Quitting smoking
6.6 How could changes in the availability of nicotine products influence quitting behaviour?
Evidence from time-series analyses indicates that increasing the availability of NRT, and introducing new smoking cessation medications to the market, increases the use of these products by smokers trying to stop smoking, but does not increase the proportion of smokers attempting to quit.40
Evidence from placebo-controlled trials indicates that use of an NRT product while continuing to smoke can increase the likelihood of a quit attempt (see Chapter 5), and that this effect is due to the nicotine in the products rather than being a placebo response.41Population-level data confirm that smokers who use an NRT product while smoking are more likely to try to stop, and eventually to succeed in quitting.42–45Although the mechanism for this effect does not appear to involve increased confidence in quitting,43it is possible that nicotine from the NRT product interferes with the maintenance of the
association between smoking and nicotine reward, and hence reduces the motivation to smoke. It is also possible that encouraging smokers to
experiment with nicotine products, including e-cigarettes, would generate more quit attempts and hence increase smoking cessation. The limited available evidence on this indicates that quit attempts are indeed more common among daily e-cigarette users who continue to smoke, but that successful quitting using the early-generation ‘cigalike’ devices is less common.46,47Research into methods of increasing quit rates among people experimenting with alternative nicotine sources, perhaps by finding ways to deliver quitting advice and behavioural support, is therefore needed.
6.7 Summary
> Approximately one in three smokers in the UK currently attempts to quit each year, but only about one in six of those who try to quit remains abstinent for more than a few weeks or months.
> Most smokers who try to quit do so without accessing professional help, preferring either to use no help or support, or else to use NRT or e-cigarettes bought over the counter.
> Those who use over-the-counter NRT appear to be no more likely to quit than those getting no help.
> Smokers who use over-the-counter e-cigarettes or prescribed medications are more likely to succeed.
> The greatest increase in the chances of stopping successfully occurs with prescribed medications used together with specialist behavioural support.
> The effectiveness of e-cigarettes used with behavioural support is uncertain, but early data demonstrate a relatively high quit rate.
> Smokers are motivated to make a quit attempt in particular by cost and health concerns.
> Price rises, media campaigns and brief advice from health professionals are therefore likely to increase the numbers of smokers trying to quit.
> Health professional advice and support to quit smoking should be offered as a routine component of healthcare consultations.
> Smokers who use nicotine products as a means of cutting down on smoking are more likely to make quit attempts. Promoting wider use of consumer nicotine products, such as e-cigarettes, could therefore substantially increase the number of smokers who quit.
> New research is needed to improve the effectiveness of over-the-counter NRT, and to find ways of providing behavioural support to smokers who choose e-cigarettes.
References
1 Smoking in England, www.smokinginengland.info [Accessed 29 March 2016].
2 Hartmann-Boyce J, Stead LF, Cahill K, Lancaster T. Efficacy of interventions to combat tobacco addiction: Cochrane update of 2012 reviews. Addiction 2013;108:1711–21.
3 Brown J, Beard E, Kotz D, Michie S, West R. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction
2014;109:1531–40.
4 Kotz D, Brown J, West R. Prospective cohort study of the effectiveness of varenicline versus nicotine replacement therapy for smoking cessation in the ‘real world’. BMC Public Health 2014;14:1163.
5 Kotz D, Brown J, West R. Prospective cohort study of the effectiveness of smoking cessation treatments used in the ‘real world’. Mayo Clinic Proc 2014;89:1360–7.
6 Kotz D, Brown J, West R. ‘Real-world’ effectiveness of smoking cessation treatments: a population study. Addiction 2014;109:491–9.
7 Hughes JR, Shiffman S, Callas P, Zhang J. A meta-analysis of the efficacy of over-the-counter nicotine replacement. Tob Control 2003;12:21–7.
8 Kotz D, Fidler J, West R. Factors associated with the use of aids to cessation in English smokers. Addiction 2009 Aug;104:1403–10.
9 McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database of Syst Rev 2014;12:CD010216.
10 Schroeder MJ, Hoffman AC. Electronic cigarettes and nicotine clinical pharmacology. Tob Control 2014;23(Suppl 2):ii30–5.
11 Le Houezec J. Role of nicotine pharmacokinetics in nicotine addiction and nicotine replacement therapy: a review. Int J Tuberc Lung Dis 2003;7:811–19.
12 Etter JF, Bullen C. Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction 2011;106:2017–28.
13 Zhang B CJ, Bondy SJ, Selby P. Duration of nicotine replacement therapy use and smoking cessation: a population-based longitudinal study. Am J Epidemiol 2015;181:513–20.
14 Silla K, Beard E, Shahab L. Characterization of long-term users of nicotine replacement therapy: evidence from a national survey. Nicotine Tob Res 2014;16:1050–5.
15 Biener L. A longitudinal study of electronic cigarette use among a population-based sample of adult smokers: association with smoking cessation and motivation to quit. Nicotine Tob Res 2015;17:127–33.
16 Rose JE, Behm FM, Westman EC, Johnson M. Dissociating nicotine and nonnicotine components of cigarette smoking. Pharmacol Biochem Behav 2000;67:71–81.
17 Buchhalter AR, Acosta MC, Evans SE, Breland AB, Eissenberg T. Tobacco abstinence symptom suppression: the role played by the smoking-related stimuli that are delivered by denicotinized cigarettes. Addiction 2005;100:550–9.
18 Hartmann-Boyce J, Stead LF, Cahill K, Lancaster T. Efficacy of interventions to combat tobacco addiction: Cochrane update of 2013 reviews. Addiction 2014;109:
1414–25.
19 Health and Social Care Information Centre. Statistics on NHS Stop Smoking Services in England – April 2014 to March 2015. London: HSCIC, 2015.
20 Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation.
Cochrane Database of Syst Rev 2012;4:CD006103.
21 Stead LF, Perera R, Bullen C et al. Nicotine replacement therapy for smoking cessation.
Cochrane Database of Syst Rev 2012;11:CD000146.
22 Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Syst Rev 2014;1:CD000031.
23 Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database of Syst Rev 2005;2:CD001292.
24 West RBJ, Shahab L. Estimating the population impact of e-cigarettes on smoking cessation and smoking prevalence in England. Addiction 2016;in press.
25 West R, Sohal T. ‘Catastrophic’ pathways to smoking cessation: findings from national survey. BMJ (Clin Res) 2006;332:458–60.
26 Vangeli E, West R. Sociodemographic differences in triggers to quit smoking: findings from a national survey. Tob Control 2008;17:410–5.
27 Vangeli E, Stapleton J, Smit ES, Borland R, West R. Predictors of attempts to stop smoking and their success in adult general population samples: a systematic review. Addiction 2011;106:2110–21.
28 Durkin S, Brennan E, Wakefield M. Mass media campaigns to promote smoking cessation among adults: an integrative review. Tob Control 2012;21:127–38.
29 Hackshaw L, McEwen A, West R, Bauld L. Quit attempts in response to smoke-free legislation in England. Tob Control 2010;19:160–4.
30 Tombor I, Shahab L, Brown J, West R. Positive smoker identity as a barrier to quitting smoking: findings from a national survey of smokers in England. Drug Alcohol Depend 2013;133:740–5.
31 Szatkowski L MR, Hubbard R, Agrawal S, Huang Y, Britton J. Prevalence of smoking among
patients treated in NHS hospitals in England in 2010/2011: a national audit. Thorax 2014;70:498–500.
32 National Institute for Health and Care Excellence. Smoking cessation services. NICE guidelines PH10. London: NICE, 2008.
33 National Institute for Health and Care Excellence. Smoking cessation in secondary care: acute, maternity and mental health services. NICE guidelines PH48. London: NICE, 2013.
34 National Institute of Health and Care Excellence. Tobacco: harm-reduction approaches to smoking. NICE guidelines PH45. London: NICE, 2013.
35 Aveyard P, Begh R, Parsons A, West R. Brief opportunistic smoking cessation interventions:
a systematic review and meta-analysis to compare advice to quit and offer of assistance.
Addiction 2012;107:1066–73.
36 Coleman T, Lewis S, Hubbard R, Smith C. Impact of contractual financial incentives on the ascertainment and management of smoking in primary care. Addiction 2007;
102:803–8.
37 Taggar JS, Coleman T, Lewis S, Szatkowski L. The impact of the Quality and Outcomes Framework (QOF) on the recording of smoking targets in primary care medical records:
cross-sectional analyses from The Health Improvement Network (THIN) database. BMC Public Health 2012;12:329.
38 Szatkowski L, Aveyard P. The impact of the 2012 revision to the UK primary care pay-for-performance system on general practitioners’ provision of smoking cessation support. Br J Gen Pract 2016;66:e10–15.
39 QIPP Programme (Quality, Innovation, Productivity and Prevention). The Lancet UK Policy Matters 2012;29 March.
40 West R, DiMarino ME, Gitchell J, McNeill A. Impact of UK policy initiatives on use of medicines to aid smoking cessation. Tob Control 2005;14:166–71.
41 Moore D, Aveyard P, Connock M et al. Effectiveness and safety of nicotine replacement therapy assisted reduction to stop smoking: systematic review and meta-analysis. BMJ (Clin Res) 2009;338:b1024.
42 Beard E, Aveyard P, Brown J, West R. Assessing the association between the use of NRT for smoking reduction and attempts to quit smoking using propensity score matching. Drug Alcohol Depend 2012;126:354–61.
43 Beard E, Aveyard P, McNeill A et al. Mediation analysis of the association between use of NRT for smoking reduction and attempts to stop smoking. Psychol Health 2012;27:1118–33.
44 Beard E, McNeill A, Aveyard P et al. Association between use of nicotine replacement therapy for harm reduction and smoking cessation: a prospective study of English smokers.
Tob Control 2013;22:118–22.
45 Beard E, West R. Use of nicotine replacement therapy for smoking reduction and temporary abstinence: an update of Beard et al. (2011). Addiction 2012;107:1186–7.
46 Brose LS, Hitchman SC, Brown J, West R, McNeill A. Is the use of electronic cigarettes while smoking associated with smoking cessation attempts, cessation and reduced cigarette consumption? A survey with a 1-year follow-up. Addiction 2015;110:1160–8.
47 Hitchman SC, Brose LS, Brown J, Robson D, McNeill A. Associations between e-cigarette type, frequency of use, and quitting smoking: findings from a longitudinal online panel survey in Great Britain. Nicotine Tob Res 2015;17:1187–94.