'Stopping the start': support for proposed tobacco control policies - a population-based survey in Great Britain 2021-2023.

OBJECTIVES: This study assessed public support for four proposed tobacco control policies in Great Britain: (1) Raising the sales age of tobacco by 1 year every year (Smokefree Generation); (2) Raising the sales age of tobacco from 18 years to 21 years; (3) Providing prescription e-cigarettes as smoking cessation aids to adults who smoke; (4) Restricting e-cigarette advertising to prevent youth uptake. DESIGN: Repeat cross-sectional population-based survey weighted to match the population of Great Britain. SETTING: The survey was conducted in England, Scotland and Wales in September 2021, October 2022 and October 2023. PARTICIPANTS: 6541 adults living in Great Britain. MAIN OUTCOME MEASURES: Support for each policy and year and prevalence ratios (PRs) comparing support between years and subgroups. RESULTS: The most popular policy each year was restricting e-cigarette advertising (74%/79%/85%), followed by raising the sales age to 21 years (50%/58%/64%), providing prescription e-cigarettes (45%/44%/47%) and Smokefree Generation (34%/44%/49%). The largest increases were for policies about the age of sale (Smokefree Generation: 2021/2022 PR=1.28, 95% CI 1.18 to 1.40, 2022/2023 PR=1.12, 95% CI 1.04 to 1.20; raising the age to 21 years: 2021/2022 PR=1.16, 95% CI 1.09 to 1.23, 2022/2023 PR=1.11, 95% CI 1.05 to 1.17). Only 30% opposed Smokefree Generation in 2023 down from 41% in 2021. CONCLUSIONS: Support for each policy increased each year, except for providing prescription e-cigarettes. Restricting e-cigarette advertising was the most popular policy, while support for age of sale policies, in particular for a Smokefree Generation, grew most. TRIAL REGISTRATION: The study protocol was published on the Open Science Framework (https://osf.io/46z2c/) prior to starting the analysis.

Intersection of gambling with smoking and alcohol use in Great Britain: a cross-sectional survey in October 2022.

OBJECTIVES: Gambling is associated with cigarette smoking and alcohol consumption. We explored the intersection of gambling across all risk levels of harm with smoking and alcohol use among adults in Great Britain. DESIGN: A nationally representative cross-sectional survey in October 2022. SETTING: Great Britain. PARTICIPANTS: A weighted total of 2398 adults (18+ years). OUTCOME MEASURES: We examined the prevalence of past-year gambling and, among those reporting gambling, assessed the associations between the outcome of any risk of harm from gambling (scoring >0 on the Problem Gambling Severity Index) and the binary predictor variables of current cigarette smoking and higher risk alcohol consumption (AUDIT-C score≥4). We also explored data on weekly expenditure on gambling with smoking and alcohol use among those categorised at any-risk of harm from gambling. RESULTS: Overall, 43.6% (95% CI 41.2% to 45.9%) of adults gambled in the past year. Among these, 7.3% (95% CI 5.3% to 9.3%) were classified at any-risk of harm from gambling, 16.0% (95% CI 13.2% to 18.8%) were currently smoking and 40.8% (95% CI 37.2% to 44.4%) were drinking at increasing and higher risk levels. There were no associations between any risk of harm from gambling and current smoking (OR adjusted=0.80, 95% CI 0.35 to 1.66) or drinking at increasing and higher risk levels (OR adjusted=0.94, 95% CI 0.52 to 1.69), respectively. Analyses using Bayes factors indicated that these data were insensitive to distinguish no effect from a range of associations (OR=95% CI 0.5 to 1.9). The mean weekly spend on gambling was £7.69 (95% CI £5.17 to £10.21) overall, £4.80 (95% CI £4.18 to £5.43) among those classified as at no risk and £45.68 (95% CI £12.07 to £79.29) among those at any risk of harm from gambling. CONCLUSIONS: Pilot data in a population-level survey on smoking and alcohol use yielded similar estimates to other population-level surveys on gambling participation and at-risk gambling. Further data are needed to elucidate the intersections more reliably between gambling, smoking and alcohol use and inform population-level approaches to reduce harm.

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.

Patterns of Alcohol, Marijuana, and Tobacco Use Among U.S. Adolescents and Young Adults by Disability Status: 2015-2019.

PURPOSE: To estimate the national prevalence of tobacco, marijuana, and alcohol use among U.S. adolescents (age 12-17) and young adults (aged 18-25; adolescents and young adults [AYAs]) with a disability and examine associations between disability and substance use from 2015 to 2019. METHODS: Data from the 2015-2019 National Survey on Drug Use and Health were used to estimate the prevalence of tobacco, marijuana, and alcohol use among AYAs with disabilities. Modified Poisson regression models evaluated linear time trends in past-month substance use and estimated adjusted prevalence ratios (aPRs) for past-month cigarette, any tobacco, alcohol, and marijuana use. RESULTS: Adolescents with any disability had a higher prevalence of past-month cigarette (aPR = 1.87; 95% CI 1.67-2.09), alcohol (aPR = 1.21; 95% CI 1.11-1.31), and marijuana use (aPR = 1.47; 95% CI 1.36-1.60) compared to those without disabilities. Cigarette smoking among adolescents decreased over this time period; however, the decline among adolescents without a disability was greater than those with any disability. Young adults with any disability had a higher prevalence of past-month cigarette (aPR = 1.42; 95% CI 1.35-1.48) and marijuana use (aPR = 1.39; 95% CI 1.34-1.45), but a lower prevalence of past-month alcohol use (aPR = 0.93; 95% CI 0.90-0.95) than those without disabilities. Alcohol use remained constant among young adults with any disability but decreased for those without disabilities. DISCUSSION: Population-level disparities in cigarette and marijuana use exist in AYAs with disabilities. Future studies should identify strategies tailored to AYAs with disabilities to encourage smoking cessation and prevent cannabis use disorder.

Prevalence of psychosocial issues among pregnant women who do and do not use illicit substances.

OBJECTIVE: The American College of Obstetricians and Gynecologists (ACOG) recommends providers screen their prenatal patients for 11 psychosocial issues because they affect patient mental and physical well-being. The prevalence and co-occurrence of these issues have rarely been compared among pregnant women who do and do not report recent illicit substance use. METHOD: Seven psychosocial issues identified by ACOG were operationalized using National Survey on Drug Use and Health variables. We report weighted prevalence and adjusted risk ratios (ARR) for these issues in pregnant women who did versus did not report past-month illicit substance use. RESULTS: Pregnant women (n = 3,657) who reported past-month illicit substance use (6.3%; 95% CI [5.4-7.3]) had significantly higher prevalence of almost all psychosocial issues examined, including past-month cigarette smoking (44.9% versus 9.5%; ARR = 2.84, 95% CI [2.21-3.65]); past-month alcohol use, 36.1% versus 7.9%; ARR = 4.71 (3.59-6.18); serious past-month distress, 23.0% versus 5.0%; ARR = 3.51 (2.39-5.15); no health insurance, 11.7% versus 6.2%; ARR = 1.71 (1.07-2.74); and receipt of food stamps, 45.0% versus 24.0%; ARR = 1.40 (1.18-1.67). Moving 3 + times in the past year followed a similar pattern, but results were compatible with there being no difference, 10.6% versus 5.5%; ARR = 1.39 (0.86-2.25). The majority of pregnant women reporting illicit substance use endorsed experiencing ≥ 2 psychosocial issues while the majority of those who did not report illicit substance use did not endorse any. CONCLUSIONS: Pregnant women who use illicit substances experience higher prevalence and greater co-occurrence of psychosocial issues compared to those who do not, reinforcing recommendations for multidisciplinary approaches to care. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Contingency management interventions for abstinence from cigarette smoking in pregnancy and postpartum: A systematic review and meta-analysis.

Contingency management is one of the most effective treatments for substance use disorders in not-pregnant people. The most recent quantitative review of its efficacy among pregnant and postpartum women who smoke cigarettes concluded with moderate certainty that those receiving contingent financial incentives were twice as likely to be abstinent compared with controls. We aimed to update and extend previous reviews. Five databases were systematically searched for randomized controlled trials (RCTs) published before December 2022 that assessed the effectiveness of incentives for abstinence from substance use. Data from trials of smoking abstinence were pooled using a random-effects meta-analysis model (restricted maximum likelihood). Results are reported as risk-ratios (RRs) with 95% confidence intervals (CIs). This study is registered with PROSPERO, CRD42022372291. Twelve RCTs (3136) pregnant women) were included. There was high certainty evidence that women receiving incentives were more likely to be abstinent than controls at the last antepartum assessment (12 RCTs; RR = 2.43, 95% CI 2.04-2.91, n = 2941, I2 = 0.0%) and moderate certainty evidence at the longest postpartum assessment while incentives were still available (five RCTs; RR = 2.72, 1.47-5.02, n = 659, I2 = 44.5%), and at the longest postpartum follow-up after incentives were discontinued (six RCTs; RR = 1.93, 1.08-3.46, n = 1753, I2 = 51.8%). Pregnant women receiving incentives are twice as likely to achieve smoking abstinence during pregnancy suggesting this intervention should be standard care for pregnant women who smoke. The results also demonstrate that abstinence continues into the postpartum period, including after incentives are discontinued, but more trials measuring outcomes in the postpartum period are needed to strengthen this conclusion.

Associations between smoking and vaping prevalence, product use characteristics, and mental health diagnoses in Great Britain: a population survey.

BACKGROUND: Rates of diseases and death from tobacco smoking are substantially higher among those with a mental health condition (MHC). Vaping can help some people quit smoking, but little is known about vaping among people with MHCs or psychological distress. We assessed the prevalence and characteristics (heaviness, product type) of smoking and/or vaping among those with and without a history of single or multiple MHC diagnoses and with no, moderate or serious psychological distress. METHODS: Data from 27,437 adults in Great Britain surveyed between 2020 and 2022. Multinomial regressions analysed associations between smoking, vaping and dual use prevalence, smoking/vaping characteristics and (a) history of a single or multiple MHC and (b) moderate or serious psychological distress, adjusted for age, gender, and socioeconomic status. RESULTS: Compared with people who had never smoked, those who currently smoked were more likely to report a history of a single (12.5% vs 15.0%, AOR=1.62, 95% CI=1.46-1.81, p<.001) or multiple MHCs (12.8% vs 29.3%, AOR=2.51, 95% CI=2.28-2.75, p<.001). Compared with non-vapers, current vapers were more likely to report a history of a single (13.5% vs 15.5%, AOR=1.28, 95% CI=1.11-1.48, p<.001) or multiple MHCs (15.5% vs 33.4%, AOR=1.66, 95% CI=1.47-1.87, p<.001). Dual users were more likely to report a history of multiple MHCs (36.8%), but not a single MHC than exclusive smokers (27.2%) and exclusive vapers (30.4%) (all p<.05). Similar associations were reported for those with moderate or serious psychological distress. Smoking roll-your-own cigarettes and smoking more heavily, were associated with a history of single or multiple MHCs. There were no associations between vaping characteristics and a history of MHCs. Frequency of vaping, device type and nicotine concentration differed by psychological distress. CONCLUSIONS: Smoking, vaping and dual use were substantially higher among those with a history of MHC, especially multiple MHC, and experiencing past month distress than those not having a history of MHC or experiencing past month distress respectively. Analysis used descriptive epidemiology and causation cannot be determined.

Prevalence of Psychosocial Issues Among Pregnant Women Who Do and Do Not Use Illicit Substances.

Objective It is often believed that pregnant women who use illicit substances are more likely to experience psychosocial issues like smoking, depression, and inadequate health care compared to pregnant women who do not. However, the prevalence of these psychosocial issues has rarely been calculated and compared using nationally representative data. Methods Important psychosocial issues identified by the American College of Obstetricians and Gynecologists were operationalized using variables in the National Survey on Drug Use and Health. We report weighted prevalence and age-adjusted odds ratios for these issues in pregnant women who did vs. did not report past-month illicit substance use. Results Pregnant women (n = 3,657) who reported past-month illicit substance use (6.3%; 95% CI 5.4-7.0) had significantly higher rates of almost all psychosocial issues examined, including past-month cigarette smoking (44.9% vs. 6.5%; age-adjusted odds ratio (AOR) = 7.14 (95% CI 4.98-10.20)); past-month alcohol use (36.1% vs. 7.8%; AOR = 6.80 (4.69, 9.86)); serious past-month distress (23.0% vs. 5.0%; AOR = 4.99 (3.07-8.11)); no health insurance (11.7% vs. 6.2%; AOR = 1.79 (1.07-2.99)); and receipt of food stamps (45.0% vs. 24.0%; AOR = 2.26 (1.55-3.29)). Moving 3 + times in the past year followed a similar pattern, but results were compatible with there being no difference between groups (10.6% vs. 5.5%; AOR = 1.59 (0.95-2.66)). In contrast to other issues examined, English language proficiency was higher among those who reported illicit substance use (4.7% vs. 0.4%; AOR = 0.08 (0.01-0.63)). Conclusions Pregnant women who use illicit substances experience higher rates of most psychosocial issues compared to those who do not, reinforcing recommendations for multidisciplinary approaches to care.

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.

Profile of menthol cigarette smokers in the months following the removal of these products from the market: a cross-sectional population survey in England.

INTRODUCTION: In May 2020, the EU Tobacco Products Directive ban on the sale of menthol cigarettes was implemented in England. This study examined the prevalence of menthol cigarette smoking after the ban, according to sociodemographic and smoking characteristics. METHODS: Cross-sectional data came from a representative survey of current smokers (18+) in England (unweighted n=2681) between July 2020 and June 2021. The weighted prevalence of menthol cigarette smoking as a proportion of total cigarette smoking was calculated, log-binomial regression explored trends over time, and χ2 statistics assessed the relationship between menthol smoking, sociodemographic and smoking characteristics. Sources of purchase of menthol cigarettes were explored. RESULTS: Between July 2020 and June 2021, 15.7% (95% CI 14.5 to 17.1) of smokers reported smoking menthol cigarettes. The fitted non-linear trend supported no initial change followed by a possible reduction across April-June 2021 and fit the data better than linear and null (no change) models (χ2(2)=2519.7, p=0.06; χ2(3)=2519.7, p=0.006). Menthol cigarette smoking was more common among younger groups (16-24=25.2%; 25-34=19.9%) and women (19.4%). Menthol cigarette smokers showed lower cigarette dependence compared with other smokers. Past-6-month purchases of menthol cigarettes from any illicit or cross-border source declined from 30.1% in the last 6 months of 2020 to 17.5% in the first 6 months of 2021. CONCLUSIONS: A substantial minority of current smokers in England reported menthol cigarette smoking between July 2020 and June 2021, despite the ban, possibly reflecting mitigation of restrictions by a variety of licit means, such as legal menthol accessories. The reduction in menthol smoking across April-June 2021 warrants further monitoring.

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.

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.

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.

Assessing the profile of support for potential tobacco control policies targeting availability in Great Britain: a cross-sectional population survey.

AIM: To examine the level of support for tobacco availability policies across Great Britain (GB) and associations between support for policy and sociodemographic, smoking and quitting characteristics. METHODS: A cross-sectional representative survey (the Smoking Toolkit Study) of adults in GB (n=2197) during September 2021. Logistic regressions estimated the associations between support for each policy and sociodemographic and smoking characteristics. FINDINGS: There was majority support for requiring retailers to have a license which can be removed if they sell to those under-age (89.6%) and for restrictions on the sale of cigarettes and tobacco near schools (69.9%). More supported than opposed raising the legal age of sale of cigarettes and tobacco to 21 (49.2% supported; 30.7% opposed; 20.1% unsure) and reducing the number of retailers selling tobacco in neighbourhoods with a high density of tobacco retailers (46.5% supported; 23.3% opposed; 30.2% unsure). More opposed than supported a ban on the sale of cigarettes and tobacco to everyone born after a certain year from 2030 onward (a 'tobacco-free generation') (41.3% opposed; 34.5% supported; 24.2% unsure). Age was positively associated with support for raising the age of sale and inversely associated with requiring tobacco retailer licenses. Women were more likely to support raising the age of sale and reducing the number of retailers. CONCLUSIONS: Requiring tobacco retailer licensing and restrictions on sales near schools received majority support. Other tobacco availability policies received substantial support despite considerable opposition.

Real-world effectiveness of smoking cessation aids: A population survey in England with 12-month follow-up, 2015-2020.

OBJECTIVE: To examine the real-world effectiveness of popular smoking cessation aids, adjusting for potential confounders measured up to 12 months before the quit attempt. METHODS: 1,045 adult (≥18y) smokers in England provided data at baseline (April 2015-November 2020) and reported a serious past-year quit attempt at 12-month follow-up. Our outcome was smoking cessation, defined as self-reported abstinence at 12 months. Independent variables were use in the most recent quit attempt of: varenicline, prescription NRT, over-the-counter NRT, e-cigarettes, and traditional behavioural support. Potential confounders were age, sex, social grade, alcohol consumption, and level of dependence (measured at baseline), variables relating to the most recent quit attempt (measured at 12-month follow-up), and survey year. RESULTS: Participants who reported using varenicline in their most recent quit attempt had significantly higher odds of abstinence than those who did not, after adjustment for potential confounders and use of other aids (OR = 2.69, 95 %CI = 1.43-5.05). Data were inconclusive regarding whether using prescription NRT, over-the-counter NRT, e-cigarettes, or traditional behavioural support was associated with increased odds of abstinence (p > 0.05; Bayes factors = 0.41-1.71, expected effect size OR = 1.19), but provided moderate evidence that using e-cigarettes was more likely associated with no effect than reduced odds (Bayes factor = 0.31, expected effect size OR = 0.75). CONCLUSIONS: Use of varenicline in a quit attempt was associated with increased odds of successful smoking cessation. Data were inconclusive regarding a benefit of e-cigarettes for cessation but showed use of e-cigarettes was unlikely to be associated with reduced odds of cessation. Associations between other cessation aids and cessation were inconclusive.

Evaluating the Outcomes of the Menthol Cigarette Ban in England by Comparing Menthol Cigarette Smoking Among Youth in England, Canada, and the US, 2018-2020.

Importance: Menthol cigarettes were prohibited in England in May 2020 and nationally in Canada in October 2017 but remain permitted in the US. Evidence on the outcomes of menthol cigarette bans among youth outside of Canada, and the characteristics of youth smokers, is lacking. Objectives: To evaluate the outcomes of menthol cigarette bans on youth menthol cigarette smoking and to characterize youth menthol cigarette smokers in terms of demographics and cigarette consumption and dependence. Design, Setting, and Participants: This survey study uses data from online repeat cross-sectional International Tobacco Control Youth Tobacco and Vaping Surveys conducted in 2018, 2019, February 2020, and August 2020. Participants included past 30-day smokers aged 16 to 19 years. Data analysis was performed from March 2021 to January 2022. Main Outcomes and Measures: Usually smoke a brand of cigarettes that was menthol, including capsule. Exposures: Menthol cigarette ban, comparing 3 countries over time: Canada, where a ban already existed, England, where a ban was implemented during the study, and the US, where no national ban was present. Age, sex, race, and consumption and dependence were also examined by menthol smoking in each country, and in England before vs after the ban. Results: The analytical sample comprised 7067 participants aged 16 to 19 years, of whom 4129 were female and 5019 were White. In England, the weighted percentage of youth smokers who reported smoking a menthol or capsule cigarette brand was stable in the 3 survey waves before the menthol ban (2018 to February 2020, 9.4% vs 12.1%; adjusted odds ratio [AOR], 1.03; 95% CI, 0.99-1.06; P = .15) but decreased to 3.0% after the ban (February 2020 vs August 2020, AOR, 1.07; 95% CI, 1.04-1.10; P < .001). The decrease between February and August 2020 in England was similar across all demographic groups but was greater among youth who perceived themselves as addicted to cigarettes (AOR, 0.37; 95% CI, 0.41-0.97; P = .04). In the 2 comparison countries, menthol or capsule smoking was stable across all waves (2018 to August 2020: US, 33.6%-36.9%; Canada, 3.1%-2.3%) and was more prevalent in the US than in England (AOR, 5.58; 95% CI, 4.63-6.72; P < .001). Menthol or capsule smoking was also more prevalent among smokers in England who were female vs male (10.9% vs 7.2%; AOR, 1.04; 95% CI, 1.01-1.06; P = .002); among smokers in the US who identified as Black vs White (60.6% vs 31.9%; AOR, 1.33; 95% CI, 1.23-1.44; P < .001) or who were frequent smokers (AOR, 1.07; 95% CI, 1.01-1.13; P = .03), smoked more cigarettes per day (2-5 vs 1, AOR, 1.09; 95% CI, 1.02-1.15; P = .006; >5 vs 1, AOR, 1.10; 95% CI, 1.03-1.18; P = .007), or had urges to smoke every or most days (AOR, 1.08; 95% CI, 1.02-1.14; P = .006); and among smokers in Canada who perceived themselves as addicted to cigarettes (AOR, 1.02; 95% CI, 1.00-1.03; P = .01). Conclusions and Relevance: In this survey study, the proportion of youth smokers who smoke menthol (including capsule) cigarettes decreased substantially after the menthol ban in England. This association was consistent across all demographic groups. Perceived addiction among menthol smokers was also lower where menthol cigarettes were banned.

Associations between smoking to relieve stress, motivation to stop and quit attempts across the social spectrum: A population survey in England.

Smoking prevalence in several high-income countries is steadily declining but remains persistently high in 'lower' socioeconomic position (SEP) groups, contributing to inequities in morbidity and mortality. Smoking to relieve stress is a commonly endorsed motive for continued smoking; however, it remains unclear whether smoking to relieve stress has a negative impact on motivation to stop and future quit attempts and if so, whether associations are moderated by SEP. This was an observational study with cross-sectional and prospective survey data from the nationally representative Smoking Toolkit Study in England. A total of 1,135 adult smokers were surveyed at baseline, with 153 (13.5%) respondents followed up at 12 months. Respondents provided information on demographic, social and smoking characteristics. A series of multivariable logistic regression analyses was conducted. Bayes Factors (BFs) were calculated to explore non-significant associations. Smoking to relieve stress was commonly endorsed by respondents from both 'lower' (43.2% [95% CI = 39.4%, 47.0%]) and 'higher' (40.5% [95% CI = 35.9%, 45.1%]) SEP groups (p = 0.39). Smoking to relieve stress was associated with high motivation to stop at baseline (ORadj = 1.48, 95% CI = 1.03-2.12, p = 0.035) but not significantly with the odds of making a quit attempt at a 12-month follow-up, although the magnitude and direction of the effect was similar to that observed for high motivation to stop (ORadj = 1.49, 95% CI = 0.69-3.20, p = 0.3). Data were insensitive to detect moderation effects of SEP (BF = 0.90 and BF = 1.65, respectively). Smoking to relieve stress is a commonly endorsed motive and is associated with high motivation to stop but not significantly with the odds of making a quit attempt in the next 12 months, although the magnitude and direction of the effect was similar for both outcomes. There was no clear evidence of moderation by SEP, although data were insensitive to distinguish the alternative from the null hypothesis.

Heated tobacco products for smoking cessation and reducing smoking prevalence.

BACKGROUND: Heated tobacco products (HTPs) are designed to heat tobacco to a high enough temperature to release aerosol, without burning it or producing smoke. They differ from e-cigarettes because they heat tobacco leaf/sheet rather than a liquid. Companies who make HTPs claim they produce fewer harmful chemicals than conventional cigarettes. Some people report stopping smoking cigarettes entirely by switching to using HTPs, so clinicians need to know whether they are effective for this purpose and relatively safe. Also, to regulate HTPs appropriately, policymakers should understand their impact on health and on cigarette smoking prevalence. OBJECTIVES: To evaluate the effectiveness and safety of HTPs for smoking cessation and the impact of HTPs on smoking prevalence.  SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group's Specialised Register, CENTRAL, MEDLINE, and six other databases for relevant records to January 2021, together with reference-checking and contact with study authors and relevant groups. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in which people who smoked cigarettes were randomised to switch to exclusive HTP use or a control condition. Eligible outcomes were smoking cessation, adverse events, and selected biomarkers.  RCTs conducted in clinic or in an ambulatory setting were deemed eligible when assessing safety, including those randomising participants to exclusively use HTPs, smoke cigarettes, or attempt abstinence from all tobacco. Time-series studies were also eligible for inclusion if they examined the population-level impact of heated tobacco on smoking prevalence or cigarette sales as an indirect measure. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking at the longest follow-up point available, adverse events, serious adverse events, and changes in smoking prevalence or cigarette sales. Other outcomes included biomarkers of harm and exposure to toxicants/carcinogens (e.g. NNAL and carboxyhaemoglobin (COHb)). We used a random-effects Mantel-Haenszel model to calculate risk ratios (RR) with 95% confidence intervals (CIs) for dichotomous outcomes. For continuous outcomes, we calculated mean differences on the log-transformed scale (LMD) with 95% CIs. We pooled data across studies using meta-analysis where possible. MAIN RESULTS: We included 13 completed studies, of which 11 were RCTs assessing safety (2666 participants) and two were time-series studies. We judged eight RCTs to be at unclear risk of bias and three at high risk. All RCTs were funded by tobacco companies. Median length of follow-up was 13 weeks. No studies reported smoking cessation outcomes.  There was insufficient evidence for a difference in risk of adverse events between smokers randomised to switch to heated tobacco or continue smoking cigarettes, limited by imprecision and risk of bias (RR 1.03, 95% CI 0.92 to 1.15; I2 = 0%; 6 studies, 1713 participants). There was insufficient evidence to determine whether risk of serious adverse events differed between groups due to very serious imprecision and risk of bias (RR 0.79, 95% CI 0.33 to 1.94; I2 = 0%; 4 studies, 1472 participants). There was moderate-certainty evidence for lower NNAL and COHb at follow-up in heated tobacco than cigarette smoking groups, limited by risk of bias (NNAL: LMD -0.81, 95% CI -1.07 to -0.55; I2 = 92%; 10 studies, 1959 participants; COHb: LMD -0.74, 95% CI -0.92 to -0.52; I2 = 96%; 9 studies, 1807 participants). Evidence for additional biomarkers of exposure are reported in the main body of the review. There was insufficient evidence for a difference in risk of adverse events in smokers randomised to switch to heated tobacco or attempt abstinence from all tobacco, limited by risk of bias and imprecision (RR 1.12, 95% CI 0.86 to 1.46; I2 = 0%; 2 studies, 237 participants). Five studies reported that no serious adverse events occurred in either group (533 participants). There was moderate-certainty evidence, limited by risk of bias, that urine concentrations of NNAL at follow-up were higher in the heated tobacco use compared with abstinence group (LMD 0.50, 95% CI 0.34 to 0.66; I2 = 0%; 5 studies, 382 participants). In addition, there was very low-certainty evidence, limited by risk of bias, inconsistency, and imprecision, for higher COHb in the heated tobacco use compared with abstinence group for intention-to-treat analyses (LMD 0.69, 95% CI 0.07 to 1.31; 3 studies, 212 participants), but lower COHb in per-protocol analyses (LMD -0.32, 95% CI -1.04 to 0.39; 2 studies, 170 participants). Evidence concerning additional biomarkers is reported in the main body of the review. Data from two time-series studies showed that the rate of decline in cigarette sales accelerated following the introduction of heated tobacco to market in Japan. This evidence was of very low-certainty as there was risk of bias, including possible confounding, and cigarette sales are an indirect measure of smoking prevalence. AUTHORS' CONCLUSIONS: No studies reported on cigarette smoking cessation, so the effectiveness of heated tobacco for this purpose remains uncertain. There was insufficient evidence for differences in risk of adverse or serious adverse events between people randomised to switch to heated tobacco, smoke cigarettes, or attempt tobacco abstinence in the short-term. There was moderate-certainty evidence that heated tobacco users have lower exposure to toxicants/carcinogens than cigarette smokers and very low- to moderate-certainty evidence of higher exposure than those attempting abstinence from  all tobacco. Independently funded research on the effectiveness and safety of HTPs is needed.  The rate of decline in cigarette sales accelerated after the introduction of heated tobacco to market in Japan but, as data were observational, it is possible other factors caused these changes. Moreover, falls in cigarette sales may not translate to declining smoking prevalence, and changes in Japan may not generalise elsewhere. To clarify the impact of rising heated tobacco use on smoking prevalence, there is a need for time-series studies that examine this association.

Inequalities in Smoking and Quitting-Related Outcomes Among Adults With and Without Children in the Household 2013-2019: A Population Survey in England.

INTRODUCTION: Smoking among those who live with children is an important influence on smoking initiation among children. This study assessed socioeconomic inequalities in smoking and quitting-related outcomes among all adults with and without children in the household. AIMS AND METHODS: Monthly repeat cross-sectional household survey of adults (16+) from 2013-2019 in England (N = 138 583). We assessed the association between cigarette smoking and quitting-related outcomes and having children in the household, and whether these relationships were moderated by occupational social grade (categories AB-E from most to least advantaged). Trends in smoking prevalence among adults with and without children in the household were explored. RESULTS: In adjusted analysis, the association of having children in the household with smoking prevalence depended on social grade: smoking prevalence was between 0.71 (95% confidence interval 0.66-0.77) and 0.93 (0.88-0.98) times lower among social grades AB-D with children in the household relative to those without. Conversely, it was 1.11 (1.05-1.16) times higher among social grade E. Yearly prevalence declined similarly among those with and without children (both prevalence ratio: 0.98, 95% confidence interval 0.97-0.99). Motivation to stop smoking was higher among those with children than those without, but lower among disadvantaged than more advantaged groups. Social grades D-E had greater heavy smoking, but higher prevalence of past-month quit attempts. CONCLUSIONS: Among the most disadvantaged social grade in England, smoking prevalence was higher in those with children in the household than without. To attenuate future smoking-related inequalities, there is an urgent need to target support and address barriers to quitting and promote longer-term quit success. IMPLICATIONS: In the most disadvantaged occupational social grade, having children in the household was associated with higher smoking prevalence compared with not having children. This contrasts with all other social grades in which there was lower comparative smoking prevalence among those with than without children in the household. Without attention this disparity could exacerbate existing and future health inequalities related to smoking.

Prevalence and characteristics of ever regular use of non-combustible nicotine for 1 year or more: a population survey in England.

INTRODUCTION: Up-to-date monitoring of non-combustible nicotine products (e.g. e-cigarettes, nicotine replacement therapies (NRT), heated tobacco products (HTP); NNP) is important to assess their impact. To date, there is little evidence on the association between ever regular use (defined here as 1 year or more) of NNP and current smoking status. AIMS/METHODS: The purpose of this study was to examine the prevalence, and sociodemographic, alcohol and smoking status correlates, of ever regular use of NNP in England in 2020. A cross-sectional survey of adults in England was conducted between February and June 2020. RESULTS: A total of 8486 adults were surveyed; 94.9% (8055) were complete cases. The weighted prevalence of ever regular NNP use was 5.4% (n = 436; 95% CI 5.0-6.0), of which 82% (n = 360; 95% CI 78.7-85.8) was single and 18% (n = 79; 95% CI 14.8-22) multiple product use. Amongst ever regular NNP users, the prevalence of ever regular NRT, e-cigarette and HTP use was 64.7% (95% CI 60.1-69), 43.4% (95% CI 38.8-48) and 2.5% (95% CI 1.4-4.5), respectively. In adjusted analysis, ever regular NNP use was associated with smoking status, being significantly higher among current (22.3%; adjusted OR (aOR) 34.9, 95% CI 24.0-50.8) and ex-smokers (12.7%, aOR 19.8, 95% CI 11.1-14.4) than among never-smokers (0.6%). More advantaged occupational grade (aOR, 1.27 95% CI 1.02-1.57) and at least hazardous alcohol use (aOR, 1.38 95% CI 1.06-1.78) were associated with greater prevalence of ever regular NNP use. CONCLUSIONS: Ever regularly using NNP was highest among smokers and ex-smokers and rare among never-smokers. Among people who have ever regularly used NNP, NRT is the most popular.