Exploring the opinions and potential impact of unflavoured e-liquid on smoking cessation among people who smoke and smoking relapse among people who previously smoked and now use e-cigarettes: findings from a UK-based mixed methods study.

BACKGROUND: Although electronic cigarettes (e-cigarettes) appear to be effective in helping people who smoke to stop smoking, concerns about use of e-cigarettes among young people have led to restrictions on non-tobacco flavoured e-liquids in some countries and some US states. These restrictions could reduce the appeal of these products to non-smoking youth but could have negative consequences for people who smoke or use e-cigarettes. METHODS: In this mixed methods study, we recruited UK adults who smoked or used to smoke and subsequently vaped to explore their opinions of unflavoured e-liquids and their beliefs about how they would be impacted by hypothetical e-liquid flavour restrictions. Participants trialled an unflavoured e-liquid instead of their usual nicotine product for four hours and completed a survey and an online interview. RESULTS: Using Interpretive Phenomenological Analysis and graphically presented data, we found differences in participants' opinions of unflavoured e-liquid. If only unflavoured, tobacco flavoured, and menthol flavoured e-liquids remained on the UK market, some people who smoke or vape may be unaffected, but some may relapse to smoking or continue smoking. Despite most wanting to prevent young people from initiating vaping, participants had varying opinions on whether flavour restrictions would be an effective method. CONCLUSIONS: The findings highlight that people who smoke and vape could be impacted by flavour restrictions in a range of ways, some of which could have a potential adverse impact on harm reduction efforts in the UK (e.g., by making smoking more appealing than vaping).

Potential smoke-free dividend across local areas in England: a cross-sectional analysis.

BACKGROUND: The value that might be added to local economies each year through the money that people who smoke tobacco would save if everyone quit smoking is called the 'smoke-free dividend'. This study aimed to estimate the value of the smoke-free dividend across local areas in England, and how it relates to the average income in those areas. METHODS: The study was a cross-sectional descriptive analysis of tobacco expenditure from the Smoking Toolkit Study (STS) matched to income and smoking prevalence data for English local authorities. The STS sample was from 2014 to 2020 and comprised 18 721 adults who smoke cigarettes. Self-reported expenditure estimates from the STS were adjusted for under-reporting. This adjustment aimed to align the total expenditure estimate with figures derived from government tax receipts and national estimates of illicit tobacco use. The smoke-free dividend is calculated as 93% of spending on legal tobacco, which is the percentage estimated to leave the local economy, plus 100% of spending on illicit tobacco. RESULTS: The total dividend in England is estimated to be £10.9 billion each year, which equates to £1776 per person who smokes or £246 per adult regardless of smoking status. The estimated dividend is greater in areas with lower average income, with a correlation coefficient of -0.521 (95% CI -0.629, -0.392) between the average income of local areas and the dividend per adult. CONCLUSIONS: This study has estimated that local economies could gain a substantial dividend if everybody stopped smoking, which is larger in lower income areas, meaning that geographical economic inequalities could be reduced.

Effects of electronic cigarette e-liquid flavouring on cigarette craving.

BACKGROUND: E-liquid flavour restrictions may discourage electronic cigarette (e-cigarette) uptake among youth. However, possible unintended consequences may include reduced appeal and effectiveness of e-cigarettes for smoking cessation. Non-tobacco flavours appear to be important for smoking cessation, but how and why are currently unclear. METHODS: We conducted an experimental study in a UK sample of adult daily smokers using an independent groups design (N=84). Participants were randomised to use an e-cigarette with nicotine-containing fruit/sweet-flavoured e-liquid (blackcurrant, strawberry, vanilla, caramel) or unflavoured e-liquid for 1 week. The primary outcomes were average, peak and cue-elicited cigarette craving (the latter was assessed using a cue exposure task). The secondary outcomes were smoking lapse occurrence, enjoyment of the e-cigarette, ease of transitioning from smoking to using an e-cigarette, intentions to continue using an e-cigarette, intentions and motivation to quit smoking, return to smoking, and continuation of e-cigarette use. RESULTS: E-liquid flavouring did not appear to have an effect on average cigarette craving (b 0.18, 95% CI -0.44 to 0.79, p=0.57), peak cigarette craving (b -0.12, 95% CI -0.59 to 0.35, p=0.62) or cue-elicited cigarette craving (b -0.21, 95% CI -3.86 to 3.43, p=0.91). We did not find evidence of a difference in secondary outcomes. CONCLUSIONS: We did not find evidence to suggest that nicotine-containing fruit/sweet-flavoured and unflavoured e-liquids have different effects on cigarette cravings after 1 week of use. Further research is needed to establish if differences emerge over longer periods of exposure and extend to smoking cessation outcomes.

Rapid growth in disposable e-cigarette vaping among young adults in Great Britain from 2021 to 2022: a repeat cross-sectional survey.

AIMS: To estimate recent trends in the prevalence of disposable e-cigarette vaping in Great Britain, overall and across ages, and to measure these trends in the context of changes in smoking and vaping prevalence. DESIGN: The Smoking Toolkit Study, a monthly representative cross-sectional survey. SETTING: Great Britain. PARTICIPANTS: A total of 36 876 adults (≥ 18 years) completed telephone interviews between January 2021 and April 2022. MEASUREMENTS: Current e-cigarette vapers were asked which type of device they mainly use. We estimated age-specific monthly time trends in the prevalence of current disposable e-cigarette use among vapers and inhaled nicotine use (vaping/smoking), smoking and vaping among adults. FINDINGS: From January 2021 to April 2022, there was an 18-fold increase in the percentage of vapers who used disposables, rising from 1.2 to 22.2% [prevalence ratio (PR) = 18.0; 95% compatibility interval (CI) = 9.18-49.0]. Growth in disposable e-cigarette vaping was most pronounced in younger adults (interaction P-value = 0.013): for example, the percentage of 18-year-old vapers using disposables rose from 0.4 to 54.8% (PR = 129; 95% CI = 28.5-4520), while it rose from 2.1 to 10.0% (PR = 4.73; 95% CI = 2.06-23.6) among 45-year-old vapers. However, the overall percentage of people currently using any inhaled nicotine remained stable over time both among all adults (20.0 versus 21.2%; PR = 1.06; 95% CI = 0.92-1.22) and among 18-year-olds (30.2 versus 29.7%; PR = 0.99; 95% CI = 0.80-1.22). In 18-year-olds, vaping prevalence grew (11.3 versus 17.7%; PR = 1.57; 95% CI = 1.12-2.29), and there was imprecise evidence for a decline in smoking (24.5 versus 19.5%; PR = 0.80; 95% CI = 0.63-1.04). In 45-year-olds, there was relatively little change in vaping (PR = 1.08; 95% CI = 0.88-1.33) or smoking prevalence (PR = 1.01; 95% CI = 0.88-1.16). CONCLUSIONS: Use of disposable e-cigarettes in Great Britain grew rapidly between 2021 and 2022, especially among younger adults, but the overall prevalence of inhaled nicotine use was stable over time. Most young adult vapers in Great Britain now use disposable products.

Tobacco-free Nicotine Pouch Use in Great Britain: A Representative Population Survey 2020-2021.

INTRODUCTION: Tobacco-free nicotine pouches are products that are placed between the lip and gum, where they deliver nicotine to users. Little is known about nicotine pouch use in Great Britain since they entered the market in 2019. METHODS: Data came from a monthly representative survey of the adult (≥18 years) population in Great Britain (England, Scotland, and Wales) between November 2020 and October 2021 (n = 25 698). We estimated the weighted prevalence of pouch use, overall and stratified by demographics, smoking status, and other nicotine use. RESULTS: Nicotine pouch use was rare among adults, with a weighted prevalence of just 0.26% (95% compatibility interval [CI] = 0.19-0.35). Prevalence doubled from November 2020 to October 2021 (0.14%-0.32%; prevalence ratio [PR] = 2.22, 95% CI = 1.33-3.70). Pouch use was over four times more common among men than women (0.42% vs. 0.09%; PR = 4.55, 95% CI = 2.27-9.09) but less common in older age groups (p < .001). Pouch use was more prevalent among current smokers (0.87%; PR = 13.60, 95% CI = 5.46-33.89), recent former smokers (0.97%; PR = 15.21, 95% CI = 4.03-57.42), and long-term (>1 year) former smokers (0.24%; PR = 3.71, 95% CI = 1.36-10.15), compared with never smokers (0.06%). Prevalence was also elevated among e-cigarette (1.64% vs. 0.15%; PR = 10.59, 95% CI = 5.74-19.52) and nicotine replacement therapy users (2.02% vs. 0.21%; PR = 9.75, 95% CI = 4.64-20.49). CONCLUSIONS: One in 400 adults in Great Britain use nicotine pouches, but the prevalence increased from 2020 to 2021. IMPLICATIONS: Tobacco-free nicotine pouches were introduced to the market in Great Britain in 2019. We found that while pouch use is currently rare in Great Britain, these products have become more popular over time. Pouch use is largely concentrated among younger and middle-aged men who use other nicotine products and have a history of smoking. Continued monitoring of nicotine pouch use is needed.

Youth use of e-liquid flavours-a systematic review exploring patterns of use of e-liquid flavours and associations with continued vaping, tobacco smoking uptake or cessation.

BACKGROUND AND AIMS: There is concern that young people may be attracted to e-liquid flavours, prompting long-term vaping in naive users and potentially subsequent tobacco smoking. We aimed to review the use of e-liquid flavours by young people and describe associations with uptake or cessation of both regular vaping and tobacco smoking, adverse effects and subjective experiences. DESIGN: Systematic review, including interventional, observational and qualitative studies reporting on the use of e-cigarette flavours by young people (aged < 18 years). SETTING: Studies published in English language from any country or cultural setting. PARTICIPANTS: Young people and their carers (aged < 18 years). MEASUREMENTS: A meta-analysis was not possible due to substantial heterogeneity, inconsistency in reporting of flavour categorizations and non-interventional study designs; thus, we narratively report findings. FINDINGS: In total, 58 studies were included. The quality of the evidence was extremely low. Most (n = 39) studies were cross-sectional survey designs. In total, 11 longitudinal cohort studies assessed trajectories; eight qualitative studies reported on user experiences. Studies reported views and experiences of a total of 512 874 young people. Both cross-sectional and longitudinal studies suggested that flavours are important for initiation and continuation of vaping. Qualitative evidence shows interest and enjoyment in flavours. There was judged to be insufficient evidence that use of e-liquid flavours specifically is associated with uptake of smoking. No studies found clear associations between flavours and cessation in this population. We found no included reports of adverse effects of flavours. CONCLUSIONS: Flavours may be an important motivator for e-cigarette uptake, but the role of flavours in tobacco smoking uptake or cessation is unclear. The quality of the evidence on use of e-cigarette flavours by young people is low overall.

The SPECTRUM Consortium: a new UK Prevention Research Partnership consortium focussed on the commercial determinants of health, the prevention of non-communicable diseases, and the reduction of health inequalities.

The main causes of non-communicable diseases (NCDs), health inequalities and health inequity include consumption of unhealthy commodities such as tobacco, alcohol and/or foods high in fat, salt and/or sugar. These exposures are preventable, but the commodities involved are highly profitable. The economic interests of 'Unhealthy Commodity Producers' (UCPs) often conflict with health goals but their role in determining health has received insufficient attention. In order to address this gap, a new research consortium has been established. This open letter introduces the SPECTRUM ( S haping  Public h Ealth poli Cies  To  Reduce ineq Ualities and har M)Consortium: a multi-disciplinary group comprising researchers from 10 United Kingdom (UK) universities and overseas, and partner organisations including three national public health agencies in Great Britain (GB), five multi-agency alliances and two companies providing data and analytic support. Through eight integrated work packages, the Consortium seeks to provide an understanding of the nature of the complex systems underlying the consumption of unhealthy commodities, the role of UCPs in shaping these systems and influencing health and policy, the role of systems-level interventions, and the effectiveness of existing and emerging policies. Co-production is central to the Consortium's approach to advance research and achieve meaningful impact and we will involve the public in the design and delivery of our research. We will also establish and sustain mutually beneficial relationships with policy makers, alongside our partners, to increase the visibility, credibility and impact of our evidence. The Consortium's ultimate aim is to achieve meaningful health benefits for the UK population by reducing harm and inequalities from the consumption of unhealthy commodities over the next five years and beyond.

Smokeless tobacco products, supply chain and retailers' practices in England: a multimethods study to inform policy.

BACKGROUND: In England, many people of South Asian origin consume smokeless tobacco (ST). ST use can lead to oral cancer, which is disproportionately high in South Asians. Our aims were to assess the compliance of ST product retailers with statutory regulations and to explore the supply chain of ST. METHODS: We undertook a multimethods study between August 2017 and July 2019 in five English boroughs with a high proportion of ethnic South Asians. We purchased ST products and conducted field surveys with ST retailers at point of sale. Qualitative interviews were conducted with ST retailers and suppliers. ST packs were assessed for regulatory compliance, while quantitative and qualitative data triangulated information on retailers' practices and the ST supply chain. RESULTS: We collected 41 unique ST products, which included dry snuff, naswar, gutka, chewing tobacco and zarda. ST products were not registered, and demonstrated low compliance with health warning (14.6%) and packaging (56.1%) requirements. ST availability in surveyed boroughs was high (38.2%-69.7%); dry snuff, naswar and zarda were most commonly available. ST retailers demonstrated limited knowledge of regulations, and one-third were found to advertise ST at point of sale. Qualitative insights revealed illicit supply and distribution networks, as well as ST production in discreet locations. CONCLUSION: ST products are widely available in England, yet non-compliant with statutory regulations. In order to safeguard consumers, in particular ethnic South Asians, stronger efforts are needed to regulate the supply chain of ST at both national and international levels.

Reciprocal influences of tobacco use on illicit opioid and alcohol use during the first six-months of specialist addiction treatment.

BACKGROUND: This is the first national study of lagged reciprocal associations between tobacco smoking frequency and change in illicit opioid or alcohol use frequency within six-months of treatment. METHODS: All adults admitted to publicly-funded specialist addiction treatment in England in 2018/19 and enrolled for at least six months for either opioid use disorder (OUD; n = 22,046; 82.4 % of those eligible) or alcohol use disorder (AUD; n = 15,251; 78.8 % of those eligible). Two cross-lagged panel models estimated, separately for OUD and AUD patients, the relationships between smoking at admission and change in main drug over six months, and between main drug use at admission and change in smoking over six months. RESULTS: Within the OUD cohort, illicit opioid use frequency reduced from 17.7 days to 8.0 days and smoking tobacco remained at 18.8 days. After controlling for available covariates, higher smoking frequency at admission was associated with a relative increase in illicit opioid use at six-months (0.02 days [95 % CI 0.00-0.03]). Within the AUD cohort, alcohol use frequency reduced from 21.2 days to 14.4 days while smoking tobacco reduced from 12.6 days to 11.5 days. Higher smoking frequency at admission was associated with a relative increase in alcohol use at six-months (0.03 days [95 % CI 0.02-0.04]) and higher alcohol use frequency at admission was associated with a relative increase in smoking at six-months (0.04 [95 % CI 0.02-0.06]), controlling for available covariates. CONCLUSIONS: Higher smoking frequency at admission is associated with higher illicit opioid and alcohol use frequency after six-months of specialist addiction treatment.

Stop Smoking Practitioners' understanding of e-cigarettes' use and efficacy with particular reference to vapers' socioeconomic status.

Introduction: We have undertaken four online surveys of Stop Smoking Service (SSS) practitioners in England, between 2011 and 2016, in order to enhance our understanding of e-cigarettes: a fast moving new phenomenon. It is important to understand whether e-cigarettes can ameliorate or exacerbate health inequalities given that smoking is one of the most serious causes of excessive mortality and morbidity among disadvantaged groups globally. Aims: To update findings of previous surveys and examine socioeconomic status differences in e-cigarette use and efficacy. Methods: Analysis was undertaken of electronic surveys, particularly, the most recent 2016 survey (n = 514) and 2015/16 SSS client routine monitoring data. Results: SSS practitioners were becoming more positive about e-cigarettes: 42% agreed that e-cigarettes were a good thing compared with 15% in 2011. Reported use of e-cigarettes among SSS clients was low (about 3%) despite higher quit rates (63% of clients reported being quit at four week follow-up, compared with 51% overall). Where socioeconomic differences in e-cigarettes' efficacy for quitting were identified, affluent and working smokers were advantaged. Conclusions: Low use of e-cigarettes by clients and practitioner opinions suggest that further education of SSS staff is needed if they are to adopt the current service recommendations about e-cigarettes.

Young People's Use of E-Cigarettes across the United Kingdom: Findings from Five Surveys 2015-2017.

Concern has been expressed about the use of e-cigarettes among young people. Our study reported e-cigarette and tobacco cigarette ever and regular use among 11-16 year olds across the UK. Data came from five large scale surveys with different designs and sampling strategies conducted between 2015 and 2017: The Youth Tobacco Policy Survey; the Schools Health Research Network Wales survey; two Action on Smoking and Health (ASH) Smokefree Great Britain-Youth Surveys; and the Scottish Schools Adolescent Lifestyle and Substance Use Survey. Cumulatively these surveys collected data from over 60,000 young people. For 2015/16 data for 11-16 year olds: ever smoking ranged from 11% to 20%; regular (at least weekly) smoking between 1% and 4%; ever use of e-cigarettes 7% to 18%; regular (at least weekly) use 1% to 3%; among never smokers, ever e-cigarette use ranged from 4% to 10% with regular use between 0.1% and 0.5%; among regular smokers, ever e-cigarette use ranged from 67% to 92% and regular use 7% to 38%. ASH surveys showed a rise in the prevalence of ever use of e-cigarettes from 7% (2016) to 11% (2017) but prevalence of regular use did not change remaining at 1%. In summary, surveys across the UK show a consistent pattern: most e-cigarette experimentation does not turn into regular use, and levels of regular use in young people who have never smoked remain very low.

Views from the Coalface: What Do English Stop Smoking Service Personnel Think about E-Cigarettes?

The UK Stop Smoking Services (SSS) are a source of information and advice on e-cigarettes for smokers and thus it is important to understand the knowledge of, and attitudes towards, e-cigarettes held by stop smoking practitioners. The datasets were English SSS quarterly monitoring returns (n = 207,883) and an online survey of English SSS practitioners, managers, and commissioners between 26th November and 15th December 2014 (n = 1801). SSS monitoring data suggested 2% of clients were using e-cigarettes to quit with SSS and that clients using e-cigarettes had similar quit rates to clients using Varenicline. Most SSS personnel are waiting for licenced e-cigarettes to become available before they will recommend them to clients. However, less than a quarter view e-cigarettes as "a good thing". Managers and commissioners were more positive than practitioners. SSS personnel working for the NHS (hospitals and GP surgeries) were less positive about e-cigarettes than those employed elsewhere. E-cigarettes were cited as the most important reason for the recent decline in service footfall. Thus dissemination of information about e-cigarettes needs to be examined and services should address their stance on e-cigarettes with some urgency.

Adolescents' exposure to tobacco and alcohol content in YouTube music videos.

AIMS: To quantify tobacco and alcohol content, including branding, in popular contemporary YouTube music videos; and measure adolescent exposure to such content. DESIGN: Ten-second interval content analysis of alcohol, tobacco or electronic cigarette imagery in all UK Top 40 YouTube music videos during a 12-week period in 2013/14; on-line national survey of adolescent viewing of the 32 most popular high-content videos. SETTING: Great Britain. PARTICIPANTS: A total of 2068 adolescents aged 11-18 years who completed an on-line survey. MEASUREMENTS: Occurrence of alcohol, tobacco and electronic cigarette use, implied use, paraphernalia or branding in music videos and proportions and estimated numbers of adolescents who had watched sampled videos. FINDINGS: Alcohol imagery appeared in 45% [95% confidence interval (CI) = 33-51%] of all videos, tobacco in 22% (95% CI = 13-27%) and electronic cigarettes in 2% (95% CI = 0-4%). Alcohol branding appeared in 7% (95% CI = 2-11%) of videos, tobacco branding in 4% (95% CI = 0-7%) and electronic cigarettes in 1% (95% CI = 0-3%). The most frequently observed alcohol, tobacco and electronic cigarette brands were, respectively, Absolut Tune, Marlboro and E-Lites. At least one of the 32 most popular music videos containing alcohol or tobacco content had been seen by 81% (95% CI = 79%, 83%) of adolescents surveyed, and of these 87% (95% CI = 85%, 89%) had re-watched at least one video. The average number of videos seen was 7.1 (95% CI = 6.8, 7.4). Girls were more likely to watch and also re-watch the videos than boys, P < 0.001. CONCLUSIONS: Popular YouTube music videos watched by a large number of British adolescents, particularly girls, include significant tobacco and alcohol content, including branding.