Use of nicotine replacement therapy to reduce or delay smoking but not to quit: prevalence and association with subsequent cessation efforts

Objective

To assess the prevalence of nicotine replacement therapy (NRT) use for purposes other than quitting smoking and examine the relation of this non‐standard NRT use (NSNRT) with subsequent smoking cessation efforts.

Design

A population based cohort study of adult smokers who were interviewed by telephone at baseline (2001–2) and at two year follow‐up. The association between NSNRT use to cut down on smoking or to delay smoking before baseline and cessation attempts and smoking outcomes at two year follow‐up was assessed using logistic regression to adjust for multiple potential confounding factors.

Setting

Massachusetts, USA.

Subjects

1712 adult smokers in Massachusetts who were selected using a random digit dial telephone survey.

Main outcome measures

Quit attempt in 12 months before follow‐up, NRT use at quit attempt in 12 months before follow‐up, smoking cessation by follow‐up, or 50% reduction in cigarettes smoked per day between baseline and follow‐up.

Results

18.7% of respondents reported ever having used NSNRT. In a multiple logistic regression analysis, there was no statistically significant association between past NSNRT use and quit attempts (OR_{cut down}  = 0.89, 95% CI 0.59 to 1.33; OR_delay  = 1.29, 95% CI 0.73 to 2.29), smoking cessation (OR_{cut down}  = 0.74, 95% CI 0.43 to 1.24; OR_delay  = 1.22, 95% CI 0.60 to 2.50) or 50% reduction in cigarettes smoked per day (OR_{cut down}  = 0.93, 95% CI 0.62 to 1.38; OR_delay  = 0.80, 95% CI 0.43 to 1.49) at follow‐up. Past use of NRT to cut down on cigarettes was associated with use of NRT at a follow‐up quit attempt (OR_{cut down}  = 2.28, 95% CI 1.50 to 3.47) but past use of NRT to delay smoking was not (OR_delay  = 1.25, 95% CI 0.67 to 2.34).

Conclusions

Use of NRT for reasons other than quitting smoking may be more common than was previously estimated. This population based survey finds no strong evidence that NRT use for purposes other than quitting smoking is either harmful or helpful.     

Increased reach and effectiveness of a statewide tobacco quitline after the addition of access to free nicotine replacement therapy

Background

Tobacco users receiving behavioural and pharmacological assistance are more likely to quit. Although telephone quitlines provide population access to counselling, few offer pharmacotherapy.

Objective

To assess change in cessation rates and programme impact after the addition of free nicotine replacement therapy (NRT) to statewide quitline services.

Design, setting, participants

An observational study of cohorts of callers to the Minnesota QUITPLAN^SM Helpline before (n  =  380) and after (n  =  373) the addition of access to free NRT.

Intervention

Mailing of NRT (patch or gum) to callers enrolling in multi‐session counselling.

Main outcome measure

Thirty‐day abstinence six months after programme registration.

Results

The number of callers increased from 155 (SD 75) to 679 (180) per month pre‐NRT to post‐NRT (difference 524, 95% confidence interval (CI) 323 to 725). Post‐NRT, the proportion of callers enrolling in multi‐session counselling (23.4% v 90.1%, difference 66.6%, 95% CI 60.8% to 71.6%) and using pharmacotherapy (46.8% v 86.8%, difference 40.0%, 95% CI 31.3% to 47.9%) increased. Thirty‐day abstinence at six months increased from 10.0% pre‐NRT to 18.2% post‐NRT (difference 8.2%, 95% CI 3.1% to 13.4%). Post‐NRT the average number of new ex‐smokers per month among registrants increased from 15.5 to 123.6 (difference 108.1, 95% CI 61.1 to 155.0). The cost per quit pre‐NRT was $1362 (SD $207). The cost per quit post‐NRT was $1934 ($215) suggesting a possible increase in cost per quit (difference $572, 95% CI −$12 to $1157).

Conclusion

The addition of free NRT to a state quitline is followed by increases in participation and abstinence rates resulting in an eightfold increase in programme impact. These findings support the addition of access to pharmacological therapy as part of state quitline services.     

Non-smokers seeking help for smokers: a preliminary study

Objectives

To examine the phenomenon of non‐smokers spontaneously taking action to seek help for smokers; to provide profiles of non‐smoking helpers by language and ethnic groups.

Setting

A large, statewide tobacco quitline (California Smokers'' Helpline) in operation since 1992 in California, providing free cessation services in English, Spanish, Mandarin, Cantonese, Korean, and Vietnamese.

Subjects

Callers between August 1992 and September 2005 who identified themselves as either white, black, Hispanic, American Indian, or Asian (n  =  349 110). A subset of these were “proxies”: callers seeking help for someone else. For more detailed analysis, n  =  2143 non‐smoking proxies calling from October 2004 through September 2005.

Main outcome measures

Proportions of proxies among all callers in each of seven language/ethnic groups; demographics of proxies; and proxies'' relationships to smokers on whose behalf they called.

Results

Over 22 000 non‐smoking proxies called. Proportions differed dramatically across language/ethnic groups, from mean (±95% confidence interval) 2.7 (0.3)% among English‐speaking American Indians through 9.3 (0.3)% among English‐speaking Hispanics to 35.3 (0.7)% among Asian‐speaking Asians. Beyond the differences in proportion, however, remarkable similarities emerged across all groups. Proxies were primarily women (79.2 (1.7)%), living in the same household as the smokers (65.0 (2.1)%), and having either explicit or implicit understandings with the smokers that calling on their behalf was acceptable (90.0 (1.3)%).

Conclusions

The willingness of non‐smokers to seek help for smokers holds promise for tobacco cessation and may help address ethnic and language disparities. Non‐smoking women in smokers'' households may be the first group to target.     

A randomised control study of a fully automated internet based smoking cessation programme

Objective

The objective of this project was to test the short term (90 days) efficacy of an automated behavioural intervention for smoking cessation, the “1‐2‐3 Smokefree” programme, delivered via an internet website.

Design

Randomised control trial. Subjects surveyed at baseline, immediately post‐intervention, and 90 days later.

Settings

The study and the intervention occurred entirely via the internet site. Subjects were recruited primarily via worksites, which referred potential subjects to the website.

Subjects

The 351 qualifying subjects were notified of the study via their worksite and required to have internet access. Additionally, subjects were required to be over 18 years of age, smoke cigarettes, and be interested in quitting smoking in the next 30 days. Eligible subjects were randomly assigned individually to treatment or control condition by computer algorithm.

Intervention

The intervention consisted of a video based internet site that presented current strategies for smoking cessation and motivational materials tailored to the user''s race/ethnicity, sex, and age. Control subjects received nothing for 90 days and were then allowed access to the programme.

Main outcome measures

The primary outcome measure was abstinence from smoking at 90 day follow up.

Results

At follow up, the cessation rate at 90 days was 24.1% (n  =  21) for the treatment group and 8.2% (n  =  9) for the control group (p  =  0.002). Using an intent‐to‐treat model, 12.3% (n  =  21) of the treatment group were abstinent, compared to 5.0% (n  =  9) in the control group (p  =  0.015).

Conclusions

These evaluation results suggest that a smoking cessation programme, with at least short term efficacy, can be successfully delivered via the internet.     

Smoking and erectile dysfunction: findings from a representative sample of Australian men

Objectives

To examine whether there is an association between smoking and erectile dysfunction in a representative sample of Australian men.

Design

Secondary analysis of cross‐sectional survey data from the Australian Study of Health and Relationships.

Participants

8367 Australian men aged 16–59 years.

Main outcome measures

Erectile dysfunction was identified in men who reported having had trouble keeping an erection when they wanted to, a problem which persisted for at least one month over the previous year. Variables examined in multivariate logistic regression analyses included age, education, presence of cardiovascular disease and diabetes, and current alcohol and tobacco consumption.

Results

Almost one in 10 of the respondents (9.1%) reported erectile dysfunction that lasted for at least one month over the previous year. More than a quarter (27.2%) of respondents were current smokers, with 20.9% smoking ⩽ 20 cigarettes per day, and 6.3% smoking > 20 cigarettes per day. Compared with non‐smokers, the adjusted odds ratios for erectile dysfunction were 1.24 (95% confidence interval (CI) 1.01 to 1.52, p  =  0.04) for those smoking ⩽ 20 cigarettes per day and 1.39 (95% CI 1.05 to 1.83, p  =  0.02) for those smoking > 20 cigarettes per day, after adjusting for other confounding factors. Older age, low level of education, and taking medications for cardiovascular disease were also independently and positively associated with erectile dysfunction. In contrast, moderate alcohol consumption (1–4 drinks per day) significantly reduced the likelihood of having erectile dysfunction.

Conclusions

Erectile dysfunction is a significant health concern affecting around one in 10 Australian men aged 16–59 years. Current smoking is significantly associated with erectile dysfunction in Australian males. This association was strengthened as the number of cigarettes smoked increased. Health promotion programmes could use the link between smoking and erectile dysfunction to help reduce smoking levels among men.     

Decline in respiratory symptoms in service workers five months after a public smoking ban

Objective

To evaluate the effect of a total ban on smoking indoors in restaurants and other hospitality business premises in Norway, on respiratory symptoms among workers in the industry.

Methods

Phone interviews with 1525 employees in the hospitality business were conducted immediately before the enacting of the law. In a follow‐up study five months later, 906 of the workers from the baseline sample participated. Questions were asked on demographic variables, passive smoking exposure, personal smoking, attitudes towards the law, and five respiratory symptoms. Change in symptom prevalence was analysed with McNemar''s test and with analysis of variance (ANOVA) for repeated measures.

Results

The prevalence of all five symptoms declined after the ban; for morning cough from 20.6% to 16.2% (p < 0.01); for daytime cough from 23.2% to 20.9%; for phlegm cough from 15.3% to 11.8% (p < 0.05); for dyspnoea from 19.2% to 13.0% (p < 0.01); and for wheezing from 9.0% to 7.8%. ANOVA showed that the largest decline in symptom prevalence was seen among workers who themselves gave up smoking, and subjects with a positive attitude towards the law before it took effect.

Conclusion

A significant decrease in respiratory symptoms among service industry workers was found five months after the enacting of a public smoking ban.     

Adolescent snus use in Finland in 1981-2003: trend, total sales ban and acquisition

Objective

To study changes in adolescent snus use from 1981 to 2003, the effects of the total snus sales ban (1995) and snus acquisition.

Design

Biennial postal surveys in 1981–2003.

Setting and participants

Entire Finland; 12‐, 14‐, 16‐, and 18‐year‐olds (n  =  73 946; 3105−8390 per year).

Main outcome measures

Snus use (experimental, daily/occasionally), snus acquisition (2001, 2003).

Results

Snus experimentation grew in popularity before the total sales ban in 16‐ and 18‐year‐old boys and after the ban in all age and sex groups. A decrease was seen between 2001 and 2003, except for 18‐year‐old boys. Daily/occasional use mainly followed the same pattern in boys while in girls the daily/occasional use was rare and no significant changes were observed. In 2003, boys experimented with snus more often than girls (12‐year‐olds 1% v 0%, 14‐year‐olds 9% v 4%, 16‐year‐olds 30% v 12%, 18‐year‐olds 44% v 18%). Hardly any girls used snus daily/occasionally, but 1% of 14‐year‐old boys, 7% of 16‐year‐olds, and 9% of 18‐year‐olds did. Of daily/occasional users, 84% acquired snus from friends or acquaintances, 55% from tourist trips to neighbouring countries (Estonia, Sweden), and 7% through sport teams; 24% obtained it from under‐the‐counter sources. For experimenters, the corresponding figures were 79%, 18%, 0.3%, and 5%.

Conclusions

The total sales ban did not stop snus use; instead, the increase continued after the ban. Friends who travel to neighbouring countries act as go‐betweens reselling snus. Snus is used even by the youngest adolescents, thus contributing to the nicotine dependence process.     

Changes in smoking prevalence in Russia, 1996-2004

Objectives

In Russia, smoking prevalence has historically been high in men and relatively low in women. Female smoking prevalence is predicted to rise but assessment of changes has been limited by the lack of comparable data. Changes in the prevalence of smoking in Russia between 1996 and 2004, and whether theses changes differed by sociodemographic groups, were investigated.

Design

Repeated national interview surveys in 1996 (731 men and 868 women) and 2004 (727 men and 864 women) aged 18 years or more.

Main outcome measure

Prevalence of current smoking.

Results

The age standardised prevalence of smoking in 1996 and 2004 was 61% and 63%, respectively in men and 15% and 16%, respectively in women (both p values > 0.4). In men, the prevalence of smoking seemed to decline in those with university education (from 51% to 40%, p  =  0.085). Among women, smoking appeared to increase in those with university education (from 10% to 17%, p  =  0.071) and low levels of self‐reported material deprivation (from 11% to 18%, p  =  0.053). There was a pronounced increase in prevalence among women living in villages (from 8% to 14%, p  =  0.049); the strong urban/rural gradient seen in 1996 became considerably weaker by 2004.

Conclusions

Overall smoking prevalence in both men and women in Russia remained stable between 1996 and 2004 but, given the sample size, a moderate increase in female smoking cannot be ruled out. In men, smoking increased among the least educated and declined in the most educated. In women the opposite appeared to occur, in addition to an increase in smoking in rural areas. More long term monitoring of smoking patterns in Russia, especially among women, using sufficiently large surveys, is required.     

Effects of preoperative smoking cessation on the incidence and risk of intraoperative and postoperative complications in adult smokers: a systematic review

Objectives

To establish the effect of preoperative smoking cessation on the risk of postoperative complications, and to identify the effect of the timing of preoperative cessation.

Data sources

The Cochrane Library Database, PsycINFO, EMBASE, Medline, and CINAHL databases were searched, using the terms: “smoking”, “smoking‐cessation”, “tobacco‐use”, “tobacco‐abstinence”, “cigarett$”, “complication$”, “postoperative‐complication$”, “preoperative”, “perioperative” and “surg$”. Further articles were obtained from reference lists. The search was limited to articles on adults, written in English and published up to November 2005.

Study selection

Prospective cohort designs exploring the effects of preoperative smoking cessation on postoperative complications were included. Two reviewers independently scanned abstracts of relevant articles to determine eligibility. Lack of agreement was resolved through discussion and consensus. Twelve studies met the inclusion criteria.

Data extraction

Methodological quality was assessed by both reviewers, exploring validation of smoking status, clear definition of the period of smoking cessation, control for confounding variables and length of follow‐up.

Data synthesis

Only four of the studies specified the exact period of smoking cessation, with six studies specifying the length of the follow‐up period. Five studies revealed a lower risk or incidence of postoperative complications in past smokers than current smokers or reported that there was no significant difference between past smokers and non‐smokers.

Conclusions

Longer periods of smoking cessation appear to be more effective in reducing the incidence/risk of postoperative complications; there was no increased risk in postoperative complications from short term cessation. An optimal period of preoperative smoking cessation could not be identified from the available evidence.     

Risk factors for tobacco dependence in adolescent smokers

Objective

To study the incidence of conversion to tobacco dependence (TD) and the prevalence of the TD state in relation to several potential determinants in a sample of adolescent smokers.

Methods

Questionnaires were administered every 3–4 months to document TD symptoms, amount of cigarette consumption, and depression symptoms in a prospective cohort of 1293 grade 7 students in a convenience sample of 10 schools.

Results

Over 54 months of follow‐up, 113 of 344 novice smokers converted to TD. The referent series for the analysis of incidence comprised 823 person‐surveys. The prevalence series included 1673 person‐surveys, contributed by 429 smokers. Conversion to TD and TD status were associated with the intensity of recent (that is, past 3‐month) cigarette consumption (adjusted incidence rate ratio (aIRR) 1.63 (95% confidence interval (CI) 1.36 to 1.97) and adjusted prevalence odds ratio (aPOR) 1.35 (95% CI 1.23 to 2.48) per 100 cigarettes per month), slowest CYP2A6 activity (aIRR 4.19 (95% CI 1.38 to 12.76) and aPOR 2.30 (95% CI 1.29 to 4.09)), depression score (aIRR 1.61 (95% CI 1.17 to 2.21) and aPOR 1.47 (95% CI 1.22, 1.75) per 1‐unit change). Additional determinants included, for conversion to TD, time since onset of cigarette use (aIRR 0.76 (95% CI 0.58 to 1.00) per year) and, for the TD state, positive TD status six months ago (aPOR 3.53 (95% CI 2.41 to 5.19)).

Conclusions

TD risk in adolescents is associated with intensity of recent cigarette consumption, while the role of more distant cigarette consumption appears small; subjects with slow nicotine metabolism and those with more depression symptoms are at increased risk of becoming tobacco dependent. The risk of being tobacco dependent is considerably higher in subjects who had previously developed the TD state.     

What contributed to the major decline in per capita cigarette consumption during California's comprehensive tobacco control programme?

Objectives

California experienced a notable decline in per capita cigarette consumption during its comprehensive tobacco control programme. This study examines what proportion of the decline occurred from: (1) fewer ever smokers in the population, (2) more ever smokers quitting, and (3) current smokers smoking less.

Design, subjects

Per capita cigarette consumption computed from cigarette sales and from adult respondents to the large, cross‐sectional, population‐based California Tobacco Surveys of 1990 (n  =  24 296), 1996 (n  =  18 616) and 2002 (n  =  20 525) were examined for similar trends.

Main outcome measure

Changes (period 1: 1990–1996; period 2: 1996–2002) in per capita cigarette consumption from self‐reported survey data were partitioned for the entire population and for demographic subgroups into the three components mentioned above.

Results

In periods 1 and 2, most of the decline in per capita cigarette consumption for the population as a whole was from current smokers smoking less followed by a reduction in ever smokers. The decline from smokers smoking less was particularly evident among young adults (18–29 years) in period 1. While the portion of the decline due to quitting in the entire population in period 1 was negligible, in period 2 it accounted for 22% of the total per capita decline. The decline from quitting in period 2 was mostly observed among women.

Conclusions

Rather than near‐term benefits from smokers quitting, population health benefits from reduced per capita cigarette consumption will likely occur over the longer term from fewer people becoming ever smokers, and more less‐addicted smokers eventually quitting successfully.     

Smokers' reactions to reduced ignition propensity cigarettes

Background

On 28 June 2004, New York State (NY) became the first jurisdiction to require cigarettes to meet a reduced ignition propensity (RIP) standard. This law resulted in cigarette manufacturers modifying nearly all of their brands sold in NY. However, the same cigarette brands sold in other states were not modified to meet the RIP standard.

Objectives

This paper examines relationships between the RIP law and smokers'' awareness of changes in the performance of their cigarettes (that is, going out more frequently, change in taste), and smoking behaviour.

Methods

Data for this analysis come from a nationwide survey of 2088 adult smokers (> 18 years of age) conducted in the USA between July and December 2004. 143 of the smokers included in the survey were residents of NY while the remainder were from other states (n  =  1945). Survey participants were asked whether their cigarettes “ever go out between puffs” and whether they had noticed any change in the taste of their cigarettes in the past 12 months.

Results

NY smokers were three times more likely than smokers in other states to report that their cigarettes often went out between puffs (17.3% v 5.6%). However, NY smokers appeared no more likely to report noticing differences in cigarette taste, an intention to quit smoking, or to have made quit attempts.

Conclusions

A significant minority of smokers in NY reported noticing changes in the performance of their cigarettes following the RIP law, as would be expected. However, the RIP law appears to have had no impact on the smoking habits of New Yorkers, countering arguments made by cigarette manufacturers that the law would impact consumer acceptability.     

An uncontrolled trial of cytisine (Tabex) for smoking cessation

Objectives

Cytisine (Tabex) has been licensed in Eastern Europe as an aid to smoking cessation for 40 years. Cytisine is a partial agonist with high affinity binding to the α4β2 nicotinic acetylcholine receptor believed to be central to the rewarding effect of nicotine. There is insufficient information on effectiveness to warrant licensing by modern standards. To assess whether full‐scale controlled trials are warranted, this study sought to obtain an estimate of the 12‐month continuous abstinence rates of smokers using cytisine with minimal behavioural support.

Design

An uncontrolled, open‐label trial.

Setting

A smokers'' clinic in an oncology centre in Warsaw, Poland.

Subjects

436 consecutive attendees of the smokers'' clinic of whom 191 were male. The mean dependence score (Fagerstrom Test for Nicotine Dependence) was 6.1.

Intervention

The standard regimen of Tabex (cytisine) was used, involving 25 days of treatment with minimal behavioural support.

Main outcome measure

Self‐reported continuous abstinence for 12 months; with abstinence verified by carbon monoxide at the final follow up (after 12 months).

Results

60 participants (13.8% of the total sample) were abstinent for 12 months. Of the 315 subjects, who had taken the drug, 49 (15.5%) stopped cytisine because of adverse effects (mostly gastric disturbances and nausea), although they were not serious. The frequency of the minor adverse effects, primarily gastric disturbance, was similar to that observed in previous studies with the drug.

Conclusions

The long‐term abstinence rates were similar to those observed in smokers receiving nicotine replacement therapy. Full‐scale randomised trials of cytisine (Tabex), conducted to the standards required by regulatory authorities, are warranted.     

Are comprehensive environmental changes as effective as health education for smoking cessation?

Objectives

To compare the effectiveness of health education on smoking cessation for all smokers regardless of their willingness to quit smoking and cumulative environmental changes including designation of smoking places, legislation, and price rise.

Design

Comparison of smoking cessation rates over two time periods: the period of health education on smoking cessation (1997–1999), and the period of cumulative environmental changes (2002–2004).

Setting

An occupational setting in a radiator manufacturing factory in Japan.

Subjects

All habitual male smokers who remained in the worksite through the pertinent time period (n  =  202 in the period of health education and n  =  170 in the period of environmental changes).

Main outcome measurements

Smoking cessation rates at the end of each time period.

Results

The smoking cessation rates over the periods of health education and environmental changes were 8.9% and 7.1%, respectively. There was no difference between these two proportions in a χ² test (p  =  0.513). The age adjustment did not significantly alter the cessation rate.

Conclusions

Cumulative environmental changes are fairly effective in promoting smoking cessation, and may yield similar smoking cessation rates as a health education intervention reaching all smokers regardless of their willingness to quit smoking.     

Health consequences of reduced daily cigarette consumption

Objective

To determine the risk of dying from specified smoking‐related diseases and from any cause in heavy smoking men and women (⩾15 cigarettes/day), who reduced their daily cigarette consumption by >50%.

Design

A prospective cohort study.

Setting

Three counties in Norway.

Participants

24 959 men and 26 251 women, aged 20–49 years, screened for risk factors of cardiovascular disease in the mid‐1970s, screened again after 3–13 years, and followed up throughout 2003.

Outcomes

Absolute mortality and relative risks adjusted for confounding variables, of dying from all causes, cardiovascular disease, ischaemic heart disease, all smoking‐related cancer and lung cancer.

Results

With sustained heavy smokers as reference, the smokers of both sexes who reduced their daily consumption (reducers) had the following adjusted relative risks (95% confidence interval (CI)): of dying from any cause, 1.02 (0.84 to 1.22); cardiovascular disease, 1.02 (0.75 to 1.39); ischaemic heart disease, 0.96 (0.65 to 1.41); smoking‐related cancer, 0.86 (0.57 to 1.29); and lung cancer, 0.66 (0.36 to 1.21). The difference in cigarette consumption between two examinations was not a significant predictor of death from any of the causes. A follow‐up from a third screening of the subgroup who were reducers at both second and third examinations (sustained reducers) did not have a lower risk than those who were heavy smokers at all three examinations.

Conclusions

Long‐term follow‐up provides no evidence that heavy smokers who cut down their daily cigarette consumption by >50% reduce their risk of premature death significantly. In health education and patient counselling, it may give people false expectations to advise that reduction in consumption is associated with reduction in harm.Does reduced daily cigarette consumption lead to lower mortality from the serious health consequences of cigarette smoking? In other words, does a reduction in consumption bring about reduction in harm?Numerous population studies have given ample evidence that quitting smoking entirely results in a marked reduction in the ill effects of smoking. Up to now, however, only one large prospective study has explored the long‐term effects of unassisted reduced smoking. Godtfredsen et al^1,2,3,4 have pioneered in this field by following up a population of nearly 20 000 men and women living in Copenhagen, Denmark (the Copenhagen Centre for Prospective Population Studies). After mean observation periods ranging from 13.8 to 18 years, they published their results in a series of articles.The aim of this paper is to determine the risk in heavy smokers who reduced their cigarette consumption by at least 50%, named “reducers”, compared with those who continued as heavy smokers. We report on a Norwegian population of 51 210 men and women, aged 20–49 years, who were examined in the mid‐1970s for cardiovascular disease risk factors and were examined again during the next 3–13 years at least once. These people were followed up throughout 2003 for deaths from serious smoking‐related diseases and from all causes. The mean observation period is 21.2 years, maximum 27 years. A subgroup attended three screenings. This gave us the possibility to compare those who were reducers at the two last screenings (sustained reducers) with those who were heavy smokers at all three screenings (sustained heavy smokers).     

The fraction of ischaemic heart disease and stroke attributable to smoking in the WHO Western Pacific and South-East Asian regions

Background

Tobacco will soon be the biggest cause of death worldwide, with the greatest burden being borne by low and middle‐income countries where 8/10 smokers now live.

Objective

This study aimed to quantify the direct burden of smoking for cardiovascular diseases (CVD) by calculating the population attributable fractions (PAF) for fatal ischaemic heart disease (IHD) and stroke (haemorrhagic and ischaemic) for all 38 countries in the World Health Organization Western Pacific and South East Asian regions.

Design and subjects

Sex‐specific prevalence of smoking was obtained from existing data. Estimates of the hazard ratio (HR) for IHD and stroke with smoking as an independent risk factor were obtained from the ∼600 000 adult subjects in the Asia Pacific Cohort Studies Collaboration (APCSC). HR estimates and prevalence were then used to calculate sex‐specific PAF for IHD and stroke by country.

Results

The prevalence of smoking in the 33 countries, for which relevant data could be obtained, ranged from 28–82% in males and from 1–65% in females. The fraction of IHD attributable to smoking ranged from 13–33% in males and from <1–28% in females. The percentage of haemorrhagic stroke attributable to smoking ranged from 4–12% in males and from <1–9% in females. Corresponding figures for ischaemic stroke were 11–27% in males and <1–22% in females.

Conclusions

Up to 30% of some cardiovascular fatalities can be attributed to smoking. This is likely an underestimate of the current burden of smoking on CVD, given that the smoking epidemic has developed further since many of the studies were conducted.     

The costs of smoking in Vietnam: the case of inpatient care

Objective

To estimate the social costs of smoking related to inpatient care in Vietnam using 2005 data.

Design

The cost of illness as a result of hospitalisation for three major smoking‐related diseases combined with the prevalence‐based approach to obtain the costs of smoking in Vietnam for inpatient care.

Main outcome measure

Smoking‐attributable costs of inpatient care for lung cancer, chronic obstructive pulmonary disease (COPD), and ischaemic heart disease.

Results

The total cost of inpatient health care caused by smoking in Vietnam reached at least 1 161 829 million Vietnamese dollars ($VN) (or $US77.5 million) in 2005. This represents about 0.22% of Vietnam gross domestic product (GDP) and 4.3% of total healthcare expenditure. The majority of these expenses are related to COPD treatment ($VN1 033 541 million or $US68.9 million per year) followed by lung cancer ($VN78 143 million, or $US5.2 million per year) and ischaemic disease ($VN50 145 million, or $US3.3 million per year). The government directly finances about 51% of these costs. The rest is financed either by households (34%) or by the insurance sector (15%).

Conclusions

The social costs of smoking in Vietnam as the percentage of GDP is lower compared to estimates from high‐income countries. The true costs would be substantially higher if all smoking‐related diseases, outpatient care and mortality‐related costs are included. More research is needed to augment the estimates presented in this paper.     

Vulnerability to smoking after trying a single cigarette can lie dormant for three years or more

Objective

To examine the development of smoking behaviour among adolescents who, at age 11, had tried cigarettes just once.

Design

A five‐year prospective study.

Setting

36 schools in South London, England.

Subjects

A socioeconomically and ethnically diverse sample of students completed questionnaires annually from age 11–16. A total of 5863 students took part, with an annual response rate ranging from 74–85%. 2041 (35%) provided smoking status data every year.

Main outcome measures

Current smoking (smoking sometimes or more often) for the first time. Cotinine assays provided biochemical verification of smoking status.

Results

Students who at age 11 reported having tried smoking cigarettes just once (n = 260), but were not smoking at the time, were more likely to take‐up smoking at a later age than those that had not tried smoking (n = 1719), even after a gap of up to three years of not smoking. The odds of starting to smoke at age 14 were 2.1 times greater (95% confidence interval 1.2 to 3.5) in the age 11 “one time triers” than the “non‐triers”, even once sex, ethnicity, deprivation, parental smoking and conduct disorder were adjusted for.

Conclusions

This is the first clear demonstration of a “sleeper effect” or period of dormant vulnerability. Our findings have implications for understanding the development of cigarette use and for policies to reduce smoking in young people. Preventing children from trying even one cigarette may be important, and the design of interventions should recognise adolescents who have smoked just once, several years previously, as potentially vulnerable to later smoking uptake.     

Nicotine replacement therapy, professional therapy, snuff use and tobacco smoking: a study of smoking cessation strategies in southern Sweden

Objectives

The strategies used to support smoking cessation among quitters were investigated according to year of smoking cessation and sociodemographic characteristics.

Methods

The 2004 public health survey in Skåne, Sweden, is a cross‐sectional study. A total of 27 757 people aged 18–80 answered a postal questionnaire. The participation rate was 59%. Different strategies to support smoking cessation—that is, no therapy, nicotine replacement (NRT), professional therapy and snus (snuff) use, were investigated among quitters according to year of smoking cessation, and demographic and socioeconomic characteristics.

Results

14.9% of the men and 18.1% of the women were daily smokers. The prevalence of daily snus use was 19.5% among men but only 2.3% among women. Stratifying the data according to year of smoking cessation (1938–2004) revealed a significant increase in active smoking cessation strategies such as NRT, professional therapy and snus use. NRT was more common among women (23.6%) than men (14.8%) among smokers who quit in 2000–4, but snus use was more common among men (30.4% versus 8.7%). No replacement or other therapy at all was significantly more common among women (63.6%) than men (52.1%). People aged 35–80 years used more nicotine replacement than people aged 18–34, while men aged 18–34 used snus to quit smoking significantly more than men aged 55–80.

Conclusions

Snus is used commonly among men as a support for smoking cessation in Sweden. Women use pharmacological NRT to a greater extent, but this can probably not compensate for the much higher extent of snuff use as a cessation strategy among men.