Lion Shahab

Prevalence, diagnosis and relation to tobacco dependence of chronic obstructive pulmonary disease in a nationally representative population sample

Background: Chronic obstructive pulmonary disease (COPD) is the fourth most common cause of death worldwide. It is caused primarily by cigarette smoking. Given its importance, it is remarkable that reliable national prevalence data are lacking for most countries. This study provides estimates of the national prevalence of COPD in England, the extent of under-detection of the disorder, and patterns of cigarette smoking, dependence, and motivation to stop smoking in those with the disease. Methods: Data from 8215 adults over the age of 35 who participated in the Health Survey for England were analysed. Information was obtained on self-reported and cotinine validated smoking status, cigarette dependence, motivation to stop smoking, COPD defined by spirometry using joint American Thoracic Society and European Respiratory Society criteria, and self-reports of diagnosis with respiratory disorders. Results: Spirometry-defined COPD was present in 13.3% (95% CI 12.6 to 14.0) of participants, over 80% of whom reported no respiratory diagnosis. Even among people with severe or very severe COPD by spirometric assessment, only 46.8% (95% CI 39.1 to 54.6) reported any diagnosed respiratory disease. A total of 34.9% (95% CI 32.1 to 37.8) of people with spirometry-defined COPD were smokers compared with 22.4% (95% CI 21.4 to 23.4) of those without, and smoking prevalence increased with disease severity. Smokers with spirometry-defined COPD were more cigarette dependent but had no greater desire to quit than other smokers. Conclusion: COPD is common among adults in England and is predominantly undiagnosed. In smokers it is associated with higher degrees of cigarette dependence but not with a greater motivation to stop smoking.

Online support for smoking cessation: a systematic review of the literature.

AIM To examine the efficacy and acceptability of online, interactive interventions for smoking cessation and to identify treatment effect moderators and mediators. METHODS A systematic review and meta-analysis of the literature (1990-2008) was conducted, finding 11 relevant randomized controlled trials. Data were extracted and risk ratios and risk differences estimated with a random effects model. RESULTS There was no evidence of publication bias. Included trials were of variable methodological quality. Web-based, tailored, interactive smoking cessation interventions were effective compared with untailored booklet or e-mail interventions [rate ratio (RR) 1.8; 95% confidence interval (CI) 1.4-2.3] increasing 6-month abstinence by 17% (95% CI 12-21%). No overall effect of interactive compared with static web-based interventions was detected but there was significant heterogeneity, with one study obtaining a clear effect and another failing to find one. Few moderating or mediating factors were evaluated in studies and those that were had little effect. Pooled results suggest that only interventions aimed at smokers motivated to quit were effective (RR 1.3, 95% CI 1.0-1.7). Fully automated interventions increased smoking cessation rates (RR 1.4, 95% CI 1.0-2.0), but evidence was less clear-cut for non-automated interventions. Overall, the web-based interventions evaluated were considered to be acceptable and user satisfaction was generally high. CONCLUSION Interactive, web-based interventions for smoking cessation can be effective in aiding cessation. More research is needed to evaluate the relative efficacy of interactive web-based interventions compared with static websites.

Prevalence and characteristics of e-cigarette users in Great Britain: Findings from a general population survey of smokers

Background E-cigarettes may be effective smoking cessation aids and their use by smokers has been growing rapidly. It is important to observe and assess natural patterns in the use of e-cigarettes whilst experimental data accumulates. This paper reports the prevalence of e-cigarette awareness, beliefs and usage, including brand choice, and characterises the socio-demographic and smoking profile associated with current use, among the general population of smokers and recent ex-smokers. Methods Data were obtained from 3538 current and 579 recent ex-smokers in a cross-sectional online survey of a national sample of smokers in Great Britain in November and December 2012. Differences between current and recent ex-smokers in the prevalence of e-cigarette awareness, beliefs and usage were examined and the socio-demographic and smoking profile associated with current use of e-cigarettes was assessed in a series of simple and multiple logistic regressions. Results Ninety-three percent of current and recent ex-smokers (n = 3841) were aware of e-cigarettes. Approximately a fifth (n = 884) were currently using e-cigarettes, whilst just over a third (n = 1507) had ever used them. Sixty-seven percent of the sample (n = 2758) believed e-cigarettes to be less harmful than cigarettes; however, almost a quarter (n = 994) remained unsure. Among both current and recent ex-smokers, the most popular reasons for using were health, cutting down and quitting (each > 80%) and 38% used the brand ‘E-lites’. Among current smokers who were aware of but had never used e-cigarettes, approximately half (n = 1040) were interested in using them in the future. Among current smokers, their use was associated with higher socio-economic status (OR = 1.48, 95%CI = 1.25–1.75), smoking more cigarettes (OR = 1.02, 95%CI = 1.01–1.03) and having a past-year quit attempt (OR = 2.82, 95%CI = 2.38–3.34). Conclusions There is a near universal awareness of e-cigarettes and their use appears to be common among smokers in Great Britain although a quarter of all smokers are unsure as to whether e-cigarettes are less harmful than cigarettes. E-lites – a brand that delivers a low dose of nicotine – is the most popular. E-cigarette users appear to have higher socio-economic status, to smoke more cigarettes per day and to have attempted to quit in the past year.

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.

Behavior change techniques used by the English Stop Smoking Services and their associations with short-term quit outcomes

OBJECTIVE To help identify effective components of behavioral support for smoking cessation, this study identified the behavior change techniques (BCTs) specified in the treatment manuals of 43 English Stop Smoking Services (SSSs) and assessed association between inclusion of specific BCTs and SSS success rates. METHODS SSSs (n = 144) were contacted to request their treatment manuals. BCTs included in the manuals were identified using a previously established taxonomy. Associations between inclusion of specific BCTs and short-term (4-week) quit outcomes were assessed. RESULTS Ninety-eight services responded, of which 43 had suitable treatment manuals. Out of 43 possible BCTs, SSS manuals included a mean of 22 (range 9-37). The number of sessions used for delivery of the smoking cessation intervention differed markedly (range 1-13) across services. Nine of the BCTs were significantly associated with both self-reported and carbon monoxide (CO)-verified 4-week quit rates (e.g., strengthen ex-smoker identity, provide rewards contingent on abstinence, advise on medication, measure CO) and a further 5 were associated with CO-verified 4-week quit rates but not self-reported quit rates (e.g., advise on/facilitate use of social support, provide reassurance). SSSs that scheduled in more sessions had higher quit rates. CONCLUSIONS English SSSs vary widely in how far their treatment manuals include specific behavior change techniques and how many do not have manuals. It is possible to identify BCTs that are reliably associated with better quit outcomes. Behavioral support for smoking cessation could be improved by a more systematic approach to identifying and applying BCTs that are associated with better quit outcomes.

'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.

To what extent should waterpipe tobacco smoking become a public health priority

BACKGROUND Waterpipe tobacco smoking (WTS) popularity is increasing world-wide, and health effects are emerging in the light of evidence that WTS is perceived by users as less harmful than cigarette smoking. However, there remains a paucity of available evidence from which to draw firm conclusions about its public health significance. AIMS This narrative review aims to summarize WTS literature to date to inform tobacco control specialists and health-care professionals about this phenomenon and help them to assess whether or not WTS should become a public health priority. METHODS Standard electronic databases as well as conference proceedings and personal libraries were searched in English, French and Arabic with inclusive terminology for the variety of names given to WTS. FINDINGS Waterpipe smoke contains significant levels of toxins, some of which are known to be carcinogenic to humans. Recent epidemiological trends have established an increasing prevalence of WTS in the Middle East and the United States, particularly among adolescents. It is used commonly across multiple ethnicities and both genders with less of a social gradient than cigarette smoking. Attitudes and beliefs have been researched widely and several reasons for believing it is less harmful than cigarette smoking include water filtration and social acceptability. A wide range of diseases have been associated with WTS, but research in this area is relatively underdeveloped and a better evidence base is needed. Worryingly, the waterpipe industry, including waterpipe cafes, operates in an almost completely unregulated market and employs deceptive marketing techniques to attract new users. CONCLUSIONS Waterpipe tobacco smoking (WTS) appears to be on the increase, especially among younger users, and therefore represents a potential public health concern. While legislators should consider enforcing and extending existing tobacco laws to a growing WTS industry, further research is required to fill gaps in the literature and provide evidence-based interventions for tobacco control specialists and health-care professionals.

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

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.

Internet-based intervention for smoking cessation (StopAdvisor) in people with low and high socioeconomic status: a randomised controlled trial

BACKGROUND Internet-based interventions for smoking cessation could help millions of people stop smoking at very low unit costs; however, long-term biochemically verified evidence is scarce and such interventions might be less effective for smokers with low socioeconomic status than for those with high status because of lower online literacy to engage with websites. We aimed to assess a new interactive internet-based intervention (StopAdvisor) for smoking cessation that was designed with particular attention directed to people with low socioeconomic status. METHODS We did this online randomised controlled trial between Dec 6, 2011, and Oct 11, 2013, in the UK. Participants aged 18 years and older who smoked every day were randomly assigned (1:1) to receive treatment with StopAdvisor or an information-only website. Randomisation was automated with an unseen random number function embedded in the website to establish which treatment was revealed after the online baseline assessment. Recruitment continued until the required sample size had been achieved from both high and low socioeconomic status subpopulations. Participants, and researchers who obtained data and did laboratory analyses, were masked to treatment allocation. The primary outcome was 6 month sustained, biochemically verified abstinence. The main secondary outcome was 6 month, 7 day biochemically verified point prevalence. Analysis was by intention to treat. Homogeneity of intervention effect across the socioeconomic subsamples was first assessed to establish whether overall or separate subsample analyses were appropriate. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN99820519. FINDINGS We randomly assigned 4613 participants to the StopAdvisor group (n=2321) or the control group (n=2292); 2142 participants were of low socioeconomic status and 2471 participants were of high status. The overall rate of smoking cessation was similar between participants in the StopAdvisor and control groups for the primary (237 [10%] vs 220 [10%] participants; relative risk [RR] 1·06, 95% CI 0·89-1·27; p=0·49) and the secondary (358 [15%] vs 332 [15%] participants; 1·06, 0·93-1·22; p=0·37) outcomes; however, the intervention effect differed across socioeconomic status subsamples (1·44, 0·99-2·09; p=0·0562 and 1·37, 1·02-1·84; p=0·0360, respectively). StopAdvisor helped participants with low socioeconomic status stop smoking compared with the information-only website (primary outcome: 90 [8%] of 1088 vs 64 [6%] of 1054 participants; RR 1·36, 95% CI 1·00-1·86; p=0·0499; secondary outcome: 136 [13%] vs 100 [10%] participants; 1·32, 1·03-1·68, p=0·0267), but did not improve cessation rates in those with high socioeconomic status (147 [12%] of 1233 vs 156 [13%] of 1238 participants; 0·95, 0·77-1·17; p=0·61 and 222 [18%] vs 232 [19%] participants; 0·96, 0·81-1·13, p=0·64, respectively). INTERPRETATION StopAdvisor was more effective than an information-only website in smokers of low, but not high, socioeconomic status. StopAdvisor could be implemented easily and made freely available, which would probably improve the success rates of smokers with low socioeconomic status who are seeking online support. FUNDING National Prevention Research Initiative.

Showing smokers with vascular disease images of their arteries to motivate cessation: A pilot study

OBJECTIVE To examine the potential impact of visual personalized biomarker feedback on intention to stop smoking and to evaluate possible underlying causal pathways. DESIGN This study is a pilot for a randomized controlled trial. Outcome measures were assessed immediately after the intervention and at 4 weeks follow-up. METHOD Twenty-three smokers attending a cardiovascular outpatient clinic in London were randomly allocated to one of two groups: to either receive a print-out of an ultrasound image of their carotid artery showing atherosclerotic plaque alongside an image of a disease-free artery, or to receive routine verbal feedback. RESULTS The intervention significantly increased perceptions of susceptibility to smoking-related diseases (Cohens h=0.99) and led to increases both in engagement in smoking cessation behaviours (Cohens h=0.79) and intentions to stop smoking (Cohns d=0.44). The latter was moderated by self-efficacy: the intervention increased intention to stop smoking only in people with higher levels of self-efficacy with regard to stopping smoking. CONCLUSIONS This study provides preliminary support for the potential effectiveness of personalized biomarker feedback to increase intentions to stop smoking. It also highlights the need to target and increase self-efficacy in smoking cessation interventions.