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.

 

 

More Proof from FDA Population Data Showing E-Cigarettes As Popular Quit-Smoking Aids

While the number of American vapers declined over the last three years (as I reported here), e-cigarettes were still far more popular quit-smoking aids than medicinal nicotine or other drugs, according to researchers at the University of California San Diego (here).

Tarik Benmarhnia and colleagues used information from Waves 1 and 2 of the FDA-funded Population Assessment of Tobacco and Health (PATH) Study to evaluate “the influence of [e-cigarettes] and pharmaceutical cessation aids [varenicline, bupropion and nicotine medicines, NRT] on persistent abstinence (≥30 days) from cigarettes, and reduced cigarette consumption” during the period 2013 to 2015.  They concluded:

“Our results indicate that [e-cigarettes] are a more popular choice than approved pharmaceutical products as a smoking cessation aid among US quit attempters, over three quarters of whom were daily smokers.  In the future, as [vapor] products continue to evolve to make nicotine delivery more similar to that obtained from a cigarette, it is possible that they may play a bigger role in assisting smokers to quit combustible tobacco.”

This study confirms my research group’s earlier analysis of Wave 1 PATH data: E-cigarettes are among the most commonly used quit aids for American smokers, and they are the only aid more likely to make one a former smoker (i.e., a successful quitter) than trying to quit cold-turkey (here). 

Population-Level Proof: E-Cigarettes Are Popular & Successful Quit-Smoking Aids

Tobacco harm reduction opponents have belittled reported use of e-cigarettes as smoking cessation aids, dismissing case studies as mere “anecdotes” (here) and claiming a lack of population evidence to support a quit-smoking claim. 

Now that evidence exists.

In a just published study, my colleague Nantaporn Plurphanswat and I use federal government data to demonstrate that e-cigarettes were one of the most commonly used quit aids by American smokers in 2013-2014, and that they were the only aid more likely to make one a former smoker (i.e., a successful quitter) than quitting cold-turkey. 

Our study, appearing in the International Journal of Environmental Research and Public Health (open access, available here), analyzed data in the Population Assessment of Tobacco and Health (PATH) Survey, a combined project of the U.S. Food and Drug Administration and the National Institutes of Health. 

The PATH survey asked current smokers which aids they used when they tried to quit, and former smokers which aids they used to quit, in the past 12 months.  Participants could pick from the following: (1) no aid, (2) support from friends and family, (3) other aids (counseling, quit line, books, pamphlets, videos, clinic, class, web program), (4) e-cigarettes, (5) other combustible tobacco (cigars, cigarillos, filtered cigars, pipe tobacco, hookah), (6) smokeless tobacco (dip, chew, or snuff, and dissolvable tobacco), (7) pharmaceutical nicotine (NRT: patch, gum, inhaler, nasal spray, lozenge or pill), and (8) prescription drugs (Chantix, varenicline, Wellbutrin, Zyban, or bupropion).

Here is a summary of the results for smokers using a single quit aid:

Single Quit Aids Used By American Smokers, 2013-2014
Aid	Current Smokers*	Former Smokers*	All*	% Former	Odds Ratio** (95% Confidence Interval
No aid	5,546,000	1,429,000	6,975,000	20.5	Referent
Support, friends family	1,992,000	446,000	2,438,000	18.3	0.98 (0.75-1.28)
Other aids	139,000	37,000	176,000	21.0	0.89 (0.36-2.17)
E-cigarettes	1,652,000	540,000	2,192,000	24.6	1.43 (1.12-1.83)
Other combustible	91,000	24,000	115,000	20.9	1.43 (0.78-2.63)***
Smokeless tobacco	92,000	32,000	124,000	25.8	1.43 (0.78-2.63)***
NRT	1,190,000	284,000	1,474,000	19.3	0.89 (0.61-1.28)
Prescription drug	347,000	70,000	417,000	16.8	0.97 (0.55-1.71)
All aids	11,049,000	2,862,000	13,911,000	20.6

*estimated from PATH survey weighting.  Some numbers do not appear in the peer-reviewed publication.

**Odds ratio of being a former smoker, adjusted for number of quit attempts, age, sex, race/ethnicity, education, income and region

***categories combined to produce a single OR

Overall, nearly 14 million smokers tried to or did quit using a single quit aid in 2013-2014.  As we note, “E-cigarettes were used…by 2.2 million smokers…, NRT by 1.47 million, prescription drugs by 418,000 and smokeless tobacco by 124,000.” 

While NRT and prescription drugs, combined, helped some 354,000 smokers quit, it was e-cigarettes, which are routinely condemned by many public health institutions, that produced the greater success, helping 540,000 smokers quit.  Given the government’s own evidence, it’s time to acknowledge the scientific legitimacy, value and benefit of e-cigarettes with respect to the health of the population.