Jennifer A. Fidler

Socioeconomic status and smoking: A review

Smoking prevalence is higher among disadvantaged groups, and disadvantaged smokers may face higher exposure to tobaccos harms. Uptake may also be higher among those with low socioeconomic status (SES), and quit attempts are less likely to be successful. Studies have suggested that this may be the result of reduced social support for quitting, low motivation to quit, stronger addiction to tobacco, increased likelihood of not completing courses of pharmacotherapy or behavioral support sessions, psychological differences such as lack of self‐efficacy, and tobacco industry marketing. Evidence of interventions that work among lower socioeconomic groups is sparse. Raising the price of tobacco products appears to be the tobacco control intervention with the most potential to reduce health inequalities from tobacco. Targeted cessation programs and mass media interventions can also contribute to reducing inequalities. To tackle the high prevalence of smoking among disadvantaged groups, a combination of tobacco control measures is required, and these should be delivered in conjunction with wider attempts to address inequalities in health.

Strength of urges to smoke as a measure of severity of cigarette dependence: comparison with the Fagerstrom Test for Nicotine Dependence and its components

AIMS Measuring the strength of urges to smoke during a normal smoking day among smokers in a culture where smoking is restricted could provide a good measure of the severity of cigarette dependence. An important criterion for a measure of cigarette dependence is how well it predicts failure of attempts to stop smoking. This study compared ratings of Strength of Urges to Smoke (SUTS) with the Fagerström Test of Nicotine Dependence (FTND) and its components, including the Heaviness of Smoking Index (HSI). DESIGN A longitudinal study involving a household survey of a representative sample of adult smokers at baseline and 6-month follow-up by postal questionnaire. SETTING England. PARTICIPANTS A total of 15,740 smokers aged 16 and over underwent the baseline interview; 2593 were followed-up 6 months later, of whom 513 reported having made a quit attempt following the baseline survey but at least 1 month prior to the follow-up. MEASUREMENTS SUTS, FTND, HSI, cigarettes per day, time to first cigarette, age, social grade and gender were measured at baseline. Quit attempts since the baseline assessment and self-reported abstinence were measured at 6-month follow-up. FINDINGS In logistic regressions, all dependence measures predicted success of subsequent quit attempts, but SUTS had the strongest association (beta for SUTS, FTND and HSI: 0.41: P < 0.001, 0.13: P = 0.005, and 0.19: P = 0.003, respectively). In multiple logistic regressions when SUTS was entered as a predictor of abstinence, together with other dependence measures, it remained as the only predictive dependence measure. CONCLUSIONS A simple rating of strength of urges on a normal smoking day appears to be a good predictor of at least short-term quit success in English smokers and as such may be a useful measure of cigarette addiction.

'The smoking toolkit study': a national study of smoking and smoking cessation in England

BackgroundUp-to-date data tracking of national smoking patterns and cessation-related behaviour is required to evaluate and inform tobacco control strategies. The Smoking Toolkit Study (STS) was designed for this role. This paper describes the methodology of the STS and examines as far as possible the representativeness of the samples.MethodsThe STS consists of monthly, cross sectional household interviews of adults aged 16 and over in England with smokers and recent ex-smokers in each monthly wave followed up by postal questionnaires three and six months later. Between November 2006 and December 2010 the baseline survey was completed by 90,568 participants. STS demographic, prevalence and cigarette consumption estimates are compared with those from the Health Survey for England (HSE) and the General Lifestyle Survey (GLF) for 2007-2009.ResultsSmoking prevalence estimates of all the surveys were similar from 2008 onwards (e.g 2008 STS = 22.0%, 95% C.I. = 21.4% to 22.6%, HSE = 21.7%, 95% C.I. = 20.9% to 22.6%, GLF = 20.8%, 95% C.I. = 19.7% to 21.9%), although there was heterogeneity in 2007 (chi-square = 50.30, p < 0.001). Some differences were observed across surveys within sociodemographic sub-groups, although largely in 2007. Cigarette consumption was virtually identical in all surveys and years.ConclusionThere is reason to believe that the STS findings (see http://www.smokinginengland.info) are generalisable to the adult population of England.

What makes for an effective stop-smoking service?

Background The English network of stop-smoking services (SSSs) is among the best-value life-preserving clinical intervention in the UK NHS and is internationally renowned. However, success varies considerably across services, making it important to examine the factors that influence their effectiveness. Methods Data from 126 890 treatment episodes in 24 SSSs in 2009–10 were used to assess the association between intervention characteristics and success rates, adjusting for key smoker characteristics. Treatment characteristics examined were setting (eg, primary care, specialist clinics, pharmacy), type of support (eg, group, one-to-one) and medication (eg, varenicline, single nicotine replacement therapy (NRT), combination of two or more forms of NRT). The main outcome measure was abstinence from smoking 4 weeks after the target quit date, verified by carbon monoxide concentration in expired air. Results There was substantial variation in success rates across intervention characteristics after adjusting for smoker characteristics. Single NRT was associated with higher success rates than no medication (OR 1.75, 95% CI 1.39 to 2.22); combination NRT and varenicline were more successful than single NRT (OR 1.42, 95% CI 1.06 to 1.91 and OR 1.78, 95% CI 1.57 to 2.02, respectively); group support was linked to higher success rates than one-to-one support (OR 1.43, 95% CI 1.16 to 1.76); primary care settings were less successful than specialist clinics (OR 0.80, 95% CI 0.66 to 0.99). Conclusions Routine clinic data support findings from randomised controlled trials that smokers receiving stop-smoking support from specialist clinics, treatment in groups and varenicline or combination NRT are more likely to succeed than those receiving treatment in primary care, one-to-one and single NRT. All smokers should have access to, and be encouraged to use, the most effective intervention options.

Perceived stress and weight gain in adolescence: a longitudinal analysis.

Although perceived stress has been hypothesized to be a risk factor for obesity, epidemiological studies relating stress to weight gain have shown mixed results. We examined prospective associations between perceived stress and changes in waist circumference and BMI in a large study of adolescents. As part of the Health and Behaviour in Teenagers Study (HABITS), height, weight, and waist circumference were measured annually in 4,065 adolescents aged from 11 to 16. Waist and BMI standard deviation scores (SDS) were used as indices of adiposity. Adolescents completed a measure of perceived stress each year, from which mean stress scores over the 5‐year period were also calculated and divided by tertile into lower, moderate, and higher stress. Associations between perceived stress at each year and adiposity 1–4 years later and also adiposity trajectories over the whole period in relation to mean stress were investigated. Analyses were adjusted for age, sex, ethnicity, socioeconomic deprivation, pubertal timing, and smoking. Perceived stress in any year was not related prospectively to increases in waist or BMI SDS 1–4 years later, nor was there any evidence that higher stress over the whole period was associated with greater gains in waist or BMI SDS. However, waist and BMI SDS were significantly higher in the moderate‐ and higher‐stress groups than the lower‐stress group across the whole 5‐year period. Persistent stress was associated with higher waist circumference and BMI in adolescence, but did not lead to differential changes over 5 years.

Persistent impact of pubertal timing on trends in smoking, food choice, activity, and stress in adolescence.

Objectives: a) To replicate the established association between early puberty and smoking; b) to see whether differences between early and late maturers narrowed with increasing age and differed by gender; and c) to determine whether other health behaviors (food choice, physical activity, sedentary behavior) and stress showed the same association with pubertal timing. Methods: The Health and Behaviour in Teenagers Study (HABITS) followed a cohort of 5863 adolescents from ages 11 to 12 years (UK year 7; US grade 6) for 5 years. Puberty was assessed with the Pubertal Development Scale. Three pubertal timing groups were created by identifying adolescents who reached midpuberty relatively early, average, or late, compared with their peers. Longitudinal trends in health behaviors and stress were compared between the three groups. Results: Smoking rates were higher throughout adolescence among early-maturing students, with no evidence that late-maturers “caught up” when they reached puberty, although group differences narrowed over time. Early-maturing students had higher rates of sedentary behaviors but also reported higher rates of vigorous activity than their “on-time” developing counterparts. Patterns in dietary behaviors and stress showed lower rates of daily breakfast and higher stress among early-maturing girls, but not boys. Overall, the effects were largest in early adolescence (ages 11–13 years) and became smaller at older ages (ages 14–16 years). Conclusion: Early-maturing adolescents are at increased risk for unhealthy behaviors, especially smoking, and although differences attenuate during adolescence, they remain significant at age 16 years. This suggests that early maturation may be a cause of, or is at least a marker for, differences in lifestyle. HABITS = Health and Behaviour in Teenagers Study; OR = odds ratio; CI = confidence interval.

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.

The role of desire, duty and intention in predicting attempts to quit smoking

AIMS Motivation to quit smoking predicts quit attempts, although little is known about the role played by its different aspects. This study assessed the predictive value of desire, duty and intention to quit, three different aspects of motivation. DESIGN A longitudinal study was conducted involving a nationally representative sample of smokers assessed at baseline and 3 and 6 months later. Baseline assessment took place by face-to-face computer-assisted interviews; follow-up assessments by postal questionnaires. SETTING England. PARTICIPANTS From April 2008 to June 2009, a total of 5593 adult smokers were recruited; 1263 were followed-up at 3 months and 1096 at 6 months. MEASUREMENTS Three dichotomous measures of motivation to quit (wanting to quit, believing one ought to quit, intention to quit soon) were taken at baseline. Whether a subsequent quit attempt was made was recorded at 3- and 6-month follow-up. FINDINGS More smokers believed they ought to quit smoking than wanted to or intended to soon (39.0, 29.3 and 23.5%, respectively). Desire and intention were independent predictors of quit attempts at both follow-ups, whereas combining them did not add predictive value and duty was not a predictor. While the predictive value of desire or intention alone disappeared when accompanied by duty, their combination was robust against its negative effect. CONCLUSIONS Desire and intention independently positively predict quit attempts, while duty appears to mitigate their effect. It would be worth monitoring all three aspects of motivation when evaluating the impact of smoking cessation interventions on motivation to quit.

Nicotine Intake in Cigarette Smokers in England: Distribution and Demographic Correlates

Documenting smoke intake by objective biochemical markers is important for quantification of exposure to toxins. The aim of this report is to show the most definitive distribution of the nicotine metabolite, cotinine, yet available from English smokers in the period before implementation of the legislation banning smoking in indoor public areas. A total of 6,423 cigarette smokers, ages 16 years and above, taking part in the Health Survey for England between 1998 and 2003 provided a saliva cotinine value. Data on cigarette consumption, age, gender, social class, deprivation (as indicated by manual or nonmanual occupation, car ownership, and housing tenure), marital status, and region were collected. Cotinine concentrations showed no overall trend over the study period. The mean value was 289.15 ng/mL (SD 174.43); excluding those who had not smoked in the past 24 hours, the mean value was 302.08 ng/mL (SD 168.78). A higher cotinine concentration was associated with being middle-aged (peaking at 40 years), being male, being single, greater economic deprivation, and not living in London. After adjusting for cigarette consumption, higher values were associated with middle age, being male, and greater deprivation. This study provides the most complete picture yet of the smoke intake of cigarette smokers in England. The fact that cotinine peaks at around the age of 40 years raises the possibility that nicotine intake continues to increase decades after a person starts to smoke. Greater nicotine intake in more deprived smokers could explain why they find it harder to stop smoking. (Cancer Epidemiol Biomarkers Prev 2008;17(12):3331–6)

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

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.