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.

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.

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.

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.

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.

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.

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.

Cutting down, quitting and motivation to stop smoking by self-reported COVID-19 status: Representative cross-sectional surveys in England.

AIM: To examine the association of self-reported COVID-19 disease status with cutting down, past-month and past-year quit attempts and motivation to stop smoking. DESIGN AND SETTING: Repeat cross-sectional survey, representative of the adult population in England. PARTICIPANTS: Past-year smokers, n = 3338 (aged ≥ 18 years) responding between May 2020 and April 2021. MEASUREMENTS: Outcomes were (i) currently cutting down, (ii) having made a quit attempt in the past month, (iii) having made a quit attempt in the past year and (iv) motivation to stop smoking. The explanatory variable was self-reported COVID-19 disease status (belief in never versus ever had COVID-19). Covariates included age, sex, occupational grade, region, children in the household, alcohol use and survey month. FINDINGS: Of past-year smokers, 720 (21.6%) reported past-COVID-19 infection and 48 (1.4%) reported current COVID-19 infection. In adjusted analyses, rates of currently cutting down [adjusted odds ratio (aOR) = 1.12, 95% confidence interval (CI) = 0.93-1.34], past-year quit attempts (aOR = 0.99, 95% CI = 0.82-1.19) and motivation to stop smoking (aOR = 1.04, 95% CI = 0.89-1.23) were comparable in those who did and did not report ever having had COVID-19. People who reported ever having had COVID-19 had 39% higher odds than those without of attempting to quit in the past month, but the confidence interval contained the possibility of no difference (aOR = 1.39, 95% CI = 0.94-2.06) and for some the quit attempt may have occurred before they had COVID-19. CONCLUSION: During the first year of the COVID-19 pandemic in England, rates of reducing smoking and attempting to quit in the past year were similar in smokers who did or did not self-report ever having had COVID-19. There was also little difference in motivation to stop smoking between groups. However, causal interpretation is limited by the study design, and there is potential misclassification of the temporal sequence of infection and changes to smoking behaviour.

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.

Characterising smoking and smoking cessation attempts by risk of alcohol dependence: A representative, cross-sectional study of adults in England between 2014-2021.

Background: There is a strong shared association between smoking tobacco and drinking alcohol. This study aimed to compare smoking prevalence and smoking characteristics in drinkers who were versus were not at risk of alcohol dependence in England. Methods: We used cross-sectional data from a monthly, nationally representative survey of adults in England (weighted n=144,583) collected between 2014-2021. Smoking and smoking cessation attempt characteristics were regressed on to alcohol dependence (drinkers at risk versus not at risk), adjusting for survey year. Findings: Past-year smoking prevalence was 63·3% (95% CI=59·7-66·8) among drinkers at risk of alcohol dependence compared with 18·7% (95% CI=18·4-18·9) among those not at risk, and 19·2% (95% CI=18·8-19·7) among non-drinkers. Among past-year smokers, drinkers at risk of alcohol dependence (versus not at risk) smoked more cigarettes per day (B=3·0, 95% CI=2·3-3·8) and were more likely to smoke their first cigarette within 5 (versus >60) minutes of waking (OR=2·81, 95% CI=2·25-3·51). Interpretation: In a representative sample of adults in England, a graded effect was observed where smoking prevalence increased with level of alcohol consumption. Past-year smokers at risk of alcohol dependence had higher levels of cigarette dependence than drinkers not at risk. Therefore, smokers at risk of alcohol dependence are a high priority group to target to reduce smoking prevalence as part of the NHS long-term plan. Funding: Cancer Research UK and the National Institute for Health Research.

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

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

Exposure to Negative News Stories About Vaping, and Harm Perceptions of Vaping, Among Youth in England, Canada, and the United States Before and After the Outbreak of E-cigarette or Vaping-Associated Lung Injury ('EVALI').

INTRODUCTION: Little is known about the international impact of E-cigarette or Vaping-Associated Lung Injury ('EVALI') on youth perceptions of vaping harms. METHODS: Repeat cross-sectional online surveys of youth aged 16-19 years in England, Canada, and the United States before (2017, 2018), during (2019 August/September), and after (2020 February/March, 2020 August) the 'EVALI' outbreak (N = 63380). Logistic regressions assessed trends, country differences, and associations between exposure to negative news stories about vaping and vaping harm perceptions. RESULTS: Exposure to negative news stories increased between 2017 and February-March 2020 in England (12.6% to 34.2%), Canada (16.7% to 56.9%), and the United States (18.0% to 64.6%), accelerating during (2019) and immediately after (February-March 2020) the outbreak (p < .001) before returning to 2019 levels by August 2020. Similarly, the accurate perception that vaping is less harmful than smoking declined between 2017 and February-March 2020 in England (77.3% to 62.2%), Canada (66.3% to 43.3%), and the United States (61.3% to 34.0%), again accelerating during and immediately after the outbreak (p < .001). The perception that vaping takes less than a year to harm users' health and worry that vaping will damage health also doubled over this period (p ≤ .001). Time trends were most pronounced in the United States. Exposure to negative news stories predicted the perception that vaping takes less than a year to harm health (Adjusted Odds Ratio = 1.55, 1.48-1.61) and worry that vaping will damage health (Adjusted Odds Ratio = 1.32, 1.18-1.48). CONCLUSIONS: Between 2017 and February-March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after 'EVALI'. Effects were seen in all countries but were most pronounced in the United States. IMPLICATIONS: This is the first study examining changes in exposure to news stories about vaping, and perceptions of vaping harms, among youth in England, Canada, and the United States before, during, and after 'EVALI'. Between 2017 and February-March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after 'EVALI'. By August 2020, exposure to negative news stories returned to 2019 levels, while perceptions of harm were sustained. Exposure to negative news stories also predicted two of the three harm perception measures. Overall, findings suggest that 'EVALI' may have exacerbated youth's perceptions of vaping harms internationally.

Children's exposure to second-hand smoke 10 years on from smoke-free legislation in England: Cotinine data from the Health Survey for England 1998-2018.

BACKGROUND: We aimed to investigate trends in children's exposure to second-hand tobacco smoke in England from 1998 to 2018. METHODS: We used twenty-one years of data from the Health Survey for England, a yearly repeated cross-sectional population study. A total of 49,460 children participated between 1998 and 2018, of whom 17,463 were biochemically confirmed non-smokers aged 4-15. We examined changes in (i) the proportion of children living in reported smoke-free homes and (ii) second-hand smoke uptake, measured quantitatively using saliva cotinine concentration. FINDINGS: The percentage of children living in a home reported to be smoke-free increased from 63.0% (95% CI 60.5%-65.2%) in 1998 to 93.3% (91.8%-94.6%) in 2018. This increase was most pronounced among children with a smoker parent, rising from 17.1% (14.7%-19.8%) to 75.9% (70.8%-80.4%). Segmented regression showed that the rate of adoption of smoke-free homes accelerated leading up to the 2007 ban on smoking in public places, growing most rapidly in the four years after its entry into law. Between 1998 and 2018, there was a ten-fold decline in geometric mean cotinine among non-smoking children, from 0.50 ng/ml (0.46-0.56) to 0.05 ng/ml (0.04-0.06). A total of 65.0% (61.2%-68.6%) of children had undetectable cotinine in 2018, up from 14.3% (12.7%-16.0%) in 1998. Children living in rented accommodation were more exposed than those from owner-occupied households, but they experienced similar relative declines across years. INTERPRETATION: Cotinine data show that children's exposure to second-hand smoke has fallen by some 90% since 1998, with an apparent acceleration in adoption of smoke-free homes since the 2007 ban on smoking in public places. A norm has emerged that sees smoking in the home as inappropriate, almost universally where parents are non-smokers, but also increasingly among smoking parents. FUNDING: Public Health England, now the Office for Health Improvement and Disparities, and Cancer Research UK.

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.