of relapse, plus static text messages (n = 60), (2) the Structured Planning and Prompting Protocol and interactive text messages (n = 57), (3) oral nicotine replacement treatment/electronic cigarettes plus the Structured Planning and Prompting Protocol with interactive text messages (n = 58) or (4) usual care plus static text messages (n = 59).

OUTCOME MEASURES

Owing to delays in study set-up and recruitment issues, the study was curtailed and the primary outcome was revised. The original objective was to determine whether or not the two interventions, together or separately, reduced relapse rates at 12 months compared with usual care. The revised primary objective was to determine whether or not number of interventions received (i.e. none, one or two) affects relapse rate at 6 months (not biochemically validated because of study curtailment). Relapse was defined as smoking on at least 7 consecutive days, or any smoking in the last month at final follow-up for both the original and curtailed outcomes. Participants with missing outcome data were included as smokers. Secondary outcomes included sustained abstinence (i.e. no more than five cigarettes smoked over the 6 months), nicotine product preferences (e.g. electronic cigarettes or nicotine replacement treatment) and Structured Planning and Prompting Protocol coping strategies used. Two substudies assessed reactions to interventions quantitatively and qualitatively. The trial statistician remained blinded until analysis was complete.

RESULTS

The 6-month relapse rates were 60.0%, 43.5% and 49.2% in the usual-care arm, one-intervention arm and the two-intervention arm, respectively (p = 0.11). Sustained abstinence rates were 41.7%, 54.8% and 50.9%, respectively (p = 0.17). Electronic cigarettes were chosen more frequently than nicotine replacement treatment in Australia (71.1% vs. 29.0%; p = 0.001), but not in England (54.0% vs. 46.0%; p = 0.57). Of participants allocated to nicotine products, 23.1% were using them daily at 6 months. The online intervention received positive ratings from 63% of participants at 6 months, but the majority of participants (72%) completed one assessment only. Coping strategies taught in the Structured Planning and Prompting Protocol were used with similar frequency in all study arms, suggesting that these are strategies people had already acquired. Only one participant used the interactive texting, and interactive and static messages received virtually identical ratings.

LIMITATIONS

The inability to recruit sufficient participants resulted in a lack of power to detect clinically relevant differences. Self-reported abstinence was not biochemically validated in the curtailed trial, and the ecological momentary assessment substudy was perceived by some as an intervention.

CONCLUSIONS

Recruiting recent ex-smokers into an interventional study proved problematic. Both interventions were well received and safe. Combining the interventions did not surpass the effects of each intervention alone. There was a trend in favour of single interventions reducing relapse, but it did not reach significance and there are reasons to interpret the trend with caution.

FUTURE WORK

Further studies of both interventions are warranted, using simpler study designs.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN11111428.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 68. See the NIHR Journals Library website for further project information. Funding was also provided by the National Health and Medical Research Council, Canberra, ACT, Australia (NHMRC APP1095880). Public Health England provided the funds to purchase the nicotine products in England.

Smokers who have not tried alternative nicotine products: a 2019 survey of adults in Great Britain

Aims

Switching from smoking to using nicotine replacement therapy (NRT), electronic cigarettes (e-cigarettes) or heated tobacco products can reduce tobacco-related health risks. However, not all smokers in Great Britain have tried these products. This study aimed to identify and describe smokers who have never tried alternative nicotine products.

Methods

We analysed cross-sectional survey data of smokers (n = 1777) from a representative adult sample from Great Britain. The online survey was run in March 2019. The proportion of smokers who had never used alternative nicotine products was measured. A multivariate logistic regression assessed the association between never having used alternative nicotine products and sociodemographic and smoking characteristics and motivation to stop smoking.

Results

One in four smokers (27.8%, 95% CI 25.8–29.9%) had never tried NRT, e-cigarettes or heated tobacco products. These smokers were more commonly from Black and Minority than White ethnic groups (AOR = 1.55; 95% CI 1.02–2.31), were more likely to smoke up to 10 versus more cigarettes per day (AOR = 1.52; 95% CI 1.14–2.03) and to report low versus moderate or high motivation to stop smoking (AOR = 1.79; 95% CI 1.20–2.74).

Conclusion

Light smokers, those unmotivated to stop and smokers from Black and Minority ethnic groups are less likely to have ever tried alternative nicotine products. Different approaches are needed to facilitate harm reduction and smoking cessation among these groups of smokers.

Association of prevalence of electronic cigarette use with smoking cessation and cigarette consumption in England: a time-series analysis between 2006 and 2017

AIMS

To provide up-to-date estimates of how changes in the prevalence of electronic cigarette (e-cigarette) use in England have been associated with changes in smoking cessation activities and daily cigarette consumption among smokers in England.

DESIGN

Time-series analysis of population trends.

SETTING

England.

PARTICIPANTS

Participants came from the Smoking Toolkit Study, which involves repeated, cross-sectional household surveys of individuals aged 16 years and older in England. Data were aggregated on approximately 1200 past-year smokers each quarter (total n = 50 498) between 2007 and 2017.

MEASUREMENTS

Prevalence of e-cigarette use in current smokers was used to predict (a) prevalence of quit attempts among last-year smokers, (b) overall quit rates among last-year smokers and (c) mean cigarette consumption per day among current smokers. Prevalence of e-cigarette use during a quit attempt among last-year smokers was used to predict (a) quit success rate among last-year smokers and (b) overall quit rates among last-year smokers.

FINDINGS

Overall quit rates increased by 0.054% [95% confidence interval (CI) = 0.032-0.076, P < 0.001] and 0.050% (95% CI = 0.031-0.069, P < 0.001) respectively for every 1% increase in the prevalence of e-cigarette use by smokers and e-cigarette use during a quit attempt. Quit success rates increased by 0.060% (95% CI = 0.043-0.078, P < 0.001) for every 1% increase in the prevalence of e-cigarette use during a quit attempt. No clear evidence was found for an association between e-cigarette use and either prevalence of quit attempt (BAdj = 0.011, 95% CI = -0.046 to 0.069, P = 0.698) or cigarette consumption (BAdj = 0.019, 95% CI = -0.043 to 0.082, P = 0.542).

CONCLUSION

Changes in prevalence of e-cigarette use in England have been positively associated with the overall quit rates and quit success rates but not clearly associated with the prevalence of quit attempts and mean cigarette consumption.

Long-term evaluation of the rise in legal age-of-sale of cigarettes from 16 to 18 in England: a trend analysis

OBJECTIVE

To assess the long-term impact of the increase in age-of-sale of cigarettes from 16 to 18 in England in October 2007.

METHODS

Data were collected between November 2006 and September 2018 on 252,601 participants taking part in a nationally representative survey of adults aged 16+ in England, the Smoking Toolkit Study (STS). We assessed the impact of the introduction of the increase in age-of-sale on prevalence of ever smoking, current smoking, and quit attempts, among 16-17 year olds compared with 18-24 year olds.

RESULTS

Following the increase in age-of-sale, there was a declining trend in ever smoking that was greater among 16-17 year olds than 18-24 year olds (OR 0.990 versus OR 0.993; p = 0.019). Data on current smoking were insensitive to detect a difference between the age groups in a step-level change or change in trend following the increase in age-of-sale (Bayes factors (BFs) 0.75 and 2.10). Data on quit attempts were also insensitive to detect a change in trend (BF 0.71), and despite a greater step-level decline among those aged 16-17 (OR 0.311 versus OR 0.547, p = 0.025), quit attempts remained higher among those aged 16-17. Secondary analysis indicated that post-policy change, trends in current and ever smoking were linear for 16-17 year olds but quadratic for 18-24 year olds (slowing decline).

CONCLUSION

There is some evidence from an assessment of long-term trends in the Smoking Toolkit Study that the increase in legal age-of-sale of cigarettes in England was associated with a greater long-term decline in ever smoking among those aged 16-17 compared with those aged 18-24.

Population-level predictors of changes in success rates of smoking quit attempts in England: a time series analysis

AIMS

To quantify associations between the success of smoking quit attempts and factors that have varied throughout 2007-2018 at a population level.

DESIGN

time series analysis using Autoregressive Integrated Moving Average with Exogeneous Input (ARIMAX) modelling.

SETTING AND PARTICIPANTS

Data were aggregated from 54 847 past-year smokers taking part in the Smoking Toolkit Study which involves monthly repeated cross-sectional household surveys of individuals aged 16+ in England.

MEASUREMENTS

The input series were: (1) attempts at smoking reduction using (a) e-cigarettes and (b) nicotine replacement therapy (NRT); (2) use during a quit attempt of (a) e-cigarettes, (b) NRT over-the-counter, (c) medication on prescription and (d) face-to-face behavioural support; (3) use of roll-your-own tobacco; (4) prevalence of (a) smoking and (b) non-daily smoking; (5) tobacco control mass media expenditure; (6) expenditure on smoking; (7) smoker characteristics in the form of (a) high motivation to quit, (b) average age, (c) socio-economic status and (d) cigarette consumption; (8) implementation of tobacco control policies; and (9) quit attempt rate.

FINDINGS

The licensing of NRT for harm reduction was associated with a 0.641% [95% confidence interval (CI) = 0.073-1.209, P = 0.027] increase in the mean point prevalence of the success rate of quit attempts. For every 1% increase in the mean point prevalence of e-cigarette use and use of prescription medication during a quit attempt, the mean point prevalence of successful quit attempts increased by 0.106% (95% CI = 0.011-0.201, P = 0.029) and 0.143% (95% CI = 0.009-0.279, P = 0.038), respectively. For every 1% increase in the mean expenditure on tobacco control mass media, the mean point prevalence of successful quit attempts increased by 0.046% (95% CI = 0.001-0.092, P = 0.046). Other associations were not statistically significant.

CONCLUSION

In England between 2007 and 2018, licensing of nicotine replacement therapy for use in harm reduction, greater use of e-cigarettes and prescription medications during a quit attempt and higher expenditure on tobacco control mass media were all associated with higher success rates of quit attempts.