Oliver West

'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.

Nicotine Intake From Electronic Cigarettes on Initial Use and After 4 Weeks of Regular Use

INTRODUCTION Electronic cigarettes (EC) have the potential to generate a substantial public health benefit if there is a switch from smoking to EC use on a population scale. The nicotine delivery from EC is likely to play a major role in their attractiveness to smokers. We assessed nicotine delivery from a first-generation EC and the effect of experience with its use on nicotine intake. METHODS Six smokers provided pharmacokinetic (PK) data after their first use of EC and again following 4 weeks of use. RESULTS The peak nicotine levels were achieved within 5 min of starting the EC use, which suggests that EC may provide nicotine via pulmonary absorption. There were large individual differences in nicotine intake. Compared with the PK profile when using EC for the first time, 4 weeks of practice generated a 24% increase in the peak plasma concentrations (from 4.6 to 5.7 ng/ml; nonsignificant) and a 79% increase in overall nicotine intake (AUC(0 → inf) increased from 115 to 206 ng*min/ml; p < .05). CONCLUSIONS First-generation EC provide faster nicotine absorption than nicotine replacement products, but to compete successfully with conventional cigarettes, EC may need to provide higher doses of nicotine. Nicotine intake from EC can increase with practice, but further studies are needed to confirm this effect.

Systematic review of the relationship between the 3-hydroxycotinine/cotinine ratio and cigarette dependence.

RationaleIndividual differences in the rate of nicotine metabolism (RNM) could be related to dependence and success in stopping smoking. A range of studies have examined RNM measured by the ratio of trans-3′-hydroxycotinine and cotinine in body fluids (the ratio). A systematic review of this literature is needed to draw conclusions and identify gaps in evidence.ObjectiveThe aim of this study is to review evidence on the association of the ratio to cigarette dependence and its role in individual tailoring of smoking cessation pharmacotherapy.ResultsWe reviewed 27 studies of the ratio related to its reliability, validity, and relationship to dependence. The ratio is a reasonably accurate proxy for RNM. There is little evidence that the ratio is related to questionnaire measures of dependence, though the existing data are limited and the ratio has been linked to smoking at night and to some aspects of smoking topography. The ratio is also only weakly associated with cigarette consumption. Its relationship to the severity of withdrawal symptoms seems also weak at best, but limited data exist. One study suggests the ratio predicts outcome of unaided quitting. Importantly, the ratio seems to predict responses both to NRT and bupropion, and thus could guide pharmacotherapy.ConclusionsThe evidence that the ratio is related to smoking behaviours and to cigarette dependence is limited, but the ratio seems to influence treatment response to two stop smoking medications. Further studies of the relationship between the ratio and cigarette dependence and trials of ratio-guided pharmacotherapy are needed.

PTU-045 Smokers with inflammatory bowel disease have low nicotine dependence

Introduction Smoking is a risk factor for developing Crohns disease (CD) and worsens its outcome. Conversely, the onset of ulcerative colitis (UC) may be triggered by smoking cessation and smoking may be beneficial. Successful smoking cessation is inversely related to nicotine dependence. We aimed to assess smoking dependence in inflammatory bowel disease (IBD) patients compared to healthy and disease-matched controls and individuals’ smoking knowledge. Methods 255 IBD patients (182CD:73UC) completed a questionnaire on smoking habits and its effect on IBD. Smokers were assessed for dependence using the Fagerstrom Test for Nicotine Dependence (FTND) score (1) (0–2 very low, 3–4 low,5 medium, 6–7 high, 8–10 very high dependence) compared to age, sex and ethnicity-matched healthy (5 subjects for each case) and asthma controls attending a smoking cessation clinic. The median (range) age was 38 (18–90) years and disease duration 9 (1–54) years for the IBD patients. Differences were sought using χ2 test in categorical and Wilcoxon signed rank or Mann–Whitney U test in continuous data. Results 35/182 (19%) CD and 9/73 (12%) UC were current smokers. In CD, the median (range) FTND score was 3 (0–8) compared to 7 (2–10) in healthy (p<0.001) and 6 (2–9) in asthma controls (p<0.001). Only six of the 35 (17%) CD patients were highly dependent (FTND score ≥ 6). Smoking dependence was unrelated to ethnicity. Similarly, in UC the FTND score was 1 (0–4), lower than healthy 6 (2–10) and asthma controls 7 (4–10) (p<0.004 for both groups). There was no difference in dependence between CD and UC patients. 88% CD smokers were interested in stopping smoking and 33% would consider attending a smoking cessation clinic. Patients with CD were better informed about the effects of smoking on their own disease compared to UC patients: 66/112 (59%) of CD patients knew that smoking worsens CD, whereas only 6/73 (8%) UC patients knew of the beneficial effects of smoking on their disease (p=0.0001). Knowledge was unrelated to smoking status. Conclusion A smaller proportion of our CD patients are smokers than has been reported in previous series (26–61%). Most patients with CD, regardless of their smoking status, recognise the detrimental effects of smoking on their disease. Nicotine dependence in IBD patients is lower than in smokers’ clinic clients and comparable to the general population. The level of interest in smoking cessation is high. Their low nicotine dependence suggests that most IBD patients could be weaned off smoking successfully in the IBD clinic and may not need referral to a smoking cessation clinic.