It doesn’t take much to spark some errant thinking and lengthy discussions. In this instance it was the release of the final quarter statistics of 2015 from the Smoking Toolkit Study which is of course performed by Professor Robert West. This survey is used, along with other evidence, to inform those that need to know how many folks are smoking, whether or not they quit smoking and how they quit.

I have used the STS statistics in a lot of correspondence to my MP and as evidence when responding to consultations, simply because the information contained in the STS is detailed, and above all asks the right questions.

So what sparked these thoughts? Well it was this tweet from Dave Dorn:

Checking through the latest statistics, there is a definite downturn in e-cigarette usage in the last quarter of 2015, but there is an upturn in the usage of NRT. Can we directly attribute that to the media scare stories and the fact that almost all negative comments include “we recommend NRT”? Possibly we can but not definitively and, as the chart below shows, the use of e-cigarettes has risen dramatically since being included in the STS overtaking traditional NRT methods:

The last quarter of 2014, and the last quarter of 2015 both show similar declines in e-cig usage, and in both cases there was a marked increase in the number of “scare stories” which may account for the decline in usage. This also coincides with the perception of harm of e-cigarettes, as noted by ASH there has been an increase in the number of people who believe e-cigarettes are harmful. Interestingly, the perception of e-cigarettes being less harmful by the user is also increasing, which would track with the general feeling within the community. However, it is clear that non-users (including smokers, ex-smokers and never-smokers) are becoming more fearful of “possible harms” of e-cigarettes with ~40% now believing they are less harmful than tobacco, with definite dips in perception around the times when the negative scare stories were most prevalent.

Again, at both Q4 results (2014 & 2015) there is a distinct decline in non-users (i.e. current/ex/never smokers) believing that e-cigarettes are less harmful than cigarettes. In both cases there had been a seemingly coordinated attack on e-cigs and vaping with big, bold and scary headlines making ridiculous claims. Correlation, but not necessarily causation. The question on harm perception should really be expanded, perhaps graded on a 1-10 scale or similar instead of a yes/no answer as that doesn’t really allow for granularity in reporting. Does someone answering “yes” mean they think that e-cigarettes are “as harmful”, “slightly more harmful” or “substantially more harmful”? Considering the questionnaire only allows a “more harmful”, “equally harmful” or “less harmful” than cigarettes.

But the really interesting part of this is the quit attempts, this is what sparked the discussion between Dave, Sarah and myself on Twitter.

After a steady decline in the use of “Over The Counter” (OTC) Nicotine Replacement Therapies, coupled with a significant rise in the use of e-cigarettes, the use of e-cigarettes as a quit method seems to have plateaued in the last quarter of 2015, more correlation to media stories perhaps?

But, this isn’t meant to be an analysis of the Smoking Toolkit Study information.

So what exactly is a quit attempt?

Well, the dictionary definition of “quit” is pretty clear – to be “rid of” – and in this case “to be rid of smoking”. So by that definition alone, a “quit attempt” is an attempt to be rid of smoking. Seems pretty clear-cut doesn’t it.

But there is some ambiguity out there, a lot of it in fact. From a public health perspective, a “quit attempt” could encompass stopping use of nicotine altogether – complete and total cessation. From the perspective of the general public a “quit attempt” could only mean the individual has stopped smoking (i.e. combustible tobacco), but not include nicotine use.

Is it worthwhile recording quit attempts at all? From a certain perspective, I would say yes it is worthwhile especially if you combine the attempt with the method used – that then gives indications of how “effective” a particular method actually is in the real world, a point that research cannot sufficiently demonstrate. Within the STS questionnaire document, a quit attempt is referred to as quitting smoking. But from there we delve into some murky waters indeed.

I am of course referring to the word “smoking”. A possibility raised by Dave, which I hadn’t fully considered myself is that some folks may view vaping AS smoking. We know that from several press releases over the last 12 months, vaping has been referred to as “smoking an e-cigarette” on several occasions, along with “e-smoke” and various other colloquialisms. We’ve also seen mention that “total abstinence is best”, which would of course include stopping the use of nicotine, either in the form of NRT or vaping.

So we’ve seen that e-cig usage has fallen (albeit slightly) in the final quarter of 2015, but what about the actually stopping smoking, and the smoking prevalence statistics?

So the smoking prevalence has risen slightly. Taken in conjunction with a slightly lower e-cigarette usage, could this mean that the scare stories are having a negative impact on uptake? Compelling, but there isn’t truly enough information to come to that kind of conclusion, however it also ties in with the number of people who have stopped smoking:

Does this suggest that the number of people attempting to quit is down? Not necessarily, but the next chart shows exactly that:

So, e-cig prevalence is down, NRT use is going up but the percentage of those who tried to stop (and stop successfully) is also going down, along with a slight increase in overall smoking prevalence. Does this mean that the survey itself is asking the wrong questions, or are there other factors?

From the discussion on Twitter it would seem it’s not a particular issue with the questionnaire as such, more a case of terminology. Some of the public do still refer to themselves as “smokers” even though they have actually quit tobacco use and are vaping instead. So interchanging “smoke”, “smoker”, & “smoking” in the survey question with “use tobacco cigarettes” and “use electronic cigarettes” instead of (or maybe in conjunction with) smoke, smoker & smoking would help to alleviate some of the confusion surrounding terminology.

This may provide some more clarity into the murky waters of “dual-use” and/or transition periods for when new users are in the process of switching and have yet to settle on one product or the other. It could also provide some valuable information of time-frames for dual-use. Is it essential? Probably not, but it could prove to be useful, especially when considering the following question from the questionnaire:

Which would seem to cover “accidental” quitters, such as those that try an e-cigarette without really wanting to quit smoking, but end up doing just that. Actually quitting smoking without making an “attempt”, as clarified by Professor West the Smoking Toolkit Study _does _find some like that, but very few:

Purely out of curiosity, I’d like to see some comments on this one; which of the answers listed in the question above applies to you (if you’ve stopped smoking that is), or are you a mix of them?

For the sake of completeness, I’m going to quickly run through some of the October 2015 Wave (109) of the STS Questionnaire:

First up, you get asked which of the following best applies with a note stating that cigarettes refer to tobacco and not e-cigarettes so a clear definition there. Remember, e-cigarettes were first included in the STS back in 2011, no doubt initial questions back then were adapted from tobacco use (just as the CDC surveys are) but have been amended and fine tuned as the level of knowledge on e-cigarettes has increased; in stark contrast to the questions _still being asked _by the CDC.

The questionnaire does ask if the individual is trying to cut down the amount they smoke (again, a definition that may be open to interpretation by the participant) and follows that with “which of the following are you currently using to help you cut back”, which includes NRT (gum, lozenges, inhaler, nasal spray, patches, and mouthspray (QuickMist) ) along with e-cigarettes and a generic “Other”. The following graph shows the collated responses:

If you answered that you stopped smoking in the last 12 months, you get asked how long it was since you last smoked. Assuming of course that the interviewee isn’t mistaking “smoking an e-cig” for “smoking a cigarette” this is reasonably straightforward. There are some additional follow-up questions reliant on the answers to the first two.

The thing is, so much relies on the interviewee responding to the terminology being used by the interviewer, whether this means that the interviewer must be 110% clear in the definitions of “smoking” (as in tobacco), “quit” (as in stopping tobacco & nicotine use) or amending the question to be more common parlance.

As we’ve seen, there are many interpretations of the phrases we, as vapers use; often we use “quit” to refer to the fact that we have stopped tobacco use, but in some cases “quit” (when viewed from a public health perspective) can also mean stopping the use of nicotine. Also remember, most of the vaping advocates can’t really be defined as representative of vapers as a whole as we do see a lot more of the science and politics than the average joes in the street, plus it also depends on what information we’re looking for.

So leading with a question such as “do you currently smoke” may need to be phrased carefully, or re-worded to be focussed in one particular direction – such as “do you currently smoke tobacco cigarettes” – especially when, and it depends on locality, some members of the public still see vaping as smoking.

I think the key question being answered in the STS to date is the comparison of e-cigarettes against NRT and other aids to cessation or smoking reduction. As can clearly be seen in the charts, e-cigarettes have rapidly overtaken more “traditional” methods of smoking cessation/reduction, and as a result the smoking prevalence rate has fallen. This is essential real world data, this on its own provides data that cannot be gathered from a Randomised Control Trial, often referred to as the “gold standard” for clinical trials. Sadly, this data is often dismissed as “anecdotal” when e-cigarette users claim that the devices helped them quit. There are of course many options to aid smoking cessation, some of those options are aimed at complete cessation of both tobacco and nicotine use. Is this the “quit attempt” terminology at work? It would certainly appear so, many surveys worldwide refer to the term “quit attempt” but don’t really make any distinction between how or more pointedly, has the individual “quit smoking” or reached “total abstinence”?

The other questions being answered are the effect e-cigarettes (either directly or indirectly), and use of other aids to cessation or smoking reduction are having on the overall smoking prevalence rate. The second of two key points. We’ve already seen in the US data from the CDC MTF survey State by State, that wherever e-cigarette prevalence is growing overall tobacco use is falling. We are also seeing the reverse in States that have implemented bans and/or taxation on vapour products. Of course this does not mean that a rise in e-cigarette prevalence is the cause of tobacco use falling, but it is certainly a compelling statistic.

Interestingly, the Smoking Toolkit Study looks at the effect that e-cigarettes might have on those that have previously smoked, and successfully stopped for more than a year as well as those who have never smoked. These two groups, the never smokers and non-vaping ex-smokers are tracked for e-cigarette and general nicotine uptake. While it is true that those who have never smoked shouldn’t really start vaping, the rate of uptake in that group is, and remains negligible, similar to that of never smokers using NRT.

However, one group, the ex-smokers, has risen up until Q3 2015, but showed a marked decline in the results from Q4, while ex-smokers using NRT remains reasonably consistent. The question here for the “long-term ex-smoker” group, which is a question that doesn’t seem to be covered, is whether the uptake of e-cigarettes for this group is a relapse to a smoking-like behaviour? Why are long-term ex-smokers taking up e-cigarettes or nicotine in general?

This leads me on the next, and possibly the final point of this post. Post 12 month relapse back to smoking after a “successful quit”. The initial question does give an opportunity to follow-up on this seeming unexplored arena:

The only follow-up question (that I can spot in the questionnaire document) is in relation to the age when the respondent stopped smoking. Whether this then leads on to the respondent being asked questions aimed at current cigarette smokers and recent ex-smokers is unfortunately not clear. Do the authors of the STS need information such as reasons for relapse (long-term ex-smoker)? It is also currently unclear, as is the potential impact on the overall prevalence rates. Is the fact that smoking prevalence seems to have plateaued at ~18% due to long-term ex-smokers restarting the habit?

We’ve already seen that less than 1% of long-term ex-smokers have taken to e-cigarettes, but are these long-term ex-smokers taking up e-cigarettes to avoid relapsing to smoking only to initiate subsequent quit attempts? This seems to be an unexplored area, and from the conversation on Twitter and Professor Wests’ comments at the E-Cigarette Summit there are some planned changes to the questions asked. Now would be a good time for an open dialogue to help answer some key questions on relapse, dual use and harm perceptions.

The Smoking Toolkit Study is by far the most comprehensive and granular of its kind, especially given that it now includes a wide array of alternatives such as e-cigarettes alongside other cessation aids, such as leaflets and books, and it does cover many of the questions policy makers are asking – gateways, do they help folk to stop smoking, are non-smokers picking them up, how often are e-cigarettes being used (instead of the generic “past 30 days” answer in US surveys) and so on – however, there are some gaps (from a vapers point of view) that could be included which may prove beneficial: (these are of course the opinions, thoughts and comments that originated from the Twitter discussion)

• e-cigarette nicotine levels – are they being reduced over time?

The reference to nicotine levels/strengths is especially important for the never-smoker and possible the long-term ex-smoker groups, but should be asked of all groups. Are never-smokers who use e-cigarettes actually using nicotine? Are long-term ex-smokers? Are recent ex-smokers who are using an e-cigarette as a cessation method reducing their nicotine level? Do they plan to stop using the e-cigarette? It may be that users of e-cigarettes that reduce their nicotine content are perhaps looking to stop entirely, this isn’t always the case as the varying styles of vaping (lung-hit or mouth to lung) do tend to show differences in nicotine levels anyway (ever tried lunging 18mg+? – wouldn’t recommend that personally!). The nicotine levels may prove interesting information, but is it data that needs to be tracked?

• Does the study need to look at reasons why never-smokers, and long-term ex-smokers are vaping?

Specifically are ex-smokers using e-cigarettes to avoid a relapse back to smoking? Are ex-smokers relapsing? What product(s) did they use on their previous quit attempt?

• Does the study need to expand questions specifically related to e-cigarettes?

Specifically in relation to the “how soon after you wake up do/did you light up” type question. Are the vaping and tobacco habits the same or are they different? The answer to that could prove very interesting indeed, after all the “addictiveness test” uses this type of question, it is more behavioural than cessation related but it could open the way for more details in why e-cigarettes work for so many.

• Seeing that Stop Smoking Services are going e-cig friendly, does this need to be included?

We know that Stop Smoking Services are e-cig friendly and offer advice on the use of the devices, but I didn’t see any reference to SSS/E-Cig advice mentioned in the questionnaire. The services themselves do keep track of the product(s) used in quit attempts (successful or not), so it may not be pertinent for the STS. It is also plausible that the information held by the services are not necessarily participants in the STS, and SSS records may not always show where the initiative to use an e-cig came from the advisor or the user. According to the HSCIC data on NHS Stop Smoking Services successful quit attempts using an “unlicensed nicotine containing product” doesn’t show the same trends as the STS information, maybe there is scope to include (or reference) HSCIC data in STS or vice-versa?

• Does there need to be additional granularity in the definitions or responses to the “quit attempts” – i.e. do the results of relapse need to be reported ?

With former smokers reporting they are using either NRT or e-cigarettes, does this indicate that they have relapsed? Does the use of an e-cigarette under these circumstances need further investigation along the lines of “why”? This could open a can of worms in relation to possible “re-normalisation” discussions as some former smokers may just “miss the sensation” of smoking or are they taking to vaping because they don’t want to go back to smoking.

These are but a few of the points and thoughts I had as a result of the discussion on Twitter, and looking back through the questionnaire documents available the STS has evolved as the smoking and smoking cessation landscapes changed, but there is scope for additional parameters to be monitored. I for one would absolutely love to sit down with Professor West and talk to him directly about the questionnaire, maybe take the survey as a “dummy” participant while bringing some of these points up at the same time, it would certainly prove an interesting conversation!

I’d also like to hear your thoughts in the comments, what other questions are needed (or you would like to see asked). What other information do you feel would be useful to Professor West in this survey?

As a final note, I would like to extend heartfelt thanks to Professor Robert West for allowing me to use the information contained within the Smoking Toolkit Study, along with his efforts on behalf of all vapers.