A comparison of the Fagerström test for nicotine dependence and smoking prevalence across countries: updated data from Spain

Tobacco harm reduction: are smokers becoming more hardcore?

We undertook a systematic review to identify and summarise studies on hardcore smoking and hardening to: determine the degree of variability in definitions of hardcore smoking and hardening; assess the evidence for claims that smokers are becoming increasingly hardened within the context of harm reduction as a policy initiative; and identify the determining characteristics of a hardcore smoker. We searched five electronic databases from 1970 to mid-April 2018 using the search term "smok* AND hard* AND (tobacco OR cigar* OR nicotin*)". We included studies if they included a definition of hardcore smokers and/or hardening, and provided a prevalence rate for hard core smokers or empirical evidence for hardening. Definitions of hardcore smoker varied substantially across studies. Hardening was not evident in the general smoking population and we found mounting evidence of softening occurring in smoking populations. These results indicate that hardening of smokers is not occurring and that calls for policy interventions on this basis should be challenged.

Are smokers "hardening" or rather "softening"? An ecological and multilevel analysis across 28 European Union countries

BACKGROUND

Tobacco control policies can reduce smoking prevalence. These measures may be less effective where smoking prevalence has significantly declined, as the remaining smokers have "hardened". Our aim was to empirically evaluate the "hardening hypothesis" at the population level in the European Union (EU) and explore factors associated with hardcore smoking.

METHODS

We conducted two separate analyses in the EU using data on smoking from the Eurobarometer surveys (2009-2017, n=112 745). 1) A panel-data fixed-effects linear regression to investigate changes over time in the percentage of hardcore smokers in relation to standardised smoking prevalence at the country level. 2) A multilevel logistic regression analysis with hardcore (daily smokers, ≥15 cigarettes per day who have not attempted to quit in the last 12 months) or light (<5 cigarettes per day) smoking as the dependent variable and time as the main independent variable, controlling for individual and ecological variables.

RESULTS

We studied 29 010 current smokers (43.8% hardcore smokers and 14.7% light smokers). The prevalence of hardcore smoking among adult smokers increased by 0.55 (95% CI 0.14-0.96) percentage points per each additional percentage point in the overall smoking prevalence. The odds of being a hardcore smoker increased over time and were higher in middle-aged males and people with financial difficulties, while the odds of being a light smoker significantly declined among females.

CONCLUSION

This study does not support the "hardening hypothesis" in the EU between 2009 and 2017, but suggests a softening of the smoking population. Existing tobacco control policies are likely to be suitable to further decrease smoking prevalence in Europe.

Smoking dependence in 18 European countries: Hard to maintain the hardening hypothesis

OBJECTIVE

When the prevalence of smoking decreases in a population, there is a hypothesis-the so-called "hardening hypothesis"-that the remaining smokers form a subgroup of "hardcore smokers." Our aims were to test the hardening hypothesis and to analyze the determinants of high dependence taking into account both individual and country-level characteristics.

METHOD

Within the Pricing Policies and Control of Tobacco in Europe (PPACTE) project, we conducted a face-to-face survey on smoking between January and July 2010 in 18 European countries, including 2882 male and 2254 female smokers with complete information on smoking dependence. The Heaviness of Smoking Index (HSI) was used as a measure of tobacco dependence. We correlated smoking prevalence and dependence using the country as unit of analysis. Moreover, we fitted multilevel logistic regression models.

RESULTS

Country-specific prevalence of smoking was positively, although not significantly, correlated with the proportion of highly tobacco-dependent smokers (overall rsp=0.203, p=0.419), both in men (rsp=0.235, p=0.347) and women (rsp=0.455, p=0.058). Using individual-level analysis, high dependence was positively related to age, and, although not significantly, to smoking prevalence, and inversely related to level of education. The lack of a smoking ban at home was positively related to smoking dependence.

CONCLUSIONS

Using both ecological and individual-level analyses, the relations between smoking prevalence and HSI were not significant, but in the opposite direction as compared to that assumed by the "hardening hypothesis." Therefore, our data provide empirical evidence against this theory, thus supporting the feasibility of an endgame strategy.

Changes in the Prevalence of Tobacco Consumption and the Profile of Spanish Smokers after a Comprehensive Smoke-Free Policy

BACKGROUND

A partial smoke-free regulation in Spain was introduced on January 1, 2006, which was subsequently amended to introduce a comprehensive smoke-free policy from 2 January 2011 onward. The objective of this study was to compare the prevalence of tobacco consumption in Spain and the profile of smokers before (2006) and after (2011) the comprehensive smoking ban passed in 2010.

METHODS

Two independent, cross-sectional, population-based surveys were carried out among the adult (≥ 18 years old) Spanish population in 2006 and 2011 through telephone interviews. Both surveys used the same methods and questionnaire. Nicotine dependence was assessed with the Fagerström Test for nicotine dependence and readiness to quit according to the stages of change.

RESULTS

The prevalence of tobacco consumption showed a nonsignificant decrease from 23.4% in 2006 to 20.7% in 2011. No changes were observed in nicotine dependence or readiness to quit. In 2011, most smokers (76%) showed low nicotine dependence and were mainly in the precontemplation stage (72%).

CONCLUSIONS

The prevalence of smokers has slightly decreased since the introduction of the total smoking ban in Spain. No differences were found in nicotine dependence or readiness to quit.

Changes in the profiles of smokers seeking cessation treatment and in its effectiveness in Galicia (Spain) 2001-10

BACKGROUND

In recent years, the prevalence of daily smokers has decreased in all developed countries due to a great variety of factors. Despite this decrease, the effectiveness of clinical treatments has decreased and several studies report a change in smokers' characteristics. The purpose of the present study is to analyze the changes in the characteristics of Spanish smokers who seek smoking cessation treatment between 2001 and 2010 and the changes in the effectiveness of such treatment.

METHODS

The sample was made up of 870 smokers who sought psychological treatment for giving up smoking at the Smoking Cessation Unit in the Faculty of Psychology of the University of Santiago de Compostela (Spain) during the period 2001 to 2010.

RESULTS

Smokers in the 2006-2010 group, compared to those in the 2001-2005 group, were older, smoked fewer cigarettes per day and of a brand with fewer mg/nicotine, had been smoking longer, were less motivated to give up smoking, and had more antecedents of depression. Quit rates were validated by testing smokers' carbon monoxide (CO) levels.Percentages of abstinence were higher in the 2001-2005 group than in the 2006-2010 group (58.7% vs. 52.15 at the end of treatment, p = 0.05); 30.8% vs. 24.2% at 6 months follow-up, p = 0.031; 27.5% vs. 22% at 12 months follow-up, p = 0.059). Although abstinence decreased more than 5% in the 2006-2010 group there were no differences between the two groups in nicotine dependence. Those participants who did not assist to the follow-up were considered smokers at pretreatment level.

CONCLUSIONS

In Spain there has been a qualitative change in the profile of the smokers seeking smoking cessation treatment. Treatment effectiveness has decreased, and the variables predicting intervention outcome have changed.

Tobacco use and nicotine dependence among conflict-affected men in the Republic of Georgia

Background: There is very little evidence globally on tobacco use and nicotine dependence among civilian populations affected by armed conflict, despite key vulnerability factors related to elevated mental disorders and socio-economic stressors. The study aim was to describe patterns of smoking and nicotine dependence among conflict-affected civilian men in the Republic of Georgia and associations with mental disorders. Methods: A cross-sectional household survey using multistage random sampling was conducted in late 2011 among conflict-affected populations in Georgia. Respondents included in this paper were 1,248 men aged ≥18 years who were internally displaced persons (IDPs) and former IDPs who had returned in their home areas. Outcomes of current tobacco use, heavy use (≥20 cigarettes per day), and nicotine dependence (using the Fagerström Test for Nicotine Dependence) were used. PTSD, depression, anxiety and hazardous alcohol use were also measured, along with exposure to traumatic events and a range of demographic and socio-economic characteristics. Results: Of 1,248 men, 592 (47.4%) smoked and 70.9% of current smokers were heavy smokers. The mean nicotine dependence score was 5.0 and the proportion with high nicotine dependence (≥6) was 41.4%. In multivariate regression analyses, nicotine dependence was significantly associated with PTSD (β 0.74) and depression (β 0.85), along with older age (except 65+ years), and being a returnee (compared to IDPs). Conclusions: The study reveals very high levels of heavy smoking and nicotine dependence among conflict-affected persons in Georgia. The associations between nicotine dependence, PTSD and depression suggest interventions could yield synergistic benefits.

[Optimal cut-point of salivary cotinine concentration to discriminate smoking status in the adult population in Barcelona]

OBJECTIVE

To assess the optimal cut-point for salivary cotinine concentration to identify smoking status in the adult population of Barcelona.

METHODS

We performed a cross-sectional study of a representative sample (n=1,117) of the adult population (>16 years) in Barcelona (2004-2005). This study gathered information on active and passive smoking by means of a questionnaire and a saliva sample for cotinine determination. We analyzed sensitivity and specificity according to sex, age, smoking status (daily and occasional), and exposure to second-hand smoke at home. ROC curves and the area under the curve were calculated.

RESULTS

The prevalence of smokers (daily and occasional) was 27.8% (95% CI: 25.2-30.4%). The optimal cut-point to discriminate smoking status was 9.2 ng/ml (sensitivity=88.7% and specificity=89.0%). The area under the ROC curve was 0.952. The optimal cut-point was 12.2 ng/ml in men and 7.6 ng/ml in women. The optimal cut-point was higher at ages with a greater prevalence of smoking. Daily smokers had a higher cut-point than occasional smokers.

CONCLUSIONS

The optimal cut-point to discriminate smoking status in the adult population is 9.2 ng/ml, with sensitivities and specificities around 90%. The cut-point was higher in men and in younger people. The cut-point increases with higher prevalence of daily smokers.