E-cigarette use in England: Latest trends from the Smoking Toolkit Study

E-cigarette use in England: Latest trends from the Smoking Toolkit Study

Dr Jamie BrownUniversity College LondonDr Emma Beard, Dr Daniel Kotz,Prof Susan Michie & Prof Robert WestSSA, York, November 2014

Financial disclosure

Funding sources for presented workCancer Research UK, English Department of Health & Pfizer funded data collection for this study, and at outset data collection for the Smoking Toolkit Study was supported by GlaxoSmithKline & Johnson and JohnsonFunders had no final role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publicationIndustry funding to the investigatorsJB, DK & EB have all received unrestricted research grants from Pfizer; RW undertakes research, consultancy & receives fees for speaking from companies that manufacture smoking cessation medications (Pfizer, J&J, McNeil, GSK, Nabi, Novartis, and Sanofi-Aventis); there are no other financial relationships with any organisations that might have an interest in the work, particularly e-cigarette companies

Outline

Real-world effectiveness of e-cigarettes when used to aid smoking cessationTrends in e-cigarette use and other tobacco control indicators in England3

Outline

Real-world effectiveness of e-cigarettes when used to aid smoking cessationTrends in e-cigarette use and other tobacco control indicators in England4

E-cigarettes and smoking cessation

E-cigarettes have rapidly become popular10% of US smokers in 2013 (King et al 2014) & 20% of English smokers in 2014 (West & Brown 2014)Majority use to try and quit or cut downHajek et al 2014Reduce craving and withdrawalBullen et al 2010; Vansickel et al 2010; Dawkins et al 2012; Goniewicz et al 2013; Vansickel & Eissenberg 2013Two RCTs suggested e-cigarettes may aid smoking cessationBullen

et al 2013; Caponnetto et al 20135

Why complement randomised trials?

Can only test limited range of products which may be obsolete by the end of the trialTake a long time to report and regulatory decisions are urgentBorland 2011; Cobb et al. 2011, 2013; Etter, 2013; Flouris et al 2010; Hajek et al 2013; The Lancet, 2013Will exclude all smokers who are not willing to volunteer or to receive another productCannot tell what happens when no health professionals are involved6

Objective

To assess the real-world effectiveness of e-cigarettes when used in a quit attempt, compared with using nothing or licensed nicotine products bought over the counter among the general population, after adjusting for important confoundersExisting studies have produced mixed resultsEtter 2010; Etter & Bullen 2011; Foulds et al 2011; Siegel et al 2011; Dawkins et al 2013; Farsalinos et al 2013; Goniewicz et al 2013; Etter & Bullen 2014; Etter & Bullen 2014; Vickerman et al 2013; Adkison et al 2013; Borderud et al 20147

Objective

To assess the real-world effectiveness of e-cigarettes when used in a quit attempt, compared with using nothing or licensed nicotine products bought over the counter among the general population, after adjusting for important confoundersExisting studies have produced mixed resultsEtter 2010; Etter & Bullen 2011; Foulds et al 2011; Siegel et al 2011; Dawkins et al 2013; Farsalinos et al 2013; Goniewicz et al 2013; Etter & Bullen 2014; Etter & Bullen 2014; Vickerman et al 2013; Adkison et al 2013; Borderud et al 20148

Objective

To assess the real-world effectiveness of e-cigarettes when used in a quit attempt, compared with using nothing or licensed nicotine products bought over the counter among the general population, after adjusting for important confoundersExisting studies have produced mixed resultsEtter 2010; Etter & Bullen 2011; Foulds et al 2011; Siegel et al 2011; Dawkins et al 2013; Farsalinos et al 2013; Goniewicz et al 2013; Etter & Bullen 2014; Etter & Bullen 2014; Vickerman et al 2013; Adkison et al 2013; Borderud et al 20149

Objective

To assess the real-world effectiveness of e-cigarettes when used in a quit attempt, compared with using nothing or licensed nicotine products bought over the counter among the general population, after adjusting for important confoundersExisting studies have produced mixed resultsEtter 2010; Etter & Bullen 2011; Foulds et al 2011; Siegel et al 2011; Dawkins et al 2013; Farsalinos et al 2013; Goniewicz et al 2013; Etter & Bullen 2014; Etter & Bullen 2014; Vickerman et al 2013; Adkison et al 2013; Borderud et al 2014

10

Study design and sampling

Cross-sectional household surveys of representative samples of adults in England (www.smokinginengland.info)

Each month new sample of ~ 1800 adults (16+) selected by random location samplingFidler et al.,

2011

Study population and measures

126,134 smokers who had tried to stop in the past 12 months using no aid, NRT-OTC or e-cigarettesBetween July 2009 and Feb 20143,477 used no aid1,922 used NRT-OTC464 used e-cigarette

Excluded using both (n=73), and

prescription

medication or beh support with NRT-OTC (n=173

) or e-cigarettes (n=25)

Study population and measures

136,134 smokers who had tried to stop in the past 12 months using no aid, NRT-OTC or e-cigarettesBetween July 2009 and Feb 20143,477 used no aid1,922 used NRT-OTC464 used e-cigarette

How many still not smoking?

Is there a difference after adjusting for range of factors? e.g. dependence and time since quit attempt

Excluded using both (n=73), and

prescription

medication or

beh

support

with NRT-OTC (n=173

) or e-cigarettes (n=25

)

Results: unadjusted analysis

14E-cigarette users were more likely not to be smoking than those using NRT bought over the counter and those using nothing**** Significantly different from both other groups

Characteristics by quitting method

15Compared with smokers using e-cigarettes:NRT-OTC:were olderhad lower SESless likely to have quit recentlywere more dependent

No aid:had lower SES

less likely to have quit recently or to have begun attempt graduallywere less dependent

After adjusting for confounders

16The odds of e-cigarette users still being abstinent were 61% greater than those using nothing and 63% greater than those using NRT bought over-the-counter

Limitations

Cannot rule out unmeasured confounding factorHowever, external validity greater than RCTsLongitudinal studies in general population adjusting for baseline characteristics would be valuableNo biochemical verificationMisreporting low in population surveys (Wong et al 2012)

Limitations

Cannot rule out unmeasured confounding factorHowever, external validity greater than RCTsLongitudinal studies in general population adjusting for baseline characteristics would be valuableNo biochemical verificationMisreporting low in population surveys (Wong et al 2012)NRT-OTC & e-cigarettes treated homogenously

Conclusion

19Among English adult smokers in the ‘real world’ stopping without professional support, those who use e-cigarettes appear more likely to remain abstinent than those who use a licensed NRT product bought over-the-counter or no aid to cessationThis difference persists after adjusting for a wide range of smoker characteristics such as nicotine dependence

Outline

Real-world effectiveness of e-cigarettes when used to aid smoking cessationTrends in e-cigarette use and other tobacco control indicators in England20

Trends in e-cigarette use and other tobacco control indicators in England

To monitor e-cigarette prevalence and characterise use over timeTo assess how far any changes in use are accompanied by changes in:key performance indicators for tobacco controlsmoking prevalenceuptake in young adultssmoking cessation ratesattempts to stop smokingsuccess of attempts to stop smokinguse of other aids to cessation or smoking reduction21

Methods

22Monthly household surveysEach month involves a new representative sample of ~1800 respondents; smokers ~450Data collected on electronic cigarettes since second quarter 2011Fidler, et al., 2011. 'The smoking toolkit study': a national study of smoking and smoking cessation in England. BMC Public Health 11:479For more info see www.smokinginengland.info

Prevalence of electronic cigarette use: smokers and recent ex-smokers

23N=14490 adults who smoke or who stopped in the past year; increase p<0.001Growth in prevalence of e-cigarette use has stalled in England

Electronic cigarette use

24N=1323 e-cigarette users not using NRTFrequency of use among users is greater in ex-smokers

Age profile of electronic cigarette users

25N=14490 adults who smoke or who stopped in the past yearE-cigarette use is distributed across the age range and representative of smokers

Proportion of e-cigarette users who are smokers

26N=1745 e-cigarette users of adults who smoke or stopped in past yearThe majority of e-cigarette users also smoke

Prevalence of nicotine products while smoking

27N=13531 smokers, increase p<0.001 e-cigs and all nicotine; decrease p=0.001 for NRTIncrease in use of e-cigarettes while smoking has more than offset a decrease in NRT use

Prevalence of nicotine products in recent ex-smokers

28N=959 adults who stopped in the past year; increase p<0.001 for e-cigs and all nicotine; decrease p=0.002 for NRTIncrease in use of e-cigarettes has more than offset a reduction in NRT use

Nicotine use by never smokers and long-term ex-smokers

29N=14619 never and long-term ex-smokers from Nov 2013Current e-cigarette use by never smokers is negligible

Prevalence of nicotine use

30N=63950 adults, decrease p<0.001 for cigarettes and overall nicotine useCigarette and nicotine show an overall decline

Uptake of smoking

31N=11338 people aged 16-24Proportion of adults under 25 years who have ever smoked regularly has remained constant

Quitting

32N=17045 adults who smoked in the past year; increase p<0.001There has been an increase in the rate of quitting smoking

Quit attempts

33N=17045 adults who smoke or who stopped in the past 3 months; increase p=0.002There has been a small increase in quit attempts

Aids used in most recent quit attempt

34N=9438 adults who smoke and tried to stop or who stopped in the past yearIncrease in use of e-cigarettes for quitting has been accompanied by a small reduction in use of other aids except behavioural support which has been static

Aids used in most recent quit attempt

35The use of either e-cigs or prescription medication has increased while use of NRT-OTC or nothing has decreased and NHS support has remained staticN=9438 adults who smoke and tried to stop or who stopped in the past year; 2009 is Jul to Dec, 2014 is Jan to Sept

Approx odds of success relative to nothing and NRT-OTC:

1.5 3.0

Cigarette smoking prevalence

36Graph shows prevalence estimate and upper and lower 95% confidence intervalsBase: All adultsCigarette smoking prevalence continues to decline

Tried to stop smoking in past year

37Graph shows prevalence estimate and upper and lower 95% confidence intervalsBase: Adults who smoked in the past yearThe rate at which smokers have tried to stop in the past year has remained relatively stable (excluding the year of smoke-free legislation)

Success rate for stopping in those who tried

38Graph shows prevalence estimate and upper and lower 95% confidence intervalsBase: Smokers who tried to stop n the past yearThe success rate in those who have tried to stop smoking is the highest for at least 7 years

Conclusions

In England, prevalence of e-cigarette use has remained stable for the past year at around 20% of smokers and recent ex-smokers, with very low rates in never smokers and long-term ex-smokersThere has been a substantial increase in the use of e-cigarettes as an aid to cessation which has coincided with a decline in use of less effective methods (NRT-OTC or nothing)Smoking cessation rates have increased over the time period when e-cigarette use has increasedSmoking prevalence is continuing to fallPopulation trends conflict with the view that e-cigarettes are undermining tobacco control and instead provide reason to be cautiously optimistic about the impact of e-cigarettes in England…but need to monitor closely!

Acknowledgments

Society for the Study of AddictionJB is funded by a SSA fellowshipCo-authors: Susan Michie, Emma Beard, Daniel Kotz & Robert WestCRUK, Dept of Health, Pfizer, GSK & Johnson & Johnson have all supported data collectionResearch team is part of the UK Centre for Tobacco and Alcohol Studies

Decrease in smoking prevalence

41Base: All adultsThe rate of decline in cigarette smoking prevalence has been relatively stable

Stopped smoking in past 12 months

42Graph shows prevalence estimate and upper and lower 95% confidence intervalsBase: Adults who smoked in the past yearThe smoking cessation rate in 2014 is higher at any time since 2007

The nicotine/cigarette market

43N=63842 adultsNicotine data only from last year smokersnondaily nicotine: <1 pw=0.1, 1+ pw=0.5The cigarette and nicotine market are both declining