Why Can’t Smokers Quit: Part II

 

Last week I introduced our new study of persistent smokers in five waves of the FDA’s Population Assessment of Tobacco and Health (PATH) Study.  I explained that menthol cigarettes and vaping had almost no effect on persistent smoking or quitting in this population, which was followed for about six years.  This week I’ll discuss some differences that distinguish persistent smokers from quitters.

Over 85% of persistent smokers puffed every day, a much higher rate than among smokers who quit in the following wave.  For example, in Wave 1, 87% of persistent smokers puffed every day, compared with 52% among quitters at Wave 2.  More persistent smokers smoked 21+ cigarettes per day, smoked within 30 minutes of waking up in the morning, and had a higher objective measure of nicotine addiction than quitters.

Fewer persistent smokers tried to quit completely in all waves, compared with those who quit.  For example, in the first wave, 19% of persistent smokers reported they had tried to quit completely during the past 12 months, compared with 30% of those who quit by the next wave and stayed smoke-free for the rest of the study.  As many as 22% of persistent smokers had stopped for a month or longer at Wave 2, compared with 42% of quitters. 

Persistent smokers’ lack of quitting success may have been due to their experiencing more adverse symptoms, including anxiety, restlessness, difficulty concentrating or sleeping, feeling depressed and/or weight gain.  Quitting cold turkey is unpleasant, and some smokers may not be able to exist comfortably when nicotine-abstinent.  Persistent smokers were honest about their likelihood to succeed: Only 31% were optimistic in Wave 1, compared to 60% of quitters.

In the previous post, I described our less-than-impressive findings with respect to quitting with e-cigarettes, but in subsequent waves, both persistent smokers and quitters showed decreased use of any quit aids.  In fact, the percentage of all smokers who reported using no aid at all increased during the study.  In our analysis, we looked at all aids, including nicotine replacement therapy (NRT) and prescription medicines such as Chantix, varenicline, Wellbutrin, Zyban, and bupropion; and others, such as family and friends, counseling and self-help material. 

In summary we wrote, “Compared with smokers who became and stayed quit, [persistent smokers] were more likely to smoke every day, have higher measures of nicotine dependence and have more adverse effects of nicotine withdrawal.  They were less interested in cessation, less likely to make a quit attempt and less confident that the attempt would be successful.  While [vapor products] and menthol are topics of current debate, neither played a prominent role in continued smoking or quitting.” 

None of these findings are new.  The reasons smokers can’t quit have been known for a long time, but our study demonstrates that these characteristics persisted throughout the six-year PATH follow-up.  Let’s consider what this means.

During our study period 2013-2018, 2.9 million Americans died from a smoking-related illness.  Over 40% of persistent smokers in our study were age 45+ years when they enrolled, so they were at risk of becoming a mortality statistic.  Another 42% were 25-44 years old, the perfect time for them to quit.  It is tragic, therefore, that the sponsor of the PATH survey, the FDA, is slow-walking reviews of smoke-free cigarette substitutes, in keeping with its ultimate goal of eliminating the entire tobacco and nicotine market.

It is long past time for FDA to alter its prohibitionist crusade and, instead, focus on truly protecting the health of persistent smokers.

 

 

Dependence Level Higher with Cigarettes Than with Smokeless Tobacco

As noted previously (here), Drs. Karl Fagerström and Tom Eissenberg have described a continuum of dependence among tobacco and nicotine products.  They concluded that cigarettes are the most dependence-producing (addictive) product and that smokeless tobacco is intermediate, evidenced by clinical trials showing that quitting cigarette smoking is more difficult than quitting ST.

In a new study published in Nicotine & Tobacco Research (abstract here), I use data from the 2003 Tobacco Use Supplement of the Current Population Survey to directly compare time to first use (TTFU) among smokers and smokeless tobacco users in a nationally representative sample.  My collaborators in the work are Nantaporn Plurphanswat, research economist at University of Louisville’s Brown Cancer Center, and Karl Fagerström.

Time to the first cigarette (TTFC) after waking up in the morning is a well-established measure of dependence among smokers – the shorter the TTFC, the stronger the addiction.  This measure is the key component of a scale developed in the late 1970s by Dr. Fagerström, for whom the scale is named.  TTFC is strongly correlated with abstinence and time to relapse among smokers enrolled in cessation trials and in nationally representative samples of smokers from four countries.  A comparable measure has been developed for smokeless tobacco use.

We examined TTFU among 10,500 white men who were daily cigarette smokers and 1,200 who were daily smokeless tobacco users.  Smokers were classified according to number of cigarettes per day (cpd) smoked: light (1-14 cpd), moderate (15-24 cpd) and heavy (25+).  Smokeless tobacco users were subgrouped as exclusive users or former smokers.

The results show that dependence among smokeless tobacco users is similar to that among light smokers (1-14 cpd), 9% of whose TTFU was less than 5 minutes, and 23% under 30 minutes.  Differences in TTFU between smokers and smokeless tobacco users can be seen in the chart below, which is from our study.

Our findings support the Fagerström-Eissenberg hypothesis that the dependence level of cigarettes is generally higher than that of smokeless tobacco.  This has positive implications for tobacco harm reduction, which is the substitution of smoke-free tobacco products for cigarettes among smokers unwilling or unable to quit.  Switching from smoking to smokeless tobacco use is associated with a huge reduction in health risks.  This study adds evidence that a switch to smokeless tobacco might also increase the chances for becoming completely tobacco-free.