Trends in vaping and smoking following the rise of disposable e-cigarettes: a repeat cross-sectional study in England between 2016 and 2023.

Background: There has been a rapid rise in disposable (single-use) e-cigarette vaping among young adults in England since June 2021 (leading to a planned ban on these products). We examined how this has affected population trends in current (i) vaping, (ii) tobacco smoking, and (iii) inhaled nicotine use. Methods: We used data from a nationally-representative monthly repeat cross-sectional survey of adults (≥18) in England (n = 132,252; July-2016-May-2023). Using interrupted time-series analyses (segmented logistic regression), we estimated yearly trends in current tobacco smoking, vaping, and inhaled nicotine use (smoking and/or vaping) before ('pre-disposables') and after June-2021 ('post-disposables'), stratified by age group (18 to 24, 25 to 44, 45 and over). We also examined trends in daily use and in vaping among never-smokers. Findings: Pre-disposables, vaping and smoking prevalence had been stable or declining across all age groups. However, post-disposables, the odds of current vaping increased by 99% per year among 18 to 24-year-olds (odds ratio [OR] = 1.99; 95% confidence interval [CI] = 1.71 to 2.31), compared with 39% (OR = 1.39; 95% CI = 1.26 to 1.52) in 25 to 44-year-olds and 23% (OR = 1.23; 95% CI = 1.12 to 1.35) in those aged 45 or older. Smoking rates continued to decline - albeit modestly - in 18 to 24-year-olds (OR = 0.88, 95% CI = 0.77 to 1.00) and 25 to 44-year-olds (OR = 0.93, 95% CI = 0.86 to 1.00), but increased among those aged 45 or older (OR = 1.12, 95% CI = 1.05 to 1.20). As a result, post-disposables, the overall prevalence of inhaled nicotine use increased across all age groups. Trends were similar for daily use, but post-disposables increases in vaping were greatest among people who had never regularly smoked (e.g., 18 to 24-year-olds: OR = 2.50, 95% CI = 1.82 to 3.43). Interpretation: Since disposable vapes started becoming popular in England, historic declines in nicotine use have reversed. Now, nicotine use appears to be rising, driven primarily by sharp increases in vaping among young people. Smoking declines have been most pronounced in age groups with the largest increases in vaping. Funding: Cancer Research UK.

Secondhand Nicotine Absorption From E-Cigarette Vapor vs Tobacco Smoke in Children.

Importance: With the prevalence of e-cigarette use (vaping) increasing worldwide, there are concerns about children's exposure to secondhand vapor. Objective: To compare nicotine absorption among children who are (1) exposed to secondhand tobacco smoke only or (2) exposed to secondhand vapor only with (3) those exposed to neither. Design, Setting, and Participants: The US Continuous National Health and Nutrition Examination Survey (NHANES) is a repeat cross-sectional survey. Participants are interviewed in their homes and, several days after, visit a mobile examination center to provide biological specimens. This study uses data from a nationally representative sample of US households from 2017 to 2020. Participants were children aged 3 to 11 years with serum cotinine levels incompatible with current firsthand nicotine use (ie, <15 µg/L). The final analysis was conducted on January 9, 2024. Exposures: Reported exposure to secondhand smoke or vapor indoors in the past 7 days (only secondhand smoke, only secondhand vapor, or neither). Covariates included age, sex, ethnicity, family income, body weight, and height. Main Outcomes and Measures: The primary outcome was serum cotinine concentration, an objective biomarker of nicotine absorption. Geometric mean cotinine levels and 95% CIs were calculated using log-normal tobit regression, accounting for the complex survey design and weights. Results: The mean (SD) age of the 1777 children surveyed was 7.4 (2.6) years, 882 (49.6%) were female, and 531 (29.9%) had family incomes below the poverty level. Nicotine absorption, as indexed by serum cotinine level, was highest among children only exposed to secondhand smoke (0.494 µg/L µg/L; 95% CI, 0.386-0.633 µg/L), followed by those exposed only to secondhand vapor (0.081 µg/L; 95% CI, 0.048-0.137 µg/L), equating to 83.6% (95% CI, 71.5%-90.5%; P < .001) lower nicotine absorption. Among children with no reported secondhand exposure, the geometric mean cotinine level was 0.016 µg/L (95% CI, 0.013-0.021 µg/L), or 96.7% (95% CI, 95.6%-97.6%; P < .001) lower than for those with exposure to secondhand smoke. Results were similar after covariate adjustment. Conclusions and Relevance: In this cross-sectional study of US children, nicotine absorption was much lower in children who were exposed to secondhand vapor vs secondhand smoke, but higher than in those exposed to neither. These findings suggest that switching from smoking to vaping indoors may substantially reduce, but not eliminate, children's secondhand exposure to nicotine and other noxious substances.

Trends in long term vaping among adults in England, 2013-23: population based study.

OBJECTIVE: To examine trends in long term (>6 months) vaping among adults in England. DESIGN: Population based study. SETTING: England. PARTICIPANTS: 179 725 adults (≥18 years) surveyed between October 2013 and October 2023. MAIN OUTCOME MEASURES: Time trends in prevalence of long term vaping using logistic regression, overall and by vaping frequency (daily or non-daily), and main type of device used (disposable, refillable, or pod). RESULTS: The proportion of adults reporting long term vaping increased non-linearly, from 1.3% (95% confidence interval 1.1% to 1.5%) in October 2013 to 10.0% (9.2% to 10.9%) in October 2023, with a particularly pronounced rise from 2021. This rise included an increase in long term daily vaping, from 0.6% (0.5% to 0.8%) to 6.7% (6.0% to 7.4%). Absolute increases in long term vaping were larger among people with a history of regular smoking (current smokers: 4.8% (4.0% to 5.8%) to 23.1% (20.4% to 25.9%); recent former smokers: 5.7% (3.4% to 9.2%) to 36.1% (27.6% to 45.4%); long term former smokers: 1.4% (1.0% to 1.9%) to 16.2% (14.2% to 18.4%)), but an increase also occurred among people who had never regularly smoked (0.1% (0.0% to 0.2%) to 3.0% (2.3% to 3.8%)). Growth was also more pronounced in young adults (eg, reaching 22.7% (19.2% to 26.5%) of 18 year olds v 4.3% (3.6% to 5.2%) of 65 year olds), including among those who had never regularly smoked (reaching 16.1% (11.1% to 22.7%) of 18 year olds v 0.3% (0.1% to 0.6%) of 65 year olds). Between October 2013 and March 2021, most long term vapers mainly or exclusively used refillable electronic cigarettes (2.5% to 3.3% of adults) and few (0.1% of adults) used disposable devices. However, prevalence of long term vaping using disposable devices subsequently rose rapidly, and by October 2023 similar proportions of adults mainly or exclusively used disposable and refillable devices (4.9% (4.2% to 5.7%) and 4.6% (4.0% to 5.3%), respectively). CONCLUSIONS: The prevalence of long term vaping increased substantially among adults in England during 2013-23. Much of this increase occurred from 2021, coinciding with the rise in popularity of disposable e-cigarettes. Half of long term vapers now mainly or exclusively use disposable devices. The growth was concentrated among people with a history of regular smoking, but an increase also occurred among people who never regularly smoked, especially young adults.

Trends in Daily Cigarette Consumption Among Smokers: A Population Study in England, 2008-2023.

INTRODUCTION: This study aimed to estimate time trends in cigarette consumption among smokers in England between 2008 and 2023 and to explore differences by key potential moderators. AIMS AND METHODS: We used data from 57 778 adult cigarette smokers participating in a nationally representative monthly cross-sectional survey between January 2008 and September 2023. We estimated monthly time trends in mean daily consumption of (1) any, (2) manufactured, and (3) hand-rolled cigarettes among all smokers and by main type of cigarettes smoked, smoking frequency, age, gender, occupational social grade, region, nicotine replacement therapy use, and vaping status. RESULTS: Overall cigarette consumption fell from 13.6 [95% CI = 13.3 to 13.9] to 10.6 [10.5 to 10.8] per day between January 2008 and October 2019 (a 22% decrease), then remained stable up to September 2023. Over this period, the proportion mainly or exclusively smoking hand-rolled cigarettes increased (from 30.6% [29.1%-32.1%] in 2008 to 52.1% [49.7%-54.5%] in 2023). As a result, manufactured cigarette consumption fell by 47%, from 9.5 [9.2-9.8] per day in January 2008 to 5.0 [4.7-5.3] in September 2023, while hand-rolled cigarette consumption increased by 35%, from 4.2 [3.9-4.4] to 5.6 [5.3-5.9], respectively. The decline in overall cigarette consumption was observed across all subgroups, but was greater among non-daily smokers, younger smokers, and those who vaped. CONCLUSIONS: Over the last 15 years, the average number of cigarettes consumed each day by smokers in England has fallen by almost a quarter, but has plateaued since October 2019. There has been a sharp decline in the number of manufactured cigarettes consumed and an increase in the number of hand-rolled cigarettes consumed, as smokers have increasingly shifted towards using hand-rolled tobacco. IMPLICATIONS: While average cigarette consumption in England has fallen over the past 15 years, this declining trend has stalled (and reversed in some population groups) since 2019. The availability of cheap, hand-rolled tobacco appears to be undermining policies that aim to reduce smoking by raising the price of tobacco (eg, through taxation) and could be targeted to reignite the decline in cigarette consumption.

Are people more likely to vape or smoke indoors? A population survey of adults in England.

BACKGROUND: Increasingly, people smoke cigarettes outdoors and avoid exposing bystanders to harm. People may not have the same motivation to vape outdoors since e-cigarettes, unlike cigarettes, do not create side stream emissions and exhaled aerosol contains fewer toxicants than secondhand smoke. This study aims to estimate the prevalence and correlates of vaping and smoking indoors among adults in England. METHODS: Data came from the Health Survey for England 2019, a cross-sectional household survey. Adults who vape or smoke (N=1,530) were asked whether they had vaped or smoked indoors inside the home, car, or other places within the past seven days. Logistic regression was used to estimate prevalence and key correlates of indoor use, including age, sex, presence of adults/children in home, housing tenure and nicotine dependence. RESULTS: People who exclusively vaped were much more likely to use their product indoors than those who exclusively smoked (87.0% versus 52.0%; odds ratio [OR]=6.16, 95% confidence interval [CI]=4.09-9.28). Similarly, people who dual used had higher odds of vaping than smoking indoors (62.1% versus 44.3%; within-person OR=3.76, 95%CI=2.06-6.84). The preference for vaping over smoking indoors was found across different locations, including at home and in cars. Those who were older, highly dependent on nicotine, and lived alone were most prone to use any product indoors. While housing tenure was not strongly associated with vaping indoors, those living in social housing were much more likely to smoke indoors than homeowners. CONCLUSIONS: Adults in England are much more likely to vape than smoke indoors. Age, nicotine dependence, and living alone are strongly associated with both behaviours. IMPLICATIONS: Our results show that people have a strong preference for vaping over smoking indoors, including in the home. Given the high prevalence of vaping indoors, policymakers, landlords and businesses must weigh up the ethics, benefits, and harms of extending smoke-free laws to include e-cigarettes.

Impact of the disruption in supply of varenicline since 2021 on smoking cessation in England: A population study.

BACKGROUND AND AIMS: Varenicline is one of the most effective smoking cessation treatments. Its supply in England was disrupted in July 2021 due to nitrosamine impurities found by its supplier, Pfizer. This study measured the impact of this disruption on smoking cessation in England. DESIGN, SETTING AND PARTICIPANTS: The study used repeated cross-sectional surveys conducted monthly, from June 2018 to December 2022. Set in England, it comprised a total of 3024 adults who reported smoking during the past year and had made at least one serious attempt to quit in the past 6 months. MEASUREMENTS: Generalized additive models analyzed the association of the varenicline supply disruption with the trend in self-reported varenicline use in the most recent quit attempt. We used these results to estimate the population-level impact of the disruption on smoking cessation. FINDINGS: Before July 2021, the proportion of past 6-month quit attempts using varenicline was stable at approximately 3.9% [risk ratio (RR)trend = 1.034, 95% confidence interval (CI) = 0.823-1.298]. The trend in varenicline use has changed sharply since the supply disruption (RRΔtrend = 0.297, 95% CI = 0.120-0.738), with prevalence falling by 69.3% per year since; from 4.1% in June 2021 to 0.8% in December 2022. Convergently, National Health Service general practitioner prescribing data reported that just 0.1% of prescriptions for smoking cessation treatments in December 2022 were for varenicline. Assuming that varenicline does not return to the market, we estimate that this could result in ~8400 fewer people stopping smoking for at least 6 months, ~4200 fewer long-term ex-smokers and ~1890 more avoidable deaths each year. CONCLUSIONS: In England, the disruption in supply of varenicline since 2021 has coincided with a substantial fall in the use of varenicline in attempts to quit smoking.

Smoking prevalence and purchasing of menthol cigarettes since the menthol flavour ban in Great Britain: a population-based survey between 2020 and 2023.

BACKGROUND: Menthol cigarettes have been banned in Great Britain (GB) since May 2020. Still, menthol accessories and unlabelled cigarettes perceived as mentholated are available, and people can buy menthol cigarettes overseas or illicitly. This study assessed: trends in smoking menthol cigarettes among all adults and 18-24-year-olds in GB between October 2020 and March 2023; trends in and differences between England, Scotland and Wales during the same period and purchase sources among people smoking menthol versus non-flavoured cigarettes. METHODS: Population-weighted data were from a monthly cross-sectional survey of adults in GB. Among people smoking cigarettes, we calculated the proportion smoking menthol cigarettes across all adults and 18-24-year-olds, and prevalence ratios (PR) between the first and last quarter. We also calculated the proportions of people smoking menthol/non-flavoured cigarettes by purchase source (including illicit sources). RESULTS: In the first quarter, 16.2% of adults smoking cigarettes reported menthol cigarette smoking with little to no decline throughout the study (PR 0.85, 95% CI 0.71 to 1.01), while it declined among 18-24-year-olds (PR 0.75, 95% CI 0.63 to 0.89). The prevalence of menthol cigarette smoking fell by two-thirds in Wales (PR 0.36, 95% CI 0.19 to 0.62) but remained relatively stable in England (PR 0.88, 95% CI 0.72 to 1.06) and Scotland (PR 0.94, 95% CI 0.59 to 1.53). The main purchasing sources were licit (93.9%), 14.8% reported illicit sources and 11.5% cross-border purchases, without notable differences from people smoking non-flavoured cigarettes. CONCLUSIONS: Roughly one million adults in GB still smoke menthol cigarettes and, with the exception of Wales and young people, there were no noteworthy changes in the post-ban period. There was no indication that the overall persistence of menthol smoking was driven by illicit purchases.

Trends in Harm Perceptions of E-Cigarettes vs Cigarettes Among Adults Who Smoke in England, 2014-2023.

Importance: Electronic cigarettes (e-cigarettes) are less harmful to users than combustible cigarettes. However, public health and media reporting have often overstated the potential risks of e-cigarettes, and inaccurate perceptions of the harms of vaping relative to smoking are pervasive. Objective: To examine time trends in harm perceptions of e-cigarettes compared with combustible cigarettes among adults who smoke. Design, Setting, and Participants: This nationally representative monthly cross-sectional survey study was conducted from November 2014 to June 2023 in England. Participants were adults who currently smoke. Main Outcomes and Measures: Participants were asked whether they thought e-cigarettes were less harmful, equally harmful, or more harmful than cigarettes, or did not know, with the proportion responding less harmful (vs all other responses) as the primary outcome. Logistic regression was used to test associations between survey wave and participants' perceptions of the harms of e-cigarettes. Results: Data were collected from 28 393 adults who smoke (mean [SD] age, 43.5 [17.3] years; 13 253 [46.7%] women). In November 2014, 44.4% (95% CI, 42.0%-46.8%) thought e-cigarettes were less harmful than cigarettes, 30.3% (95% CI, 28.2%-32.6%) thought e-cigarettes were equally harmful, 10.8% (95% CI, 9.4%-12.3%) thought they were more harmful, and 14.5% (95% CI, 12.9%-16.4%) did not know. However, by June 2023, the proportion who thought e-cigarettes were less harmful had decreased by 40% (prevalence ratio, 0.60; 95% CI, 0.55-0.66), and the proportion who thought e-cigarettes were more harmful had more than doubled (prevalence ratio, 2.16; 95% CI, 1.84-2.54). Changes over time were nonlinear: late 2019 saw a sharp decline in the proportion who thought e-cigarettes were less harmful and increases in the proportions who thought they were equally or more harmful. These changes were short-lived, returning to pre-2019 levels by the end of 2020. However, perceptions worsened again from 2021 up to the end of the study period: the proportion who thought e-cigarettes were more harmful increased to a new high, and the proportion who thought e-cigarettes were less harmful decreased to levels comparable to those in late 2019. As a result, in June 2023, the perception that e-cigarettes were equally as harmful as cigarettes was the most commonly held view among adults who smoke (33.7%; 95% CI, 31.4%-36.1%), with roughly similar proportions perceiving e-cigarettes to be less (26.7%; 95% CI, 24.6%-28.9%) and more (23.3%; 95% CI, 21.1%-25.7%) harmful. Conclusions and Relevance: This survey study of adults who smoke in England found that harm perceptions of e-cigarettes have worsened substantially over the last decade, such that most adults who smoked in 2023 believed e-cigarettes to be at least as harmful as cigarettes. The timing of the 2 most notable changes in harm perceptions coincided with the e-cigarette, or vaping product, use-associated lung injury outbreak in 2019 and the recent increase in youth vaping in England since 2021.

Who would be affected by a ban on disposable vapes? A population study in Great Britain.

OBJECTIVES: The UK government is consulting on banning disposable e-cigarettes. This study aimed to describe trends in disposable e-cigarette use among adults in Great Britain since 2021 and establish who would currently be affected by a ban on disposables. STUDY DESIGN: Nationally-representative monthly cross-sectional survey. METHODS: We analysed data from 69,973 adults surveyed between January 2021 and August 2023. We estimated monthly time trends in the weighted prevalence of current disposable e-cigarette use among adults and by sociodemographic characteristics and smoking status. RESULTS: From January 2021 to August 2023, the prevalence of disposable e-cigarette use grew from 0.1 % to 4.9 %. This rise was observed across all population subgroups but was most pronounced among younger adults (e.g. reaching 15.9 % of 18-year-olds compared with 1.3 % of 65-year-olds), those who currently smoke (16.3 %), and those who stopped smoking in the past year (18.2 %). Use among never smokers remained relatively rare (1.5 %), except among 18- to 24-year-olds (7.1 %). Use was significantly higher in England than Wales or Scotland (5.3 % vs. 2.0 % and 2.8 %) and among less (vs. more) advantaged social grades (6.1 % vs. 4.0 %), those with (vs. without) children (6.4 % vs. 4.4 %), and those with (vs. without) a history of mental health conditions (9.3 % vs. 3.1 %). CONCLUSIONS: A ban on disposable e-cigarettes would currently affect one in 20 adults in Great Britain (approximately 2.6 million people). The proportion who would be affected would be greatest among young people, including the 316,000 18-24 year-olds who currently use disposables but who have never regularly smoked tobacco, which may discourage uptake of vaping in this group. However, a ban would also affect 1.2 million people who currently smoke and a further 744,000 who previously smoked. It would also have a disproportionate impact on disadvantaged groups that have higher rates of smoking and typically find it harder to quit.

Brief interventions for smoking and alcohol associated with the COVID-19 pandemic: a population survey in England.

BACKGROUND: Following the onset of the COVID-19 pandemic, in March 2020 health care delivery underwent considerable changes. It is unclear how this may have affected the delivery of Brief Interventions (BIs) for smoking and alcohol. We examined the impact of the COVID-19 pandemic on the receipt of BIs for smoking and alcohol in primary care in England and whether certain priority groups (e.g., less advantaged socioeconomic positions, or a history of a mental health condition) were differentially affected. METHODS: We used nationally representative data from a monthly cross-sectional survey in England between 03/2014 and 06/2022. Monthly trends in the receipt of BIs for smoking and alcohol were examined using generalised additive models among adults who smoked in the past-year (weighted N = 31,390) and those using alcohol at increasing and higher risk levels (AUDIT score 38, weighted N = 22,386), respectively. Interactions were tested between social grade and the change in slope after the onset of the COVID-19 pandemic, and results reported stratified by social grade. Further logistic regression models assessed whether changes in the of receipt of BIs for smoking and alcohol, respectively, from 12/2016 to 01/2017 and 10/2020 to 06/2022 (or 03/2022 in the case of BIs for alcohol), depended on history of a mental health condition. RESULTS: The receipt of smoking BIs declined from an average prevalence of 31.8% (95%CI 29.4-35.0) pre-March 2020 to 24.4% (95%CI 23.5-25.4) post-March 2020. The best-fitting model found that after March 2020 there was a 12-month decline before stabilising by June 2022 in social grade ABC1 at a lower level (~ 20%) and rebounding among social grade C2DE (~ 27%). Receipt of BIs for alcohol was low (overall: 4.1%, 95%CI 3.9-4.4) and the prevalence was similar pre- and post-March 2020. CONCLUSIONS: The receipt of BIs for smoking declined following March 2020 but rebounded among priority socioeconomic groups of people who smoked. BIs for alcohol among those who use alcohol at increasing and higher risk levels were low and there was no appreciable change over time. Maintaining higher BI delivery among socioeconomic and mental health priority groups of smokers and increasing and higher risk alcohol users is important to support reductions in smoking and alcohol related inequalities.

Comparing identity, attitudes, and indicators of effectiveness in people who smoke, vape or use heated tobacco products: A cross-sectional study.

BACKGROUND: There is limited long-term and independent research on heated tobacco products (HTPs). We compared people who used HTPs with those who used nicotine vaping products (NVP) or cigarettes on smoker identity, indicators of effectiveness and, among NVP/HTP users, perceptions of these products. METHODS: Adults exclusive cigarette smokers (N = 45) and ex-smokers with medium/long-term (>3months) NVP (N = 46) or HTP use (N = 45) were recruited in London, UK. Participants completed a questionnaire assessing socio-demographics, smoking characteristics, smoker identity, dependence, intention to stop and attitudes towards HTP/NVP. RESULTS: In adjusted analysis, people who used cigarettes (Mean Difference (MD) = 1.4, 95%Confidence Intervals (CI) 0.7,2.0) and HTPs (MD = 0.8, 95%CI 0.1, 1.5) reported stronger smoker identities than those who used NVPs. Compared with smokers, HTP/NVP users had lower cravings for cigarettes (MD = 3.0, 95%CI 1.6, 4.3; MD = 3.1, 95%CI 1.9, 4.3, respectively), and higher intention to stop product use (MD = -0.8, 95%CI -1.7,-0.01; MD = -1.2, 95%CI -2.0, -0.3, respectively). People using HTPs or NVPs reported similar perceived product satisfaction (HTP:M = 3.4, 95%CI 2.8, 3.9; NVP:M = 3.0, 95%CI 2.5, 3.5), efficacy for smoking cessation (HTP:M = 4.5, 95%CI 4.2, 4.9; NVP:M = 4.6, 95%CI 4.3, 4.9) and safety (HTP:M = 2.1, 95%CI 2.0, 2.2; NVP:M = 2.0, 95%CI 1.8, 2.1). HTP users reported greater perceived addictiveness than NVPs (MD = 0.3, 95%CI 0.2, 0.6). CONCLUSIONS: HTP and NVP users perceived products to be similarly acceptable and effective suggesting that HTPs, like NVPs, may support smoking cessation. However, since HTP use appears to maintain a stronger smoker identity and perceived addiction, this may suggest a more limited role of HTP for a permanent transition away from cigarettes.

Have there been sustained impacts of the COVID-19 pandemic on trends in smoking prevalence, uptake, quitting, use of treatment, and relapse? A monthly population study in England, 2017-2022.

BACKGROUND: Studies conducted during the early stages of the pandemic documented mixed changes in smoking behaviour: more smokers quitting successfully but little change in prevalence. This study aimed to examine whether there have been sustained impacts of the COVID-19 pandemic on smoking patterns in England. METHODS: Data were from 101,960 adults (≥ 18 years) participating in the Smoking Toolkit Study, a monthly representative household survey, between June 2017 and August 2022. Interviews were conducted face-to-face until March 2020 and via telephone thereafter. Generalised additive models estimated associations of the pandemic onset (March 2020) with current smoking, uptake, cessation, quit attempts, and use of support. Models adjusted for seasonality, sociodemographic characteristics, and (where relevant) dependence and tobacco control mass-media expenditure. RESULTS: Before the COVID-19 pandemic, smoking prevalence fell by 5.2% per year; this rate of decline slowed to 0.3% per year during the pandemic (RRΔtrend = 1.06, 95% CI = 1.02, 1.09). This slowing was evident in more but not less advantaged social grades (RRΔtrend = 1.15, 1.08, 1.21; RRΔtrend = 1.00, 0.96, 1.05). There were sustained step-level changes in different age groups: a 34.9% (95% CI = 17.7, 54.7%) increase in smoking prevalence among 18-24-year-olds, indicating a potential rise in uptake, in contrast to a 13.6% (95% CI = 4.4, 21.9%) decrease among 45-65-year-olds. In both age groups, these step-level changes were followed by the pre-pandemic declines stopping, and prevalence remaining flat. There were sustained increases in quitting among past-year smokers, with a 120.4% (95% CI = 79.4, 170.9%) step-level increase in cessation and a 41.7% (95% CI = 29.7, 54.7%) increase in quit attempts. The main limitation was the change in modality of data collection when the pandemic started; while this may have contributed to the step-level changes we observed, it is unlikely to explain changes in the slope of trends. CONCLUSIONS: In England, the rate of decline in adult smoking prevalence stagnated during the COVID-19 pandemic through to 2022. At the start of the pandemic, a potential reduction in smoking prevalence among middle-aged adults and increases in quitting among smokers may have been offset by an increase in smoking among young adults. The slowing in the rate of decline was pronounced in more advantaged social grades.

Examining acute psychopharmacological effects of nicotine vaping versus heated tobacco products in a randomised crossover study of product naïve adult smokers.

Nicotine vaping products (NVPs) and heated tobacco products (HTPs) are designed to replicate the sensory and behavioural aspects of smoking cigarettes while avoiding combustion. The success of these products as harm reduction tools will partially depend on their ability to satisfy smokers and alleviate nicotine-related withdrawal symptoms. This study aims to compare short-term effects of NVPs (Juul and Aspire PockeX) versus HTPs (IQOS) on smoking-related withdrawal relief, product satisfaction, intention to switch to NVP/HTP, perceptions and attitudes in UK adult cigarette smokers naïve to these products. In a randomized cross-over study, 45 participants visited the lab twice, at each visit trying one of the two products (NVP/HTP) and completing a questionnaire. Responses were normalized on a 0-100% scale and mean differences (MD) between NVP and HTP scores computed, with positive and negative MD values indicating greater endorsement for NVP and HTP, respectively. Cigarette cravings were reduced similarly (~ 20.0%) by both products (MD = 4.5%, 95%Confidence Interval (CI) - 4.8, 13.8). Direct positive effects (MD = - 3.5%, 95%CI - 7.2, 0.2) and adverse side effects (MD = 1.8%, 95%CI - 0.3, 3.8) were comparable after each product use, though marginally favouring HTPs. HTPs were perceived as more satisfying overall (MD = - 13.2%, 95%CI - 20.3 - 6.1) than NVPs but both were perceived as similarly addictive (MD = 3.6%, 95%CI - 4.6, 11.8), relative to cigarettes. Intention to switch to either product was comparable (MD = 4.0%, 95%CI - 5.7, 13.8). Comparison of acute use of NVP versus HTP in a sample of UK smokers naïve to these products suggests that HTPs are perceived as more satisfying than NVPs, though still less satisfying than cigarettes.Registration: The analysis plan was pre-registered, and it is available at https://osf.io/6ymdu.

Trends in where people buy their vaping products and differences by user and device characteristics: A population study in England, 2016-23.

AIMS: To explore where people in England typically buy e-cigarettes/vaping products, how their characteristics and the types of products purchased differ according to the source of purchase and whether this is changing over time. DESIGN: This was a nationally representative monthly cross-sectional survey. SETTING: The study was conducted in England, 2016-23. PARTICIPANTS: A total of 6507 adults (≥ 18 years) who reported current vaping. MEASUREMENTS: Participants were asked where they usually buy their vaping products: vape shops, supermarkets/convenience stores, on-line or other sources ('other' or cheap from friends). FINDINGS: Up to 2020, vape shops were the most common source of purchase (mean monthly proportion = 43.3%), followed by supermarkets/convenience stores (29.7%) and on-line retailers (20.5%). In 2020, these purchasing patterns shifted: on-line purchasing increased and vape-shop purchasing fell. The rise in on-line purchasing was short-lived, peaking at 33.6% [95% confidence interval (CI) = 31.0-36.5%] in July 2021, and soon returned to baseline levels. However, the fall in vape-shop purchasing persisted, remaining below 31% from July 2021 onwards, displaced by a rapid rise in purchasing from supermarkets and convenience stores from 31.6% (95% CI = 29.6-33.7%) in January 2021 to 48.5% (95% CI = 42.9-54.8%) by April 2023. This rise was most pronounced among younger adults (aged 18-35 years; Pinteraction < 0.001) and those mainly using disposable devices (Pinteraction = 0.013). Purchasing from other sources was relatively rare, and declined from 9.1% (95% CI = 6.6-12.7%) in July 2016 to 4.3% (95% CI = 2.6-7.1%) in April 2023. CONCLUSIONS: Supermarkets and convenience stores have recently overtaken vape shops to become the most popular places to buy vaping products in England. This change appears to have been driven by the rising popularity of new disposable e-cigarettes among younger adults, who tend to buy these products from supermarkets/convenience stores.

How has Expenditure on Nicotine Products Changed in a Fast-Evolving Marketplace? A Representative Population Survey in England, 2018-2022.

INTRODUCTION: In the last 5 years, there has been a dramatic shift in the types of nicotine products being purchased. This study aimed to estimate how much users spend on types of cigarettes and alternative nicotine products (e-cigarettes, nicotine replacement therapy (NRT), heated tobacco, and nicotine pouches) and describe changes between 2018 and 2022. AIMS AND METHODS: Monthly representative cross-sectional survey in England. 10 323 adults who smoked cigarettes or used alternative nicotine reported their average weekly expenditure on these products, adjusted for inflation. RESULTS: Smokers spent £20.49 [95% CI = 20.09-20.91] on cigarettes each week (£27.66 [26.84-28.50] and £15.96 [15.49-16.28] among those who mainly smoked manufactured and hand-rolled cigarettes, respectively), e-cigarette users spent £6.30 [5.99-6.55] (£8.41 [7.17-9.78], £6.42 [5.58-7.39], and £5.93 [5.64-6.30] among those who mainly used disposable, pod, and refillable devices, respectively), NRT users £6.11 [5.53-6.69], and heated tobacco users £13.87 [9.58-20.09]. Expenditure on cigarettes grew by 10% from September 2018 to July 2020, then fell by 10% from July 2020 to June 2022. These changes coincided with a 13% reduction in cigarette consumption and a 14% increase in the proportion mainly smoking hand-rolled cigarettes. Expenditure on e-cigarettes was stable between 2018 and late 2020, then rose by 31% up to mid-2022. Expenditure on NRT increased slowly in 2018-2020 (+4%) and more quickly thereafter (+20%). CONCLUSIONS: Inflation-adjusted expenditure on cigarettes has fallen since 2020, such that the average smoker in England currently spends the same on cigarettes each week as in 2018. This has been achieved by smoking fewer cigarettes and switching to cheaper hand-rolled cigarettes. Expenditure on alternative nicotine has increased above inflation; users spent around a third more on these products in 2022 than between 2018-2020. IMPLICATIONS: People in England continue to spend substantially more on smoking cigarettes than using alternative nicotine products. The average smoker in England spends around £13 a week (~£670 a year) more than people using only e-cigarettes or NRT. The average expenditure on manufactured cigarettes is double that of hand-rolled cigarettes.

What drives public perceptions of e-cigarettes? A mixed-methods study exploring reasons behind adults' perceptions of e-cigarettes in Northern England.

BACKGROUND: Despite growing evidence that e-cigarettes are likely less harmful than cigarettes, perceptions of equal or more harm have increased worldwide. This study aimed to identify the most common reasons behind adults' perceptions of the (i) relative harm of e-cigarettes compared with cigarettes and (ii) effectiveness of e-cigarettes for smoking cessation. METHODS: Adults (N = 1646) from Northern England were recruited through online panels from December-March 2017/2018, using quota sampling to guarantee socio-demographic representativeness. Qualitative content analysis of open-ended responses was performed with codes representing reasons for a given perception about e-cigarettes. Percentages of participants who gave each reason for each perception were calculated. RESULTS: 823 (49.9%) participants agreed that e-cigarettes were less harmful than cigarettes, 283 (17.1%) disagreed, and 540 (32.8%) were undecided. The most common reasons for agreeing that e-cigarettes were less harmful than cigarettes were that they produce no smoke (29.8%) and fewer toxins (28.9%). Those who disagreed were most concerned about a perceived lack of trustworthy research (23.7%) and safety issues (20.8%). Lacking knowledge (50.4%) was the most common reason for being undecided. 815 (49.5%) of participants agreed that e-cigarettes were an effective smoking cessation aid, 216 (13.2%) disagreed, and 615 (37.4%) were undecided. The most common reasons participants gave for agreeing were related to e-cigarettes being successful smoking replacements (50.3%) and advice from family, friends or health professionals (20.0%). Respondents who disagreed were most concerned about e-cigarettes being addictive (34.3%) and containing nicotine (15.3%). Lacking knowledge (45.2%) was the most common reason for being undecided. CONCLUSIONS: Negative perceptions of e-cigarette harm were driven by concerns about a perceived lack of research and safety issues. Adults who viewed e-cigarettes as ineffective for smoking cessation feared that they perpetuate nicotine addiction. Campaigns and guidelines that address these concerns may help promote informed perceptions.

Association of psychological distress with smoking cessation, duration of abstinence from smoking, and use of non-combustible nicotine-containing products: A cross-sectional population survey in Great Britain.

BACKGROUND: Tobacco smoking cessation is associated with improvements in mental health. This study assessed psychological distress, using the K6 non-specific screening tool ((items cover feelings of nervousness, hopelessness, restlessness, depression, 'everything an effort' and worthlessness), by smoking status, time since quit, and use of a non-combustible nicotine product. METHODS: Monthly repeat cross-sectional household survey of adults (18 + ) from October 2020-February 2022 in Great Britain (N = 32,727). Using unadjusted and adjusted logistic regression (adjusted models included socio-demographic characteristics and ever diagnosis with a mental health condition), we assessed: associations between any/serious past-month psychological distress and smoking status and time since quit, whether these relationships were moderated by ever diagnosis with a mental health condition, and associations between distress and use of a nicotine product by people who formerly smoked. RESULTS: In the unadjusted model, those who had not smoked for > 1y and who had never smoked had lower odds of any distress (OR = 0·42, 95 % CI 0·39-0·45; OR = 0·44, 0·41-0·47) compared with those who currently smoked. Moreover, the association of lower distress in those who had not smoked for > 1y and never smoked compared with those who currently smoked was more pronounced among those who had ever been diagnosed with a mental health condition (AOR = 0·58, 0·51-0·66; AOR = 0·60, 0·53-0·67) than among those who had not (AOR = 0·86, 0·76-0·98; AOR = 0·72, 0·65-0·81). In adjusted models of people who formerly smoked, current use of any nicotine product was associated with higher odds of distress compared with not using any nicotine product (AOR 1·23, 1·06-1·42). CONCLUSION: People who had never smoked, or had not smoked for > 1y had lower levels of distress than those who currently smoked. The lower odds of distress among people who had not smoked for > 1y was more pronounced among those with an ever (vs never) diagnosis of a mental health condition. Nicotine product use among those who formerly smoked was associated with greater distress. Due to potential residual confounding and selection bias more research is needed to determine causality.

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.

E-cigarettes to Augment Stop Smoking In-person Support and Treatment With Varenicline (E-ASSIST): A Pragmatic Randomized Controlled Trial.

AIM: To examine whether, in adults receiving behavioral support, offering e-cigarettes together with varenicline helps more people stop smoking cigarettes than varenicline alone. METHODS: A two-group, parallel arm, pragmatic randomized controlled trial was conducted in six English stop smoking services from 2019-2020. Adults enrolled onto a 12-week programme of in-person one-to-one behavioral smoking cessation support (N  =  92) were randomized to receive either (1) a nicotine e-cigarette starter kit alongside varenicline or (2) varenicline alone. The primary outcome was biochemically verified abstinence from cigarette smoking between weeks 9-to-12 post quit date, with those lost to follow-up considered not abstinent. The trial was stopped early due to COVID-19 restrictions and a varenicline recall (92/1266 participants used). RESULTS: Nine-to-12-week smoking abstinence rates were 47.9% (23/48) in the e-cigarette-varenicline group compared with 31.8% (14/44) in the varenicline-only group, a 51% increase in abstinence among those offered e-cigarettes; however, the confidence interval (CI) was wide, including the possibility of no difference (risk ratio [RR] = 1.51, 95% CI = 0.91-2.64). The e-cigarette-varenicline group had 43% lower hazards of relapse from continuous abstinence than the varenicline-only group (hazards ratio [HR] = 0.57, 95% CI =  0.34-0.96). Attendance for 12 weeks was higher in the e-cigarette-varenicline than varenicline-only group (54.2% vs. 36.4%; RR = 1.49, 95% CI = 0.95-2.47), but similar proportions of participants in both groups used varenicline daily for ≥8 weeks after quitting (22.9% versus 22.7%; RR = 1.01, 95% CI = 0.47-2.20). Estimates were too imprecise to determine how adverse events differed by group. CONCLUSION: Tentative evidence suggests that offering e-cigarettes alongside varenicline to people receiving behavioral support may be more effective for smoking cessation than varenicline alone. IMPLICATIONS: Offering e-cigarettes to people quitting smoking with varenicline may help them remain abstinent from cigarettes, but the evidence is tentative because our sample size was smaller than planned-caused by Coronavirus Disease 2019 (COVID-19) restrictions and a manufacturing recall. This meant our effect estimates were imprecise, and additional evidence is needed to confirm that providing e-cigarettes and varenicline together helps more people remain abstinent than varenicline alone.