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Jonathan Foulds, PhD

Joined: 12/13/2010

Expert Profile:

Jonathan Foulds, PhD. is a Professor of Public Health Sciences at Penn State University, College of Medicine. After obtaining a first class honors degree in psychology at University of Aberdeen in Scotland, he trained as a clinical psychologist at the University of Glasgow, and then spent most of his career developing and evaluating methods to help smokers beat their addiction to tobacco. He obtained his PhD at the Institute of Psychiatry, University of London and then worked at St George's Hospital Medical School as the UK's first "lecturer in tobacco addiction". He then moved to University of Surrey and continued to work as a principal clinical psychologist at Broodmoor Hospital, a large maximum security facility for mentally disordered offenders. He was on the Management Group of the Hungarian Anti-Smoking Campaign (1995-6), has been a technical leader of a World Health Organization project to improve the regulation of tobacco dependence treatment in Europe (2000), and was Director of Research for the UK charity, Quit, which ran the largest telephone helpline for smokers in the world at that time. He was a founding member and Vice President of the Association for the Treatment of Tobacco Use and Dependence (ATTUD) 2004-6. Dr Foulds has received funding support on grants totaling well over $7 million from a various public and private organizations (including New Jersey Department of Health and Senior Services, CDC and the Robert Wood Johnson Foundation). He has worked as a paid consultant for a number of agencies involved in promoting health, including pharmaceutical companies involved in production of tobacco dependence treatment medications (e.g. Pfizer, GSK, Novartis). He has been invited to speak on smoking cessation in over 15 countries, and has published over 80 papers on tobacco and health in peer-reviewed scientific journals. He continues to treat addicted smokers, teach on smoking cessation and conduct research on tobacco and health at Penn State College of Medicine in Hershey, PA.

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Reply: day 1

So how is it going Donna?

Posted by Jonathan Foulds, PhD

1 Reply | Reply | Watch This DiscussionReport This| Share this:day 1 So how is it going Donna?

Study finds no increase in cardiovascular events w...

Last year a review of clinical trials of varenicline (Chantix) concluded that...

Posted by Jonathan Foulds, PhD

2 Replies | Reply | Watch This DiscussionReport This| Share this:Study finds no increase in cardiovascular events with varenicline (Chantix) Last year a review of clinical trials of varenicline (Chantix) concluded that...

Reply: How addicted are you?

More addicted smokers (i.e. those who smoke more per day and have their first...

Posted by Jonathan Foulds, PhD

2 Replies | Reply | Watch This DiscussionReport This| Share this:How addicted are you? More addicted smokers (i.e. those who smoke more per day and have their first...

How addicted are you?

One of the most widely used questionnaires designed to measure the strength of...

Posted by Jonathan Foulds, PhD

One of the most widely used questionnaires designed to measure the strength of addiction to cigarettes is called the "Fagerstrom Test for Nicotine Dependence" or FTND . It is a 6-item questionnaire, yielding a score from 0-10, with a higher score implying stronger addiction. Dr Karl Fagerstrom, the Swedish researcher who originally developed the FTND recently published a study that examined the relationship between baseline (pre quit attempt) FTND score and success in quitting smoking among almost 5000 smokers who participated in placebo-controlled trials of varenicline (marketed as Chantix in the USA). The study confirmed that smokers with lower pre-quit FTND scores had a much better chance of successfully quitting 6 months later. For example, smokers with the lowest scores (0-1) were twice as likely to successfully quit smoking as those with the highest scores (9-10). The study also found that a shorter, two-question version was just about as predictive of success in quitting smoking. The two key questions were:
1. How many cigarettes per day do you smoke?
2. How soon after you wake do you smoke your first cigarette of the day?
Those who smoke more than 30 cigarettes per day or smoke within 5 minutes of waking in the morning have a lower quit rate than those who smoke less than 11 cigarettes per day and typically don't smoke their first of the day until over an hour after waking in the morning. It appears that these two questions on their own can give a reasonable but fairly rough guide to how addicted a smoker is. I say "fairly rough" because even among those scoring a zero on these addiction assessments (i.e. the least addicted), the six month quit rate among those receiving placebo in the clinical trials was only twenty percent. This suggests to me that significant addiction is present among people who smoke less than 11 cigarettes per day. It also suggests that we need some additional questions that can help measure level of addiction at the low levels of daily cigarette consumption (i.e. <11 per day). It is unclear whether an individual actively delaying the first smoke of the day and reducing their daily cigarette consumption over time can make themselves "less addicted". It is possible, if sustained over a reasonably long period (i.e. greater than a month). However, perhaps a more practical use of these types of quick addiction assessments is to guide the smoker about whether they would likely benefit from assistance in quitting (e.g. counseling and/or medication). It seems that people who smoke just a few cigarettes per day and don't smoke within an hour of waking in the morning may have a good chance of success by picking a day and making a serious quit attempt on their own. Heavier smokers may be more likely to benefit from additional assistance. However, in this recent study, even those who had a zero score on the addiction questionnaires were more than twice as likely to successfully quit smoking for 6 months if they received varenicline as compared to those receiving placebo (47% v 20%).View Thread

Posted byJonathan Foulds, PhD

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Reply: Nicotine/Cotinine

Nicotine has an average "half-life" of 2 hours in the human body, but it can...

Posted by Jonathan Foulds, PhD

1 Reply | Reply | Watch This DiscussionReport This| Share this:Nicotine/Cotinine Nicotine has an average "half-life" of 2 hours in the human body, but it can...

New CDC Smoking Education Ads: What Do You Think?

The Centers for Disease Control and Prevention (CDC) just launched a set of...

Posted by Jonathan Foulds, PhD

Take the Poll

Which of the new CDC smoking education ads do you think is most effective in motivating smokers to quit?

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Nicotine patch safe but not effective for smoking ...

A new study was published in the New England Journal of Medicine last week...

Posted by Jonathan Foulds, PhD

A new study was published in the New England Journal of Medicine last week by Dr Tim Colemen (University of Nottingham, UK) and colleagues, examining whether daytime nicotine patches (initially for one month) increase quit rates among pregnant smokers. This was a large and thoroughly conducted study. The investigators informed around 21,000 women about the trial, screened 2410 women who were initially interested, and finally recruited 1050 pregnant smokers to the study. The women included in the trial had an average age of 26, had smoked 20 cigarettes per day prior to pregnancy and were smoking an average of 14 cigarettes per day when recruited to the study, approximately 16 weeks into the pregnancy. The majority of the women smoked their first cigarette of the day within 15 minutes of waking in the morning, suggesting that most were highly addicted to nicotine. All of the women were given around 45 minutes of face-to-face smoking cessation counseling at the start of the study, and then 2-3 sessions of telephone counseling. All the women were given a month supply of skin patches, but half were given patches containing nicotine, and half received patches not containing nicotine ("placebos"). Neither the women nor the midwives were told which type of patches each woman received ("double blind"). Those women who were quit at one month follow-up were offered another month of patches. The main aim of the study was to find out whether using nicotine patches increased quit rates.
At one month follow-up, more women receiving nicotine patches than placebo patches had quit (21% v 12%). However, only 7% of the nicotine patch group and 3% of the placebo patch group continued with the second month of patches. By delivery of the babies, there was no significant difference in quit rates between the two groups (9% v 8%). The study also measured a range of side effects and pregnancy outcomes and for most of these there were no differences between nicotine and placebo patches. For example, 6% of both groups reported neonatal adverse events, and the birth weight of the babies was very similar in both groups. The authors concluded that adding 15mg daily nicotine patches to brief behavioral counseling for pregnant smokers neither increases the quit rates, nor increases the risk of adverse pregnancy or birth outcomes.
A couple of things are striking about the results. The first is that, despite being seemingly highly motivated to quit smoking, less than one in five managed to quit for a month, and less than 10% were quit at the time of delivery (around 5 months after initially trying to quit). The other striking result is the very low compliance with patch use and the low use of additional counseling. 76% of those given placebo patches and 60% of those given nicotine patches used them for less than 15 days. The lower patch use in the placebo group suggests this was not caused by nicotine-related side-effects. Part of this early termination of patch use may be due to a perception that they were not helping to quit smoking, and part may have been (ironically) due to concerns about potential harm to the baby.(Ironic because there is much greater harm to the baby from continued smoking). In particular, it is likely that women would have stopped using the patches when they had a smoking lapse, because of (misplaced) concern that smoking while using the patch may be particularly harmful. The women were also given the opportunity for additional face-to-face counseling sessions but only around 10% did so. Clearly the search must continue for widely applicable and effective ways to help pregnant smokers to quit.
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Posted byJonathan Foulds, PhD

1 Reply | Reply | Watch This DiscussionReport This| Share this:Nicotine patch safe but not effective for smoking cessation in pregnancy. A new study was published in the New England Journal of Medicine last week...

The Natural History of Quitting Smoking

A new research study has recently been published in the journal Addiction, by...

Posted by Jonathan Foulds, PhD

A new research study has recently been published in the journal Addiction, by Professor Ron Borland and an international team of researchers which gives perhaps the best data on the smoking cessation process yet seen. This study conducted telephone interviews with approximately 2000 smokers in Australia, Canada, UK and USA each year from 2002 to 2008. They attempted to recall those who quit smoking in subsequent years, resulting in a sample of almost 22,000 people. At each interview, participants were asked detailed questions about their quit attempts both in the past and since their last interview. At the first wave of interviews, 82% reported having made a prior quit attempt, reaching 94% among those who participated in all 7 waves of interviews. 43% reported a quit attempt in the prior 12 months. Over a 5 year period, 69% of those starting as smokers had reported quit attempts of at least a month, and overall 16% managed to quit and remain quit for at least a year. The study shows that quit attempts are very common, with around 40% of smokers trying to quit each year, each making an average of 2 attempts per year. Thoughts of quitting that do not result in serious attempts are even more common, with an additional 30% of smokers having "serious thoughts" about quitting but not making a serious attempt. One other finding from this study is that smokers tend to forget their short-lived quit attempts, with 20% being forgotten within a year. Based on detailed analyses of their longitudinal data, the authors estimate that the average 40 year-old smoker who started smoking in their teens will have made more than 20 failed quit attempts. More than half of current smokers have succeeded in quitting for at least a month, and a majority of these for over 6 months.
This study, perhaps the most detailed of its kind, reminds us that quitting smoking is best conceptualized as a process requiring efforts, often repeated, over a long period of time, rather than as a single event.
Reference: Borland et al (2012). How much unsuccessful quitting activity is going on among adult smokers? Data from the International Tobacco Control Four Country Cohort Study. Addiction, 107, issue 3. P673-682.View Thread

Posted byJonathan Foulds, PhD

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Reply: Time to prepare for New Year Quitting

Check out my comments on the recent study claiming to show that nicotine...

Posted by Jonathan Foulds, PhD

3 Replies | Reply | Watch This DiscussionReport This| Share this:Time to prepare for New Year Quitting Check out my comments on the recent study claiming to show that nicotine...

Does Nicotine Replacement Therapy Help Smokers To ...

A new study has recently gained substantial media attention, with the...

Posted by Jonathan Foulds, PhD

A new study has recently gained substantial media attention, with the authors claiming that nicotine replacement may not help smokers to quit smoking. The study recruited 4991 smokers and recent ex-smokers via telephone survey in 2001 and 2002, and then again 2003-4 when 2805 (56%) were reached, and again in 2005-6 when 1916 were reached (38% of original sample). The study focused on those who at one of the first two interviews claimed they had quit smoking in the previous 2 years, and then were later interviewed again (728). The main finding was that the chances of relapsing were not significantly different between those who had previously used NRT to quit, either with or without professional counseling. The authors concluded that these results "raise serious questions regarding the population-level effectiveness of widely popular smoking cessation medications used with or without behavioral counseling." They then suggest that increases in insurance "coverage for individual treatment must not be at the expense of public health programs and policy interventions that have proven effective in promoting cessation."
There are many serious problems with this study (such as the low 38% overall follow-up rate), but the main problems lie with the misunderstanding of the purpose of tobacco dependence treatment and the misinterpretation of the data presented. Nicotine replacement therapy is currently marketed for short term use as an aid to smoking cessation. Counseling is similarly primarily conducted to help current smokers to successfully quit. Both of these interventions have been shown to increase the chances that smokers will successfully quit, but there is no evidence, from randomized controlled trials or population studies suggesting that after the medication or counseling has stopped that the relapse rate is dramatically different than from smokers who quit without treatment. So the benefit of treatment is of increasing the initial quit rates, meaning that even with similar relapse rates, there are more long term quitters. So for this study to ignore the first part, the "getting quit" and then focus on the second part, the "staying quit" and to find no difference is really unsurprising .
There are other surprising weaknesses in this report, including a failure to cite other population studies that fail to support the claimed findings of this study. For example, a population-based study published by West and colleagues in 2007 concluded that NRT use by smokers making self-initiated quit attempts without behavioral support is associated with improved long term abstinence rates. Amazingly the authors failed to cite recent population-based studies from their own state finding that use of a comprehensive tobacco cessation pharmacotherapy Medicaid benefit was associated with a significant decrease in smoking prevalence and claims for hospitalizations for acute myocardial infarction and acute coronary heart disease .
So does this recent study show that NRT doesn't help smokers to quit? No. Despite the headlines, this wasn't even a study of whether NRT use helps smokers to quit. Rather it was a rather weak study of whether people who quit smoking a long time ago have a tendency to relapse long after. The sad reality is that relapse continues. But of course this is a long recognized characteristic of an addiction, not a new finding. So this study has little bearing on the solid evidence that nicotine replacement therapy helps smokers to quit, and that tobacco treatment remains one of the most cost effective healthcare interventions available.View Thread

Posted byJonathan Foulds, PhD

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