#3 - Use of Tobacco Cessation Aids
#3 - Use of Tobacco Cessation Aids
#3 - Use of Tobacco Cessation Aids
A R T I C L E I N F O A B S T R A C T
Keywords: Although smoking prevalence has been decreasing worldwide, sustained tobacco cessation remains a challenging
Cessation goal for many smokers. Several types of tobacco cessation aids are available such as nicotine replacement therapy
Electronic nicotine delivery devices (NRT) and electronic cigarette, the effectiveness of the latter is still a matter of debate. This study aims to test
Addiction
differences in successful smoking cessation according to the type of aid used, considering selection and con
Duration of abstinence
founding factors.
Cessation aids
We used data from the 2017 French Health Barometer, a cross-sectional survey conducted by France’s Public
Health Agency. We studied the relationship between e-cigarette and NRT use and three distinct outcomes
collected retrospectively: smoking status 6, 12 and 24 months after the cessation attempt (yes vs no). All results
were weighted to be nationally-representative and controlled for propensity scores included via overlap
weighting (OW).
The use of an e-cigarette was significantly associated with tobacco cessation at 6 months (OWeighted OR =
1.38, 95 % CI: 1.03–1.99) as well as at 12 months (OWeighted OR = 1.61, 95 % CI: 1.13–2.27) and 24 months
(OWeighted OR = 1.61, 95 % CI: 1.01–2.57). The use of NRT was negatively associated with tobacco cessation at
12 months (OWeighted OR = 0.62, 95 % CI: 0.43–0.89) and 24 months (OWeighted OR = 0.57, 95 % CI:
0.35–0.92). While the use of an e-cigarette alone or combined with NRT is associated with an increase in the
likelihood of smoking cessation, the effects of the use of NRT alone on long-term smoking abstinence are
probably limited.
1. Introduction taxation, as well as support for smokers who wish to quit (World Health
Organization WHO, 2019).
While tobacco smoking prevalence has significantly diminished in The question of the long-term effectiveness of different types of
industrialized countries over past decades, long-term cessation remains smoking cessation aids in real-life settings is still under debate in the
an issue for many smokers (Halpern et al., 2018). Sustained tobacco public health community, in particular regarding electronic cigarettes
cessation is associated with psychological, social and environmental (e-cigarettes), which are mainly nicotine-based devices that are
factors and thereby represents a challenging goal to achieve. As a result, disseminated since 2010 (Fairchild et al., 2019). Although research
comprehensive tobacco control strategies are actively promoted, such as suggests that e-cigarettes are safer than traditional cigarettes (McNeill
the MPOWER strategy launched in 2007 by the World Health Organi et al., 2015), the level of risk reduction is still being discussed (Balfour,
zation, which includes extensive tobacco cessation support for smokers 2021; Haute Autorité de Santé, 2016). On the one hand, one may argue
(World Health Organization WHO, 2008). In practice, in many coun that smokers are primarily addicted to the nicotine itself, and that e-
tries, anti-smoking policies have been implemented. Those policies cigarettes represent a suitable substitute for traditional cigarettes to
include smoking and tobacco advertisement bans, communication on avoid nicotine withdrawal symptoms (Hartmann-Boyce et al., 2021). On
the dangers of smoking and the benefits of quitting, increases in the other hand, some studies suggest that e-cigarette use might enhance
* Corresponding author.
E-mail address: mathilde.fekom@iplesp.upmc.fr (M. Fekom).
https://doi.org/10.1016/j.pmedr.2022.102044
Received 19 October 2022; Received in revised form 2 November 2022; Accepted 5 November 2022
Available online 12 November 2022
2211-3355/© 2022 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
M. Fekom et al. Preventive Medicine Reports 30 (2022) 102044
nicotine dependence (Chen, 2020) and therefore reduce the odds of consumption. In particular, the 2017 wave of the French Health
successful smoking cessation in the long term. Other studies have shown Barometer survey (response rate: 48.5 %) included questions regarding
that children exposed to e-cigarette adverts might reduce the perceived smoking and tobacco cessation patterns, use of smoking cessation aids,
harm of regular tobacco smoking (Vasiljevic et al., 2018). Moreover, the as well as a number of relevant socio-demographic and health-related
European Respiratory Society which gathered publications on e-ciga questions.
rette use, highlighted the lack of evidence regarding the safety of e-
cigarettes in the long term, due to the potentially toxic chemicals they 2.2. Populations
contain (Bals et al., 2019). An additional issue is that many e-cigarette
users keep on smoking traditional cigarettes in parallel to vaping, France’s 2017 National Health Barometer survey was carried out
increasing the risk of deleterious effects on their health. Yet, data from a from January 5th to July 8th and included 25,319 individuals aged 18 to
cohort study of dual users of both e-cigarettes and traditional cigarettes 75 years. Interviews lasted 31 min on average. We excluded from the
indicate that compared to traditional cigarette users only, dual users statistical analyses never-smokers and participants who smoked or used
were more likely to be abstinent at 6 months, but this was no longer the to smoke only occasionally yielding a sample of 12,101 daily smokers
case at 12 or 18 months (Sweet, 2018). A randomized controlled trial and former daily smokers. Individuals were classified as former smokers
conducted in the United States showed that sustainable tobacco cessa if they had smoked for at least 6 months and reported quitting for at least
tion at 6 months is not facilitated by the use of e-cigarettes when com one week prior to the survey. To keep exposure groups comparable, the
bined with usual care (Halpern et al., 2018). study sample was limited to individuals who tried to stop smoking at
A meta-analysis gathering 136 studies on nicotine replacement least once and for at least one week (successfully or not), that is 87.2 %
therapy (NRT) concluded that licensed forms of NRT can significantly of ever-daily smokers (n = 10,556). In this subgroup, 41.9 % (n = 4,423)
increase smoking cessation rates (Hartmann-Boyce et al., 2019). How were current daily smokers while 58.1 % (n = 6,133) were former daily
ever, the effectiveness of NRT in terms of long-term abstinence appears smokers. Since we aimed to assess the association between e-cigarette
to be limited: a randomized trial failed to demonstrate additional effi use and smoking cessation, we limited the study to the 4,022 individuals
cacy beyond 24 consecutive weeks of use (Schnoll et al., 2015) and re who attempted to quit smoking in the 4 years prior to the study, which
sults from a meta-analysis further showed that focusing on durations of 6 roughly corresponds to the period when e-cigarettes were marketed in
to 12 months after the cessation might overestimate the lifetime benefit France. In addition, to compare smokers and former smokers only par
of NRT by 30 % (Etter and Stapleton, 2006). E-cigarettes and NRT have ticipants whose last smoking cessation attempt was at least 6 months
also been compared in randomized trials, and the former appears to be before the survey were included, yielding a sample of n = 2,783
more effective than the latter for successful tobacco cessation (Hart participants.
mann-Boyce et al., 2019; Schnoll et al., 2015). Finally, real-life use and
effectiveness are probably different from what has been observed in 3. Variables
clinical trials and there is need for updated information on this topic.
In addition to studying successful smoking cessation (Halpern et al., 3.1. Exposure – Type of smoking cessation aid
2018; Balfour, 2021; Schnoll et al., 2015) additional information can be
conveyed by the duration of abstinence (Marti, 2010). This distinction Participants who reported attempting to quit smoking were asked
matters as the intervention necessary to address the two goals might ‘Which smoking cessation aid did you use to quit smoking?’. It was a
differ. In France, since January the 1st 2019, up to 65 % of the cost of question with 9 non-exclusive pre-coded response choices. Similarly to
NRT is covered by the national health insurance scheme when pre previous work (Guignard, 2021), we distinguished 5 groups: use of 1) an
scribed by a health professional. In addition, the French National Au e-cigarette and no NRT (called e-cigarette), 2) NRT and no e-cigarette
thority for Health (HAS) emphasizes the importance of support and (called NRT), 3) both an e-cigarette and NRT (called e-cigarette and
guidance by a medical professional for sustainable tobacco cessation NRT), 4) another type of help and 5) nothing. The last option was used as
through motivational interviews, therapy, etc. (Haute Autorité de Santé, the reference category.
2014). More recently, the HAS proposed a specific tool to be used by
health professionals for early identification and brief intervention on 4. Study outcomes
patients’ tobacco consumption (Haute Autorité de Santé, 2021).
Using data from the French Health Barometer survey, we aimed to We considered three different study outcomes corresponding to
contribute to the ongoing discussion about effective ways of initiating participants’ smoking status 6, 12 and 24 months after the smoking
and maintaining tobacco cessation in a real-life rather than an experi cessation attempt reported. 6 months is a standard period to consider
mental setting. In particular, we studied the relationship between use of smoking abstinence as sustainable (Lee and Kahende, 2007). Partici
NRT and/or an electronic cigarette use with regard to smoking cessation pants who quit smoking for at least 6/12/24 months at the time of
6, 12 and 24 months after the smoking cessation attempt among smokers survey were considered as former smokers. The 3 outcomes yielded
drawn from the general population. samples of respectively N = 2,783, N = 1,947 and N = 1,079 partici
pants. More specifically, a participant who answered “yes” to “Do you
2. Methods smoke?”, “yes” to “Do you smoke every day?” and “More than 6/12/24
months” to “When was the last time you tried to stop smoking?” was
2.1. Source classified as a smoker and a participant who answered “no” to “Do you
smoke?”, “yes” to “Had you smoked daily for more than 6 months?” and
Data for this study come from the French Health Barometer, a “More than 6/12/24 months ago” to “When did you stop smoking?” was
representative general population telephone survey which aims to assess classified as a former smoker.
population levels of knowledge, behaviors and beliefs regarding health.
These surveys have been carried out since 1992 by the National Institute 4.1. Covariates
for Prevention and Health Education (Inpes) and now by the French
National Public Health Agency (Santé publique France). Telephone The socio-demographic variables controlled for in these analyses
numbers (landlines and mobile phones) are generated randomly include participants’ sex (woman vs man), age (in years), number of
(Richard et al., 2016). For landlines, only one individual per household persons in the household (headcount), work status (employed (refer
is randomly selected to participate (Kish, 1949). ence), student, out-of the labour force, retired), occupational grade
The survey includes a section dedicated to the assessment of tobacco (worker (reference), supervisor/office employee or equivalent,
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M. Fekom et al. Preventive Medicine Reports 30 (2022) 102044
executive, other, not working), highest level of education (<high school are close enough to you so that you can count on them in case of a
(reference), high school graduate, college or > college), income per serious personal problem?’, below 3 (reference), 3–5, 6 and above).
consumption unit (split into terciles), relationship status (in a relation Additionally, we considered participants’ age of regular smoking
ship vs single) and having children (yes vs no). initiation, number of quit attempts prior to the survey and cessation type
Behavioral and health-related characteristics studied were: negative (radical vs progressive).
life events (>=1 among: serious money issues, loss of family member or
unwanted sexual relationship), frequency of physical activity (never 5. Statistical analyses
(reference), monthly/annually, weekly), chronic disease (based on the
question: ‘Do you have a chronic disease or health issue?’ yes vs no), life 5.1. Weights
satisfaction (based on the question ‘On a scale from 0 to 10, how would
you rate your life currently?’), psychotropic medication (based on the All results were weighted to consider the probability of being
question: ‘Have you ever taken any medication for nerves or sleep included in the survey, which depended on the respondent’s phone lines
problems, such as a tranquilizer, sleeping pills, antidepressants, etc.?’ number and of the number of eligible persons in the household. Weights
yes vs no) and social support (based on the question ‘How many people were calculated using the 2016 employment survey from National
Table 1
Characteristics of ever smokers who attempted to quit at least 6 months and at most4 years before the survey stratified by tobacco cessation help type.
Overall None E-cigarette NRT** E-cig. & NRT Other p
Nb quit attempts* (mean (SD)) 3.70 (7.69) 3.60 (8.19) 3.81 (7.04) 3.75 (7.81) 5.12 (5.75) 3.55 (4.68) 0.151
Cessation type* = Progressive (%) 696 (25) 398 (23) 137 (32) 90 (27) 31 (33) 41 (20) 0.005
Smoking status =Former smoker 987 (35) 573 (33) 188 (44) 100 (30) 44 (47) 82 (39) 0.001
(%)
Data come from the 2017 French Health Barometer phone survey from Santé publique France. All headcounts and percentages were weighted by margin calibration. p-
values from Pearson chi-square tests for categorical variables and from.
one-way ANOVA tests for continuous variables were reported.
*Imputed using Multiple Imputation by Chained Equations (mice package in R).
** NRT = Nicotine Replacement Therapy.
◦
Consumption units (CU) are calculated the following way: 1 CU for the first adult in the household, 0.5 CU for the other persons aged 14 years or older, 0.3 CU for the
children under 14 years.
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M. Fekom et al. Preventive Medicine Reports 30 (2022) 102044
6.1.1. Factors associated with the use and types of smoking cessation aid cigarette use and smoking cessation for at least 6 months (OWeighted
In our first sample (N = 2783), 1716 individuals reported no aids OR = 1.38, 95 % CI: 1.03–1.99), 12 months (OWeighted OR = 1.61, 95
during their last tobacco cessation attempt, representing 61.7 % of the % CI: 1.13–2.27), and 24 months (OWeighted OR = 1.61, 95 % CI:
overall sample, while 15.5 % used an e-cigarette without NRT (n = 430), 1.01–2.57).
12.0 % NRT without an e-cigarette (n = 334) and 3.4 % both (n = 95), In contrast, there was a negative gradient between NRT use and
see Table 1. Participants who reported no smoking cessation aid as well smoking cessation for at least 6 months (OWeighted OR = 0.73, 95 % CI:
as those who used an e-cigarette were younger (respectively 39.06 and 0.53–1.00), 12 months (OWeighted OR = 0.62, 95 % CI: 0.43–0.89) and
40.54 years) than those who used NRT (46.78 years-old). While neither 24 months (OWeighted OR = 0.57, 95 % CI: 0.35–0.92). For those who
sex, level of education, having children nor life satisfaction were used both an e-cigarette and NRT, the odds ratio of smoking cessation
significantly associated with the type of smoking cessation aid used, was the highest 12 months after the quit attempt (OWeighted OR = 2.15,
other characteristics were, namely the number of persons in the 95 % CI: 1.21–3.84) and then decreased and became statistically non-
household, work status, occupational grade, relationship status, income, significant at 24 months (OWeighted OR = 1.74, 95 % CI: 0.80–3.77).
no physical activity, experience of negative life events, presence of a
chronic disease and use of psychotropic medication. 7. Discussion
Finally, individuals who used an e-cigarette without NRT were more
likely to report satisfactory social support, initiated regular smoking 7.1. Main findings
earlier (average of 18.56 years-old), quit smoking progressively and the
proportion of former smokers was higher there than in the NRT group or Our study, based on nationally-representative data collected among
in the group with no aids. smokers and former smokers, suggests that while e-cigarette use is
associated with both short and medium-term transition from being a
6.1.2. Regression analyses smoker to being a former smoker, its protective effect on a longer-term
Table 2 displays the results of both bivariate and propensity-score remains uncertain. In addition, NRT use does not appear to help sus
controlled logistic regression analyses. In bivariate analyses, only the tainable abstinence in the long term. Thus, limiting the study of tobacco
use of an e-cigarette alone (6 months: OR = 1.54, 95 % CI: 1.19–2.00, 12 cessation to a short-term binary outcome can lead to wrong conclusions
months: 1.65 (1.21–2.26), 24 months: 1.76 (1.15–2.71)) was signifi about the real-life effectiveness of e-cigarette and NRT use with regard
cantly associated with smoking cessation at 6, 12 and 24 months. to long-term smoking abstinence. Standard tobacco cessation aids
After controlling for potential selection and confounding factors, all should therefore be considered as short-term support, which may need
odds ratios were attenuated but similar to those observed in bivariate to be complemented by other forms of support to lead to lasting results.
analyses. There was a positive gradient in the association between e-
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M. Fekom et al. Preventive Medicine Reports 30 (2022) 102044
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M. Fekom et al. Preventive Medicine Reports 30 (2022) 102044
field of the 2017 Health Barometer. Haute Autorité de Santé, 2014. Arrêt de la consommation de tabac: du dépistage
individuel au maintien de l’abstinence en premier recours.
Haute Autorité de Santé, 2016. Relatif aux bénéfices-risques de la cigarette électronique
Appendix A. Supplementary data ou e-cigarette étendus en population générale.
Haute Autorité de Santé, 2021. Outil d’aide au repérage précoce et intervention brève:
Supplementary data to this article can be found online at https://doi. alcool, cannabis, tabac chez l’adulte.
Jackson, S.E., Kotz, D., West, R., Brown, J., 2019. Moderators of real-world effectiveness
org/10.1016/j.pmedr.2022.102044. of smoking cessation aids: a population study. Addiction (Abingdon, England) 114
(9), 1627–1638. https://doi.org/10.1111/add.14656.
References Kasza, K. et al., Association of e-cigarette use with discontinuation of cigarette smoking
among adult smokers who were initially never planning to quit, JAMA Netw. Open, 4,
p. e2140880, 2021, doi: 10.1001/jamanetworkopen.2021.40880.
Aljandaleh, H., Bolze, C., El-Khoury Lesueur, F., Melchior, M., Mary-Krause, M., 2020. Kish, L., 1949. A procedure for objective respondent selection within the household.
Factors associated with electronic cigarette use among young adults: the French J. Am. Stat. Assoc. 44 (247), 380–387. https://doi.org/10.1080/
‘Trajectoires EpidéMiologiques en POpulation’ (TEMPO) Cohort Study. Subst. Use 01621459.1949.10483314.
Misuse 55 (6), 964–972. Lee, C., Kahende, J., 2007. Factors associated with successful smoking cessation in the
Balfour, D.J.K., et al., 2021. Balancing consideration of the risks and benefits of E- United States, 2000. Am. J. Public Health 97 (8), 1503–1509. https://doi.org/
cigarettes. Am. J. Public Health 111 (9), 1661–1672. 10.2105/ajph.2005.083527.
Bals, R., Boyd, J., Esposito, S., Foronjy, R., Hiemstra, P., Jiménez-Ruiz, C.A., Li, F., Morgan, K.L., Zaslavsky, A.M., 2018. Balancing covariates via propensity score
Katsaounou, P., Lindberg, A., Metz, C., Schober, W., Spira, A., Blasi, F., 2019. weighting. J. Am. Stat. Assoc. 113 (521), 390–400. https://doi.org/10.1080/
Electronic cigarettes: a task force report from the European Respiratory Society. Eur. 01621459.2016.1260466.
Respir. J. 53 (2), 1801151. Marti, J., 2010. Successful smoking cessation and duration of abstinence—an analysis of
Berlin, I., Berlin, N., Malecot, M., Breton, M., Jusot, F., Goldzahl, L., 2021. Financial socioeconomic determinants. Int. J. Environ. Res. Public Health 7 (7), 2789–2799.
incentives for smoking cessation in pregnancy: multicentre randomised controlled https://doi.org/10.3390/ijerph7072789.
trial. BMJ 375, e065217. McNeill, A., Brose, L., Calder, R., Hitchman, S., Hajek, P., McRobbie, H., 2015. E-
Chen, R., et al., 2020. Use of electronic cigarettes to aid long-term smoking cessation in cigarettes: an evidence update A report commissioned by Public Health England.
the United States: prospective evidence from the PATH cohort study. Am. J. Public Health England.
Epidemiol. 189 (12), 1529–1537. https://doi.org/10.1093/aje/kwaa161. Organization, W.H., 2019. Report on the global tobacco epidemic 2019: offer help to quit
Etter, J.-F., Stapleton, J.A., 2006. Nicotine replacement therapy for long-term smoking tobacco use.
cessation: a meta-analysis. Tob Control 15 (4), 280–285. https://doi.org/10.1136/ Team, R.C., 2021. R: A language and environment for statistical computing. Foundation
tc.2005.015487. for Statistical Computing, Vienna, Austria.
Fairchild, A.L., Bayer, R., Lee, J.S., 2019. The E-cigarette debate: what counts as Pasquereau, Anne, et al., 2021. “Consommation de tabac parmi les adultes en 2020:
evidence? Am. J. Public Health 109 (7), 1000–1006. https://doi.org/10.2105/ résultats du Baromètre de Santé publique France”. Santé publique France.
ajph.2019.305107. Richard, J.-B., Andler, R., Gautier, A., Guignard, R., Léon, C., François, B., 2016. Effects
Friedman, J.H., 2001. Greedy function approximation: a gradient boosting machine. of using an overlapping dual-frame design on estimates of health behaviors: a French
Ann. Statistics 29 (5), 1189–1232. https://doi.org/10.1214/aos/1013203451. general population telephone survey. J. Surv. Stat. Methodol. 5, p. smw028. https://
Guignard, R., et al., 2021. Smoking quit attempts, use of cessation help, and smoking doi.org/10.1093/jssam/smw028.
abstinence: a retrospective analysis of santé publique france health barometer 2017. Schnoll, R.A., Goelz, P.M., Veluz-Wilkins, A., Blazekovic, S., Powers, L., Leone, F.T.,
Bull. Epidémiol. Hebd. 2021 (1), 2–11. Gariti, P., Wileyto, E.P., Hitsman, B., 2015. Long-term nicotine replacement therapy:
Hajek, P., Phillips-Waller, A., Przulj, D., Pesola, F., Smith, K.M., Bisal, N., Li, J., a randomized clinical trial. JAMA Intern. Med. 175 (4), 504.
Parrott, S., Sasieni, P., Dawkins, L., Ross, L., Goniewicz, M., Wu, Q.i., McRobbie, H. Sweet, L., et al., 2018. Quitting behaviors among dual cigarette and E-cigarette users and
J., 2019. E-cigarettes compared with nicotine replacement therapy within the UK cigarette smokers enrolled in the tobacco user adult cohort. Nicotine Tobacco Res.
Stop Smoking Services: the TEC RCT. Health Technol. Assess. 23 (43), 1–82. 21 (3), 278–284. https://doi.org/10.1093/ntr/nty222.
Halpern, S.D., Harhay, M.O., Saulsgiver, K., Brophy, C., Troxel, A.B., Volpp, K.G., 2018. Vasiljevic, M., St John Wallis, A., Codling, S., Couturier, D.-L., Sutton, S., Marteau, T.M.,
A pragmatic trial of E-cigarettes, incentives, and drugs for smoking cessation. 2018. E-cigarette adverts and children’s perceptions of tobacco smoking harms: an
N. Engl. J. Med. 378 (24), 2302–2310. https://doi.org/10.1056/NEJMsa1715757. experimental study and meta-analysis. BMJ Open 8 (7), e020247.
Hartmann-Boyce, J., et al., 2021. Electronic cigarettes for smoking cessation. Cochrane World Health Organization (WHO), 2008. MPOWER: a policy package to reverse the
Database System. Rev. 9 https://doi.org/10.1002/14651858.CD010216.pub6. tobacco epidemic. World Health Organization, p. 39.
Hartmann-Boyce, J., Chepkin, S.C., Ye, W., Bullen, C., Lancaster, T., 2019. Nicotine Zhou, Y., Matsouaka, R.A., Thomas, L., 2020. Propensity score weighting under limited
replacement therapy versus control for smoking cessation. Cochrane Database overlap and model misspecification. Stat. Methods Med. Res. 29 (12), 3721–3756.
System. Rev. 1, 2018. https://doi.org/10.1002/14651858.cd000146.pub5. https://doi.org/10.1177/0962280220940334.
Hartmann-Boyce, J., Ordóñez-Mena, J.M., Livingstone-Banks, J., Fanshawe, T.R., Zhou, T., Tong, G., Li, F., Thomas, L.E., 2020. PSweight: an R package for propensity
Lindson, N., Freeman, S.C., Sutton, A.J., Theodoulou, A., Aveyard, P., 2022. score weighting analysis. arXiv Methodology.
Behavioural programmes for cigarette smoking cessation: investigating interactions
between behavioural, motivational and delivery components in a systematic review
and component network meta-analysis. Addiction 117 (8), 2145–2156.