Examining differences in real-world effectiveness of e-cigarettes for smoking cessation by source of purchase in England: an observational study of different contexts before and after the COVID-19 pandemic.

INTRODUCTION: The effectiveness of e-cigarettes for smoking cessation may differ by source of purchase. The changing influence of self-selection on purchase location caused by COVID-19 pandemic-related vape shop closures means we can examine the association between smoking abstinence e-cigarette use by purchase source and test for moderation of this association by the timing of the pandemic. METHODS: Repeat-cross-sectional nationally representative surveys, conducted between January-2017 and August-2023. Participants (N=1,284; ≥18y, 46.9% women) who made a past-year quit attempt, used an e-cigarette in their most recent attempt, currently vaping and provided data on the purchase source were included. The association between e-cigarette purchase source and continuous abstinence following the most recent quit attempt was assessed with adjusted regression, including an interaction between the timing of pandemic restrictions (March-2020 through January-2022). RESULTS: Overall, 48.1% usually purchasing their e-cigarettes from vape shops, declining from 53.6% pre-pandemic to 40.6% during the pandemic. There was inconclusive evidence that those purchasing from vape shops had greater odds of quitting smoking (ORadj=1.25, 95%CI 0.92-1.76). The association between purchase source and successful quitting did not depend upon whether purchasing occurred before or during the pandemic (F=0.08, pinteraction=0.774; pre-pandemic: ORadj=1.23, 0.79-1.91; and pandemic: ORadj=1.29, 0.81-2.06). CONCLUSIONS: More data are needed to conclusively determine whether purchasing from a specialist vape shop increases smoking cessation. Given the changing influence of self-selection on purchase location caused by the pandemic, the similar associations between purchase source and quit success across both periods suggests it is unlikely an artefact of unmeasured confounding. IMPLICATIONS: It is important to know if where e-cigarettes are purchased can increase their effectiveness for smoking cessation. While we found a positive association between purchasing from a specialist vape shop and abstinence rates, the results were inconclusive. Further studies are required to establish whether purchasing from specialist vape shops improves smoking cessation outcomes compared with other purchase sources.

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.

Rationale and design of the Self-TI Study protocol: a cross-sectional human papillomavirus self-testing pilot study among transgender adults in England.

INTRODUCTION: Persistent infection with high-risk human papillomavirus (HPV) is the causal agent of several cancers including cervical, anal and oropharyngeal cancer. Transgender men and transmasculine non-binary (TMNB) people with a cervix are much less likely to undergo cervical cancer screening than cisgender women. Transgender women and transfeminine non-binary (TWNB) people assigned male at birth may be at increased risk of HPV. Both TMNB and TWNB people face many barriers to HPV testing including medical mistrust due to stigma and discrimination. METHODS AND ANALYSIS: The Self-TI Study (Self-TI) is a pilot study designed to measure acceptability and feasibility of HPV self-testing among transgender and non-binary people in England. TMNB people aged 25-65 years, with at least 1 year of testosterone, and TWNB people, aged 18 years and over, are eligible to participate. Participants self-collect up to four samples: an oral rinse, a first void urine sample, a vaginal swab (if applicable) and an anal swab. TMNB participants are asked to have an additional clinician-collected cervical swab taken following their routine Cervical Screening Programme sample. TWNB people are asked to take a self-collection kit to perform additional self-collection at home and mail the samples back to the clinic. Acceptability is assessed by a self-administered online survey and feasibility is measured as the proportion of samples returned in the clinic and from home. ETHICS AND DISSEMINATION: Self-TI received ethical approval from the Research Ethics Committee of Wales 4 and ethical review panel within the Division of Cancer Epidemiology and Genetics at the US National Cancer Institute. Self-TI was coproduced by members of the transgender and non-binary community, who served as authors, collaborators and members of the patient and public involvement (PPI) group. Results of this study will be shared with the community prior to being published in peer-reviewed journals and the PPI group will help to design the results dissemination strategy. The evidence generated from this pilot study could be used to inform a larger, international study of HPV self-testing in the transgender and non-binary community. TRIAL REGISTRATION NUMBER: NCT05883111.

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.

Electronic cigarettes and subsequent use of cigarettes in young people: An evidence and gap map.

BACKGROUND AND AIMS: The use of e-cigarettes may influence later smoking uptake in young people. Evidence and gap maps (EGMs) are interactive on-line tools that display the evidence and gaps in a specific area of policy or research. The aim of this study was to map clusters and gaps in evidence exploring the relationship between e-cigarette use or availability and subsequent combustible tobacco use in people aged < 30 years. METHODS: We conducted an EGM of primary studies and systematic reviews. A framework and an interactive EGM was developed in consultation with an expert advisory group. A systematic search of five databases retrieved 9057 records, from which 134 studies were included. Systematic reviews were appraised using AMSTAR-2, and all included studies were coded into the EGM framework resulting in the interactive web-based EGM. A descriptive analysis of key characteristics of the identified evidence clusters and gaps resulted in this report. RESULTS: Studies were completed between 2015 and 2023, with the first systematic reviews being published in 2017. Most studies were conducted in western high-income countries, predominantly the United States. Cohort studies were the most frequently used study design. The evidence is clustered on e-cigarette use as an exposure, with an absolute gap identified for evidence looking into the availability of e-cigarettes and subsequent cessation of cigarette smoking. We also found little evidence analysing equity factors, and little exploring characteristics of e-cigarette devices. CONCLUSIONS: This evidence and gap map (EGM) offers a tool to explore the available evidence regarding the e-cigarette use/availability and later cigarette smoking in people under the age of 30 years at the time of the search. The majority of the 134 reports is from high-income countries, with an uneven geographic distribution. Most of the systematic reviews are of lower quality, suggesting the need for higher-quality reviews. The evidence is clustered around e-cigarette use as an exposure and subsequent frequency/intensity of current combustible tobacco use. Gaps in evidence focusing on e-cigarette availability, as well as on the influence of equity factors may warrant further research. This EGM can support funders and researchers in identifying future research priorities, while guiding practitioners and policymakers to the current evidence base.

Iron status is associated with tibial structure and vitamin D metabolites in healthy young men.

The influence of iron on collagen synthesis and vitamin D metabolism has implications for bone health. This cross-sectional observational study investigated associations between markers of iron status and tibial structure, vitamin D metabolites, and circulating biochemical markers of bone metabolism in young healthy men. A total of 343 male British Army recruits participated (age 22 ± 3 y, height 1.77 ± 0.06 m, body mass 75.5 ± 10.1 kg). Circulating biochemical markers of iron status, vitamin D metabolites, and bone metabolism, and tibial structure and density by high-resolution peripheral quantitative computed tomography scans (HRpQCT) were measured in participants during week 1 of basic military training. Associations between markers of iron status and HRpQCT outcomes, bone metabolism, and vitamin D metabolites were tested, controlling for age, height, lean body mass, and childhood exercise volume. Higher ferritin was associated with higher total, trabecular, and cortical volumetric bone mineral density, trabecular volume, cortical area and thickness, stiffness, and failure load (all p ≤ 0.037). Higher soluble transferrin receptor (sTfR) was associated with lower trabecular number, and higher trabecular thickness and separation, cortical thickness, and cortical pore diameter (all p ≤ 0.033). Higher haemoglobin was associated with higher cortical thickness (p = 0.043). Higher ferritin was associated with lower ßCTX, PINP, total 25(OH)D, and total 24,25(OH)2D, and higher 1,25(OH)2D:24,25(OH)2D ratio (all p ≤ 0.029). Higher sTfR was associated with higher PINP, total 25(OH)D, and total 24,25(OH)2D (all p ≤ 0.025). The greater density, size, and strength of the tibia, and lower circulating concentrations of markers of bone resorption and formation with better iron stores (higher ferritin) are likely as a result of the direct role of iron in collagen synthesis.

Changes in sex-specific incidence of lymphoid neoplasms across the lifespan.

Not available.

Evaluation of a regional tobacco control programme (Greater Manchester's Making Smoking History) on quitting and smoking in England 2014 to 2022: a time-series analysis.

INTRODUCTION: This study aimed to assess the impact of Greater Manchester's Making Smoking History programme - a region-wide smoking cessation programme launched in January 2018 - on key smoking and quitting outcomes. METHODS: Data were from a nationally-representative monthly survey, 2014-2022 (n=171,281). We used interrupted time-series analyses (Autoregressive Integrated Moving Average [ARIMA] and generalised additive models [GAM]) to examine regional differences between Greater Manchester and the rest of England, before and during the programme's first five years. Outcomes were rates of quit attempts and overall quits among smokers, quit success rates among smokers who tried to quit (pre-registered outcomes), and current smoking prevalence among adults (unregistered outcome). RESULTS: Results showed mixed effects of the programme on quitting. Primary ARIMA models showed comparative reductions in quit success rates (change in quarterly difference between regions = -11.03%; 95%CI -18.96;-3.11) and overall quit rates in Greater Manchester compared with the rest of England (-2.56%; 95%CI -4.95;-0.18), and no significant change in the difference in the quit attempt rate (+2.95%; 95%CI -11.64;17.54). These results were not consistently observed across sensitivity analyses or GAM analyses. Exploratory ARIMA models consistently showed smoking prevalence in Greater Manchester declined more quickly than in the rest of England following initiation of the programme (-2.14%; 95%CI -4.02;-0.27). CONCLUSIONS: The first five years of Greater Manchester's Making Smoking History programme did not appear to be associated with substantial increases in quitting activity. However, exploratory analyses showed a significant reduction in the regional smoking rate, over and above changes in the rest of England over the same period. IMPLICATIONS: Taken together, these results show a relative decline in smoking prevalence in Greater Manchester but equivocal data on quitting, introducing some uncertainty. It is possible the programme has reduced smoking prevalence in the absence of any substantial change in quitting activity by changing norms around smoking and reducing uptake, or by reducing the rate of late relapse. It is also possible that an undetected effect on quitting outcomes has still contributed to the programme's impact on reducing prevalence to some degree. It will be important to evaluate the overall impact of the programme over a longer timeframe.

Impact of Standardised Packaging of Tobacco Products Regulations on cigarette consumption and youth smoking in England: interrupted time-series analysis.

BACKGROUND: In the UK in May 2016, standardised packaging of tobacco products was implemented, including minimum pack sizes of 20 sticks or 30 g loose tobacco. The change was intended to reduce uptake by increasing upfront costs to young people, but there was concern it may unintentionally increase consumption among people smoking. This study aimed to assess whether the introduction of the policy was associated with changes in (1) mean daily factory-made (FM)/roll-your-own (RYO) cigarettes consumption among people smoking predominantly (a) FM and (b) RYO cigarettes; and (2) current smoking prevalence among 16-24-year-olds. METHODS: Data (N=257 929) were from a representative monthly cross-sectional survey of adults (≥16 years) in England, collected between November 2007 and January 2020. Outcome measures were mean daily (FM/RYO) cigarette consumption among those smoking FM/RYO cigarettes, and prevalence of current smoking among 16-24-year-olds. Time-series analyses were conducted using Autoregressive Integrated Moving Average with Exogenous variables (ARIMAX) regression models including a gradual level change starting in June 2017 and ending in May 2018 for cigarette consumption and a step change in June 2016 for prevalence of current smoking. RESULTS: The ARIMAX model was not able to detect a change in mean daily cigarette consumption-for FM (Badj=-0.543, 95% CI -1.381 to 0.296) or RYO (Badj=0.002, 95% CI -0.518 to 0.522) following the implementation of standardised packaging. The unadjusted analysis suggested the implementation of standardised packaging was associated with a small (3%) decrease in smoking prevalence among 16-24-year-olds (Bunadj=-0.031, 95% CI -0.062 to 0.000), but this association was attenuated after adjustment for covariates (Badj=-0.010, 95% CI -0.039 to 0.019). CONCLUSIONS: The implementation of standardised packaging of tobacco products was not associated with a meaningful change in the mean number of FM or RYO cigarettes consumed by people smoking in England, suggesting the larger pack size has not had an unintended consequence of substantially increasing cigarette consumption. However, there was also little evidence that the policy substantially reduced smoking among 16-24-year-olds.

Nicotine strength of e-liquids used by adult vapers in Great Britain: A population survey 2016 to 2024.

BACKGROUND AND AIMS: In March 2024, the UK government announced plans to introduce a Vaping Products Duty that will tax e-liquids based on their nicotine strength. This study examined trends in the nicotine strength of e-liquids used by adult vapers and differences in those currently used across relevant subgroups. DESIGN: Nationally-representative, cross-sectional household survey, July 2016 to January 2024. SETTING: Great Britain. PARTICIPANTS: 7981 adult vapers. MEASUREMENTS: Participants were asked whether the e-cigarette they mainly use contains nicotine (yes/no) and the e-liquid strength (no nicotine, >0-≤ 6, 7-11, 12-19 or ≥20 mg/ml). We also collected information on the main device type used (disposable/refillable/pod), age, gender, occupational social grade, history of ≥1 mental health conditions, smoking status and (among past-year smokers) level of cigarette addiction. FINDINGS: The proportion of vapers in England using high-strength (≥20 mg/ml) e-liquids increased from an average of 3.8% (95% confidence interval [CI] = 2.9-5.0) up to June 2021 to 32.5% (CI = 27.9-37.4) in January 2024 (the vast majority of whom [93.3% in January 2024] reported using exactly 20 mg/ml; the legal limit). This rise was most pronounced among those using disposable e-cigarettes, those aged 18-24 years and all smoking statuses (including never smokers) except long-term (≥1y) ex-smokers. Of those surveyed in 2022-2024 in Great Britain, overall, 89.5% (CI = 88.1-90.8) said they usually used e-cigarettes containing nicotine, 8.7% (CI = 7.5-10.0) used nicotine-free e-cigarettes, and 1.8% (CI = 1.2-2.4) were unsure. The proportion using ≥20 mg/ml was higher among those mainly using disposable (47.9%) compared with pod (16.3%) or refillable (11.5%) devices; never smokers (36.0%), current smokers (28.8%) or recent (<1y) ex-smokers (27.4%), compared with long-term ex-smokers (13.9%); and younger (16-24y; 44.2%) compared with older (≥25y; range 9.4-25.1%) age groups. There were no notable differences across other subgroups of interest. CONCLUSIONS: Use of high-strength nicotine e-liquids in England appears to have increased sharply in recent years. Most adult vapers in Great Britain appear to use e-cigarettes that contain nicotine but different subgroups use different strengths: nicotine strengths tend to be higher among those who mainly use disposable devices and those aged 16-24y, and lower among long-term ex-smokers.

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.

Social smoker identity and associations with smoking and quitting behaviour: A cross-sectional study in England.

BACKGROUND: 'Social smoking' typically occurs predominantly or exclusively in the presence of others who are smoking. Relatively little is known about changes in the prevalence of 'social smoking identity' over time and its association with other smoking-related correlates. METHODS: Data were from the Smoking Toolkit Study, a nationally-representative cross-sectional survey in England. Participants were 26,774 adults who currently smoked or had quit in the past year, surveyed between February-2014 and April-2021. We estimated the proportion identifying as having a social smoking identity, changes over time, and associations with smoking in social situations, cigarette dependence, motivation to stop, quit attempts and success. RESULTS: Of adults who currently smoked or had quit in the past year, 34.0% (95% Confidence Interval (CI)=33.5-34.6) identified as having a social smoking identity. There was a near linear increase in this proportion from 31.9% (95%CI=29.7-34.2) in February-2014 to 36.5% (95%CI=34.1-38.9) in April-2021. Adults who currenty smoked identifying as having a social smoking identity were less cigarette dependent (adjusted B=0.34, 95%CI=0.31-0.37) and more motivated to stop (aOR=1.20, 95%CI=1.15-1.26) than those who did not. Adults who currently smoked or had quit in the past year identifying as having a social smoking identity reported more smoking in social situations (aOR=6.45, 95%CI=6.13-6.80) and past-year quit attempts (aOR=1.22, 95%CI=1.14-1.30) than those who did not. Quit success was not associated with having a social smoking identity among adults who currently smoked or had quit in the past year and who had attempted to quit (aOR=0.90, 95%CI=0.79-1.02). CONCLUSIONS: An increasing proportion, over a third, of adults who currently smoked or had quit in the past year in England identify as having a social smoking identity. Despite being associated with lower dependence, greater motivation to quit and more quit attempts, social smoking identity is not associated with greater quit success, suggesting a complex interplay between identity and smoking-related behaviours.

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.

Characterising smoking and nicotine use behaviours among women of reproductive age: a 10-year population study in England.

BACKGROUND: Tobacco smoking affects women's fertility and is associated with substantial risks of adverse pregnancy outcomes. This study explored trends by socioeconomic position in patterns of smoking, use of non-combustible nicotine products, and quitting activity among women of reproductive age in England. METHODS: Data come from a nationally representative monthly cross-sectional survey. Between October 2013 and October 2023, 197,266 adults (≥ 18 years) were surveyed, of whom 44,052 were women of reproductive age (18-45 years). Main outcome measures were current smoking, vaping, and use of nicotine replacement therapy (NRT), heated tobacco products (HTPs), and nicotine pouches; mainly/exclusively smoking hand-rolled cigarettes and level of dependence among current smokers; past-year quit attempts among past-year smokers; and success of quit attempts among those who tried to quit. We modelled time trends in these outcomes, overall and by occupational social grade (ABC1 = more advantaged/C2DE = less advantaged). RESULTS: Smoking prevalence among women of reproductive age fell from 28.7% [95%CI = 26.3-31.2%] to 22.4% [19.6-25.5%] in social grades C2DE but there was an uncertain increase from 11.7% [10.2-13.5%] to 14.9% [13.4-16.6%] in ABC1. By contrast, among all adults and among men of the same age, smoking prevalence remained relatively stable in ABC1. Vaping prevalence among women of reproductive age more than tripled, from 5.1% [4.3-6.0%] to 19.7% [18.0-21.5%], with the absolute increase more pronounced among those in social grades C2DE (reaching 26.7%; 23.3-30.3%); these changes were larger than those observed among all adults but similar to those among men of the same age. The proportion of smokers mainly/exclusively smoking hand-rolled cigarettes increased from 40.5% [36.3-44.9%] to 61.4% [56.5-66.1%] among women of reproductive age; smaller increases were observed among all adults and among men of the same age. Patterns on other outcomes were largely similar between groups. CONCLUSIONS: Among women of reproductive age, there appears to have been a rise in smoking prevalence in the more advantaged social grades over the past decade. Across social grades, there have been substantial increases in the proportion of women of reproductive age who vape and shifts from use of manufactured to hand-rolled cigarettes among those who smoke. These changes have been more pronounced than those observed in the general adult population over the same period.

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.

Sex Differences in Cancer Incidence Rates by Race and Ethnicity: Results from the Surveillance, Epidemiology, and End Results (SEER) Registry (2000-2019).

Men have 2-3 times the rate of most non-sex-specific cancers compared to women, but whether this is due to differences in biological or environmental factors remains poorly understood. This study investigated sex differences in cancer incidence by race and ethnicity. Cancer incidence data from the Surveillance, Epidemiology, and End Result (SEER) program (2000-2019) were used to calculate male-to-female incidence rate ratios (MF IRRs) for each cancer site, stratified by race and ethnicity, and age-standardized to the 2000 U.S. population for individuals ages ≥ 20 years. Among 49 cancer sites, 44 showed male predominance (MF IRR > 1), with seven inconsistencies across race and ethnicity, including cancers of the lip, tongue, hypopharynx, retroperitoneum, larynx, pleura cancers, and Kaposi sarcoma. Four cancers exhibited a female predominance (MF IRR < 1), with only gallbladder and anus cancers varying by race and ethnicity. The MF IRRs for cancer of the cranial nerves and other nervous system malignancies showed no sex differences and were consistent (MF IRR = 1) across race and ethnicity. The MF IRRs for most cancers were consistent across race and ethnicity, implying that biological etiologies are driving the observed sex difference. The lack of MF IRR variability by race and ethnicity suggests a minimal impact of environmental exposure on sex differences in cancer incidence. Further research is needed to identify biological drivers of sex differences in cancer etiology.

Trends in Exclusive Non-Cigarette Tobacco Smoking in England: A Population Survey 2013-2023.

INTRODUCTION: The UK Government intends to implement a "smokefree generation" policy prohibiting the sale of all tobacco products to people born after 2008. National surveys provide comprehensive data on cigarette smoking, but little is known about patterns of non-cigarette tobacco smoking across key population groups. AIMS AND METHODS: Using data from a nationally representative cross-sectional survey of adults in England, collected monthly between September 2013 and September 2023 (n = 196 721), we estimated time trends in exclusive non-cigarette tobacco (eg, cigar/pipe/shisha) smoking prevalence, overall and by age, gender, occupational social grade, region, ethnicity, and vaping status. Interviews were conducted face-to-face until March 2020 and via telephone thereafter. RESULTS: From September 2013 to September 2023, there was a non-linear increase in exclusive non-cigarette tobacco smoking prevalence (from 0.36% to 1.68%; prevalence ratio = 4.72 [95% CI = 3.43-6.48]). Prevalence was relatively stable up to February 2020 (at an average of 0.46%), then increased sharply at the start of the COVID-19 pandemic (at the same time as survey methods changed), to 0.90% (0.82%-0.99%) in March 2020. This was followed by a steadier rise, peaking at 1.97% in May 2022, before falling slightly to 1.68% by September 2023. In 2022/2023, 1 in 10 smokers (10.8% [9.64%-12.0%]) exclusively used non-cigarette tobacco. The rise in prevalence was observed across all subgroups but was most pronounced among younger adults (eg, reaching 3.21% of 18-year-olds vs. 1.09% of 65-year-olds). Prevalence was consistently higher among men and current vapers. CONCLUSIONS: Although exclusive use of non-cigarette combustible tobacco remains rare among adults in England, it has increased in recent years, particularly among younger ages. As of September 2023, there were approximately 772 800 adult exclusive non-cigarette tobacco smokers in England; around five times more than a decade earlier. IMPLICATIONS: The proportion of adults in England who do not use cigarettes at all but smoke other combustible tobacco products has increased substantially in recent years, with a particularly pronounced rise among young people. The inclusion of non-cigarette combustible tobacco products under the proposed "smokefree generation" policy is therefore likely to be important for achieving the greatest reduction in youth uptake of tobacco smoking, as it would ensure young people who are unable to legally buy cigarettes do not buy other combustible tobacco products that are similarly harmful to health.

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.