Why Can’t Smokers Quit: Part I

 

Along with my research colleague Nantaporn Plurphanswat, I recently published a study entitled “Why can’t smokers quit? Longitudinal study of smokers in the US using the Population Assessment of Tobacco and Health (PATH) waves 1 to 5.”  It was published in Addictive Behaviors Reports.

We attempted to determine the factors that may be associated with persistent smoking.  There have been many other studies of this subject, but most have only involved a single cross-sectional survey.  The FDA’s PATH survey is different, because it has followed thousands of people for several years.  We started with 5,860 current (C) smokers enrolled in the PATH study (i.e. Wave 1) in 2013-14 who had follow-up smoking information in the next four waves, or six years.  Almost 4,000 smokers continued to smoke (designated CCCCC), while others became former (F) smokers and and stayed quit in subsequent waves (CFFFF, CCFFF, CCCFF, and CCCCF).  Our analysis focused on differences between persistent smokers and quitters.  We made sure that we adjusted our results for differences in demographic factors such as age, sex, race/ethnicity, education, marital status and where they lived.

This was a big effort, so it will take more than one blog post to describe our results.  In this post I’ll provide results for two hot topics, menthol cigarettes and vaping.

Everyone knows about the FDA’s intention to ban menthol flavored cigarettes, which the agency says lures teens into smoking.  Our goal was to determine whether menthol was associated with persistent smoking or less quitting, because previous studies have produced mixed results (here, here, here, here).

We found that 39–45 % of all smoker groups reported that they had initiated with menthol or mint flavored cigarettes, and 36–48 % currently used menthol or mint flavor in all waves.  Furthermore, among smokers who initiated with menthol, 53–66 % continued to smoke them in all waves. However, we found no statistically significant differences between persistent smokers and quitters with respect to initiation with or current menthol smoking.

In general, vaping produced mixed results. First, the bad news was that the proportions of everyday vape use among persistent smokers were relatively stable throughout all five waves, and the percentage of former vaping grew. However, quitters had higher current vaping in the wave they became former smokers, and smokers who quit in the next wave tended to increase the percentage of everyday vaping at that wave. Our findings are consistent with other PATH studies revealing that vaping has helped some smokers to quit (here, here and here).  We also found that CFFFF who quit after Wave 1 and continued to vape did not return to smoking.

In summary, menthol didn’t play a role in persistent smoking or quitting in the first five waves of the PATH survey.  But there wasn’t a lot of evidence that vaping played a major role.  Stay tuned for more results.

 

Another Engineered Study on Teen Vaping

 

Purdue, Ohio State and Penn State faculty, led by Brian C. Kelly, published an article in the April 2023 edition of Tobacco Control titled, “E-cigarette use among early adolescent tobacco cigarette smokers: testing the disruption and entrenchment hypotheses in two longitudinal cohorts.”  They concluded, “there is evidence e-cigarette use among early adolescent smokers in the UK and USA leads to higher odds of any smoking and more frequent tobacco cigarette use later in adolescence.” 

Lacking access to the U.K. data used by the authors, I focused on the findings from the U.S., which were based on the federal Population Assessment of Tobacco and Health (PATH) survey.  To clarify details of the authors’ methods, I reached out to them with some basic questions.

I telephoned and emailed the authors numerous times over seven weeks from April to June, and copied my last email request to journal editor Ruth Malone.  She responded, suggesting that I submit my questions via the journal’s Rapid Response system, which I did on June 12. On June 30, the authors finally responded, with less than full disclosure.

My questions are numbered, and they are followed by the authors’ responses in quotes, and then by my analysis in bold of what those responses mean for the study’s results and conclusions.

        1. Was public use or restricted PATH data used? This is important, since Table 2 contains a cell, n=7, that is not generally approved by NAHDAP.

            “…the analyses were based on the public use data from…the PATH Study.”

            It is critical to clearly identify the data used, which wasn’t the case in the article.

        2. Was the PATH cohort drawn from Waves 1 and 4, with follow-ups to age 17 years as needed from the other waves?

            “the PATH study sample was drawn from the original cohort, the replenishment cohort, and the shadow cohorts (see 1st and 2nd paragraphs of Methods Section).”

            The 1^st paragraph described the British cohort; it had nothing to do with PATH.  The 2^nd paragraph is a general description of the PATH youth survey, and while it mentions the replenishment and shadow cohorts, it does not state that the authors actually used them.

3. There were significant differences in youth smoking-vaping between Wave 1 (2013-14) and Wave 4 (2016-18) that might have affected the results. Was each wave analyzed separately as well as together?

            The authors didn’t answer this question.

4. The analysis included a variable relating to “parent(s) smoking of cigarettes, cigars, or pipes.” Did the analysis include other combustible tobacco product consumption by the subjects themselves?

The authors failed to respond to this question, or question #5 below.

5. Did the authors account for age at first smoking or vaping (public use, < 12 years and 12-14 years) or which product(s) had been used first?

            The authors instead provided the following statement:

“Regarding the remaining questions, please note that our stated goal was to make the MCS [the British dataset] and PATH analytical samples as comparable as possible when testing our hypotheses using both cohorts (3rd paragraph of Methods section).  As we note in the limitations section (5th paragraph of Discussion section), the MCS had relatively limited items on e-cigarette use and tobacco smoking compared to PATH. The MCS did not assess other combustible tobacco product consumption in early adolescence, nor did MCS measure the sequencing of early adolescent tobacco and e-cigarette use (noted in the limitation section).”

The 3rd paragraph of the Methods section says that they “restricted the PATH cohort to adolescents who were approximately the same age as youth in the MCS cohort.” 

While the authors noted the “limited items” and lack of “sequencing” in the MCS data, they did not specify that they stripped the rich PATH data of the comparable variables relating to #4 and #5 above.  Since the PATH and British datasets were entirely different, there was no scientific reason to strip PATH to make it “comparable” to the MCS.  It appears that the authors took this action only to support their predetermined finding.

In summary, this was another questionable article claiming that vaping leads to smoking.  The authors’ non-answers to my questions make it clear that they engineered this study to produce their desired result.

 

American Teens’ Gross Misperception of Nicotine Leaves FDA Study Authors Unperturbed

A new study by Erin Keely O’Brien and colleagues at the FDA Center for Tobacco Products (CTP) underscores the FDA’s failure to accurately educate consumers about nicotine.  The report appears in Nicotine & Tobacco Research.

The authors analyzed perceptions of nicotine among 12-17 year-old participants during two waves of the Population Assessment of Tobacco and Health (PATH) study, in 2016-17 and 2017-18.

While their journal article includes some positive messages on tobacco harm reduction, its main finding is worrisome: 75% of surveyed youth “incorrectly responded that nicotine is the main substance that causes smoking-related cancer.”  O’Brien noted that this figure was “similar to adults.”   

O’Brien et al. do acknowledge a critical fact: “…it is tobacco combustion and the accompanying release of thousands of harmful chemicals, rather than nicotine itself, that is responsible for most [sic] of the negative tobacco-related health outcomes (eg, the myriad of cancers related to tobacco use).”  They even acknowledge that the FDA’s reduced-nicotine standard for cigarettes “would not decrease the toxicity or harmfulness” of smoking.

The authors reveal why the FDA has done so little to educate consumers about nicotine: “Among youth who did not use at [the 2016-17 wave], greater harm perceptions of nicotine in cigarettes, e-cigarettes, and NRT were associated with lower likelihood of reporting current tobacco use at [the subsequent wave].” (Emphasis added)  They call these misperceptions “protective (preventing initiation among youth who do not use tobacco),” but they also label them “harmful,” in so much as these misperceptions are “preventing youth who use combustible tobacco from switching to [pharmaceutical nicotine].”

In other words, the FDA authors think that teens who mistakenly believe that nicotine kills are more likely not to initiate tobacco.  Even more ominously, “Among youth who currently used cigarettes or e-cigarettes [in the 2016-17 wave], nicotine perceptions did not predict switching to e-cigarettes or cigarettes [in the subsequent wave].”  Of course not.  The misinformation prevents teen – and adult – smokers from switching to tobacco products that are objectively no more hazardous than nicotine medicines.

O’Brien and colleagues conclude that their “findings underscore the challenge of developing effective and comprehensive communication strategies that accurately convey the effects of nicotine without encouraging tobacco use.

Why, when 480,000 Americans die from tobacco smoke inhalation every year, are FDA officials worried more about “encouraging tobacco use” than sharing accurate information about nearly harmless nicotine?  Why do they need “comprehensive communication strategies” to simply tell adult smokers the truth?  The answers lie in the government’s obsession with creating a tobacco-free society.