Smokers' use of nicotine replacement therapy for reasons other than stopping smoking: findings from the ITC Four Country Survey

Trends in Over-the-Counter Nicotine Replacement Therapy Sales, U.S., 2017‒2020

INTRODUCTION

Few studies have examined trends in over-the-counter U.S. Food and Drug Administration‒approved nicotine replacement therapy sales data and consumer preferences for nicotine replacement therapy attributes (e.g., flavor). Examination of consumer preferences may inform both public health smoking cessation programs as well as subsequent research on consumer preferences for potentially reduced-risk tobacco products U.S. Food and Drug Administration may authorize.

METHODS

NielsenIQ Retail Measurement Service data were used to examine national trends in over-the-counter nicotine replacement therapy dollar sales from 2017 to 2020 and dollar sales by retail channel and product attributes for the most recent year available at the time of analysis (2020).

RESULTS

Over-the-counter nicotine replacement therapy sales totaled about $1 billion annually between 2017 and 2020. Across the 4-year period, sales of gum and patches decreased, whereas lozenge sales increased (p<0.05 for all). In 2020, gum accounted for 52.7% ($511 million), lozenges accounted for 33.3% ($322 million), and patches accounted for 14.1% ($137 million) of over-the-counter nicotine replacement therapy sales. Drug stores were the retail channel accounting for the largest percentage of total over-the-counter nicotine replacement therapy sales (42.9%). Three leading brands-private label or store brands (62.8%), Nicorette (30.7%,), and NicoDerm CQ (5.7%)-accounted for 99.2% of the total over-the-counter nicotine replacement therapy market. Mint was the most common flavor, representing 41.2% of total gum and 73.6% of total lozenge sales.

CONCLUSIONS

This analysis of over-the-counter nicotine replacement therapy sales sheds light on consumer preferences for attributes that can inform efforts to facilitate smoking cessation and research on preferences related to potentially reduced-risk tobacco products.

Case for investment in tobacco cessation: a population-based analysis in low- and middle-income countries

This study aimed to estimate the return on investments of three population-level tobacco cessation strategies and three pharmacological interventions. The analysis included 124 low- and middle-income countries, and assumed a 10-year investment period (2021–2030). The results indicate that all six cessation programmes could help about 152 million tobacco users quit and save 2.7 million lives during 2021–2030. If quitters were followed until 65 years of age, 16 million lives could be saved from quitting. The combined investment cost was estimated at 1.68 United States dollars (US$) per capita a year, or US$ 115 billion over the period 2021–2030, with Caribbean countries showing the lowest investment cost at US$ 0.50 per capita a year. Return on investments was estimated at 0.79 (at the end of 2030) and 7.50 if benefits were assessed by the time quitters reach the age of 65 years. Disaggregated results by country income level and region also showed a return on investments less than 1.0 in the short term and greater than 1.0 in the medium-to-long term. In all countries, population-level interventions were less expensive and yielded a return on investments greater than 1.0 in the short and long term, with investment cost estimated at US$ 0.21 per capita a year, or US$ 14.3 billion over 2021–2030. Pharmacological interventions were more expensive and became cost beneficial over a longer time. These results are likely conservative and provide support for a phased approach implementing population-level strategies first, where most countries would reach break-even before 2030.

E-liquid purchase as a function of workplace restriction in the experimental tobacco marketplace

E-cigarette use is prohibited in most smoke-free environments. The effect of this policy on tobacco consumption could be examined using the Experimental Tobacco Marketplace (ETM). The ETM allows observation of policy on smokers' purchasing behavior under conditions that simulate "real-world" circumstances. A within-subject design was used to evaluate the effect of workplace policy (Vaping Allowed vs. Not Allowed) and nicotine concentration (24 mg/mL vs. 0 mg/mL) on tobacco product consumption. Participants (n = 31) completed one sampling and two ETM/workplace sessions per week for 2 weeks. During the sampling session, participants were given an e-cigarette with a 2-day supply of a commercially available e-liquid of their preferred flavor. Before purchasing, participants were informed whether e-cigarette use was permitted. During the four ETM sessions, participants purchased for the following 24 hr, including the 4-hr work shift that started immediately after buying products in the ETM. The workplace session consisted of data entry tasks in a mock office environment. Participants could use any purchased tobacco products during two 15-min breaks. Condition order was counterbalanced. The results show that permitting E-cigarette use in the workplace increased e-liquid purchase on average, but nicotine concentration had no effect on e-liquid demand. Cigarette demand was unaltered across conditions. The present study suggests that allowing e-cigarette use in the workplace would increase demand for e-liquid regardless of nicotine strength. However, it would not change conventional cigarette demand. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

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.

Electronic cigarettes in physician practice: a complex debate

E-cigarettes, or electronic nicotine delivery systems (ENDS), have been suggested as a potential aid for smoking cessation, but many questions about their efficacy and safety remain unanswered. Until very recently, the evidence for ENDS in smoking cessation was largely based on observational studies or randomised controlled trials with methodological flaws and did not provide adequate evidence to support strongly ENDS for smoking cessation. Concerns about the uptake of ENDS by nonsmoking populations (such as adolescents) remain. More recent evidence may indicate the effect of ENDS in smoking cessation, but many questions remain unanswered. In this article, we address recent claims that failure to recommend ENDS for smoking cessation represents unethical practice. We strongly dispute this claim, analysing the many complex issues that clinicians working in smoking cessation should consider.

Potential for non-combustible nicotine products to reduce socioeconomic inequalities in smoking: a systematic review and synthesis of best available evidence

BACKGROUND

While some experts have emphasised the potential for e-cigarettes to facilitate cessation among smokers with low socioeconomic status (SES), there is limited evidence of their likely equity impact. We assessed the potential for electronic cigarettes and other non-combustible nicotine-containing products (NCNPs) to reduce inequalities in smoking by systematically reviewing evidence on their use by SES in countries at stage IV of the cigarette epidemic.

METHODS

Ten electronic databases were searched in February 2017 using terms relating to e-cigarettes, smokeless tobacco and nicotine replacement therapy (NRT); and SES. We included studies published since 1980 that were available in English and examined product use by SES indicators such as income and education. Data synthesis was based on those studies judged to be of medium- to high-quality using guidelines adapted from the Critical Appraisal Skills Programme.

RESULTS

We identified 54 studies describing NCNP use by SES across 12 countries, of which 27 were judged of sufficient quality to include in data synthesis. We found mixed patterns of e-cigarette current use by SES, with evidence of higher use among low-income adults but unclear or mixed findings by education and occupation. In contrast, smokeless tobacco current use was consistently higher among low SES adults. There was very limited evidence on the SES distribution of NRT in adults and of all NCNPs in young people.

CONCLUSIONS

The only NCNP for which there are clear patterns of use by SES is smokeless tobacco, where prevalence is higher among low SES groups. While this suggests a potentially positive impact on inequalities in smoking (if NCNP use displaces smoked tobacco use), this has not been seen in practice. These findings do not support the suggestion that e-cigarettes have the potential to reduce social inequalities in smoking, since i) current evidence does not show a clear trend of higher e-cigarette use in population groups with higher tobacco consumption, and ii) the experience of smokeless tobacco suggests that - even where NCNP use is higher among low SES groups - this does not necessarily replace smoked tobacco use in these groups.

How do we determine the impact of e-cigarettes on cigarette smoking cessation or reduction? Review and recommendations for answering the research question with scientific rigor

AIMS

To propose a hierarchy of methodological criteria to consider when determining whether a study provides sufficient information to answer the question of whether e-cigarettes can facilitate cigarette smoking cessation or reduction.

DESIGN

A PubMed search to 1 February 2017 was conducted of all studies related to e-cigarettes and smoking cessation or reduction.

SETTINGS

Australia, Europe, Iran, Korea, New Zealand and the United States.

PARTICIPANTS AND STUDIES

91 articles.

MEASUREMENTS

Coders organized studies according to six proposed methodological criteria: (1) examines outcome of interest (cigarette abstinence or reduction), (2) assesses e-cigarette use for cessation as exposure of interest, (3) employs appropriate control/comparison groups, (4) ensures that measurement of exposure precedes the outcome, (5) evaluates dose and duration of the exposure and (6) evaluates the type and quality of the e-cigarette used.

FINDINGS

Twenty-four papers did not examine the outcomes of interest. Forty did not assess the specific reason for e-cigarette use as an exposure of interest. Twenty papers did not employ prospective study designs with appropriate comparison groups. The few observational studies meeting some of the criteria (duration, type, use for cessation) triangulated with findings from three randomized trials to suggest that e-cigarettes can help adult smokers quit or reduce cigarette smoking.

CONCLUSIONS

Only a small proportion of studies seeking to address the effect of e-cigarettes on smoking cessation or reduction meet a set of proposed quality standards. Those that do are consistent with randomized controlled trial evidence in suggesting that e-cigarettes can help with smoking cessation or reduction.

Use of smoking cessation products: A survey of patients in community pharmacies

OBJECTIVES

At 17.3%, smoking rates in Manitoba continue to exceed the national average. In this province, a total health care spending of more than $200 million per year has been attributed to smoking. This study examined the use of smoking cessation agents, including nicotine replacement products and prescription medications, in a sample of smokers in the city of Winnipeg.

METHODS

A simple multiple-choice questionnaire was administered to willing individuals attending 2 community pharmacies in Winnipeg, Manitoba. Data on demographics, smoking habits, previous attempts of smoking cessation and previous and current use of over-the-counter and prescription smoking cessation products were collected anonymously.

RESULTS

Of the 2237 individuals who were approached, 586 were smokers (26.2%) and 180 responded to the survey (30.7%); 48.9% were female. A majority of smokers (32.8%) reported smoking 16 to 25 cigarettes per day. More than 90% had smoked for more than 5 years, 27.2% had more than 5 previous quit attempts and 82.1% used smoking cessation products with the intention to quit. Self-motivation (44.4%) and family/friend advice (28.3%) were major reasons for quitting. Impact of health care practitioners' advice was low (6.4%). More than 80% of respondents reported that they had no insurance coverage for their smoking cessation products. Despite having the highest rate of use, both nicotine gum (33.3%) and patches (24.4%) were reported to have lower rates of perceived efficacy. Electronic cigarette (97.9%) and varenicline (70.6%) had the highest rates of reported effectiveness.

CONCLUSION

Smokers wanting to quit undergo many attempts. Pharmacists should assume a key role in reaching out to smokers.

Association between adherence to free nicotine replacement therapy and successful quitting

INTRODUCTION

Providing free nicotine replacement therapy (NRT) can be a cost-effective strategy for increasing quit attempts and cessation rates at a population level. However, the optimal amount of NRT to provide is unknown. Associations between duration of NRT use and abstinence may be overestimated as a result of reverse causality due to discontinuation following relapse. We examined the association between adherence to 10weeks of cost-free NRT and quit success at 6-month follow-up, after controlling for reverse causation by excluding participants who reported nonadherence due to relapse.

METHODS

Individuals 18years or older who smoked at least 10 cigarettes daily and intended to quit within 30days received 10weeks of NRT at a smoking cessation workshop. There were 3922 participants who attended one of 114 workshops in 70 different localities in Ontario, Canada from 2007 to 2008.

RESULTS

At end of treatment participants were asked whether they had used "all" of the NRT (20%), "most" of it (28%), "some" of it (47%), or whether they "did not use any" of it (5%). After controlling for reverse causation and adjusting for potential confounding variables, poorer quit success was reported by those who used either some (AOR=0.43, 95% CI=0.26-0.69, p=0.001) or none (AOR=0.30, 95% CI=0.09-0.95, p=0.041) of the NRT versus all 10weeks. Post-estimation contrasts revealed using some versus most of the NRT was also associated with poorer quit success (p=0.026).

CONCLUSIONS

After controlling for reverse causation, adherence to 10weeks of cost-free NRT was associated with successful abstinence at six months post-treatment.

New Pharmacological Agents to Aid Smoking Cessation and Tobacco Harm Reduction: What Has Been Investigated, and What Is in the Pipeline?

A wide range of support is available to help smokers to quit and to aid attempts at harm reduction, including three first-line smoking cessation medications: nicotine replacement therapy, varenicline and bupropion. Despite the efficacy of these, there is a continual need to diversify the range of medications so that the needs of tobacco users are met. This paper compares the first-line smoking cessation medications with (1) two variants of these existing products: new galenic formulations of varenicline and novel nicotine delivery devices; and (2) 24 alternative products: cytisine (novel outside Central and Eastern Europe), nortriptyline, other tricyclic antidepressants, electronic cigarettes, clonidine (an anxiolytic), other anxiolytics (e.g. buspirone), selective serotonin reuptake inhibitors, supplements (e.g. St John's wort), silver acetate, Nicobrevin, modafinil, venlafaxine, monoamine oxidase inhibitors (MAOIs), opioid antagonists, nicotinic acetylcholine receptor (nAChR) antagonists, glucose tablets, selective cannabinoid type 1 receptor antagonists, nicotine vaccines, drugs that affect gamma-aminobutyric acid (GABA) transmission, drugs that affect N-methyl-D-aspartate (NMDA) receptors, dopamine agonists (e.g. levodopa), pioglitazone (Actos; OMS405), noradrenaline reuptake inhibitors and the weight management drug lorcaserin. Six 'ESCUSE' criteria-relative efficacy, relative safety, relative cost, relative use (overall impact of effective medication use), relative scope (ability to serve new groups of patients) and relative ease of use-are used. Many of these products are in the early stages of clinical trials; however, cytisine looks most promising in having established efficacy and safety with low cost. Electronic cigarettes have become very popular, appear to be efficacious and are safer than smoking, but issues of continued dependence and possible harms need to be considered.

Effects of Televised Direct-to-Consumer Advertising for Varenicline on Prescription Dispensing in the United States, 2006-2009

INTRODUCTION

Televised direct-to-consumer advertising (DTCA) for prescription drugs is controversial, especially for tobacco cessation products such as varenicline, given safety concerns that arose only after its market approval. We aim to quantify the extent to which DTCA influenced varenicline use.

METHODS

We linked monthly DTCA television ratings with monthly prescription data from IMS Health's National Prescription Audit across top 75 media markets in 2006-2009. We used Poisson models with Generalized Estimating Equations to analyze effects of exposures to DTCA for both varenicline and nicotine replacement therapies on rate of dispensed varenicline prescriptions among smokers, controlling for population characteristics and varenicline-related events.

RESULTS

Varenicline prescriptions increased dramatically following DTCA launch and declined sharply after safety risks were publicized and US Food and Drug Administration (FDA) issued an advisory. DTCA had significant impact on new prescription dispensing in the subsequent month: before the FDA advisory, one additional exposure to varenicline DTCA was associated with a 1.8% (rate ratio [RR] = 1.018 [1.015-1.021]) higher rate of new prescriptions; no effect was observed after the advisory (RR = 1.000 [0.997-1.003]). Prior to the advisory, cross-product effects of nicotine replacement therapy advertising on varenicline prescribing were negligible (RR = 1.002 [0.999-1.004]); after the advisory, effects were positive (RR = 1.015 [1.012-1.019]).

CONCLUSIONS

DTCA for varenicline had a significant impact on varenicline prescribing when the drug's safety profile was not well characterized, supporting arguments to limit DTCA for newly approved products whose real-world safety is unclear.

IMPLICATIONS

We examined the fluctuations in varenicline use in association with DTCA for varenicline and other tobacco cessation aids. To our knowledge this is the first study to quantify the effects of televised DTCA for varenicline and other tobacco cessation aids on varenicline prescription dispensing. We believe that understanding these relationships is critical for formulating effective public health policy and interventions.

Comparison of the characteristics of long-term users of electronic cigarettes versus nicotine replacement therapy: A cross-sectional survey of English ex-smokers and current smokers

BACKGROUND

Electronic cigarettes (ECs) and nicotine replacement therapy (NRT) are non-combustible nicotine delivery devices being widely used as a partial or a complete long-term substitute for smoking. Little is known about the characteristics of long-term users, their smoking behaviour, attachment to smoking, experience of nicotine withdrawal symptoms, or their views on these devices. This study aimed to provide preliminary evidence on this and compare users of the different products.

METHODS

UK participants were recruited from four naturally occurring groups of long-term (≥6 months) users of either EC or NRT who had stopped or continued to smoke (N=36 per group, total N=144). Participants completed a questionnaire assessing socio-demographic and smoking characteristics, nicotine withdrawal symptoms, smoker identity and attitudes towards the products they were using.

RESULTS

Adjusting for relevant confounders, EC use was associated with a stronger smoker identity (Wald X(2)(1)=3.9, p=0.048) and greater product endorsement (Wald X(2)(1)=4.6, p=0.024) than NRT use, irrespective of smoking status. Among ex-smokers, EC users reported less severe mood and physical symptoms (Wald X(2)(1)=6.1, p=0.014) and cravings (Wald X(2)(1)=8.5, p=0.003), higher perceived helpfulness of the product (Wald X(2)(1)=4.8, p=0.028) and lower intentions to stop using the product (Wald X(2)(1)=17.6, p<0.001) than NRT users.

CONCLUSIONS

Compared with people who use NRT for at least 6 months, those who use EC over that time period appear to have a stronger smoker identity and like their products more. Among long-term users who have stopped smoking, ECs are perceived as more helpful than NRT, appear more effective in controlling withdrawal symptoms and continued use may be more likely.

Has growth in electronic cigarette use by smokers been responsible for the decline in use of licensed nicotine products? Findings from repeated cross-sectional surveys

Background

The rise in electronic cigarette use by smokers may be responsible for the decreased use of licensed nicotine products and/or increased overall use of non-tobacco nicotine-containing products. This paper reports findings from the Smoking Toolkit Study (STS) tracking use of electronic cigarettes and licensed nicotine products to address this issue.

Methods

Data were obtained from monthly surveys involving 14 502 cigarette smokers in England between March 2011 and November 2014. Smokers were asked about their use of electronic cigarettes and licensed nicotine products.

Results

Prevalence of electronic cigarette use increased rapidly from 2.2% (95% CI 1.4% to 3.2%) in quarter 2 of 2011 to 20.8% (95% CI 18.3% to 23.4%) in quarter 3 of 2013, after which there was no change. Prevalence of licensed nicotine product use in smokers remained stable from quarter 2 of 2011 (17.4%, 95% CI 15.3% to 19.8%) to quarter 3 of 2013 (17.9%, 95% CI 15.62% to 20.5%), and thereafter declined steadily to 7.9% (95% CI 6.0% to 10.4%). Prevalence of use of any product was stable to quarter 1 of 2012, after which it increased from 18.5% (95% CI 16.3% to 21.0%) to 33.3% (95% CI 30.4% to 36.3%) in quarter 3 of 2013, and then decreased to 22.7% (95% CI 19.3% to 26.3%).

Conclusions

The shapes of trajectories since 2011 suggest that electronic cigarettes are probably not responsible for the decline in use of licensed nicotine products. Electronic cigarettes appear to have increased the total market for use of non-tobacco nicotine-containing products.

Does the Magnitude of Reduction in Cigarettes Per Day Predict Smoking Cessation? A Qualitative Review

INTRODUCTION

Reduction in cigarettes per day (CPD) aided by nicotine replacement therapy (NRT) increases cessation in smokers; however, it is unclear whether this is due to use of NRT or reduction per se. If the latter, a greater magnitude of reduction in CPD should increase the odds of cessation.

METHODS

The authors searched PubMed, Cochrane, PsychINFO, http://clinicaltrials.gov and their personal libraries for studies on smoking reduction. Seven of the 76 (9%) identified intervention trials and four of 28 naturalistic studies (14%) reported on the magnitude of reduction in relation to the odds of cessation.

RESULTS

Five of the seven intervention trials and three of the four naturalistic observational (cohort) studies found that increased reduction in CPD was associated with increased cessation. The intervention trials that reported effect sizes found that every 1% decrease in CPD or carbon monoxide was associated with a 3% to 4% increase in the odds of cessation. The naturalistic studies found that ordinal (eg, quartile) increases in participants' magnitude of reduction in CPD were associated with 50% to 290% increases in the odds of cessation. All of the naturalistic studies and four of the intervention trials included covariates; however, reduction's association with cessation could still be due to its association with NRT use or motivation.

CONCLUSION

Although prospective prediction does not necessarily indicate causality, our findings suggest reduction in CPD is a mechanism of increased cessation in prior NRT-aided reduction studies.

Association of amount and duration of NRT use in smokers with cigarette consumption and motivation to stop smoking: a national survey of smokers in England

INTRODUCTION

Clinical trials have found that the use of nicotine replacement therapy (NRT) to reduce cigarette consumption results in significant declines in cigarette consumption and increases smokers' propensity to quit. However, observational "real-world" studies have found much smaller effects. This may be because of low levels of NRT use. This study examined the association between amount and duration of NRT use amongst those attempting to reduce their cigarette consumption with motivation to quit and cigarette consumption.

METHODS

Data came from 2,158 smokers who took part in the Smoking Toolkit Study. A representative survey of smokers in England aged 16+.

RESULTS

Only 54.4% of patch users and 32.2% of non-transdermal NRT users reported using NRT with a frequency that would be expected to substantially influence cigarette consumption (4+ units per day for acute NRT forms and at least daily for transdermal patches). Those using the patch at or above this threshold smoked 1.3 cigarettes per day fewer than those using it below the threshold (p=0.059), whilst those using non-transdermal NRT at or above this threshold smoked 0.9 cigarettes less per day (p=0.022). In both cases, those using NRT more frequently had greater motivation to quit. Less than 1/5th of participants reported using a combination of NRT products. Use of NRT long-term was associated with lower motivation to quit and higher cigarette consumption.

CONCLUSION

Smokers attempting to reduce their cigarette intake are underusing NRT and this is associated with cigarette consumption and motivation to quit. These findings may explain why population-based studies have failed to report similar findings to clinical trials.

Nicotine replacement therapy use among smokers and ex-smokers: associated attitudes and beliefs: a qualitative study

Background

Smokers who are unwilling or unable to quit smoking may benefit from using nicotine replacement therapy (NRT) for harm reduction. This may include the partial or complete substitution of cigarettes with NRT. A taxonomy of the characteristics of those using NRT for harm reduction would be helpful in tailoring advice and treatment. Although attempts to categorize those using NRT for harm reduction have been made, these have largely been based on quantitative data. In order to provide further in-depth exploration of views, beliefs and experiences, the current study probed issues surrounding NRT and harm reduction qualitatively to better understand barriers and facilitators to this approach.

Methods

Three groups of participants (n = 15) were recruited from a student sample: current smokers with a history of NRT use, smokers without a history of NRT use, and ex-smokers with a history of NRT use. Participants were asked about their demographic characteristics, smoking behaviours, intention and perceived ability to quit smoking, awareness and use of NRT, beliefs about the health consequences of using NRT, and the safety and efficacy of NRT, using semi-structured telephone interviews.

Results

Twenty-four themes were identified; these themes were clustered into three main issues of cross-cutting themes: attitudes towards smoking and motivation to quit; smoking reduction and quit attempts; and beliefs, use and concerns about NRT. Those with a history of NRT use were more motivated and engaged with the quitting process than non-users. However, irrespective of smoking status and past NRT use, all participants showed misperceptions about NRT, such as the health consequences associated with NRT use.

Conclusions

NRT users are more motivated to quit smoking than non-users and are more likely to employ techniques to assist their cessation attempts. The majority of smokers have misperceptions regarding the safety and efficacy of NRT which may act as a barrier to its usage.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1311) contains supplementary material, which is available to authorized users.

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.

Clinical strategies to enhance the efficacy of nicotine replacement therapy for smoking cessation: a review of the literature

A number of smoking cessation pharmacotherapies have led to increases in quitting and thus to significant benefits to public health. Among existing medications, nicotine replacement therapy (NRT) has been available the longest, has the largest literature base in support, and is the only option for over-the-counter access. While the short-term efficacy of NRT is well documented in clinical trials, long-term abstinence rates associated with using NRT are modest, as most smokers will relapse. This literature review examines emerging clinical strategies to improve NRT efficacy. After an initial overview of NRT and its FDA-approved indications for use, we review randomized trials in which clinical delivery of NRT was manipulated and tested, in an attempt to enhance efficacy, through (1) duration of use (pre-quit and extended use), (2) amount of use (high-dose and combination NRT), (3) tailoring to specific smoker groups (genotype and phenotype), or (4) use of NRT for novel purposes (relapse prevention, temporary abstinence, cessation induction). Outcomes vary within and across topic area, and we highlight areas that offer stronger promise. Combination NRT likely represents the most promising strategy moving forward; other clinical strategies offer conflicting evidence but deserve further testing (pre-quit NRT or tailored treatment) or offer potential utility but are in need of further, direct tests. Some areas, though based on a limited set of studies, do not offer great promise (high-dose and extended treatment NRT). We conclude with a brief discussion of emergent NRT products (e.g., oral nicotine spray, among others), which may ultimately offer greater efficacy than current formulations. In order to further lower the prevalence of smoking, novel strategies designed to optimize NRT efficacy are needed.

How are the English Stop Smoking Services responding to growth in use of electronic cigarettes?

OBJECTIVE

To assess extent of electronic cigarette use by smokers attending Stop Smoking Services, the advice given about electronic cigarettes and whether this usage is recorded.

METHODS

Fifty-eight managers and 1284 practitioners completed an online survey. Questions covered use of electronic cigarettes, the advice given and whether use was recorded in client databases.

RESULTS

Ninety per cent (n=1150) and 95% (n=1215) of practitioners respectively, reported that their clients were using electronic cigarettes and that they had been asked about them. Seventy-one per cent (n=41) of managers reported that they had a policy on the advice to be given; of whom 85% (n=35) said that practitioners should say that products were unlicensed. Fifty-five per cent (n=707) of practitioners reported giving such advice and 11% (n=138) said they warned smokers about their safety. Only 9% (n=119) reported that they recorded clients' use.

CONCLUSION

Although use of electronic cigarettes by smokers in Stop Smoking Services is common, few provisions are in place to record their use. Practitioners mostly advise that products are not licensed.

PRACTICAL IMPLICATIONS

There is a need to consider additional training for practitioners on use of e-cigarettes and harm reduction generally to ensure that advice is consistent and evidence-based.

Does smoking reduction make smokers happier? Evidence from a cross-sectional survey

Objectives: Stopping smoking leads to greater happiness and life satisfaction. This raises the question as to whether harm reduction, i.e. smoking reduction (SR) and the use of Nicotine Replacement Therapy (NRT) for SR, might lead to a similar benefit. This is of importance, given that the National Institute of Clinical Excellence in the UK is due to release guidance on harm reduction in 2013.

Design: Data were collected from 1,532 smokers involved in the Smoking Toolkit Study.

Method: Participants were asked if they were cutting down and if they were using Nicotine Replacement Therapy (NRT). Smokers also rated happiness and life satisfaction.

Results: There was no evidence of an association between SR or use of NRT for SR and either reported ‘happiness’ or ‘life satisfaction’. Nor was there an association between measures of ‘happiness’ or ‘life satisfaction’ and cigarette consumption.

Conclusion: It appears that SR is not associated with mental health benefits. This suggests that complete cessation may be necessary for benefits to be incurred. Prospective studies are necessary to confirm these findings.

Does Use of Nicotine Replacement Therapy While Continuing to Smoke Undermine Cessation?: A Systematic Review

Aims: To review population surveys to assess (a) prevalence of the use of NRT for smoking reduction (SR) and temporary abstinence (TA) and (b) how far this is associated with attempts to stop smoking, smoking cessation and reduction in cigarette consumption.

Methods: An electronic search was undertaken of EMBASE, MEDLINE, Web of Science and PsycINFO. Articles were selected if they (1) assessed whether smokers had used or were currently using NRT for SR and/or TA; (2) involved smokers who had not taken part in a harm reduction programme; and (3) assessed prevalence and/or association of SR and/or TA with reductions in cigarette consumption and/or attempts to stop smoking and/or with smoking cessation. Twelve studies met the inclusion criteria and results were extracted independently by two researchers.

Results: Data were available from five countries (US, UK, Canada, Switzerland and Australia). Between 1% and 23% of smokers reported having ever used NRT for smoking reduction and between 2% and 14% during periods of temporary abstinence. Use of NRT for SR and/or TA was associated with little or no reduction in cigarette consumption. There was some evidence that it was positively associated with attempts to stop smoking and smoking cessation.

Conclusion: In smoking populations use of NRT to aid SR and in situations where smoking is not permitted appears to be having little effect on achieving a reduction in cigarette consumption but does not undermine cessation and may promote it.

Reducing harm from tobacco use

If current trends in smoking prevalence continue, even with the implementation of enhanced tobacco control measures, millions of smokers will continue to fall ill and die as a direct result of their smoking. Many of these will be from the most deprived groups in society - smoking continues to be one of the strongest drivers of health inequalities. The personal costs of this morbidity and mortality, as well as costs to business and the economy, are unequalled and will therefore remain high for several decades to come. However, there is an addition to the tobacco control armoury that could have a marked impact on public health, but it requires radical action to be taken. This would be to embrace harm reduction, but this approach is as controversial in the case of tobacco as it is in the case of illicit drugs from where it derives. However, harm reduction remains the Cinderella of the three major strategies for reducing smoking-related harm, the others being prevention and cessation. Here we make the case that harm reduction has an important role to play in reducing the health burden of tobacco use.

Longitudinal associations between smoking cessation medications and alcohol consumption among smokers in the International Tobacco Control Four Country survey

BACKGROUND

Available evidence suggests that quitting smoking does not alter alcohol consumption. However, smoking cessation medications may have a direct impact on alcohol consumption independent of any effects on smoking cessation. Using an international longitudinal epidemiological sample of smokers, we evaluated whether smoking cessation medications altered alcohol consumption independent of quitting smoking.

METHODS

Longitudinal data were analyzed from the International Tobacco Control Four Country (ITC-4) Survey between 2007 and 2008, a telephone survey of nationally representative samples of smokers from the United Kingdom, Australia, Canada, and the United States (n = 4,995). Quantity and frequency of alcohol consumption, use of smoking cessation medications (varenicline, nicotine replacement [NRT], and no medications), and smoking behavior were assessed across 2 yearly waves. Controlling for baseline drinking and changes in smoking status, we evaluated whether smoking cessation medications were associated with reduced alcohol consumption.

RESULTS

Varenicline was associated with a reduced likelihood of any drinking compared with nicotine replacement (OR = 0.56; 95% CI = 0.34 to 0.94), and consuming alcohol once a month or more compared to nicotine replacement (OR = 0.43; 95% CI = 0.27 to 0.69) or no medication (OR = 0.63; 95% CI = 0.41 to 0.99). Nicotine replacement was associated with an increased likelihood of consuming alcohol once a month or more compared to no medication (OR = 1.14; 95% CI = 1.03 to 1.25). Smoking cessation medications were not associated with more frequent drinking (once a week or more) or typical quantity consumed per episode. Medication effects on drinking frequency were independent of smoking cessation.

CONCLUSIONS

This epidemiological investigation demonstrated that varenicline was associated with a reduced frequency of alcohol consumption. Continued work should clarify under what conditions nicotine replacement therapies may increase or decrease patterns of alcohol consumption.

Assessing the association between the use of NRT for smoking reduction and attempts to quit smoking using propensity score matching

BACKGROUND

Smokers who use nicotine replacement therapy (NRT) to aid smoking reduction (SR) are more likely to quit smoking than those who try to reduce without NRT. This could be because NRT enhances the likelihood of quitting or because those who are motivated to quit choose to use NRT (i.e., selection bias).

METHODS

'Propensity score matching' was used to assess whether the increased likelihood of a quit attempt in those using NRT for SR would remain in a subsample of smokers paired on variables indicative of the likelihood of making a quit attempt and using NRT (i.e., when selection bias is reduced). Measures were obtained on a range of smoking and socio-demographic variables at baseline, then after 3 and 6 months. Fifty-eight smokers who were attempting SR at 3 months were matched on baseline measures to 58 smokers not using NRT for SR. The odds of their going on to make a quit attempt in the following 3 months were then compared.

RESULTS

In smokers matched on motivational and other variables for their propensity to use NRT to aid smoking reduction, those using NRT for SR had three times greater odds of reporting a quit attempt than those not using NRT (OR 3.23; CI 1.49-7.01; p<0.01).

CONCLUSION

The increased likelihood of subsequently trying to stop smoking among smokers who use NRT to aid SR versus those who try to reduce without NRT, remains following the matching of participants on motivational and other potentially relevant variables.

Student and school characteristics associated with use of nicotine replacement therapy: a multilevel analysis among Canadian youth

BACKGROUND

Research indicates that it is common for youths to use nicotine replacement therapy (NRT) despite limited empirical evidence for its effectiveness within this population. Since very little is known about the characteristics associated with NRT use by youth, the current study examined the association between ever and current use of NRT as a function of student characteristics and the characteristics of the schools they attend.

METHODS

This study used nationally representative student-level data from 29,296 grade 9 to 12 students who participated in the 2008-2009 Canadian Youth Smoking Survey (YSS). School-level data on the built environment surrounding schools were provided by DMTI-Spatial, and data on school location were provided by the Canadian Census. Two multilevel logistic regression models were used to predict ever use of NRT and current use of NRT as a function of student and school characteristics among current smokers.

RESULTS

Overall, 21.1% of youth smokers in Canada had ever used NRT and 5.1% were currently using NRT. Odds of ever and current NRT use were highest among daily smokers and boys, while youths who had made multiple quit attempts or participated in a quit and win contest were more likely to be ever NRT users. Attending a school located within an urban area increased youths' odds of ever and current NRT use, whereas higher density of pharmacies surrounding a school was inversely associated with current NRT use.

CONCLUSIONS

Characteristics of students and the schools they attend were associated with the likelihood of youth smokers using NRT. Significant between-school differences in NRT use exist, however further research is needed to identify which school characteristics account for these differences and understand how youth are accessing NRT.

Mediation analysis of the association between use of NRT for smoking reduction and attempts to stop smoking

OBJECTIVES

Use of nicotine replacement therapy (NRT) for smoking reduction (SR) is linked to higher quit attempt rates than SR without NRT. This study aimed to assess the possible mediating roles of confidence in ability to quit, enjoyment of smoking and motivation to quit in this association.

DESIGN

Cross-sectional survey.

MAIN OUTCOME MEASURES

Smokers were asked if they were currently attempting SR, and if they were, whether they were using NRT. Motivation to stop, enjoyment of smoking, confidence in ability to stop, and previous quit attempts, were also assessed.

RESULTS

There was no evidence that confidence in ability to quit or enjoyment of smoking mediated the association between the use of NRT for SR and attempts to quit. Only motivation to stop partially mediated between the use of NRT for SR and attempts to stop (indirect effect: odds ratio 1.08, p < 0.001).

CONCLUSION

Although this study is limited by its cross-sectional design, the findings point towards the possibility that the use of NRT to aid SR may promote attempts to stop through increasing motivation to quit but not by increasing confidence or by reducing enjoyment of smoking. Longitudinal studies are required to draw firmer conclusions about the possible mediating effects of motivation to quit.

Stability of cigarette consumption over time among continuing smokers: a latent growth curve analysis

OBJECTIVES

This paper examined the stability over time of daily cigarette consumption of continuing smokers and explored factors that might account for the patterns of change in consumption using a latent growth curve (LGC) analytic approach.

METHODS

Data come from the first 5 waves of the International Tobacco Control Four-Country Survey, conducted in Canada, the United States, the United Kingdom, and Australia where a cohort of over 2,000 smokers from each country were recruited and followed up annually with replenishment.

RESULTS

Raw data revealed that continuing smokers showed a marked steep decline in cigarettes per day during the first 2 waves followed by a gentler linear decline in consumption over the remaining waves of the study period. This pattern of change in cigarette consumption was best modelled using a piecewise linear LGC model. Baseline consumption level was highest in Australia and lowest in the United Kingdom, although the rate of decline was similar across the 4 countries. Being older than 55 years and having made at least 1 quit attempt were related to greater rate of decline in consumption.

CONCLUSIONS

Continuing smokers who are unwilling or unable to quit smoking can and do attempt to reduce their daily cigarette consumption over time. Factors such as making a quit attempt even if unsuccessful and experiencing smoking bans at work and at homes can contribute to reduced smoking among this group, which suggests that interventions focusing in on these factors, along with providing cessation help, may greatly improve their chances of quitting smoking altogether.

Non-cigarette tobacco products: what have we learnt and where are we headed?

A wide variety of non-cigarette forms of tobacco and nicotine exist, and their use varies regionally and globally. Smoked forms of tobacco such as cigars, bidis, kreteks and waterpipes have high popularity and are often perceived erroneously as less hazardous than cigarettes, when in fact their health burden is similar. Smokeless tobacco products vary widely around the world in form and the health hazards they present, with some clearly toxic forms (eg, in South Asia) and some forms with far fewer hazards (eg, in Sweden). Nicotine delivery systems not directly reliant on tobacco are also emerging (eg, electronic nicotine delivery systems). The presence of such products presents challenges and opportunities for public health. Future regulatory actions such as expansion of smoke-free environments, product health warnings and taxation may serve to increase or decrease the use of non-cigarette forms of tobacco. These regulations may also bring about changes in non-cigarette tobacco products themselves that could impact public health by affecting attractiveness and/or toxicity.

Planned quit attempts among Ontario smokers: impact on abstinence

AIMS

To examine the use and role of planned quit attempts by smokers and their impact on abstinence.

DESIGN

Retrospective, using longitudinal data from the Ontario Tobacco Survey.

SETTING

Ontario, Canada.

PARTICIPANTS

A total of 551 adult smokers who reported having made a quit attempt during 2007-08.

MEASUREMENTS

Reported planning of the most recent quit attempt (i.e. unplanned or planned some time in advance), engaging in preparatory behaviours believed to be related to planning (i.e. use of quit aids such as pharmacotherapy, formal support or health professionals) and abstinence at 1 week and 1 month following the attempt.

FINDINGS

Of the smokers, 73.6% planned their quit attempt in advance. Reported planning was more likely among those who thought they were very addicted, compared with those who were less addicted [odds ratio (OR)=2.22, 95% confidence interval (CI): 1.15-4.28]. Smokers who planned a quit attempt were much more likely to use a quit aid (OR=3.50, 95% CI: 1.80-6.79), particularly pharmacotherapy (OR=6.13, 95% CI: 3.05-12.34). The odds of abstaining for 1 week were lower among those who planned (OR=0.45, 95% CI: 0.22-0.89), independent of perceived addiction. No significant difference was observed for abstinence lasting 1 month. Other factors associated with abstinence were smoking fewer cigarettes per day and having personal support.

CONCLUSIONS

Although most quit attempts were planned and planners had higher odds of using quit aids, planning did not increase the likelihood of success.

Adolescents' self-reported reasons for using nicotine replacement therapy products: a population-based study

BACKGROUND

Available research provides evidence that adolescents use nicotine replacement therapy (NRT) products. Yet, little is known about reasons and motives behind their use. The present study examined the reasons for NRT use among 14-18-year-old Finnish adolescents.

METHOD

A national Adolescent Health and Lifestyle Survey was conducted in Finland in 2009 (N=4834, response rate 55%). Main measures were prevalence of NRT use, self-reported reasons for using NRT and smoking status.

RESULTS

Overall, 10% had used NRT. Boys used NRT more often than girls (11.5% versus 8.7%, p<.001). The three most commonly reported reasons were 'just try' (56%), 'to quit' (33%) and 'smoking not possible' (24%). "Just try" was the most common reason given by non-smokers/experimental smokers whereas daily/occasional smokers used NRT mainly for quitting purposes and when smoking was impossible.

CONCLUSIONS

These findings suggest that when planning treatment plans for adolescent smokers, health care personnel should pay particular attention to adolescents' primary reasons and motives for using NRT before suggesting its use.

Effectiveness of over-the-counter nicotine replacement therapy: a qualitative review of nonrandomized trials

AIM

Randomized trials conducted in over-the-counter (OTC) settings have shown that nicotine replacement therapy (NRT) is effective. This paper reviews nonrandomized tests of the effectiveness of OTC NRT.

METHODS

Literature search via computer and other methods located (a) retrospective cohort studies of users versus nonusers of OTC NRT and (b) studies of quit rates before versus after NRT went OTC or before versus after NRT was given free to quitline callers. The methods were too heterogeneous to allow meta-analysis.

RESULTS

The results were similar for cohort and pre- versus post-studies. Most of the studies found numerically greater quitting among NRT users than nonusers. Often when NRT was not found effective, other assumed effective treatments (e.g., phone counseling) were also not found effective, suggesting biased or insensitive study methods. Only about half of the studies found statistically greater quitting among NRT users, and the most rigorous studies did not find greater quitting among users. Many studies found selection bias, for example, NRT users are more dependent smokers.

CONCLUSIONS

Some lines of evidence appear to confirm the effectiveness of OTC NRT, but others do not. We believe further secondary analyses using nonrandomized comparisons are unlikely to resolve this issue due to sensitivity, specificity, and selection bias problems.

Cautions and warnings on the US OTC label for nicotine replacement: what's a doctor to do?

BACKGROUND

FDA-approved labeling for over-the-counter (OTC) nicotine replacement therapy (NRT) limits duration of use to a relatively short period of time (10-12 weeks) and explicitly advises against NRT use while smoking or with additional forms of NRT.

OBJECTIVE

To consider and summarize evidence accumulated since the OTC label was created regarding the safety and efficacy of longer-term and concomitant use to provide recommendations regarding these uses.

METHOD

Literature searches were conducted on Medline, journal websites, and Internet search engines, with findings reviewed by six smoking cessation researchers.

RESULTS

Persistent (i.e., long-term) use of NRT does not appear harmful and self-selected persistent use is primarily driven by concerns about relapse to smoking, not addiction. Similarly, continued use of NRT and tobacco during a lapse or relapse and combination NRT treatment do not appear harmful and appear to enhance efficacy.

CONCLUSIONS

Persistent users of NRT should be counseled to reduce and stop NRT only when they are not concerned about relapsing to smoking. Use of NRT with return to smoking during a lapse or relapse should not be automatically discontinued. Combination NRT therapy should be considered for all smokers, especially those who are unable to quit smoking using a single form of NRT.

Adherence to and reasons for premature discontinuation from stop-smoking medications: data from the ITC Four-Country Survey

INTRODUCTION

Nicotine replacement therapies (NRTs) have been demonstrated to be effective in clinical trials but may have lower efficacy when purchased over-the-counter (OTC). Premature discontinuation and insufficient dosing have been offered as possible explanations. The aims are to (a) investigate the prevalence of and reasons for premature discontinuation of stop-smoking medications (including prescription only) and (b) how these differ by type, duration of use, and source (prescription or OTC).

METHODS

The sample includes 1,219 smokers or recent quitters who had used medication in the last year (80.5% NRT, 19.5% prescription only). Data were from Waves 5 and 6 of the International Tobacco Control (ITC) Four-Country Survey.

RESULTS

Most of the sample (69.1%) discontinued medication use prematurely. This was more common among NRT users (71.4%) than in users of bupropion and varenicline (59.6%). OTC NRT users were particularly likely to discontinue (76.3%). Relapse back to smoking was the most common reason for discontinuation of medication reported by 41.6% of respondents. Side effects (18.3%) and believing that the medication was no longer needed (17.1%) were also commonly reported. Of those who completed treatment, 37.9% achieved 6-month continuous abstinence compared with 15.6% who discontinued prematurely. Notably, 65.6% who discontinued because they believed the medication had worked were abstinent.

CONCLUSIONS

Premature discontinuation of stop-smoking medications is common but is not a plausible reason for poorer quit outcomes for most people. Encouraging persistence of medication use after relapse or in the face of minor side effects may help increase long-term cessation outcomes.

US smokers' reactions to a brief trial of oral nicotine products

BACKGROUND

It has been suggested that cigarette smokers will switch to alternative oral nicotine delivery products to reduce their health risks if informed of the relative risk difference. However, it is important to assess how smokers are likely to use cigarette alternatives before making predictions about their potential to promote individual or population harm reduction.

OBJECTIVES

This study examines smokers' interest in using a smokeless tobacco or a nicotine replacement product as a substitute for their cigarettes.

METHODS

The study included 67 adult cigarette smokers, not currently interested in quitting, who were given an opportunity to sample four alternative oral nicotine products: 1) Camel Snus, 2) Marlboro Snus, 3) Stonewall dissolvable tobacco tablets, and 4) Commit nicotine lozenges. At visit 1, subjects were presented information about the relative benefits/risks of oral nicotine delivery compared to cigarettes. At visit 2, subjects were given a supply of each of the four products to sample at home for a week. At visit 3, subjects received a one-week supply of their preferred product to see if using such products reduced or eliminated cigarette use.

RESULTS

After multiple product sampling, participants preferred the Commit lozenges over the three smokeless tobacco products (p = 0.011). Following the one week single-product trial experience, GEE models controlling for gender, age, level of education, baseline cigarettes use, and alternative product chosen, indicated a significant decline in cigarettes smoked per day across one week of single-product sampling (p < 0.01, from 11.8 to 8.7 cigarettes per day), but no change in alternative product use (approximately 4.5 units per day). Biomarkers of exposure showed no change in cotinine, but a 19% reduction in exhaled CO (p < 0.001).

CONCLUSIONS

Findings from this study show that smokers, who are currently unwilling to make a quit attempt, may be willing to use alternative products in the short term as a temporary substitute for smoking. However, this use is more likely to be for partial substitution (i.e. they will continue to smoke, albeit at a lower rate) rather than complete substitution. Of the various substitutes offered, smokers were more willing to use a nicotine replacement product over a tobacco-based product.

Use of nicotine replacement therapy for smoking reduction and during enforced temporary abstinence: a national survey of English smokers

AIMS

To assess the prevalence of nicotine replacement therapy (NRT) use for smoking reduction (SR) and temporary abstinence (TA), the association between the two and the strength of the association between NRT use for SR or TA and socio-demographic characteristics, cigarette consumption and past quit attempts.

DESIGN

Cross-sectional monthly surveys.

SETTING

England.

PARTICIPANTS

A total of 11, 414 smokers.

MEASUREMENTS

Participants were asked (i) whether they were reducing the amount they smoked: if so, whether they used NRT; and (ii) whether they used NRT for TA. Demographic characteristics, daily cigarette consumption and whether a quit attempt had been made in the past 12 months were also assessed.

FINDINGS

Of the participants, 56% were attempting SR, 14% were using NRT for SR and 14% were using NRT for TA. Use of NRT for SR and TA were highly correlated. The nicotine patch was the most commonly used form of NRT. The use of NRT for SR, compared with unassisted SR, was more common among older smokers, while the use of NRT for TA was more common among women. Cigarette consumption was higher in those using NRT for SR than those attempting SR without NRT. The use of NRT for SR and TA was associated positively with past quit attempts.

CONCLUSIONS

Nicotine replacement therapy use for smoking reduction and temporary abstinence is common in England. The use of NRT for SR and TA does not appear to be associated with lower cigarette consumption relative to SR or TA without NRT, but is associated with a higher rate of past quit attempts.

Is web interviewing a good alternative to telephone interviewing? Findings from the International Tobacco Control (ITC) Netherlands survey

Background

Web interviewing is becoming increasingly popular worldwide, because it has several advantages over telephone interviewing such as lower costs and shorter fieldwork periods. However, there are also concerns about data quality of web surveys. The aim of this study was to compare the International Tobacco Control (ITC) Netherlands web and telephone samples on demographic and smoking related variables to assess differences in data quality.

Methods

Wave 1 of the ITC Netherlands Survey was completed by 1,668 web respondents and 404 telephone respondents of 18 years and older. The two surveys were conducted in parallel among adults who reported smoking at least monthly and had smoked at least 100 cigarettes over their lifetime.

Results

Both the web and telephone survey had a cooperation rate of 78%. Web respondents with a fixed line telephone were significantly more often married, had a lower educational level, and were older than web respondents without a fixed line telephone. Telephone respondents with internet access were significantly more often married, had a higher educational level, and were younger than telephone respondents without internet. Web respondents were significantly less often married and lower educated than the Dutch population of smokers. Telephone respondents were significantly less often married and higher educated than the Dutch population of smokers. Web respondents used the "don't know" options more often than telephone respondents. Telephone respondents were somewhat more negative about smoking, had less intention to quit smoking, and had more self efficacy for quitting. The known association between educational level and self efficacy was present only in the web survey.

Conclusions

Differences between the web and telephone sample were present, but the differences were small and not consistently favourable for either web or telephone interviewing. Our study findings suggested sometimes a better data quality in the web than in the telephone survey. Therefore, web interviewing can be a good alternative to telephone interviewing.

Smoking attitudes, behaviour and nicotine dependence among mental health acute inpatients: an exploratory study

BACKGROUND

In 2008, mental health units in England went smoke-free by law. This study explores inpatients' experience with a smoke-free policy, their smoking behaviour, dependence, withdrawal and related issues.

MATERIAL

Semi-structured interviews in a criterion sample of 15 inpatient smokers.

DISCUSSION

Patients generally approved of the smoke-free policy, provided they could smoke outside. Most participants had changed their smoking behaviour following admission. Most had little knowledge of nicotine dependence, reported a lack of structured support for smoking cessation, and a general interest in this being made available. Nicotine dependence was reportedly lower in the ward than in the home setting.

CONCLUSIONS

More structured support is needed to ensure that opportunities for health promotion in a vulnerable population are not being missed.

Factors associated with the use of aids to cessation in English smokers

AIMS

To assess factors associated with the use of smoking cessation aids among smokers trying to quit in a country where these aids are widely available and free or cheap to access.

DESIGN

Cross-sectional household survey, the 'Smoking Toolkit Study'.

SETTING

England.

PARTICIPANTS

A total of 3767 respondents who smoked and made at least one serious quit attempt in the past 12 months were interviewed from November 2006 to April 2008.

MEASUREMENTS

We analysed differences across socio-demographic and smoking characteristics in the use of nicotine replacement therapy (NRT) over the counter or on prescription, bupropion, varenicline, telephone support and the National Health Service Stop Smoking Service (NHS-SSS) which combines behavioural support with medication.

FINDINGS

More than half of smokers trying to quit (51.2%) had used any kind of treatment; 48.4% had used some form of medication but only 6.2% had used the NHS-SSS. The use of some form of smoking cessation treatment was higher in female than in male smokers [odds ratio (OR): 1.24, 95% confidence interval (CI): 1.08, 1.43] and increased with age (OR: 1.19, 95% CI: 1.14,1.25) and cigarettes smoked per day (OR = 1.05, 95% CI = 1.04,1.06). There was no association with social grade. Smokers who planned their quit attempt were more likely to have used all types of smoking cessation treatments, except for telephone support.

CONCLUSIONS

In England, half of all attempts to quit smoking are aided by some form of pharmacological or behavioural treatment. However, the use of the most effective treatment option (the NHS-SSS) is low, despite it being free of charge. Factors associated with an increased use of aids to cessation were female sex, older age, more cigarettes smoked per day and planning a quit attempt. Research is needed into how to increase utilization rates, particularly among males and younger smokers.

The impact of changing nicotine replacement therapy licensing laws in the United Kingdom: findings from the International Tobacco Control Four Country Survey

AIM

To evaluate the impact of a new licence for some nicotine replacement therapy products (NRT) for cutting down to stop (CDTS) on changes in the pattern of NRT use.

DESIGN

Quasi-experimental design comparing changes in NRT use across two waves of a population-based, replenished-panel, telephone survey conducted before and after the introduction of new licensing laws in the United Kingdom with changes in NRT use in three comparison countries (Australia, Canada and United States) without a licensing change.

PARTICIPANTS

A total of 7386 and 7013 smokers and recent ex-smokers participating in the 2004 and/or 2006/7 survey.

MEASUREMENTS

Data were collected on demographic and smoking characteristics as well as NRT use and access. In order to account for interdependence resulting from some participants being present in both waves, generalized estimation equations with an exchangeable correlation matrix were used to assess within-country changes and linear and logistic regressions to assess between-country differences in adjusted analyses.

FINDINGS

NRT use was more prevalent in the United Kingdom and increased across waves in all countries but no wave x country interaction was observed. There was no evidence that the licensing change increased the prevalence of CDTS or the use of NRT (irrespective of how it was accessed) for CDTS in the United Kingdom relative to comparison countries. There was also no evidence for a change in concurrent smoking and NRT use among smokers not attempting to stop in the United Kingdom relative to comparison countries.

CONCLUSION

The addition of the CDTS licence for some NRT products in the United Kingdom appears to have had very limited, if any, impact on NRT use in the first year after the licence change.