Beliefs about the harms of long-term use of nicotinereplacement therapy: perceptions of smokersin England
Andrew Black1, Emma Beard2, Jamie Brown2, Jenny Fidler2 & Robert West2
Tobacco Programme, Department of Health, Wellington House, London, UK1and Cancer Research UK Health Behaviour Research Centre, University CollegeLondon, London, UK2
ABSTRACT
Aims Previous research has shown that a substantial proportion of smokers believe that nicotine causes seriousdiseases such as cancer, possibly deterring the use of nicotine replacement therapy (NRT) for smoking cessation orsmoking reduction. This study examined beliefs about the harms specifically from long-term use of NRT and associa-tions between these and its use for smoking cessation and smoking reduction. Design and setting Data were collectedfrom 1657 smokers and recent ex-smokers involved in the Smoking Toolkit Study, a series of monthly householdsurveys of English adults aged 16 and over. Measurements Participants were asked if they thought the use of NRTfor a year or more was harmful, and if so, to volunteer what they believed the harms to be. They were also asked if theywere using NRT for smoking reduction and/or if they had used NRT in the past year during a quit attempt.Findings Six percent and 25% of smokers respectively, believed that the long term use of NRT was very or quitharmful to health; and a further 29% reported that they ‘didn’t know’. The most commonly reported harms wereaddiction and lung cancer. There was no association between these beliefs and use of NRT for smoking reduction orsmoking cessation. Conclusion A significant minority of smokers in England believe that the use of nicotine replace-ment therapy for a year or more is harmful. However, belief that long-term nicotine replacement therapy use can causehealth harm does not appear to act as a deterrent to using it in a quit attempt or for smoking reduction.
Correspondence to: Andrew Black, Tobacco Programme, Department of Health, Wellington House, London SE1 8UG, UK. E-mail: [email protected] 20 February 2012; initial review completed 9 April 2012; final version accepted 17 May 2012
INTRODUCTION
A substantial proportion of smokers believe that nicotineis harmful to health [1–11]. Such concerns include itsaddictive potential (16–76%), carcinogenic properties(14–67%) and association with heart attacks/the risk ofa stroke (7–93%). Other, milder concerns are skin prob-lems (10%), nausea or dizziness (9–13%), mouth ulcersor sore throat (18–30%), nasal bleeding (10–76%) andsleep disturbances (7%). These misperceptions appear tobe more common among those from lower social gradesand differ as a function of ethnicity, gender, age, nicotinedependence, nicotine replacement therapy (NRT) productused and country [1,5,8,9,11]; they are also prevalentamong health-care professionals [12,13].
This is despite evidence that nicotine in the doses thatsmokers receive from NRT does not lead to significant
harm [14–16]. Generally only mild adverse side effectsare associated with the use of NRT, which include irrita-tion from the patch, gastrointestinal disturbance from thegum, mouth ulcers from lozenges and irritations by theinhalator and nasal spray [17]. There is no evidence thatNRT causes cancer or lung disease, or increases the riskof a heart attack; it can also be used safely by those withhigh blood pressure, diabetes and cardiovascular disease[18,19]. However, nicotine possibly poses some risk to thefetus and also to rare individuals with a susceptibility toBuerger’s disease [20,21].
One concern is that these misperceptions may act as adeterrent to use of NRT to aid smoking cessation. Accord-ing to social cognition models, behaviour is guided byan individual’s knowledge, beliefs and attitudes towardscertain behaviour [22]. These cognitive factors have beenshown to play a role in medication adherence [23]. A few
studies have assessed the roles of beliefs in the use ofsmoking pharmacotherapy, with positive beliefs havingbeen found to be associated with stronger motivation touse NRT and actual NRT use [6–10]. There is also evi-dence that smokers’ knowledge and attitudes aboutNRT can be modified, although data are mixed regardingwhether or not these modifications can increase the useof NRT [7,8,24].
However, research to date has tended to ask smokersfor their beliefs about nicotine [1–11]. It is possible thatsmokers would respond differently when asked specifi-cally about NRT. This is because when asked about nico-tine they may conjure up an image of smoking even if itis excluded specifically in the question. Moreover, muchof the research to date on beliefs about nicotine hasoccurred within countries with somewhat conservativeregulatory frameworks. This study aimed to rectify this byfocusing specifically on English smokers’ beliefs concern-ing NRT. England has one of the most liberal regulatoryNRT frameworks, with NRT available on prescription andgeneral sale, and indicated for both smoking cessationand harm reduction [25]. Thus, smokers in Englandmight be expected to hold more positive beliefs about NRTand have fewer concerns than in other countries.
The main questions that were addressed were: (1)what is the prevalence of concerns among smokers aboutthe harmfulness of NRT; (2) do beliefs differ as a functionof smokers’ socio-demographic characteristics; and (3)what is the association with use as an aid to cessation?In addition, the study addressed the question: (4) what isthe association between concerns about harmfulness ofNRT and its use for smoking reduction? This is becauseof recent evidence that NRT use for smoking reductioncan be helpful in leading smokers to quit at a later date[26–28].
METHODS
Study design and sampling
The study formed part of the Smoking Toolkit Study (STS)(http://www.smokinginengland.info), an ongoing popu-lation study designed to provide information on smokingand smoking cessation patterns among smokers andrecent ex-smokers in England. Data for this paper wereobtained between April 2009 and July 2009. Fidler et al.[29] provides further details about the STS.
Measures
Current smokers and recent ex-smokers (those who hadstopped within the past year) were asked: ‘Do you thinkthat nicotine replacement products such as patches andgum are harmful to health if used for a year or more?’(no; yes quite harmful; yes very harmful; don’t know).
Those respondents who answered ‘yes quite harmful’ or‘yes very harmful’ were then asked: ‘What do you thinkthe harms are? You can say as many things as you wish’.The answers that respondents volunteered were catego-rized using a list of diseases and symptoms. STS partici-pants were also asked if they were currently using NRT(i.e. gum, patch, inhalator, nasal spray, lozenges) to cutdown the amount they smoked and whether they hadused NRT in the past 12 months during an attempt to quitsmoking. The STS also gathers data on the number ciga-rettes smoked per day, social grade, age and gender ofrespondents.
Analysis
Differences in beliefs as a function of socio-demographiccharacteristics were assessed using c2 and analyses ofvariance (ANOVA), using Bonferroni’s post-hoc test. Theassociations between beliefs and use of NRT for smokingreduction and smoking cessation were assessed usinglogistic regression analyses, adjusting for socio-demographic characteristics (i.e. age, gender and socialgrade); 95% confidence intervals (CI) are given unlessstated otherwise. For analysis of the association betweenbeliefs and use of NRT for smoking reduction, onlysmokers were included in the analysis; both ex-smokersand smokers were included in the analysis of the associa-tion between beliefs and NRT for smoking cessation.
RESULTS
Between April 2009 and July 2009, 7074 people over theage of 16 years were surveyed, of whom 1657 reportedthat they were current smokers (n = 1549) or recentex-smokers (n = 108), with an average [standard devia-tion (SD)] age of 40.8 years (16.16). Fifty-three per cent(n = 879) were male, with percentages in each socialgrade as follows: AB 16.4% (n = 272), C1 25.0%(n = 415), C2 24.3% (n = 402), D 22.4% (n = 372) and E11.8% (n = 195).
Six per cent (n = 93) of smokers and recentex-smokers reported that they believed the long-term useof NRT for a year or more was ‘very harmful’ to health,25.1% (n = 417) that it was ‘quite harmful’ to health,40.2% (n = 667) that it was ‘not harmful’ to health, and29% (n = 480) that they ‘didn’t know’. Among thosereporting that it was ‘very’ or ‘quite’ harmful, the mostcommonly reported concerns were addiction and lungcancer (see Fig. 1a).
Table 1 shows beliefs about the long-term use of NRTas a function of socio-demographic characteristics. Therewas no significant difference in beliefs about the harmful-ness of long-term NRT use among those of different socialgrades (c2 = 6.0, d.f. 12, P = 0.919) or among males and
females (c2 = 7.5, d.f. 3, P = 0.058). In contrast, beliefsdiffered as a function of age (F(3, 1653) = 19.2, P < 0.001).Those who reported that they did not know whether thelong-term use of NRT was harmful to health were olderthan those who reported that it was not harmful or quiteharmful to health (P < 0.001).
Of the respondents, 15.5% (n = 257) reported havingused NRT in the past year as part of a quit attempt, while13.9% (n = 215) of smokers reported that they were cur-rently using NRT for smoking reduction. Figure 1b and1c shows beliefs as a function of smokers NRT use forsmoking reduction and during a recent quit attempt.
a
Figure 1a Reports of the potential harms of the long-term use of nicotine replacement therapy (NRT) among smokers and recentex-smokers who believed that the use of NRT for a year or more was ‘very’ or ‘somewhat’ harmful to health. Data were weighted to matchthe 2001 census
Table 1 Characteristics of respondents as a function of their beliefs about the long-term use of nicotine replacement therapy.
After adjusting for socio-demographic characteristics,those who believed that the long-term use of NRT wasvery harmful to health were as likely to report the use ofNRT for smoking reduction as those who thought it wassomewhat harmful [odds ratio (OR) 1.90; CI: 0.93–3.87],those who thought it was not harmful to health (OR 1.46;CI: 0.73–2.94) and those who reported that they did notknow (OR 0.62; CI: 0.29–1.30). Similarly, those whobelieved that the long-term use of NRT was very harmfulto health were as likely to have used NRT during a previ-ous quit attempt as those who thought it was somewhatharmful (OR 1.22; CI: 0.45–3.30), those who thought it
was not harmful to health (OR 0.77; CI: 0.29–2.05) andthose who reported that they did not know (OR 0.60;CI: 0.21–1.71).
DISCUSSION
In England, where NRT use is widespread and encour-aged as an aid to smoking cessation and reduction,almost one-third of smokers and recent ex-smokersbelieve it is harmful when used long term. However, con-trary to expectation, such belief does not appear to deteruse for smoking cessation or reduction.
b
Figure 1b Beliefs about the long-termuse of nicotine replacement therapy (NRT)among smokers as a function of whether ornot they were using NRT for smokingreduction. Data were weighted to matchthe 2001 census; smokers using NRT forsmoking reduction: n = 215; smokers notusing NRT for smoking reduction: n = 1334
c
Figure 1c Beliefs about the long-termuse of nicotine replacement therapy (NRT)among smokers and recent ex-smokers asa function of whether they had used NRTin the past year during a quit attempt. Datawere weighted to match the 2001 census;smokers and ex-smokers using NRT duringa quit attempt: n = 257; smokers andex-smokers not using NRT during a quitattempt: n = 1400
These findings are in line with previous studies whichhave reported a lack of understanding among smokersabout the established harms of NRT use [1–11]. The factthat smokers view the main concerns as addiction,cancer and heart attack, suggests that they may be con-fusing the harms of using NRT with those of smokedtobacco. Of interest, is that these concerns are similar tothose held by health-care professionals [12,13]. Beardet al. [13] reported recently that 16 and 30% of thesample respectively, believed that NRT use for a year ormore and the concurrent use of NRT and cigarettes washarmful to health. The main concerns were addiction,mouth/oral cancer and overdose.
However, the failure to find an association withNRT use is in contrast to previous studies [6–10]. Thismay reflect the cross-sectional nature of the study. It ispossible that following the use of NRT smokers’ beliefschange to become more in line with those not usingNRT, as consequence of smokers assigning withdrawalsymptoms to NRT medication. It also remains possiblethat even if beliefs do not affect initiation of NRT theycould affect the dose and duration of use. There is evi-dence that smokers use too little and terminate use pre-maturely [30–32]. Further studies are needed on this.Moreover, it should be recognized that behaviour isnot dependent simply on beliefs but other psychosocialfactors, such as the cost of purchasing NRT concur-rently with cigarettes [33] and the unacceptability ofNRT products [6]. Currently available medicinal nico-tine products do not deliver nicotine in either the con-centration or at the same speed as cigarettes, with manyfailing to provide necessary sensory and/or behaviouralstimulation.
The strengths of the present study were the involve-ment of a large representative population sample, aclear focus on NRT and the requirement that respond-ents volunteer their thoughts about the harms ratherthan identify harms from a list. One limitation was thatthe study asked about the long-term use of NRT. Thereason for doing so was that it seemed implausible thatsmokers would hold beliefs about NRT causing diseasessuch as cancer from short-term use. However, given thataddiction emerged as the most common concern, thequestion arises as to what concerns might have beenexpressed if respondents had been asked about the useof NRT for cessation and reduction separately, andwithout giving a time-scale. This is an important issuefor further research. Further research is also necessaryto determine the reasons for these beliefs; these mayinclude unfavourable experiences or reactions to NRT,media or advertisement and advice from health-careprofessionals. Such an understanding will help todevelop effective interventions to correct misperceptionsabout NRT.
Declarations of interest
The STS is funded by the Cancer Research UK, Pfizer,GlaxoSmithKline and Johnson & Johnson, none of whichhad any involvement in the design of the study, analysisor interpretation of the data, the writing of the report orthe decision to submit the paper for publication. The STSalso receives funding from the Department of Health,where AB is employed as the Tobacco ProgrammeManager. EB has received conference funding from Pfizer.RW undertakes research and consultancy and receivesfees for speaking from companies that develop and manu-facture smoking cessation medications. He also has ashare of a patent for a novel nicotine delivery device.
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