Financial incentives for smoking cessation in pregnancy

By Meg Fluharty @MegEliz_

This blog originally appeared on the Mental Elf site on 11th March 2015.


Smoking during pregnancy is thought to cause approximately 25,000 miscarriages per year in the United Kingdom (Health and Social Care Information Centre, 2010).

Additionally, smoking while pregnant is attributable to 4-7% of stillbirths (Flenady et al., 2011), and 3-5% of infant deaths (Gray et al., 2009) with these rates even higher in deprived areas, where remaining a smoker during pregnancy is more common (Gray et al., 2009).

In 2009, 24% of women attending antenatal appointments in Scotland were smokers (NHS, 2009). However only 1 in 10 reported using cessation services, and 3% were abstaining by four weeks (Tappin et al., 2010).

A recent Cochrane systematic review suggested financial incentives may be beneficial in helping pregnant women stop smoking, although it concluded that further evidence was needed (Chamberlain et al., 2013). Tappin et al (2015) investigated the effectiveness of shopping vouchers in addition to NHS Stop Smoking Services to aid quit attempts in pregnant women.

Nearly 1 in 4 women attending antenatal appointments in Scotland were smokers (NHS, 2009).


The authors conducted a randomised controlled trial of 609 pregnant smokers recruited from NHS Greater Glasgow and Clyde. Women were randomly allocated to routine smoking cessation care (control group) or to routine care and up to £400 in shopping vouchers if they engaged with services and successfully quit smoking (incentives group).

Routine care

Routine specialist pregnancy care involved an initial meeting to discuss quitting smoking and set a quit date. This was followed by 4 weekly telephone calls, and free nicotine replacement therapy for 10 weeks.

Incentives group

The incentives group received £50 in shopping vouchers for attending the initial meeting to set a quit date. If participants were smoke-free 4 weeks later, they would receive another £50 voucher, and if smoke-free at 12 weeks, participants received £100 in gift vouchers. Between 34-38 weeks gestation, women were once again asked smoking status, and those who had quit received a final £200 voucher. In all instances, smoking status was verified by a carbon monoxide breath test. 

Women who successfully quit smoking in this study received up to £400 in shopping vouchers.


  • More women successfully quit smoking in the incentives group (22.5%) than the routine care group (8.6%).
  • There was a higher quit rate at 4 weeks in the incentives group compared to the routine care group.
  • 12 months after quit date, there was still large difference in self-reported quit rates (15% incentives, 4% control).
  • Women lost to follow-up were assumed to be smokers, which was validated by analysing residual routine blood samples for cotinine.



This study demonstrated that financial incentives with routine care could be beneficial in motivating quit attempts in pregnant smokers, as well as aiding them in continuing to abstain up to 12 months after their quit date. Furthermore, the quit rates reported in this trial were larger than many pharmaceutical (Coleman et al., 2012) or behavioural (Chamberlain et al., 2013) intervention trials in pregnant women. Although, it should be noted that women in the control group had higher nicotine addiction scores than those in the incentives group.

While the evidence from this study suggests using financial incentives may be beneficial in helping pregnant smokers to stop, there may be practical and ethical issues in implementing this as an intervention.

Additionally, other studies are needed to determine the generalizability and possible cost effectiveness of this intervention, as well as what cessation services are best suited to pair with financial incentives. However, it will be interesting to see how this study may be used to inform future policy.


Tappin D, Bauld L, Purves D, Boyd K, Sinclair L, MacAskill S et al. Financial incentives for smoking cessation in pregnancy: randomised controlled trial (pdf). BMJ 2015; 350:h134

Health and Social Care Information Centre, Infant feeding survey 2010 (pdf). HSCIC, 2012.

Flenady V, Koopmans L, Middleton P, Frøen JF, Smith GC, Gibbons K, et al. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. Lancet 2011;377:1331-40. [Abstract]

Gray R, Bonellie SR, Chalmers J, Greer I, Jarvis S, Kurinczuk J, et al. Contribution of smoking during pregnancy to inequalities in stillbirth and infant death in Scotland 1994-2003: retrospective population based study using hospital maternity records. BMJ 2009;339:b3754.

Information Services Division, NHS National Services Scotland. Births and babies: smoking and pregnancy, 2009.

Tappin DM, MacAskill S, Bauld L, Eadie D, Shipton D, Galbraith L. Smoking prevalence and smoking cessation services for pregnant women in Scotland. Subst Abuse Treat Prev Policy 2010;5:1.

Coleman T, Chamberlain C, Davey MA, Cooper SE, Leonardi-Bee J. Pharmacological interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 2012;9:CD010078. [Abstract]

Chamberlain C, O’Mara-Eves A, Oliver S, Caird JR, Perlen SM, Eades SJ, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev 2013;10:CD001055

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Smoking cessation in the emergency setting

By Olivia Maynard @OliviaMaynard17

This blog originally appeared on the Mental Elf site on 20th October 2014


The prevalence of smoking among patients in emergency departments (ED) is reported to be higher than in the general population, so encouraging smoking cessation in these settings has been recommended. However, 57% of ED staff believe that smoking cessation treatments are inappropriate for the ED setting, citing time constraints, lack of patient interest and treatment ineffectiveness as the main causes of these beliefs (Tong et al., 2010).

A systematic review published in the American Journal of Emergency Medicine (Pelletier et al., 2014), has recently analysed the most up to date research on the effectiveness, feasibility and appropriateness of smoking cessation interventions in ED settings.

The primary outcome measure was:

  • Self-reported and/or biomarker-assessed smoking cessation.

Secondary outcomes were:

  • All-cause mortality;
  • Cost per quit;
  • Patient satisfaction;
  • Practitioner time spent and non-practitioner time spent (these last two were considered together).


The authors included all original studies of smoking cessation interventions performed in either adult or paediatric ED settings that assessed at least one of the outcome measures outlined above.

One investigator conducted the literature search (on the Medline and CINAHL databases), identifying 17 articles which were then examined for sources of bias (such as lack of randomisation, non-blinding of participants or study personnel and incomplete outcome data reporting). Four studies were excluded due to a high or unclear risk of bias, leaving 13 studies to undergo full systematic review.

Although a meta-analysis of these studies was planned, their heterogeneity precluded this and therefore only a systematic review was conducted. All studies were also rated on a three point scale for quality, using 19 quality criteria questions.

This review looked at a range of

This review looked at a range of interventions for helping people to quit smoking in the emergency setting.


Of the 13 studies, 11 were conducted in the USA, one in Germany and one in Turkey. Six studies used a single time-point follow-up for assessing smoking cessation, three had two follow-ups, three studies had three follow-ups and one had four follow-ups.

The smoking cessation interventions varied between studies and fell into six broad categories:

  1. Administration of self-help materials;
  2. Faxed referrals to other programmes;
  3. Brief advice;
  4. Counselling;
  5. Nicotine replacement therapy (NRT);
  6. Motivational interviewing-based interventions.

Eleven studies included at least two of these interventions and there was no consistent control group across the studies.

The main findings of the systematic review were as follows:

  • The overall quality of the studies was relatively poor:
    • Quality ratings ranged from 31 to 81% (where 100% refers to a study scoring top marks on all 19 quality criteria)
    • The average quality rating was 57% (SD = 15.1%).
    • Studies generally scored poorly on the documentation of participant retention and follow-up, justification of sample size and appropriate follow-up.
    • Data on all-cause mortality and cost per quit were absent or inadequate in the majority of studies and therefore these two secondary outcome measures were dropped from further consideration.
  • The majority of studies found no difference between intervention and control groups in terms of cessation rates (the primary outcome measure):
    • Twelve studies reported cessation rates and 10 of these reported no beneficial effect of the intervention.
    • Two studies reported a beneficial effect of smoking cessation intervention (Bock et al, 2008; Bernstein et al, 2013), however, this was only observed at three months in the first study and only one and three months, but not six months in the second study.
    • The authors of the systematic review note that these two studies used motivational interviewing-based techniques, and suggest that these techniques may be particularly effective. However, it is important to note that four other studies also used motivational interviewing, but did not find any beneficial effect.
    • Although the majority of these studies did not observe a beneficial effect of smoking cessation interventions, the authors note that many did find that overall smoking cessation rates (in both intervention and control arms) was higher than that reported among the general population in the USA (according to the 2010 National Health Interview Survey [NHIS]). This is a crude comparison however, as the 13 studies included in this review were conducted between 2000 and 2014, and were conducted in Turkey and Germany as well as the USA, whereas the NHIS survey was conducted in 2010 only in the USA.
  • Patient satisfaction was high, but was not often reported:
    • In the two studies reporting patient satisfaction, this was found to be 90% or above.
    • Both of these studies used motivational interviewing-based interventions and both considered paediatric patients or their parents, rather than adult patients receiving treatment for themselves.
  • Intervention time varied, but was not often reported:
    • A faxed referral was reported to take an average of 3 minutes, brief advice 5 minutes and motivational interviewing-based interventions 37 minutes.

MOst studies found no difference between intervention and control groups in terms of cessation rates.

Most studies found no difference between intervention and control groups in terms of cessation rates.

Conclusions and implications for practice

The authors of this systematic review conclude that:

ED-based cessation interventions may be effective, but the available data are somewhat limited and heterogeneous.

Only two of the 13 studies included in the review found any benefit of smoking cessation intervention in the ED settings, with both using motivational interviewing. This led the authors of this review to further conclude that:

Motivational interviewing may prove to be a promising strategy where feasible.

However, it is important to note that four of the six studies which used motivational interviewing did not find any beneficial effect of this intervention.

The authors recommend that:

ED providers ask about smoking status, provide brief motivational interviewing or brief advice to quit as time allows, and provide a pamphlet with information about the benefits of smoking cessation and information about the benefits of smoking cessation and information for verified smoking cessation programs to all patients.

The evidence supporting emergency based interventions for smoking cessation is limited and heterogeneous. Further research is required to determine whether smoking cessation interventions are more effective in encouraging cessation than simply visiting the ED alone, and if so, which interventions are most effective.

The evidence-base is not yet of sufficient quality for us to draw any conclusions about the best course of action for smoking cessation in emergency departments.

The evidence-base is not yet of sufficient quality for us to draw any conclusions about the best course of action for smoking cessation in emergency departments.


  • The reviewers only searched two databases (Medline and CINAHL) so are likely to have missed studies published in journals not indexed on those databases.
  • The general quality of the studies included in the systematic review was weak to moderate, even after studies with high risk of bias were excluded. Future research should use rigorous designs with large sample sizes.
  • No studies investigated time-effectiveness, all-cause mortality, or cost per quit as outcomes and these factors should be considered in future research.
  • Only four studies pre-registered study information, meaning that the degree to which the remaining studies fully reported all study outcomes cannot be guaranteed.
  • Smoking cessation was assessed by the majority of studies using self-report, rather than through biometrically confirmed abstinence, potentially artificially increasing cessation success.
  • The lack of a standardised control group meant that study findings could not be pooled into a meta-analysis.
  • None of the studies included in this systematic review were conducted in the UK, with the focus on EDs in the USA.

The reviewers could have done more to find studies to include in their review.

The reviewers could have done more to find studies to include in their review.


Pelletier JH, Strout TD, Baumann MR. A systematic review of smoking cessation interventions in the emergency setting. Am J Emerg Med. 2014 Jul;32(7):713-24. doi: 10.1016/j.ajem.2014.03.042. Epub 2014 Apr 2. [PubMed abstract]

Bernstein SL Bijur P, Cooperman N et al. Efficacy of an ED-cased multi-component intervention for smokers with substance use disorders. Journal of Substance Abuse Treatment, 2013; 44(1): 139-42.

Bock BC, Becker BM, Niaura RS et al. Smoking cessation among patients in an emergency chest pain observation unit; outcomes of the Chest Pain Smoking Study (CPSS). Nicotine and Tobacco Research, 2008; 10(10):1523-31. [PubMed abstract]

Quitting Smoking Among Adults – United States, 2001-2010. Centers for Disease Control and Prevention; 2011 [11/11/2011]

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Quitting smoking is associated with decreased anxiety, depression and stress, says new systematic review

It is well known that tobacco is the leading cause of preventable death in the world (WHO, 2011). However, the associations between smoking and mental health are less well established.

Smokers often want to quit, but the belief that cigarettes can be used to regulate mood can often deter them, and this is especially true for individuals with mental health problems (Zhou et al, 2009; Thompson et al 2005). However, this is somewhat paradoxical because smoking is often associated with poor mental health (Coulthard et al, 2002). So it’s interesting to report on this new study by Taylor et al (2014) who reviewed the current literature evaluating changes in mental health in those who quit smoking compared with those who continued to smoke.


The authors conducted a systematic review by searching Web of Science, Cochrane, Medline, Embase & PsychINFO, as well as contacting authors for missing data, and translating non-English papers.

Eligibility was determined using the following criteria:

  • Studies took smokers from the general population or from populations with a defined clinical diagnosis
  • They were longitudinal studies collecting data on mental health prior to quit attempts and again 6 weeks after

A meta-analysis was performed using a random effects model to pool the standard mean difference (SMD) between the change in mental health in quitters and continued smokers from baseline to follow-up. The SMD was used, as different scoring systems couldn’t be standardised across studies.   The mental health outcomes they measured were anxiety, depression, mixed anxiety/depression, positive affect, psychological quality of life & stress.

Results of systematic review

After data extraction, 15 full text articles were included:

Study type

11 cohort studies, 14 secondary analyses of cessation interventions, and 1 randomised controlled trial.

Participant population

14 studies included the general population, 3 included patients living with chronic physical condition, 2 with pregnant patients, 1 included postoperative patients, 2 studies included either chronic physical or psychiatric conditions, and 4 studies included patients with psychiatric conditions.

48% of participants were male with a median age of 44, and on average smoked 20 cigarettes per day. The average participant scored as moderately dependent to nicotine on a dependence test.

Results of meta-analysis

Compared with continuing to smoke:

People who quit smoking were less anxious, depressed and stressed than those who continued to smoke

People who quit smoking were less anxious, depressed and stressed than those who continued to smoke

  • Quitting was associated with a decrease in anxiety (SMD -0.37, 95% CI  -0.70 to -0.03; P=0.03)
  • Quitting was associated with a decrease in depression (SMD -0.25, 95% CI -0.37 to -0.12; P<0.001)
  • Quitting was associated with a decrease in mixed anxiety and depression (SMD -0.31, 95% CI -0.47 to -0.14; P<0.001)
  • Quitting was associated with a decrease in stress (SMD -0.27, 95% CI -0.40 to -0.13; P<0.001)
  • Quitting was associated with an improved psychological quality of life (SMD 0.22, 95% CI 0.09 to 0.36; P<0.001)
  • Quitting was associated with increased positive affect (SMD 0.40, 95% CI 0.09 to 0.71; P=0.01)

Subgroup Analyses

  • Analyses for study quality did not change summary estimates
  • Studies which adjusted for covariates showed a larger difference between quitters and those who continued to smoke compared to studies which did not adjust

Additional Analyses

  • There was no evidence that effect size differed across different clinical populations
  • There was no evidence of subgroup differences between study designs
  • The studies were ordered according to length in a forest plot and no clear chronological pattern in effect estimates was found


This review shows that quitting smoking is associated with reduced depression, anxiety and stress, and improved psychological quality of life and positive affect compared to continuing to smoke. The strength of the association was similar for all populations; both general and clinical. The authors suggest three possible interpretations of the data:

  1. Quitting smoking results in improved mental health
  2. Improved mental health causes an individual to quit smoking
  3. There is a common factor that explains both the improved mental health and smoking cessation

The authors hypothesise that quitting smoking improves mood is supposed by a biological mechanism caused by brain changes in the nicotinic pathways due to chronic smoking (Wang & Sun, 2005). These brain changes result in low mood (irritation, anxiety, and depressed mood) after smoking a cigarette. While an individual is actually feeling withdrawal symptoms, they are misattributed to low mood, and more cigarettes are smoked to alleviate their symptoms (Benowitz, 1995; Benowitz, 2010).

However, not all of the data supports this interpretation.  For example, a study using Mendelian randomisation- an instrumental variable approach that uses gene relating to smoking behaviour to examine health related outcomes, did not find a causal association between smoking and mental health (Bjorngaard et al 2013).

While this review displays that there are strong associations between quitting smoking and mental health, the authors recommend future studies examining this association to help strengthen causal inferences which come from observation research. The authors suggest further epidemiological studies using Mendelian randomisation, or using statistical analysis of observational data using propensity score matching to reduce the bias of confounding variables.


Many people believe that quitting smoking can have adverse psychiatric effects. This high quality research suggests the opposite

Many people believe that quitting smoking can have adverse psychiatric effects. This high quality research suggests the opposite

These are important findings as smokers can find reassurance in the fact that quitting is likely to result in improved mental wellbeing. Additionally, these findings are important as they show that quitting smoking is likely to improve your mental health if you are mentally ill or mentally well.

Hopefully these findings will help overcome some of the current barriers within the mental health field; for example the continued belief that quitting smoking or certain pharmacological treatments can have adverse psychiatric effects.  See our recent Lee Cook et al (2013) blog, which showed that individuals with mental illness treated as outpatients were more likely to decrease and quit smoking than those in inpatient facilities.

Furthermore, the NICE guidelines on smoking cessation, which we blogged about here, recommend that all NHS hospitals and clinics should become smoke-free, as well as identifying smokers and offering behavioural and pharmacotherapy onsite. Additionally, the guidelines suggest staff should be trained on stop-smoking services and should abstain from smoking on-site themselves (NICE, 2013).


Taylor G et al. Change in mental health after smoking cessation: systematic review and meta-analysis. BMJ 2014;348:g1151 doi: 10.1136/bmj.g1151

Coulthard M, Farrell M, Singleton N, Meltzer H. Tobacco, alcohol and drug use and mental health (PDF). Office for National Statistics, 2002.

World Health Organization. WHO report on the global tobacco epidemic. WHO, 2011.

Zhou X, Nonnemaker J, Sherrill B, Gilsenan A, Coste F, West R. Attempts to quit smoking and relapse: factors associated with success or failure from the ATTEMP cohort study (PDF). Addict Behav 2009;34:365-73.

Thompson B, Thompson LA, Thompson J, Fredickson C, Bishop S. Heavy smokers: a qualitative analysis of attitudes and beliefs concerning cessation and continued smoking. Nicotine Tob Res 2003;5:923-33. [PubMed abstract]

Le Cook B, Wayne GF, Kafali EN, Lui Z, Shu C Flore M. Trends in Smoking Among Adults with Mental Illness and Association Between Mental Health Treatment and Smoking Cessation. JAMA. 2014; 311 (2): 172-182. [Abstract]

Smoking cessation: acute, maternity and mental health services: guidance (PDF). NICE, PH48, 27 Nov 2013.

Wang H, Sun X. Desensitized nicotinic receptors in brain. Brain Res Rev 2005;48:420-37. [Abstract]

Benowitz NL. Nicotine addiction. Prim Care 1999;26:611-31 [PubMed abstract]

Benowitz NL. Nicotine addiction. N Engl J Med 2010;362:2295 [Abstract]

Bjorngaard JH, Gunnell D, Elvestad MB, Davey-Smith G, Skorpen F, Krokan H, et al. The causal role of smoking in anxiety and depression: a Mendelian randomization analysis of the HUNT study. Psychol Med 2013;43:711-9 [PubMed abstract]

This article first appeared on the Mental Elf website on 13 March 2014 and is posted by Meg Fluharty. Follow Meg on Twitter @MegEliz_

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Diary of a dependent smoker: The e-cigarette experience

This blog post reflects the author’s personal experience.

Day 1. Saturday 28th September 2013, 1.21pm. Inadvertent quit date.

It didn’t cross my mind for a second that this would be my last cigarette. Whilst I’d been away at a (tobacco control) conference, my husband had, out of the blue, decided to invest in an e-cigarette. That was four days ago. He hasn’t had a cigarette since. So, today, I decided to finally invest. I’m a pretty heavy smoker (~25 per day), and have been for about eight years (I appreciate the irony of this, having devoted five years of my life to the study of tobacco dependence). Anyone who has been unfortunate enough to fly long-haul with me will testify just how horrendous I am to be around without tobacco. Ditto my colleagues who’ve experienced my wrath after enlisting me as guinea pig in any experiment involving overnight abstinence. Anyway, I digress. I visited a local store dedicated to the sale of e-cigarettes (‘e-cigs’). Now I’m pretty au fait with the literature on these things. I had lots of questions (mainly relating to vapour composition and actual nicotine delivery), to which I didn’t really receive any satisfactory answers (the general public must not press with such line of questioning – they offered me a job in the store!). But I did learn a lot about the mechanics of these things, and tried out a lot of flavours. Seriously, you have a lot of options! I tried cherry, apple, mango, kiwi, very berry, raspberry, candy floss, blueberry, cherry cola, grape, and barely scratched the surface. There’s also an extensive range of tobacco flavours, dessert flavours (cheesecake anyone?!), rum, beer (?!); the list goes on… I was pretty stunned at the variety. But, in the end, I settled for blueberry and cherry cola. These flavoured nicotine solutions come in several strengths. I was advised, as a 25 cigarette per day smoker, to go for the 18mg mix. So, e-cig ‘starter pack’ in hand [pic], I carried on running my Saturday errands. Three hours later, I suddenly realised I hadn’t had (or wanted) a real cigarette. Now, honestly, it was not my intention to give up smoking. I was just curious (from both a personal and professional perspective) and thought this device might be a useful travel aid. But hey, why not see how long I could run with this? My husband was doing incredibly well so far, so why shouldn’t I try too. So how was I feeling at this point? A little restless. My throat was a little sore. But I wasn’t feeling irritable. I’ve tried giving up before. Nicotine gum, inhalator, bupropion – on all of these, giving up smoking had taken over my ENTIRE LIFE. Cigarettes were always on my mind. Today, that hasn’t been the case. But I have felt like something has been missing. For some reason I’ve been craving the scratch of metal on flint (my trusty clipper, a.k.a. conditioned reinforcer). ‘Smoking’ inside has been a novelty though. I guess I’ve been enjoying the novelty of it all. The cravings kicked in in force after dinner, but a 15 minute ‘vaping’ session helped check them. And yet I didn’t feel totally satisfied… A night in, watching back-to-back episodes of ‘24’, kept me suitably distracted and on track though. Oh, and I downloaded a stop smoking app to keep track of my progress – more on that tomorrow…



Day 2. Sunday 29th September 2013.

I knew this was going to be hard. The first cigarette of the morning has always been my favourite. For eight years, the first thing I’ve done every morning, without fail, is roll out of bed, head down to the kitchen to roll a cigarette, and sit out in the garden to smoke. That was all I could think about when I woke up. So, this morning, I went out and sat in exactly the same place, and spent 10 minutes vaping. It wasn’t the same, but it helped. I spent almost half of my morning puffing away on that thing (I’m curious to know what my total daily inhalation volume is). I’ve also been really hungry today. We decided to head down to the pub to treat ourselves to a Sunday roast. This was going to be hard – two glasses of wine and a big lunch. We sat out in the garden for half an hour afterwards. That thing was glued to my mouth. But I didn’t crack. When we got home I ended up taking a four hour ‘nap’ (I should add, my sleep has been pretty irregular, and I’ve been having very lucid dreams). I woke up with a dry mouth (again, that’s becoming a pretty regular feature), and a deep sense of incompleteness. More vaping. I’m writing at 11.24pm, and my stop smoking app informs me of the following:

Time since last cigarette:   1 d 10 h 03 mins

Money saved: £7.98

Not smoked: 35.48 cigarettes

Time saved: 0 d 3 h 32 mins


Day 3. Monday 30th September. Hell hath no fury like a girl without cherry cola flavoured nicotine.

Today has been the hardest day to date. I woke up, after a disturbed night’s sleep, from a particularly violent and lucid dream, with a painfully dry mouth. Reaching for an (empty) glass of water, I noticed the time. ****. I was horribly late for work (read: I have a meeting in 20 minutes and even if I jump straight into the car now I’ll still be late). Thirsty, flustered, and desperate for a cigarette, I flew into a whirlwind, got ready in 25 minutes (a record), and leapt into the car, ready to vape the hell out of that magic stick. However, two deep breaths in, the battery dies on me. Damn. I’m already 40 minutes late at this point. I get to work, park up, and run to the supermarket round the corner. I’ve devoted way too much effort to this cause to give up now. So instead of buying tobacco (the cheaper option by the way), I invested in a disposable e-cigarette. Now this model is very different to the one I’ve been using. It actually looks like a cigarette (see pic). No charging and no refilling needed. So I tear open the packet and start puffing away whilst running into work. It tasted DISGUSTING. I forgot to add, this e-cig was tobacco flavoured, not the fruity concoction I’m starting to grow used to (is cherry cola becoming a new conditioned reinforcer for me?!). I think this was the first time it hit me that my sense of taste had returned in force. Anyway, this hit the spot. Despite the vile taste in my mouth.


A day of data analysis ensues. I have a growing sense of unfulfilment. By 5pm I am in a terrible mood – irritable, hungry, restless. Driving home, my new e-cig, supposedly equivalent to 20 cigarettes, containing an advertised 16mg of nicotine, starts tauntingly flashing at me, before promptly giving up the ghost. At this point I should highlight that I’ve been going through about 2.5ml a day of a solution that contains 18mg nicotine per 10ml bottle. Now, I haven’t been keeping tabs on my circulating nicotine and cotinine levels (I should have been), but a moment of grumpy mental arithmetic en route home tells me something is amiss here. If the advertised nicotine content is correct, then the actual nicotine delivery of these things must wildly fluctuate across models (we know this to be true). So anyway, I get home, disproportionately angry that my husband hasn’t bought baked beans, and spend the next 15 minutes glued to his (cotton candy flavoured) e-cig while mine charges. At the shop (buying beans), I feel a quiet satisfaction in not adding a pouch of tobacco to my basket at the counter. It’s now 7.26pm:

Time since last cigarette:   2 d 6 h 05 mins

Money saved: £12.68

Not smoked: 56.35 cigarettes

Time saved: 0 d 5 h 38 mins

Day 4. Tuesday 1st October.

Nothing much to report today, other than generally feeling a bit tetchy and low, for no real reason. That’s new I guess. And my throat is still a bit sore. Night.

Day 5. Wednesday 2nd October.

So today I passed the 100 cigarettes not smoked mark. That feels pretty damn good! This morning also marked the first morning to date that I’ve woken up and haven’t been desperate for a cigarette. I still wanted one, but I didn’t feel like I needed one. And that is a big deal, at least to me. I also managed to resist the urge following a night out with friends, despite a lot of curry and a lot of wine. Jen 1, tobacco 0.

Day 6. Thursday 3rd October.

I think I’m getting used to this now. I also realised that I’m not so reliant on my e-cigarette anymore. I mean, I’m still using it a lot, and definitely devoting more time to it than I ever did with cigarettes, but it’s not permanently glued to my mouth today. I did have one particularly big craving to smoke today after an argument on the phone – definitely the biggest craving since day one. But that soon passed. I think the increasing brevity of these posts stands testament to the fact that this is getting easier. It’s now 9.25pm:

Time since last cigarette:   5 d 8 h 04 mins

Money saved: £30.02

Not smoked: 133.40 cigarettes

Time saved: 0 d 13 h 20 mins

Day 7. Friday 4th October.

I encountered my first bar tonight that prohibits e-cigarette use. I asked why this was and was informed that “people get very drunk and we’re worried that people might see other people smoking e-cigarettes and think it’s ok to smoke real cigarettes inside too”. Hmm…

Day 8. Saturday 5th October.

My throat is KILLING me. I was genuinely in agony when I woke up this morning. My teeth have been hurting a lot too. They’ve been pretty sensitive since I had them bleached a couple of years ago, but the pain has flared up in style recently. Coincidence perhaps? Obviously association does not imply causation, but, the vapour is very sweet tasting – need to check which sweeteners are used in that nicotine solution… By the way, today marks one entire week tobacco free! It’s 12.21pm.

Time since last cigarette:   6 d 23 h 01 mins

Money saved: £39.15

Not smoked: 173.99 cigarettes

Time saved: 0 d 17 h 23 mins

Day 10. Monday 7th October.

So my teeth feel fine again now. But for the last couple of days I’ve really had a sore throat – so sore that I’ve been putting off using my e-cig until I’m literally desperate for nicotine. And my nose has been running, constantly. I’m not sure if this is just my airways clearing themselves, a side effect of the e-cig, or just a cold. Whichever it is, I decided to try and remedy it by really heavily cutting back on my vaping today, and to patch up the withdrawal with nicotine lozenges. That actually seems to be working pretty well. Let’s see how the throat fares tomorrow… It’s 8.55pm:

Time since last cigarette:   9 d 07 h 34 mins

Money saved: £52.40

Not smoked: 232.89 cigarettes

Time saved: 0 d 23 h 17 mins

Day 12. Wednesday 9th October

My throat feels fine. However, my e-cig is a long way from fine. In fact, it tastes like burnt metal. I’m no expert on these things, but from what I can tell the heating element has burnt out. I was told this would only need to be replaced every two months, but I guess I’ve been using it a lot, particularly during week one. Anyway, this means I ended up stuck at work without any withdrawal soothing vapour. But I did have a pack of nicotine lozenges on hand as back up, and you know what? I actually did pretty well on those today. And I have a back up mouthpiece at home, so life is good.

Day 13. Thursday 10th October

Absolutely nothing to report today, other than passing the ‘1 day of my life saved’ milestone (Fun fact: Adults between the ages of 25 and 34 years who quit smoking gain around 10 years of life compared to those who continue to smoke! More info here). Oh, and I’ve just read back through this blog for the first time. It feels pretty good to have come this far! It’s now 11.11pm.

Time since last cigarette:   12 d 09 h 50 mins

Money saved: £69.81

Not smoked: 310.26 cigarettes

Time saved: 1 d 07 h 01 mins

Day 16. Sunday 13th October.

I feel like I’ve spent a lot of this blog complaining about my teeth. But I have to mention it again, because I’ve started to notice a trend – they only seem to start hurting when I’m using the Cherry Cola flavour solution. No problems with Blueberry. There’s no information as to exactly what ‘flavourings’ consist of in these solutions on the company website. I’m going to dig deeper on this. Also, another observation: I seem to be much more sensitive to the effects of alcohol since quitting smoking. Two glasses of wine really have been knocking me for six. Anecdotal evidence, of course, although my husband has independently also made the same connection. Is there any research into this?! A five minute literature search does indeed suggest that nicotine decreases blood alcohol concentration! Surely this information needs to be publicised more widely for clear safety reasons… It’s 10.19pm:

Time since last cigarette:   15 d 08 h 58 mins

Money saved: £86.48

Not smoked: 384.35 cigarettes

Time saved: 1 d 14 h 26 mins

Day 19. Wednesday 16th October.

Why do I always leave it to the last minute to pack for holiday?! Super quick update today. It’s 12.29am:

Time since last cigarette:   18 d 11 h 21 mins

Money saved: £103.86

Not smoked: 461.62 cigarettes

Time saved: 1 d 22 h 09 mins

Day 20. Thursday 17th October.

HOLIDAY! Operation mini-break is go. I’m currently sitting at the airport. For some reason, I am DESPERATE for a cigarette right now – more so than I have been all week. I’m pinning this to one of two reasons: 1) I actually can’t have a cigarette right now (rather than just choosing not to); or 2) Whenever I’m at an airport I’m always in some growing state of nicotine withdrawal, and now my surroundings are basically acting as cues to provoke the deep state of unrest with which they’ve become associated. Possibly both. Plus I’m drinking coffee, which always makes me want to smoke.

Day 34. Thursday 31st October.

Woah. It’s been a REALLY long time since my last entry. I’ve been meaning to squeeze in an update for ages but a back-to-back holiday, business trip, and unexpected stint in hospital have all gotten in the way (incidentally, not having to drag a drip outside every hour for a smoke has definitely been an unexpected bonus to quitting). So…update. And this is going to be my final entry, as I only planned to keep this diary going until the 1 month mark.

Today marks my 34th day smoke-free. I am genuinely feeling pretty proud of myself, given that the longest I’ve gone without tobacco in the last eight years is a little under 24 hours. It hasn’t been easy. There have definitely been times when I’ve been desperate for a cigarette. And I have begged friends for a drag whilst out (they refused, for which I was grateful, at least the next morning). However, I have not (yet) slipped at all, which is pretty great considering I never even intended on quitting in the first place.

I also wanted to sum up on my experiences of quitting using an e-cigarette. Firstly, I should make it clear that I almost certainly wouldn’t have been able to quit without these. As I said in one of my first entries, I have tried a LOT of different cessation methods before, and failed royally with each every time. However, I also have some concerns. Before starting this experiment, I felt quite strongly that these products shouldn’t come under MHRA regulation. Why should products which seem to be proving to be so helpful in getting people off cigarettes be regulated more tightly than cigarettes themselves? However, over the course of the last month it has become very clear that some regulation of e-cigarettes is certainly warranted. There is a huge degree of variability between brands and models, for example, in terms of actual nicotine delivery. I have also experienced a number of negative symptoms which have coincided with the use of these products. These have ranged from the relatively minor (e.g., dry mouth, sore throat, and tooth ache, as discussed), to the more serious (e.g., coughing up bloody phlegm, as I rather worryingly experienced last night). All in all, however, I really am in favour of these devices. But for now, I think I’ll be switching to nicotine lozenges. It’s 3pm. My final stats are:

Time since last cigarette:   33 d 02 h 39 mins

Money saved: £186.25

Not smoked: 827.78 cigarettes

Time saved: 3 d 10 h 47 mins

P.s. If you’re interested in learning more about e-cigarettes, you might want to check out this briefing, recently released by Action on Smoking and Health.

This article is posted by Jen Ware

Health Technology Assessment report finds computer and other electronic aids can help people stop smoking

Smoking continues to be the greatest single preventable cause of premature illness and death in developed countries. Although rates of smoking have fallen, over 20% of the adult population in the UK continues to smoke. Anything which can be done to help people stop smoking will therefore have substantial public health benefits.

More and more people now have access to computers and other electronic devices (such as mobile ‘phones), and there is growing interest in whether these can be used to prompt or support attempts to stop smoking. This could be by providing a prompt to quit, reaching smokers who would otherwise use no support, and/or supporting the degree to which people use their smoking cessation medication (e.g., nicotine replacement therapy).

A recent Health Technology Assessment review assessed the effectiveness of internet sites, computer programs, mobile telephone text messages and other electronic aids for helping smokers to quit, and/or to reduce relapse to smoking among those who had quit.


The reviewers conducted a systematic review of the literature from 1980 to 2009 and found 60 randomised controlled trials (RCTs) and quasi-RCTs evaluating smoking cessation programmes that utilised computer, internet, mobile telephone or other electronic aids. The review was restricted to studies of adult smokers.

The primary outcomes were smoking abstinence, measured in two ways: Point prevalence abstinence and prolonged abstinence. The first is typically available in more studies (because it is easier to measure) but a rather liberal measure of abstinence (since the smoker need only be abstinent at the point the assessment is made to count as having quit). The latter is more conservative (since it requires the smoker to have been abstinent for an extended period to count as having quit), and is generally the preferred measure. Smoking abstinence at the longest follow-up available in each study was used, again because this is most conservative.


Combining the data from the 60 trials indicated that, overall, the use of computer and other electronic aids increased quit rates for both prolonged (pooled RR = 1.32, 95% CI 1.21 to 1.45) and point prevalence (pooled RR = 1.14, 95% CI 1.07 to 1.22) abstinence at longest follow-up,  compared with no intervention or generic self-help materials.

The authors also looked at whether studies which aided cessation differed from those which prompted cessation, and found no evidence of any difference in the effect size between these. The effectiveness of the interventions also did not appear to vary with respect to mode of delivery or the concurrent use non-electronic co-interventions (e.g., nicotine replacement therapies).


Computer and other electronic aids do indeed increase the likelihood of cessation compared with no intervention or generic self-help materials, but the effect is small

The review concluded that computer and other electronic aids do indeed increase the likelihood of cessation compared with no intervention or generic self-help materials, but the effect is small. However, even a small effect is likely to have important public health benefits, given the large number of people who smoke and the impact of smoking on health. The authors also note that uncertainty remains around the comparative effectiveness of different types of electronic intervention, which will require further study.

The authors argue that further research is needed on the relative benefits of different forms of delivery for electronic aids, the content of delivery, and the acceptability of these technologies for smoking cessation with subpopulations of smokers, particularly disadvantaged groups. More evidence is also required on how electronic aids developed and tested in research settings are applied in routine practice and in the community.


Chen YF, Madan J, Welton N, Yahaya I, Aveyard P, Bauld L, Wang D, Fry-Smith A, Munafò MR. Effectiveness and cost-effectiveness of computer and other electronic aids for smoking cessation: a systematic review and network meta-analysis (PDF). Health Technol Assess 2012; 16(38): 1-205, iii-v. doi: 10.3310/hta16380.

This article first appeared on the Mental Elf website on 11th March 2013 and is posted by Marcus Munafo