Development of a framework for action to advocate for a coherent prevention policy for tobacco, alcohol, and foods high in fats, salt, or sugar: a mixed-methods approach.

BACKGROUND: Tobacco, alcohol, and foods high in fats, salt, or sugar (HFSS) are health harming products. Limited progress in prevention is partly due to health-harming industry lobbying. Action on Smoking and Health (ASH), Alcohol Health Alliance, and Obesity Health Alliance collaborated with the aim of developing a framework for action to address the saturation of these products in our environment. METHODS: We used a mixed-methods approach. Focus groups with academic experts, local government, and national government, recruited through snowball sampling were held in Nov 3, 2022 (14 participants); April 25, 2023 (20 participants); and June 15, 2023 (20 participants). Iteratively, data analysis was presented, and key themes tested. Commissioned economic analysis of national survey datasets quantified consumer spend on tobacco, alcohol, and food products above government recommendations (all tobacco use, >14 units of alcohol, and national dietary guidelines) and industry percentage of revenues (net of tax). Public opinion data from the ASH YouGov Smokefree Survey 2022 on a nationally representative sample of 13 088 adults were descriptively analysed for specific policy options. FINDINGS: The framework for action to achieve a coherent prevention approach across products included three key enablers (secure funding for prevention, a comprehensive strategy, and protecting health policy from industry interference). Five key actions were: regulate advertising to limit harm, regulate product use and environments they can be used in, promote healthy messaging, raise the price of health-harming products, and fund treatment services. Economic analysis identified 100% of tobacco usage, 43·4% of alcohol purchased, and 28·8% of food purchased by households was above government recommendations. Post-tax industry revenue was £7·3 billion for tobacco, £11·2 billion for alcohol, and £34·2 billion for HFSS foods. Strong public support for levies (5%, n=8495) and protecting health policy from industry influence (69%, n=9006) was apparent. INTERPRETATION: A coherent approach to prevention across health-harming products is effective and has public support. Strengths include the iterative process to develop the framework for action among focus groups and use of nationally representative datasets. Limitations include the snowball sampling. The findings were built into a strategy intended to inform future collaborative work in the area. FUNDING: Cancer Research UK (grant PICADV-Feb22\100004).

'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.

Changing awareness and sources of tobacco and e-cigarettes among children and adolescents in Great Britain.

INTRODUCTION: It is illegal in the UK to sell tobacco or nicotine e-cigarettes to people under the age of 18 years, as is displaying tobacco cigarettes at the point of sale. This paper examined changes in exposure to display of these products in shops and sources of these products among children and adolescent users over time METHODS: Data from representative repeated online cross-sectional surveys of youth in Great Britain (11-18 years) were used (2018-2022; n=12 445). Outcome measures included noticing product displays and sources of e-cigarettes and tobacco cigarettes. Logistic regressions examined the associations of these outcome variables over time and with sociodemographic variables. RESULTS: Of 12 040 participants with complete data, 10.1% used some form of nicotine product (4.2% cigarettes, 2.9% e-cigarettes, 3.0% both) at least occasionally. The likelihood of noticing tobacco cigarettes on display fell over time for both supermarkets (2018: 67.1% to 2022: 58.5%) and small shops (2018: 81.3% to 2022: 66.3%), but the likelihood of noticing e-cigarettes in supermarkets rose (2018: 57.4% to 2022: 66.5%). Sources of tobacco cigarettes did not differ over time, but e-cigarette users were more likely to get their e-cigarettes from small shops in 2022 (51.2%) vs 2019 (34.2%) (OR 2.02, 95% CI 1.24, 3.29). CONCLUSION: This study provides evidence that current policies to limit awareness of and access to both tobacco and e-cigarettes among adolescents in the UK may not be effective. UK policies on the advertising, promotion and sale of both tobacco and e-cigarettes need to be reinforced to deter use among children and adolescents.

When is Subnational, Supralocal Tobacco Control "just right"? A Qualitative Study in England.

INTRODUCTION: Subnational, supralocal (or "regional") approaches to tobacco control are often central federal nation tobacco control and can be superfluous for very small nations. However, their relevance to countries with weak intermediate tiers of governance are less clear. This study explores expert and policymaker perceptions on the function, form, footprint, and funding of regional tobacco control (RTC) in England. AIMS AND METHODS: One-to-one semistructured interviews (n = 16) and four focus groups (n = 26) exploring knowledge and perceptions of the past, present, and future of RTC in England were conducted with public health leaders, clinicians, tobacco control practitioners, civil servants, and politicians. Interviews were audio-recorded, transcribed verbatim, and analyzed thematically. RESULTS: Participants reported several key functions for RTC, including illicit tobacco control, media campaigns, advocacy, policy development, and network facilitation for local actors. A small minority of participants reported little role for RTC. Broader perceived features of effective RTC included subject expertise, strong regional ties, systems leadership, and a distinctive program of work. Views varied on whether regional programs should be developed nationally or locally, and their optimal footprint. Participants generally agreed stable funding was a prerequisite for success, although there was lesser agreement on funding sources. CONCLUSIONS: Pooling resources at the regional level in countries with weak intermediate tiers of governance may increase reach, cost-effectiveness and impact of campaigns, policy interventions, and advocacy, whilst retaining the ability to tailor approaches to regional populations. IMPLICATIONS: There are likely to be greater funding and governance challenges associated with introducing or strengthening RTC in countries with weak intermediate tiers of governance. Despite this, evidence from England shows it is possible to develop RTC approaches reported as effective by key stakeholders. Possible benefits of regional approaches in this context include cost-effective delivery of illicit tobacco control, media campaigns, advocacy, research, policy development, and coordinated support for local action on tobacco.

Smoking and Quitting Behavior by Sexual Orientation: A Cross-Sectional Survey of Adults in England.

OBJECTIVE: To assess associations between sexual orientation and smoking and quitting behavior among adults in England. METHODS: Data were collected from 112 537 adults (≥16 years) participating in a nationally representative monthly cross-sectional survey between July 2013 and February 2019. Sexual orientation was self-reported as heterosexual, bisexual, lesbian/gay, or prefer-not-to-say. Main outcomes were smoking status, e-cigarette use, cigarettes per day, time to first cigarette, motivation to stop smoking, motives for quitting, use of cessation support, and past-year quit attempts. Associations were analyzed separately for men and women using multivariable regression models adjusted for relevant covariates. RESULTS: Smoking prevalence is now similar between gay (21.6%), prefer-not-to-say (20.5%) and heterosexual men (20.0%), and lesbian (18.3%) and heterosexual women (16.9%), but remains higher among bisexual men (28.2%, adjusted odds ratio [ORadj] = 1.41, 95% confidence interval [CI] = 1.11 to 1.79) and bisexual women (29.8%, ORadj = 1.64, 95% CI = 1.33 to 2.03) and lower among prefer-not-to-say women (14.5%, ORadj = 0.85, 95% CI = 0.72 to 0.99). Among smokers, bisexuals were less addicted than heterosexuals, with bisexual men smoking fewer cigarettes per day (Badj = -2.41, 95% CI = -4.06 to -0.75) and bisexual women less likely to start smoking within 30 min of waking (ORadj = 0.66, 95% CI = 0.45 to 0.95) than heterosexuals. However, motivation to stop smoking and quit attempts did not differ significantly. CONCLUSIONS: In England, differences in smoking prevalence among people with different sexual orientations have narrowed, primarily driven by a larger decline in smoking rates among sexual minority groups than heterosexuals. Bisexual men and women remain more likely to smoke but have lower levels of addiction while being no less likely to try to quit. IMPLICATIONS: This population-based study provides an up-to-date picture of smoking and quitting behavior in relation to sexual orientation among adults in England. Findings suggest that widely documented disparities in smoking prevalence have narrowed over recent years, with gay men and lesbian women no longer significantly more likely to smoke than heterosexuals, although smoking remains more common among bisexual men and women. Insights into differences in level of addiction, use of cessation support, and motives for quitting may help inform the development of targeted interventions to further reduce smoking among sexual minority groups.

Reducing Secondhand Smoke Exposure Among Nonsmoking Pregnant Women: A Systematic Review.

INTRODUCTION: Exposure to secondhand smoke (SHS) in pregnancy leads to an increased risk of stillbirths, congenital malformations, and low birth weight. There is a lack of evidence about how best to achieve reductions in SHS exposure among nonsmoking pregnant women. This work systematically reviews individual or household interventions to reduce pregnant women's exposure to SHS. METHODS: MEDLINE, EMBASE, and CINAHL databases were searched from their dates of inception to April 17, 2019. Studies were included if: participants were nonsmoking pregnant women; involved an intervention to reduce SHS exposure or encourage partner quitting; and measured SHS exposure of pregnant women and/or recorded quit rates among partners. The UK National Institute for Health & Care Excellence (NICE) Quality Appraisal checklist was used to determine internal and external validity. RESULTS: Nine studies met the inclusion criteria. Educational interventions were primarily targeted at the pregnant woman to change her or others' behavior, with only two studies involving the partner who smoked. Intervention delivery was mixed, spanning brief discussions through to more involving sessions with role play. The effective interventions involved multiple follow-ups. There was no standardized method of assessing exposure to SHS. Many of the included studies had moderate to high risk of bias. CONCLUSION: There is mixed evidence for interventions aimed at reducing pregnant women's exposure to SHS, though multi-component interventions seem to be more effective. The effectiveness of family-centered approaches involving creating smoke-free homes alongside partner smoking cessation, perhaps involving pharmacological support and/or financial incentives, should be explored. IMPLICATIONS: • Measures to protect nonsmoking pregnant women from SHS tend to place the responsibility for "avoidance" on the woman.• There is little work that seeks to involve the smoking partner or other smokers in protecting pregnant women from SHS.• Interventions to create smoke-free homes and/or smoking partner cessation need to be developed: pharmacological and financial support should be explored.

Smokers who have not tried alternative nicotine products: a 2019 survey of adults in Great Britain.

AIMS: Switching from smoking to using nicotine replacement therapy (NRT), electronic cigarettes (e-cigarettes) or heated tobacco products can reduce tobacco-related health risks. However, not all smokers in Great Britain have tried these products. This study aimed to identify and describe smokers who have never tried alternative nicotine products. METHODS: We analysed cross-sectional survey data of smokers (n = 1777) from a representative adult sample from Great Britain. The online survey was run in March 2019. The proportion of smokers who had never used alternative nicotine products was measured. A multivariate logistic regression assessed the association between never having used alternative nicotine products and sociodemographic and smoking characteristics and motivation to stop smoking. RESULTS: One in four smokers (27.8%, 95% CI 25.8-29.9%) had never tried NRT, e-cigarettes or heated tobacco products. These smokers were more commonly from Black and Minority than White ethnic groups (AOR = 1.55; 95% CI 1.02-2.31), were more likely to smoke up to 10 versus more cigarettes per day (AOR = 1.52; 95% CI 1.14-2.03) and to report low versus moderate or high motivation to stop smoking (AOR = 1.79; 95% CI 1.20-2.74). CONCLUSION: Light smokers, those unmotivated to stop and smokers from Black and Minority ethnic groups are less likely to have ever tried alternative nicotine products. Different approaches are needed to facilitate harm reduction and smoking cessation among these groups of smokers.

Waterpipe tobacco smoking prevalence among young people in Great Britain, 2013-2016.

Background: One percent of adults in Great Britain use waterpipe tobacco at least monthly, however national epidemiological evidence among young people is absent. This study aims to assess waterpipe tobacco prevalence and correlates among young people in Great Britain. Methods: Data were analyzed from online surveys conducted annually from 2013 to 2016 with weighted national samples of 11 to 18-year olds in Great Britain (annual n = 1936-2059). Primary outcome measures were at least monthly waterpipe tobacco use and lifetime waterpipe tobacco use. Binary logistic regression models tested the association between these outcomes and age, sex, country of residence and other tobacco consumption. Results: Between 2013 and 2016, 1.7% (95% CI 1.5-2.1%) used waterpipe tobacco at least monthly and 9.9% (95% CI 9.2-10.7%) used waterpipe in their lifetime. There were no changes in prevalence over time. At least monthly use was associated with older age groups [16-18 years vs. 11-15 years, adjusted odds ratio (AOR) 2.63, 95% CI 1.55-4.46], male sex (AOR 1.82, 95% CI 1.23-2.71) and other tobacco consumption (e.g. lifetime cigarette use AOR 10.30, 95% CI 5.22-20.29). Lifetime use had similar correlates, but was not associated with male sex (AOR 0.97, 95% CI 0.80-1.17). Conclusions: One in 10 young people in Great Britain have tried waterpipe tobacco, though more frequent use appears low. We found no evidence of increasing or decreasing prevalence of waterpipe use between 2013 and 2016. Being male, older and a concurrent user of other tobacco products were correlated with waterpipe tobacco use.

Restrictions on the use of e-cigarettes in public and private places-current practice and support among adults in Great Britain.

Background: Debates around policies regulating e-cigarette use make it important to obtain an overview of current practice, people's attitudes and correlates of policy support. Aims were to assess (i) current practices for e-cigarette use in homes and workplaces; (ii) characteristics associated with allowing e-cigarette use in the home; and (iii) level of, and characteristics associated with, support for extending smoke-free legislation to include e-cigarettes. Methods: Online survey in 2016, n = 11 389 adults in Great Britain. Descriptives for all measures; multivariable logistic regressions assessed correlates of allowing e-cigarette use and support for extension of legislation. Results: Most (79%) reporting on workplace policies reported some level of restrictions on e-cigarette use. Small majorities would not allow e-cigarette use in their home (58%) and supported an extension of smoke-free legislation (52%; 21% opposed). Allowing use was less likely and supporting an extension more likely among men, respondents from a higher socio-economic status, ex-smokers, never-smokers, non-users of e-cigarettes and respondents with increased perceived harm of e-cigarettes or nicotine (all P < 0.001). Older respondents were less likely to allow use and to support an extension and Labour voters more likely to allow use. Conclusions: In Great Britain, the majority of workplaces has policies restricting e-cigarette use. Over half of adults would not allow use of e-cigarettes in their home and support prohibiting the use of e-cigarettes in smoke-free places. Adjusting for socio-demographics, more restrictive attitudes are more common among never-smokers, never-users and those with increased perception of relative harms of e-cigarettes or nicotine as cause of smoking-related illness.

Prevalence and characteristics of co-occurrence of smoking and increasing-and-higher-risk drinking: A population survey in England.

BACKGROUND: Smoking and drinking alcohol both significantly contribute to mortality and morbidity, and there is a need to characterise the sociodemographic and health-related characteristics (e.g. mental distress) of people who do both in order to target resources. This study reports the prevalence and characteristics of adults in the general population in England who both drink alcohol at increasing-and-higher-risk levels and smoke. METHODS: We used cross-sectional data from a monthly, nationally representative survey of adults in England (n = 37,258; April 2020-March 2022). Weighted data were used to report prevalence and unweighted data were used to report descriptive statistics for sociodemographic and health-related characteristics. RESULTS: The prevalence of both smoking and increasing-and-higher-risk drinking was 4.6% (95% CI = 4.4-4.9; n = 1,574). They smoked a mean of 10.4 (SD = 8.86) cigarettes per day and had a mean AUDIT score of 12.8 (SD = 5.18). Nearly half (48.2%, n = 751) were trying to cut down on their smoking and 28.0% (n = 441) on their drinking. A quarter (25.3%, n = 397) had received General Practitioner advice on smoking while 8.7% (n = 76) had received advice on their drinking. Nearly half (48.6%, n = 745) reported experiencing psychological distress in the past month and 44.6% (n = 529) had a diagnosed mental health condition, both of which were higher than among all adults (28.1% and 29.1%, respectively). CONCLUSION: In England, from April 2020 to March 2022, the prevalence of both smoking and increasing-and-higher-risk drinking was 4.6%. This group appears to experience high rates of mental health problems and targeted support is needed.

Opportunistic smoking cessation interventions for people accessing financial support settings: A scoping review.

AIM: The aim of this work was to systematically scope the evidence on opportunistic tobacco smoking cessation interventions for people accessing financial support settings. METHODS: We searched MEDLINE, Embase, PsycINFO and the Cochrane Tobacco Addiction Group specialized register to 21 March 2023. We duplicate screened 20% of titles/abstracts and all full texts. We included primary studies investigating smoking cessation interventions delivered opportunistically to people who smoked tobacco, within settings offering support for problems caused by financial hardship, for example homeless support services, social housing and food banks. Data were charted by one reviewer, checked by another and narratively synthesized. RESULTS: We included 25 studies conducted in a range of financial support settings using qualitative (e.g. interviews and focus groups) and quantitative (e.g. randomized controlled trials, surveys and single arm intervention studies) methodologies. Evidence on the acceptability and feasibility of opportunistic smoking cessation advice was investigated among both clients and providers. Approximately 90% of service providers supported such interventions; however, lack of resources, staff training and a belief that tobacco smoking reduced illicit substance use were perceived barriers. Clients welcomed being asked about smoking and offered assistance to quit and expressed interest in interventions including the provision of nicotine replacement therapy, e-cigarettes and incentives to quit smoking. Six studies investigated the comparative effectiveness of opportunistic smoking cessation interventions on quitting success, with five comparing more to less intensive interventions, with mixed results. CONCLUSIONS: Most studies investigating opportunistic smoking cessation interventions in financial support settings have not measured their effectiveness. Where they have, settings, populations, interventions and findings have varied. There is more evidence investigating acceptability, with promising results.

Use of tobacco and e-cigarettes among youth in Great Britain in 2022: Analysis of a cross-sectional survey.

INTRODUCTION: Although e-cigarettes can be an effective form of nicotine substitution for adults attempting to quit smoking, their use among children and young people is a concern. Accurate data about this are needed to inform debates over policy and regulation in the UK and elsewhere. METHODS: Using data from an online survey of 2613 youth aged 11-18 years, conducted by the market research company YouGov in March 2022, we present prevalence estimates of e-cigarette and tobacco use. We use logistic regression models to assess differences in e-cigarette use, tobacco use and use of disposable e-cigarettes across a range of covariates including age, sex, tobacco smoking status, social class, and country. RESULTS: Among the 18.0% of those surveyed who reported ever having smoked a cigarette, 83.9% were not regular (at least once per week) smokers and 16.1% were (15.1% and 2.9% of the total sample, respectively). Among the 19.2% of those surveyed who had ever used an e-cigarette, 79.2% were not regular users, while 20.8% were (15.2% and 4.0% of the total sample, respectively). Regular e-cigarette use was more common than regular tobacco smoking (4.0% vs 2.9%). E-cigarette use was more common among those who also smoked tobacco, with 9.0% of never e-cigarette users ever smoking tobacco, compared with 89.4% of regular e-cigarette users. Both smoking and e-cigarette use were associated with increasing age and use by others within the home, but not with social class. Use of disposable e-cigarettes was reported by 53.8% of those who have ever used an e-cigarette, and more common among females than males. CONCLUSIONS: Regular e-cigarette use is now more common than smoking in children and youth, though the majority of this is among those who have also smoked tobacco. Measures to reduce the appeal of both e-cigarettes and tobacco to children and young people are warranted.

Association of Fully Branded and Standardized e-Cigarette Packaging With Interest in Trying Products Among Youths and Adults in Great Britain.

Importance: e-Cigarette vaping among youths and adults has increased in Great Britain. The design of e-cigarette packaging may appeal to youths. Regulations that reduce the appeal of e-cigarettes to youths may deter adult smokers from trying e-cigarettes to help them quit smoking. Objective: To examine the association of fully branded and standardized e-cigarette packaging with interest in trying products among youths and adults in Great Britain. Design, Setting, and Participants: In this survey study comprising 2 surveys, the online Action on Smoking and Health Smokefree Great Britain survey collected data between March 25 and April 16, 2021, from a representative sample of 2469 youths (aged 11-18 years) and between February 18 and March 18, 2021, from a representative sample of 12 046 adults (aged ≥18 years). Interventions: A between-individuals experimental design was used to examine participants' perceptions of e-cigarette packs that were digitally altered to remove brand imagery and color. Participants were randomly assigned to view a set of 3 e-cigarette packs from 1 of 3 different packaging conditions: (1) fully branded packs (control), (2) white standardized packs with brand name, or (3) green standardized packs with brand name. Main Outcomes and Measures: Youth participants were asked which product people their age would be most interested in trying, while adult participants were asked which product they would be most interested in trying. All participants could respond "no interest" or "don't know." Logistic regression models tested whether reporting no interest in trying the e-cigarettes differed between the pack conditions. Results: This study included 2469 youths (1286 female youths [52.1%]; mean [SD] age, 15.0 [2.3] years) and 12 046 adults (6412 female [53.2%]; mean [SD] age, 49.9 [17.4] years). Youths had higher odds of reporting no interest among people their age in trying the e-cigarettes packaged in green (292 of 815 [35.8%]; adjusted odds ratio [AOR], 1.37; 95% CI, 1.10-1.71; P = .005) but not white (264 of 826 [32.0%]; AOR, 1.16; 95% CI, 0.93-1.44; P = .20) standardized packaging compared with the fully branded packaging (238 of 828 [28.7%]). Adults had lower odds of reporting no interest in trying e-cigarettes in green standardized packaging (3505 of 4040 [86.8%]; AOR, 0.85; 95% CI, 0.73-0.99; P = .046) but not white packaging (3532 of 4006 [88.2%]; AOR, 1.05; 95% CI, 0.89-1.23; P = .59) compared with branded packaging (3526 of 4000 [88.1%]). Youths who had never vaped (275 of 699 [39.3%]; AOR, 1.34; 95% CI, 1.07-1.69; P = .01) and youths who had never smoked (271 of 676 [40.1%]; AOR, 1.38; 95% CI, 1.10-1.75; P = .006) were more likely to report no interest in trying e-cigarettes in green packaging compared with branded packaging (224 of 688 [32.6%] never vaping; 216 of 662 [32.6%] never smoking). There were no significant differences by vaping or smoking status among adults. Conclusions and Relevance: The findings of this survey study suggest that standardized packaging measures may reduce the appeal of e-cigarettes among youths without reducing their appeal among adults.

Smoking in social housing among adults in England, 2015-2020: a nationally representative survey.

OBJECTIVES: To analyse associations between living in social housing and smoking in England and to evaluate progress towards reducing disparities in smoking prevalence among residents of social housing compared with other housing types. DESIGN: Cross-sectional analysis of nationally representative data collected between January 2015 and February 2020. SETTING: England. PARTICIPANTS: 105 562 adults (≥16 years). PRIMARY AND SECONDARY OUTCOME MEASURES: Linear and logistic regression were used to analyse associations between living in social housing (vs other housing types) and smoking status, cigarettes per day, time to first cigarette, exposure to others' smoking, motivation to stop smoking, quit attempts and use of cessation support. Analyses were adjusted for sex, age, social grade, region and year. RESULTS: Adults living in social housing had two times the odds of being a smoker (ORadj=2.17, 95% CI 2.08 to 2.27), and the decline in smoking prevalence between 2015 and 2020 was less pronounced in this high-risk group (-7%; ORadj=0.98, 95% CI 0.96 to 1.01) than among adults living in other housing types (-24%; ORadj=0.95, 95% CI 0.94 to 0.96; housing tenure-survey year interaction p=0.020). Smokers living in social housing were more addicted than those in other housing types (smoking within 30 min of waking: ORadj=1.50, 95% CI 1.39 to 1.61), but were no less motivated to stop smoking (ORadj=1.06, 95% CI 0.96 to 1.17) and had higher odds of having made a serious attempt to quit in the past year (ORadj=1.16, 95% CI 1.07 to 1.25). Among smokers who had tried to quit, those living in social housing had higher odds of using evidence-based cessation support (ORadj=1.22, 95% CI 1.07 to 1.39) but lower odds of remaining abstinent (ORadj=0.63, 95% CI 0.52 to 0.76). CONCLUSIONS: There remain stark inequalities in smoking and quitting behaviour by housing tenure in England, with declines in prevalence stalling between 2015 and 2020 despite progress in the rest of the population. In the absence of targeted interventions to boost quitting among social housing residents, inequalities in health are likely to worsen.

Cannabis use and co-use in tobacco smokers and non-smokers: prevalence and associations with mental health in a cross-sectional, nationally representative sample of adults in Great Britain, 2020.

BACKGROUND AND AIMS: In Great Britain, cannabis and tobacco are commonly used substances, both independently and together. Use of either substance is associated with mental health problems, but prevalence of co-use within these populations is unknown. We aimed to (1) estimate prevalence of cannabis use, frequency of use and routes of administration (ROA) among tobacco smokers and non-smokers and (2) investigate mental health problems among non-users, tobacco-only, cannabis-only and co-users of both substances. DESIGN: Cross-sectional national on-line survey (Action on Smoking and Health) fielded in February-March 2020. SETTING: Great Britain. PARTICIPANTS: Adults in Great Britain aged ≥ 18 years (n = 12 809) MEASUREMENTS: Tobacco use status [smoker (daily or non-daily) or non-smoker (never or ex-smoker)], cannabis use frequency (never to daily), detailed ROAs of cannabis, self-reported treatment for mental health disorders (depression, anxiety and any). Statistically weighted prevalence estimates were computed to ensure representativeness. Correlates were assessed using χ2 tests and logistic regression. FINDINGS: In Great Britain in 2020, 7.1% of the sample had used cannabis in the past year. Tobacco smokers had greater odds of using cannabis in the past year (21.9%) and using cannabis daily (8.7%) than non-smokers [past-year: 4.7%; adjusted odds ratio (aOR) = 10.07, 95% confidence interval (CI) = 8.4-12.0; daily: 0.7%; aOR = 24.6, 95% CI = 18.0-33.6)]. Co-administration with tobacco was common (46.2% of non-smokers, 80.8% of tobacco smokers). Co-users reported the highest prevalence of any treatment for mental health problems (54.2%) in comparison to cannabis-only (45.8%), tobacco-only (33.2%) and non-users (22.7%; all P ≤ 0.05). CONCLUSION: Approximately one in 13 adults in Great Britain reports having used cannabis in the past year, approximately four times as many among cigarette smokers as non-smokers. Co-administration of cannabis and tobacco, via smoking, appears to be common, including among self-identified non-smokers. Mental health problems appear to be particularly common among dual users.

Tobacco point-of-sale displays in England: a snapshot survey of current practices.

BACKGROUND: Tobacco displays at the point of sale (PoS) are an important means for the tobacco industry to communicate with consumers. With regulations prohibiting PoS displays recently having come into force in Ireland, passed into law in England, Wales and Northern Ireland and some Australian states, and being considered in New Zealand, Finland and Brazil, this is an increasingly important issue. This study explores the nature of displays, the extent to which they are tobacco industry funded, and the relation between the tobacco companies and retailers. METHODS: Three areas were chosen to gain a snapshot of PoS displays in England. Over 100 retailers were visited, with interviews taking place on site. Information was gathered on the type and size of tobacco display, who was paying for the display, requirements and incentives, and visits by industry representatives. RESULTS: The majority of retailers had gantries provided by tobacco companies. A minority of these were fitted with automated dispensers called retail vending machines. Attractive lighting and colour were often used to highlight particular products. Most retailers were being visited by industry representatives who checked displays. Some retailers also reported incentives offered to them for displaying products. CONCLUSIONS: The results suggest that the tobacco industry presence and control in the retail environment is significant. Tobacco companies overwhelmingly provided tobacco gantries in the shops surveyed and influenced displays through a combination of requirements and incentives. The extensive involvement of tobacco companies in providing and monitoring retail displays suggests the importance of implementing policies to end this form of advertising.

Finding smoking hot-spots: a cross-sectional survey of smoking patterns by housing tenure in England.

AIMS: To examine smoking prevalence, motivation and attempts to stop smoking, markers of cigarette addiction and success in quit attempts of people living in social housing in England compared with other housing tenures. DESIGN AND SETTING: A large cross-sectional survey of a representative sample of the English population conducted between January 2015 and October 2017. PARTICIPANTS: A total of 57 522 adults (aged ≥ 16 years). MEASUREMENTS: Main outcomes were smoking status, number of cigarettes per day, time to first cigarette, exposure to smoking by others, motivation to stop smoking, past-year quit attempts and use of cessation support. Covariates were age, sex, social grade, region and survey year. FINDINGS: Adults in social housing had twice the odds of being smokers than those living in other housing types [odds ratio (OR) = 2.09, 95% confidence interval (CI) = 1.98-2.22, P < 0.001]. Smokers in social housing consumed more cigarettes daily (adjusted mean difference = 1.09 cigarettes, 95% CI = 0.72-1.46, P < 0.001) and were more likely to smoke within 30 minutes of waking (OR = 1.63, 95% CI = 1.48-1.79, P < 0.001) than smokers living in other housing types. Prevalence of high motivation to stop smoking was similar across housing types (OR = 1.04, 95% CI = 0.91-1.19, P = 0.553). The prevalence of quit attempts and use of cessation support within the past year were greater in social compared with other housing (OR = 1.14, 95% CI = 1.03-1.26, P = 0.011; OR = 1.30, 95% CI = 1.09-1.54, P = 0.003), but success in quitting was much lower (OR = 0.57, 95% CI = 0.45-0.72, P < 0.001). CONCLUSIONS: In England, living in social housing is a major independent risk factor for smoking. These easily identifiable hot-spots consist of smokers who are at least as motivated to stop as other smokers, but find it more difficult.

Harm perceptions of electronic cigarettes and nicotine: A nationally representative cross-sectional survey of young people in Great Britain.

BACKGROUND: E-cigarettes often contain nicotine without the most harmful constituents of tobacco smoke. AIMS: This study aims to assess prevalence and correlates of accurately perceiving e-cigarettes as less harmful than cigarettes and that none or a small amount of the harm from smoking comes from nicotine. METHODS: Cross-sectional survey of 2,103 11-18-year-olds in Great Britain in 2016. Prevalence of e-cigarette and nicotine harm perceptions were calculated. Logistic regressions assessed associations between accurate e-cigarette and nicotine harm perceptions and smoking, e-cigarette use, gender, age, region, social grade, family smoking, family e-cigarette use, smoking friends, public approval of smoking, and public approval of e-cigarettes. Associations between accurate e-cigarette and nicotine harm perceptions were also assessed. RESULTS: Most (63.4%) accurate e-cigarette harm perceptions were higher among those aged 16+ (OR = 1.89 [95%CI = 1.45-2.47]), 14-15 (OR = 1.29 [1.00-1.65]), who tried/used an e-cigarette sometimes (OR = 1.51 [1.03-2.21]), with family e-cigarette use (OR = 2.11 [1.46-3.04]), who perceived public disapproval of smoking (OR = 2.11 [1.18-3.77]) and approval of e-cigarettes (OR = 2.44 [1.73-3.45]), and with accurate nicotine harm perceptions (OR = 2.05 [1.28-3.28]). Accurate nicotine harm perceptions were higher among those aged 16+ (OR = 2.60 [1.62-4.16]), from North England (OR = 1.87 [1.02-3.43]) and Wales/Scotland (OR = 2.61 [1.35-5.03]) vs. London, with family smoking (OR = 1.59 [1.05-2.42]), and with accurate e-cigarette harm perceptions (OR = 2.12 [1.32-3.41]). CONCLUSIONS: Many young people have inaccurate harm perceptions of e-cigarettes and nicotine. Accurate e-cigarette and nicotine harm perceptions were associated with one another. E-cigarette use was associated with accurate e-cigarette but not nicotine harm perceptions; smoking was not associated with either.

The Association Between Smoking and Electronic Cigarette Use in a Cohort of Young People.

PURPOSE: Electronic cigarette (e-cigarette) use is associated with smoking initiation among young people; however, it is also possible that smoking is associated with e-cigarette initiation. This study explores these associations among young people in Great Britain. METHODS: A longitudinal survey of 1,152 11- to 18-year-olds was conducted with baseline in April 2016 and follow-up between August and October 2016. Logistic regression models and causal mediation analyses assessed whether (1) ever e-cigarette use and escalation were associated with smoking initiation (ever smoking at follow-up) among baseline never smokers (n = 923), and (2) ever smoking and escalation were associated with e-cigarette initiation (ever e-cigarette use at follow-up) among baseline never e-cigarette users (n = 1,020). RESULTS: At baseline, 19.8% were ever smokers and 11.4% were ever e-cigarette users. Respondents who were ever e-cigarette users (vs. never users, 53% vs. 8%, odds ratio [OR] = 11.89, 95% confidence interval [CI] = 3.56-39.72) and escalated their e-cigarette use (vs. did not, 41% vs. 8%, OR = 7.89, 95% CI = 3.06-20.38) were more likely to initiate smoking. Respondents who were ever smokers (vs. never smokers, 32% vs. 4%, OR = 3.54, 95% CI = 1.68-7.45) and escalated their smoking (vs. did not, 34% vs. 6%, OR = 5.79, 95% CI = 2.55-13.15) were more likely to initiate e-cigarette use. There was a direct effect of ever e-cigarette use on smoking initiation (OR = 1.34, 95% CI = 1.05-1.72), and ever smoking on e-cigarette initiation (OR = 1.08, 95% CI = 1.01-1.17); e-cigarette and smoking escalation, respectively, did not mediate these effects. CONCLUSIONS: Among young people in Great Britain, ever e-cigarette use is associated with smoking initiation, and ever smoking is associated with e-cigarette initiation.