smoking cessation

Maximum cigarette pack size: a neglected aspect of tobacco control

Posted on June 16, 2020June 16, 2020 by lindsey.pike

Written by Anna Blackwell, Senior Research Associate

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The manufacturing or importing of packs of cigarettes with fewer than 20 cigarettes per pack was prohibited in the UK when the EU Tobacco Products Directive and standardised packaging legislation were fully implemented in May 2017. This change was aimed at reducing the affordability of cigarettes and thereby discouraging young people from smoking. This directive also required the removal of branding and established a standard shape and dark green colour for packaging, including pictorial health warnings, which prevented the use of packaging for promotion and reduced its appeal.

However, the tobacco industry has been able to exploit loopholes in recent packaging regulations, including the absence of a regulated maximum pack size, by introducing non-standard and larger pack sizes to the market to distinguish products. This is a public health concern given evidence that larger pack sizes are linked to increased smoking, and could undermine existing tobacco control success.

Evidence shows that larger pack sizes are linked to increased smoking.

In a recent Addiction Opinion and Debate paper, we proposed that a cap on cigarette pack size should be introduced; a pragmatic solution would be to permit only a single pack size of 20, which is now the minimum in many countries. This approach would reduce the number of cigarettes in packs in several countries such as Australia – where packs up to sizes of 50 are available – and prevent larger sizes being introduced elsewhere.

Capping cigarette pack size therefore has the potential to both reduce smoking and prevent increased smoking. While the health benefits of reducing smoking alone are small, it may have important indirect effects on health through its role in facilitating quitting. Those smoking fewer cigarettes per day are more likely to attempt to quit and succeed in doing so. Trials of smoking-reduction interventions have also found that these can lead to increased quitting when combined with nicotine replacement therapy.

Our Opinion and Debate paper drew on evidence from a range of sources including industry documents and analyses, population surveys, intervention trials and Mendelian randomization analyses. Together these suggest that consumption increases with larger pack size, and cessation increases with reduced consumption. However, direct experimental evidence is not currently available to determine whether pack size influences the amount of tobacco consumed, or whether the association is due to other factors.

People who want to quit may be using smaller packs as a method of self-control, and smokers who successfully cut down and later quit may be more motivated to do so. Cost is also an important factor and larger packs may be linked to increased smoking because they have a lower cost per cigarette. Further research is needed to determine whether the associations between pack size, smoking and cessation are causal to estimate the impact of policies to cap cigarette pack size.

Commentaries on our Opinion and Debate paper, published in the May 2020 Issue of Addiction highlight the need to understand the mechanisms for the associations observed between pack size and smoking in order to identify the optimal cigarette pack size. Although mandating packs of 20 is a pragmatic approach, pack size regulation needs to achieve a compromise between tobacco affordability and smokers’ self-regulation. Nevertheless, the policy debate should start now to address this neglected aspect of tobacco control.

To find out more visit the Behaviour Change by Design website or follow us on Twitter @BehavChangeDsgn @BristolTARG

This blog post is reposted from the TARG blog.

stopWatch – a smartwatch system that could help people quit smoking

Posted on October 24, 2019October 22, 2019 by lindsey.pike

Dr Andy Skinner and Chris Stone

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October sees the return of Stoptober, a Public Health England initiative to encourage smokers to quit. Campaigns like this and many others have been effective in reducing smoking in the UK over a number of decades. However, on average, about 15% of the UK’s population still smoke, and this costs the NHS more than £2.5bn each year.

To help address this, the NHS Long Term Plan has identified a range of measures to encourage healthier behaviours, including the need to speed up the introduction of innovative new health interventions based on digital technologies.

Here in the MRC IEU we’ve been working on a new wearable system that could help people stop smoking; stopWatch is a smartwatch-based system that automatically detects cigarette smoking. Because the system can detect when someone is smoking a cigarette, it can trigger the delivery of interventions to help that person quit smoking at precisely the time the interventions will be most effective.

Hand and wrist wearing stopWatch and holding a cigarette — The stopWatch could help people to stop smoking

What is stopWatch, and how does it work?

stopWatch is an application that runs on a commercially available Android smartwatch. Smartwatches now come equipped with motion sensors, just like the ones in smartphones that measure step counts and activity levels. As smartwatches are attached to the wrist, the motion sensors in a smartwatch can tell us how a person’s hand is moving. stopWatch takes data from the smartwatch’s motion sensors and applies machine learning methods to look for the particular pattern of hand movements that are unique to smoking a cigarette.

How can we use stopWatch to help people quit smoking?

It’s estimated about a third of UK smokers try to stop each year, but only a fifth of those that try manage to succeed. For most smokers an attempt to stop smoking ends with a lapse (having just one cigarette), that can quickly lead to a full relapse to smoking. As stopWatch can detect the exact moment a smoker lapses and has a cigarette, it can trigger the precise delivery of an intervention aimed specifically at helping prevent the lapse turning into a full relapse back to smoking.

Will the intervention work?

A recent article highlighted the potential for using mobile and wearable technologies, like stopWatch, to deliver these kinds of ‘just-in-time’ interventions for smoking. To develop our smoking relapse intervention we will be using the person-based approach, which has an excellent track record of delivering effective health behaviour change interventions. We will also be engaging the highly interdisciplinary cohort of PhD students in the new EPSRC Center for Doctoral Training in Digital Health and care, which brings together students with backgrounds in health, computer science, design and engineering.

However, that same article also pointed out that these types of intervention are still new, and that there has been little formal evaluation of them so far. So we don’t yet know how effective these will be, and it’s important interventions of this kind are subject to a thorough evaluation.

We will be working closely with colleagues in NIHR’s Applied Research Collaboration (ARC) West and Bristol Biomedical Research Centre who have expertise in developing, and importantly, evaluating interventions. We will also be working with the CRUK-funded Integrative Cancer Epidemiology Unit at the University of Bristol, collaborating with researchers who have detailed knowledge of developing interventions for specific patient groups.

The StopWatch display — On average, stopWatch detected 71% of cigarettes smoked and of the events stopWatch thought were cigarette smoking, 86% were actually cigarette smoking.

How good is stopWatch at detecting cigarette smoking?

In any system designed to recognise behaviours there is a trade-off between performance and cost/complexity. Other systems that use wearables to detect smoking are available, but these require the wearable be paired with a smartphone and need a data connection to a cloud-based platform in order to work properly. stopWatch is different in that it runs entirely on a smartwatch. It doesn’t need to be paired with a smartphone, and doesn’t need a data connection. This makes it cheaper and simpler than the other systems, but this also means its performance isn’t quite as good.

We recently validated the performance of stopWatch by asking thirteen participants to use stopWatch for a day as they went about their normal lives. On average, stopWatch detected 71% of cigarettes smoked (the system’s sensitivity), and of the events stopWatch thought were cigarette smoking, 86% were actually cigarette smoking (its specificity). This compares with a sensitivity of 82% and specificity of 97% for the systems that require smartphones and data networks.

When will stopWatch and the smoking relapse intervention be available and what will they cost?

The stopWatch system itself is available for research purposes to academic partners now, free of charge. We’re open to discussions with potential commercial partners – please get in touch if you’d like to discuss this (contact details below).

We aim to begin work on the smoking relapse intervention based on stopWatch next year, and we expect development and evaluation to take between 18 and 24 months. The cost of the intervention has yet to be determined. That will depend on many factors, including the partnerships we form to take the intervention forward.

What’s next?

We’re currently putting stopWatch through its paces in some tough testing in occupational settings. This will stress the system so that we can identify any weaknesses, find out to how to improve the system, and develop recommendations for optimising the use of stopWatch in future studies and interventions.

We’re also developing a new smartwatch-based system for the low burden collection of self-report data called ‘dataWatch’. This is currently undergoing feasibility testing in the Children of the 90s study.

Contact the researchers

Dr Andy Skinner Andy.Skinner@bristol.ac.uk

Why haven’t e-cigarettes stubbed out cigarettes?

Posted on May 31, 2019May 31, 2019 by lindsey.pike

On World No Tobacco Day, PhD researcher Jasmine Khouja outlines the evidence around e-cigarettes.

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There are an estimated 3.2 million e-cigarette users in Great Britain, and the majority of users have switched from smoking to vaping in search of a less harmful alternative to help them quit. In a recent study, people who used e-cigarettes to quit smoking were more likely to be smoke-free after one year compared to people who used more traditional methods such as nicotine patches. So, why are some smokers reluctant to try e-cigarettes, and why have some people been unable to quit smoking using them? The media, researchers, public health officials, and the general public have all played a role in discouraging some smokers from vaping.

E-cigarettes in the media

As a researcher in the field of e-cigarette use, I have often looked at news articles about vaping and felt exasperated. We frequently see e-cigarettes portrayed as a harmful option; according to many news articles, e-cigarettes are dangerous, lead to heart attacks and are as bad for your lungs as cigarettes. The same news outlets often report the opposite finding and say e-cigarettes are actually better for you. This flip-flopping leaves smokers confused and could discourage them from trying e-cigarettes for fear that vaping is actually more harmful than smoking.

Science in the media

So, why do the media keep switching their stance on e-cigarettes? They’re getting their information from the research community, and this community is divided. Some researchers claim that the costs of unknown health risks of vaping and the popularity of e-cigarettes among children and adolescents outweigh the potential benefits of helping smokers to quit, and others claim vice versa.

As researchers, we should be impartial and only provide the public with information which we can back up with evidence from our research, but, as we are still human, our opinions tend to seep through into how we report our findings and even what we choose to research. This lack of agreement in the research community is fuelling the media’s flip-flopping , leading to public confusion and reluctance to try e-cigarettes to help them quit smoking.

Public attitudes to vaping

With all of this contrasting information, it’s no wonder the general public’s opinion of vaping seems to be split too. Negative public opinion can have an impact on whether a smoker wants to try an e-cigarette. Quitting smoking isn’t easy; the last thing smokers want is to feel judged when they are trying to quit.

Negative public attitudes to vaping could put smokers off trying vaping but also affects where they can vape. Many businesses include e-cigarettes in their smoke free policies so that vapers have to stand outside with smokers. When trying to quit, it’s not ideal to be surrounded by the very thing you’re trying to wean yourself off. It’s like being on a diet and spending every meal at an all you can eat buffet when all you can eat is a salad; it’s tempting to slip into old habits. So, despite there being no indoor vaping ban (as there is with cigarettes), vapers are forced outside into a situation where they are more likely to start smoking again.

Unintended consequences of policy

It’s not just organisational policies attempting to control e-cigarette use; in 2016, a legislation called the Tobacco Products Directive (TPD) added a section on e-cigarettes in an attempt to regulate the devices. There were a number of unpopular changes to e-cigarette products as a result. Changes to the amount of nicotine allowed in products and restrictions on innovation of new products may have had unintended consequences.

With the introduction of the TPD, a limit was set on how much nicotine a vape product could contain. Nicotine is the key ingredient in cigarettes which keeps people smoking, and although it is highly addictive, nicotine is not the cigarette ingredient which is likely to kill smokers. E-cigarettes help people to quit smoking because they can contain nicotine which satisfies smokers cravings while exposing them to fewer toxins than smoking would. Limiting the amount of nicotine in these products means that heavier smokers don’t receive enough nicotine from an e-cigarette to satisfy their nicotine addiction and this makes them more likely to start smoking again.

The TPD also requires companies to register products in advance of bringing them to market. Where the e-cigarette industry was creating new, more effective devices at a very fast pace, users now can’t buy these products for a substantial amount of time after they have been developed. This restriction on innovation means that while consumers are waiting for these better products to become available, they could be trying products that don’t meet their needs. I often hear tales of “I tried one once and it was just like puffing air, so I kept smoking instead”. They have tried one product, it wasn’t good enough, and they assume all other products will be just as bad. By restricting innovation, we limit the amount of better-quality devices on the market and increase the likelihood that a smoker looking to quit will come across a poor device and turn back to smoking.

Making it easy to stop smoking

Many smokers want to quit and we, as researchers, media representatives, public health officials and even members of the public, need to make it as easy as possible for them to do so. We need to be clearer in the information we provide, be more accepting of vaping and not limit products which could help the most addicted smokers. I still have hope that smoking will be stubbed out in my generation, and that e-cigarettes could be the disruptive technology needed to help us achieve this.