Abstract in English
Introduction: Smoking has a significant negative impact on health. Preventing harm from smoking
is therefore central in promoting health in society. Since the 1950s the prevalence of smokers has
decreased significantly in Denmark and in other developed countries. Yet, in recent years the
decrease in prevalence has stopped. The stagnation of the number of smokers who give up smoking,
has led to a shift in paradigm towards the treatment of smokers. Earlier the sole focus was for the
smokers to achieve smoking cessation. Now, to achieve tobacco harm reduction, the option of
substituting tobacco with nicotine replacement therapy products (NRTs) long-term, has also been
introduced. Tobacco harm reduction is suggested for smokers, who are unable or unwilling to give
up all nicotine products, as NRTs are regarded as substantially less harmful compared to continued
smoking. The sales of NRTs have been increasingly liberalised to make the products more available
as aid for smoking cessation. In Denmark, the sale of NRTs has increased substantially since the sale
of the products were liberalised in 2001. Results from a national survey conducted in 2012 suggested
that 1.3% of the adult population used NRTs beyond the recommended 12 months.
Aim: The overall aim of this thesis was to provide a comprehensive understanding of what
characterises the long-term users of NRTs, and their experiences and considerations in regards to
their continued use of NRTs.
Methods: A mixed methods approach was applied. Sub-study I was cross sectional survey conducted
in a population sample. Participants were recruited via advertisements in three Danish newspapers.
Descriptive statistics were used to describe the basic characteristics of the participants, including
their smoking history and current NRTs use. Reasons for sustaining or wanting to give up NRTs were
asked as open-ended questions, allowing for the participant to elaborate in their own words. Linear
regression was used to undertake a validation check of a modified version of the Heaviness of
Smoking Index. First, to assert a negative association and to measure the strength of this association
between time to first NRTs (TTFN) and NRTs use (pieces/day). Second to assert the association
between TTFN and recalled smoking (cig/day).
Sub-study II was a qualitative study. In-depth semi-structured interviews were conducted with 19
long-term users of NRTs. The interviews were all audio-recorded and transcribed verbatim for
subsequent hermeneutic analysis conducted in an iterative cycle.
Lastly, in sub-study III, data on NRTs and E-cigarette users in the Danish Smoking Habits (DSH) 2012
and 2014 were analysed and categorised into three groups ‘NRTs users’, ‘E-cigarette users’, and
‘NRTs & E-cigarette users’. Smoking status was characterised as smoker, ex-smoker, or non-smoker.
Smokers were either daily, weekly, or less-than- weekly smokers. Association between groups and
demographic variables, smoking status, and cigarette consumption were assessed with chi-square
test of independence for categorical variables and with one-way ANOVA for continuous variables
(age).
Results: The characteristics found in a population sample in sub-study I, matched those found in
previous studies on long-term uses of NRTs. However, due to the study design the results were not
generalizable. A significant majority of the participants (88%) stated that the reason they wished to
give up using NRTs was the cost of the products, addiction, and fear of adverse consequences. Per the
modified Heaviness of Smoking Index (HSI), the majority of participants (70%) were estimated to be
moderately to highly dependent on NRTs, while 30% were estimated to be low dependent. In substudy II, non-nicotinic factors, such as taste, texture, the strong sensation from the gum, and the habit
of chewing, were found to play an important part in developing addiction to NRTs. Also, the use of
NRTs yielded some of the expected benefits and helped avoid some of the expected drawbacks of
smoking cessation, such as providing enjoyment, convenience, health improvements, increased
ability to concentrate, and avoidance of weight gain. However, long-term use of NRTs entails some of
the same concerns as smoking in terms of long-term health effects and continued addiction. The
significant majority of the interviewees were not motivated to give up the use of NRTs, yet none of
the ex-smokers feared relapsing to smoking if they give up the use of NRTs. Finally, the results from
sub-study III indicated that the prevalence of NRTs use has stagnated while use of E-cigarettes may
still be increasing. E-cigarette users are younger and more likely to be dual users of E-cigarettes and
tobacco cigarettes compared to NRTs users. The apparent use of E-cigarettes and NRTs in different
segments of the smoking population shows promise for the harm reducing effects of E-cigarettes.
However, the effectiveness of E-cigarettes in promoting smoking cessation and not acting as a
gateway to tobacco smoking should be investigated further.
Conclusion: A significant segment of ex-smokers using NRTs long-term wish to give up using NRTs.
Reasons stated for wishing to give up use of NRTs are cost of products, continued addiction, and fear
of adverse consequences. The majority of long-term users are estimated to be moderately to highly
dependent on NRTs. However, many long-term users may not be motivated to give up the use of
NRTs, even if the long-term user does not fear relapsing to smoking. The lacking motivation could be
explained by experience of improved health, decreased fear of adverse effects compared to continued
smoking, the convenience of using NRTs, and the decreased sense of addiction. The non-nicotinic
factors of NRTs use seem to play an important part in the continued use of NRTs. However, the major
drawbacks of continued use of NRTs are 1) a persistent, albeit reduced fear of adverse effects and 2)
the persistent addiction. The social aspect of continued use of NRTs is also two-sided, as long-term
users experience an increased social acceptance of NRTs use compared to smoking, but self-reproach
for not stopping use of NRTs and a societal label of being an ‘addict’ is still present. Use of E-cigarettes
is increasing in Denmark, with E-cigarette users being significantly younger than NRTs users.
Concomitant use of E-cigarettes and tobacco smoking is significant, and may limit the harm reductive
effects of E-cigarettes. Lastly, the use of NRTs as ‘civilising agents’ or for recreational purposes as
consumer products has not been fully accepted. Yet, NRTs use seems significantly more acceptable
in society compared to tobacco smoking.