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Key Publications

These are a selection of important publications in academic journals relating to smoking trends and research in England. The information below includes summaries of each publication.
pub. October '13

The effect of reducing the threshold for carbon monoxide validation of smoking abstinence - Evidence from the English Stop Smoking Services

Addictive behaviors [38(10):2529-31]
PMID: 23773961
Brose LS, Tombor I, Shahab L, West R.

ABSTRACT

INTRODUCTION:

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

METHODS:

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

RESULTS:

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

CONCLUSIONS:

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

Copyright © 2013 Elsevier Ltd. All rights reserved.

pub. July '13

Effectiveness of varenicline versus nicotine replacement therapy for smoking cessation with minimal professional support: evidence from an English population study

Psychopharmacology
PMID: 23873417
Kotz D, Brown J, West R.

ABSTRACT

RATIONALE:

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

OBJECTIVES:

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

METHODS:

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

RESULTS:

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

CONCLUSIONS:

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

pub. July '13

Randomized trial of NRT, bupropion, and NRT plus bupropion for smoking cessation: effectiveness in clinical practice

Addiction (Abingdon, England)
PMID: 23859696
Stapleton J, West R, Hajek P, Wheeler J, Vangeli E, Abdi Z, O'Gara C, McRobbie H, Humphrey K, Ali R, Strang J, Sutherland G.

ABSTRACT

BACKGROUND AND AIMS:

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

DESIGN:

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

SETTING:

Four UK NHS smoking cessation clinics.

PARTICIPANTS:

Smokers (n=1071) received 7 weekly behavioural support sessions and were randomized to an NRT product of their choice (n=418), bupropion (n=409) or NRT plus bupropion (n=244).

MEASURES:

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

FINDINGS:

Abstinence rates for bupropion (27.9%) and NRT (24.2%) were not significantly different (OR=1.21, 95% C.I.=0.88-1.67), and the combination rate (24.2%) was similar to that for either treatment alone. There was some evidence that the relative effectiveness of bupropion and NRT differed according to depression (X2=2.86, p=0.091), with bupropion appearing more beneficial than NRT in those with a history of depression (29.8% vs 18.5%). Several unwanted symptoms were more common with bupropion.

CONCLUSION:

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

This article is protected by copyright. All rights reserved.

pub. July '13

Characterising tobacco control mass media campaigns in England

Addiction (Abingdon, England)
PMID: 23834209
Langley T, Lewis S, McNeill A, Gilmore A, Szatkowski L, West R, Sims M.

ABSTRACT

AIMS:

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

DESIGN:

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

SETTING:

England.

MEASUREMENTS:

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

FINDINGS:

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

CONCLUSIONS:

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

This article is protected by copyright. All rights reserved.

pub. July '13

Factors associated with differences in quit rates between "specialist" and "community" stop-smoking practitioners in the english stop-smoking services

Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco [15(7):1239-47]
PMID: 23239841
McDermott MS, Beard E, Brose LS, West R, McEwen A.

ABSTRACT

INTRODUCTION:

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

METHOD:

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

RESULTS:

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

CONCLUSIONS:

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

pub. May '13

Association between nicotine replacement therapy use in pregnancy and smoking cessation

Drug and alcohol dependence
PMID: 23680076
Brose LS, McEwen A, West R.

ABSTRACT

BACKGROUND:

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

METHODS:

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

RESULTS:

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

CONCLUSIONS:

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

Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

pub. May '13

How does rate of smoking cessation vary by age, gender and social grade? Findings from a population survey in England

Addiction (Abingdon, England)
PMID: 23668684
Fidler J, Ferguson SG, Brown J, Stapleton J, West R.

ABSTRACT

AIMS:

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

DESIGN AND SETTING:

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

PARTICIPANTS:

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

MEASUREMENTS:

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

FINDINGS:

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

© 2013 Society for the Study of Addiction.

pub. September '12

Subjective social status predicts smoking abstinence among light smokers

American journal of health behavior [36(5):639-46]
PMID: 22584091
Whembolua GL, Davis JT, Reitzel LR, Guo H, Thomas JL, Goldade KR, Okuyemi KS, Ahluwalia JS.

ABSTRACT

OBJECTIVES:

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

METHODS:

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

RESULTS:

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

CONCLUSIONS:

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

pub. June '12

A pilot study of StopAdvisor: A theory-based interactive internet-based smoking cessation intervention aimed across the social spectrum

Addictive behaviors
PMID: 22795643
Brown J, Michie S, Geraghty AW, Miller S, Yardley L, Gardner B, Shahab L, Stapleton JA, West R.

ABSTRACT

BACKGROUND:

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

METHODS:

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

RESULTS:

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

CONCLUSIONS:

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

Copyright © 2012 Elsevier Ltd. All rights reserved.

pub. May '12

Very low rate and light smokers: smoking patterns and cessation-related behaviour in England, 2006-11

Addiction (Abingdon, England) [107(5):995-1002]
PMID: 22126678
Kotz D, Fidler J, West R.

ABSTRACT

AIMS:

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

DESIGN:

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

SETTING:

England.

PARTICIPANTS:

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

MEASUREMENTS:

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

FINDINGS:

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

CONCLUSIONS:

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

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

pub. February '12

Differences in happiness between smokers, ex-smokers and never smokers: cross-sectional findings from a national household survey

Drug and alcohol dependence [121(1-2):38-44]
PMID: 21906891
Shahab L, West R.

ABSTRACT

BACKGROUND:

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

METHODS:

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

RESULTS:

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

CONCLUSIONS:

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

Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.