1. 1 Key findings from the Smoking Toolkit Study University College London 19 January 2012 Robert West Jamie Brown Jenny Fidler

2. 2 Topics Background and methods Smoking prevalence Motivation to stop smoking Attempts to stop smoking Smoking cessation Smokers’ attempts at harm reduction

3. 3 Background and methods

4. 4 Background England has made substantial progress in reducing smoking prevalence and tobacco-related harm but the scale of the problem is such that faster progress is a priority Less affluent smokers continue to have a higher smoking prevalence than more affluent smokers and more needs to be done to narrow the gap Many smokers are trying to cut down on their smoking and using nicotine products to help them with this and in situations where they cannot smoke; it is not clear what benefits accrue to them from this or the effect on cessation

5. 5 Background (cont’d) To help with this, we need timely information on key performance indicators (KPIs) to determine: –progress overall and in particular target groups –the effects of policy initiatives –the effects of national campaigns and events –trends in smokers’ attempts at harm reduction and its association with cessation We also need a better understanding of why people try to stop smoking and what enables them to succeed

6. 6 Aims of the STS To provide timely information on KPIs relating to tobacco control, and particularly smoking cessation To provide contextual information to help with understanding how events, campaigns and policy initiatives have their effects To provide a better understanding of the process of smoking cessation

7. 7 Methods 1 of 2 A series of national household surveys of representative samples of approximately 1700 adults aged 16+ in England with a special focus on the ~500 who have smoked within the past year Sample size from Nov 2006 to Dec 2011: –112,462 adults –28,624 smoked within the past year –26,233 current cigarette smokers –10,726 smokers tried to stop in the preceding 12 months –1,741 smokers who had stopped in the preceding 12 months Sample weighted to match census on demographics

8. 8 Methods 2 of 2 Computer-assisted interviews Focus on smoking, smoking reduction and smoking cessation activities After each household survey, those who have smoked in the past year are followed up by postal surveys 3 months and 6 months later Saliva samples collected from sub-sample in postal surveys for cotinine analyses The study is funded up to 2012

9. 9 Key performance indicators 1 of 3 Each month: Percentage of adults (16+) who are cigarette smokers Percentage of smokers who want to stop smoking and intend to stop soon Percentage of smokers who tried to stop in the preceding month Percentage of smokers who report currently trying to cut down Percentage of smokers who report currently using NRT to cut down Percentage of smokers who report currently using NRT in situations when they cannot smoke

10. 10 Key performance indicators 2 of 3 Each year: Percentage of last-year attempters who used: –nicotine replacement therapy (NRT) bought over the counter –NRT, Zyban and Champix on prescription –NHS Stop Smoking Services Percentage of last year smokers who report being non- smokers at time of the survey –of all last-year smokers –of those attempting to quit

11. 11 Key performance indicators 3 of 3 Overall –relative success rates using different methods of quitting adjusting for nicotine dependence and other confounding factors

12. 12 Smoking prevalence

13. 13 Smoking prevalence: question Which of the following best applies to you? –I smoke cigarettes (including hand-rolled) every day –I smoke cigarettes (including hand-rolled), but not every day –I do not smoke cigarettes at all, but I do smoke tobacco of some kind (e.g. pipe or cigar) –I have stopped smoking completely in the last year –I stopped smoking completely more than a year ago –I have never been a smoker (i.e. smoked for a year or more –Don't Know

14. 14 Smoking prevalence before ‘smoke-free’ implementation www.smokinginengland.info

15. 15 Smoking prevalence immediately after ‘smoke-free’ www.smokinginengland.info

16. 16 Smoking prevalence post-recession www.smokinginengland.info

17. 17 Smoking prevalence 2007-2010 : social grade A-C1 www.smokinginengland.info A-C1: professional to clerical C2-E: skilled manual to long-term unemployed

18. 18 Smoking prevalence 2007-2010 : social grade C2-E www.smokinginengland.info

19. 19 Smoking prevalence in England: Nov 06 to Oct 11 C2-E All A-C1

20. 20 Prevalence by Government Office Region

21. 21 Cigarette smoking prevalence by age group

22. 22 Cigarette smoking prevalence by gender and occupational group

23. 23 Smoking prevalence projection since Nov 2006 www.smokinginengland.info

24. 24 Smoking prevalence projection post-recession www.smokinginengland.info

25. 25 Amount smoked and cost of smoking

26. 26 Amount smoked N=10,353; p<0.001 for increase in percent hand-rolled and exclusive use of hand-rolled

27. 27 Cost of smoking N=11,356 smokers, 6,478 manufactured cigarette smokers, 3,054 hand-rolled smokers; cost per cigarette of both hand-rolled and manufactured cigarettes has increase p<0.001

28. 28 Motivation to stop smoking

29. 29 Motivation to stop smoking: question Which one of the following applies to you? –I REALLY want to stop smoking and intend to in the next month –I REALLY want to stop smoking and intend to in the next 3 months –I want to stop smoking and hope to soon –I REALLY want to stop smoking but I don't know when I will –I want to stop smoking but haven't thought about when –I think I should stop smoking but don't really want to –I don't want to stop smoking –Don't Know

30. 30 Trends in motivation to stop

31. 31 Motivation to stop by year N=15,096, p<0.001 for nonlinear change over time

32. 32 Motivation to stop predicting quit attempts N=2088, p<0.001 for linear trend

33. 33 Attempts to stop smoking

34. 34 Monthly rate of attempts to stop smoking

35. 35 Monthly rate of attempts to stop smoking by year

36. 36 Changes in main external triggers to cessation

37. 37 Association between smoking motives and attempts to quit in the past year Final model from forward stepwise logistic regression of attempt to stop in past 12 months on to beliefs about smoking. Odds ratios less than 1 represent negative associations. N=3033

38. 38 Association between motives to stop smoking and attempts to quit in the past year Final model from forward stepwise logistic regression of attempt to stop in past 12 months on to beliefs about smoking. Odds ratios less than 1 represent negative associations. N=5647

39. 39 GP advice to stop smoking Percentage of smokers and recent ex-smokers for whom …; data from Smoking Toolkit Study, N=7611

40. 40 Attempts to stop according to GP advice to stop smoking N=7611, p<0.001 for difference between offer of support/prescription and others

41. 41 Cessation aids: question Which, if any, of the following did you try to help you stop smoking during the... serious quit attempt? –Nicotine replacement product (eg. patches/gum/inhaler) without a prescription –Nicotine replacement product on prescription or given to you by a health professional –Zyban (bupropion) –Champix (varenicline) –Attended an NHS Stop Smoking Service group –Attended an NHS Stop Smoking Service one to one counselling session –Smoking helpline such as NHS smoking helpline or Quitline etc –Don't Know/Can't remember –Nothing –Other

42. 42 Aids in most recent quit attempt Data from 3,705 smokers who tried to quit in past year, surveyed Jan 2010 onwards

43. 43 Use of aids to cessation

44. 44 Routes to quit Where more than one method is used the most intensive one is represented

45. 45 Use of aids to stop according to GP advice to stop smoking N=2714, p<0.001 for difference in use of aids

46. 46 Quit attempts pre- and post- smoking ban Base: smoked in last year; p<.05 for decline; unpublished data Attempts to stop smoking were not higher post-ban

47. 47 Smoking cessation

48. 48 Percentage of ever regular smokers who have quit for at least a year Moving average of 3 ages. Green Line: A-C1; Blue Line: C2-E, Red Line: All

49. 49 Monthly prevalence of abstinence in those who smoked in the past year

50. 50 Quit rate

51. 51 Success of quit attempts pre- and post- smoking ban Base: made quit attempt in last month; p<.05 for increase post-smoke-free; unpublished data Attempts to stop smoking were more successful post-ban

52. 52 Relative success rate by ‘route to quit’ Significantly better than no aid adjusting for confounding variables, p<0.001 Data from www.smokinginengland.info; based on smokers who tried to stop in the past year who report still not smoking at the survey adjusting for other predictors of success (age, dependence, time since quit attempt, social grade, recent prior quit attempts, abrupt vs gradual cessation): N=10,728www.smokinginengland.info

53. 53 Smokers’ attempts at harm reduction

54. 54 Smoking reduction: question Are you currently trying to cut down on the amount you smoke? –Yes –No –Don’t know

55. 55 Trend in prevalence of ‘cutting down’

56. 56 NRT for reduction: question Which, if any, of the following are you currently using to help you cut down the amount you smoke? –Nicorette nicotine replacement gum –Niquitin nicotine replacement gum –Other nicotine replacement gum –Niquitin nicotine replacement lozenges/tablets –Nicorette nicotine replacement lozenges/tablets –Other nicotine replacement lozenges/tablets –Nicotine replacement inhaler –Nicotine replacement nasal spray –Niquitin nicotine patch –Nicorette nicotine patch –Other nicotine patch –Don't Know –None of these

57. 57 Trends in use of NRT to cut down

58. 58 Use of NRT in situations where smoking not allowed

59. 59 Main contacts Dr Jamie Brown: jbimrosebrown@gmail.com Prof Robert West: robertwest100@gmail.com